VanLanen 1

Luke VanLanen
Lung Project
Plan 1:
The prescription for this plan was 60 Gy in 30 fractions resulting in 200 cGy per fraction. The set
up for the plan included a field with the gantry set to 0 degrees and this field was labeled 1a Ant.
The opposing field was set to 180 degrees and this field was labeled 1b Post. The weighting on
each field ws 50-50 meaning they were equally weighted. This weighting gave a dose
distribution shape that resembles an hourglass. The posterior area of the patient received a
much higher dose. This may be due to the fact that the posterior area is thicker allowing more
dose to build up. The superficial areas received more dose in a wider region, and as the dose
traveled toward the PTV it pinched in towards the isocenter. In this plan 10.4% of the Lung-PTV
is receiving 100% of the dose. One of the advantages of parallel opposed field set up is the
simplicity of the setup as well as the ability to consistently reproduce the setup daily.​1 ​ Another
advantage of this setup is that utilizing parallel opposed fields minimizes the possibility of
geometric miss in comparison to angled beams. 1​ ​Below is the view of the isodose distribution
as seen from an axial slice.

Plan 2:
For this plan, the setup was exactly the same as in plan 1 except a third beam was added. This
beam was labeled 1c L Lat at was positioned by rotating the gantry to 90 degrees. The three
fields received equal weighting of 33.33% weight on each field. Once adding field 1c the
isodose distribution changed. Instead of resembling and hourglass shape it now had a square
 VanLanen 2

appearance around the PTV. In fact, the 90% isodose line made a square around the entire
PTV when looking from the axial view. In this plan the 25% of the Lung-PTV is covered by 100%
of the dose. Below is the screenshot of the isodose distribution as seen from an axial slice.

Plan 3:
For plan 3 the setup was identical to plan 2 except I added in two oblique fields. The first field I
added was set to the gantry angle of 45 degrees. This field is then located on the left lateral
anterior oblique position (LAO). The next field added was set to the gantry angle of 135
degrees. This beam is then located in the left lateral posterior position (LPO). The purpose of
these beam angles is to ensure equal distribution of dose. If beams are located to closely
together then the overlapping area increases. This overlapping area then increases the dose
outside of the PTV. I decided to split the beams up so that they all had equal amount space
between them. Having equal field distribution allows the dose to be more evenly distributed and
less hot area outside the PTV.
 VanLanen 3

At the clinic I am at we only use 6MV energy for all lung treatments. This has to do with the
low density of the lung. Since the lung has a low density, when higher energies are used there
is a loss of electronic equilibrium.​1​ This causes an increased number of electrons to travel
outside the specified geometric beam profile.​1​ In return there is a less sharp beam and the this
allows the possibility of compromised coverage of the PTV. Another issue with using higher
energies for lung plans is the fact that the low density of the lung can allow dose to travel past
the target volume into normal structures. For these reasons it is always best to use low energy
when treating lung tumors. Below is the screenshot of the isodose distribution of plan 3 as seen
from the axial view.

Plan 4:
Plan 4 was kept exactly the same as plan 3 except weighting on beams was changed for this
plan. The weighting of the plan moved the dose around. The biggest change in isodose
distribution has to do with the 50% isodose lines. Since the lung has a low density the majority
of the high dose area is concentrated to within the PTV which is more dense than the lung
tissue. However, areas outside the PTV within lung tissue are susceptible to dose overlap.
Changing the weight can change how intense or little the dose overlap occurs. The weighting for
this plan was 27% weight from the anterior, 25% weight from the posterior, 18% weight from the
lateral, 13% weight from the anterior oblique, and 17% weight from the posterior oblique.
 VanLanen 4

