Lung Clinical Lab Assignment

Use the Lung CT data set provided to complete the following assignment:

Prescription: 60 Gy in 30 fractions to the PTV

Planning Directions: Place the isocenter in the center of the designated PTV—make sure it isn’t
in air. Note: calculation point will be at isocenter. Create a single AP field using the lowest
photon energy in your clinic. Create an MLC block on the AP beam with a uniform 1 cm margin
around the PTV. Apply the following changes (one at a time) as listed in each plan exercise
below. Each plan will build in complexity off of the previous one. After adjusting each plan,
answer the provided questions. Include an axial screen shot for each plan to show the isodose
distribution along with a DVH clearly displaying your PTV coverage.
 Important: Please do not normalize your plan when making these adjustments until
instructed to do so in the final plan.
 Tip: Copy and paste each plan after making the requested changes so you can compare
all of them as needed.

Plan 1: Create a field directly opposed to the original field (PA). Assign equal (50/50) weighting
to each field