Plan 5:
For plan 5 I added in 4 different wedges. The wedges for this plan are enhanced dynamic
wedges. The purpose of the wedges was to push dose to the medial portion of the PTV. The the
lateral and superior portion of the PTV was receiving the prescription dose, but as the PTV
traveled deeper the dose was falling off. The purpose of the wedges was to try and get the dose
pushed deeper into the PTV. The first wege was a 10 degree wedge placed on the anterior field
with the heal to the left and toe to the right. The next wedge was a 10 degree wedge placed on
the anterior oblique field with the heel to the posterior and the toe toward the anterior. The next
wedge was 10 degrees and was on the posterior oblique field. The heel of this wedge was
toward the anterior and the toe toward the posterior. The final wedge was 10 degrees and was
placed on the posterior field with the heel toward the left and the toe to the right. For this plan
with no normalization 17% of the PTV is covered by the 100% isodose line. The purpose of the
wedges was to try and push dose into the area of the PTV that was drawn in low density lung
tissue.

Beam’s eye view anterior field.

Beam’s eye view left anterior

oblique field.
 VanLanen 5

Beam’s eye view left posterior

oblique field.

Beam's eye view posterior

field.

Plan 6:
 VanLanen 6

Normalization is a dose requirement that tells the linac how many MUs it needs. When
normalizing the treatment planning system will continue to increase the MUs on each beam until
the normalization, or dose requirement, is met. For this plan the normalization was 95% of the
PTV receiving 100% of the prescribed dose. This normalization requirement means when 95%
of the volume of the PTV is covered by the 100% Isodose line then the dose requirement is
achieved and the result is the number of MU’s needed. Plan 6 was similar to plan 5 except the
plan was normalized so that 95% of the PTV was receiving 100% of the dose. This did two
major things to my plan. The first change that happened when I normalized was the coverage of
my PTV significantly increased. The second change was that my plan heated up quite a bit from
what it was before normalization. This was because more MU’s were needed in order to get the
coverage I normalized to. The more MUs needed the more dose that gets pushed into the plan,
and the result was a hotter plan. The final hotspot on this plan was 112.9% of the prescription
dose which is 6774.2 cGy. The location of the hotspot is right in the tumor volume 1 cm below
the isocenter. As far as the location of the hotspot I am happy. I like that it is in the PTV and
even better within the tumor mass. I would like to make the plan itself a little cooler. Ideally the
hot spot would be in the same spot but it would be under 110% of the prescribed dose.

Plan 6 hotspot.
 VanLanen 7

Plan 6 isodose distribution.

Plan 7:
For my final plan I ended up using 7 beams total all with 6x energy. The 6 x energy is used
because the lower energy is better suited for lung plans. It allows for more accurate dose
estimations, and spares normal tissue. The fields were 1a right anterior oblique(RAO), 1b left
anterior oblique (LAO), 1c LAO, 1d LAO, 1e left posterior oblique(LPO), 1f LPO, and 1g
Posterior. The angles of each beam were set such that 1a was at 340 degrees, 1b set to 13
degrees, 1c set to 46 degrees, 1d set to 79 degrees, 1e set to 112 degrees, 1f set to 145
degrees, and finally 1g set to 180 degrees. The weighting on the plan is as follows; 1a weighted
12.2%, 1b weighted 16.9%, 1c weighted 14.7%, 1d weighted 2.5%, 1e weighted 14.2%, 1f
weighted 19.7%, amd 1g weighted 19.8%. The maximum hotspot of the plan is 6598.4 cGy
which is 110% of the prescribed dose. The hotspot is found within the PTV right next to the
isocenter. This hotspot is clinically acceptable within our clinic here at the St. Paul Cancer
Center. The maximum dose allowed in plans at my clinic is 110% of the prescribed dose, and
this hotspot has to be within the PTV. Below is the axial, sagittal, and coronal views of my plan.
Along with that is the DVH for the plan and the constraints at risk template.
VanLanen 8
VanLanen 9
VanLanen 10
 VanLanen 11

Dose constraints from TG263 study.

 VanLanen 12

References

1.) Kahn F, Gibbons JP, Sperduto PW. ​Treatment Planning in Radiation Oncology.​
4​th​ Ed. Philadelphia, PA: Wolters Kluwer; 2016.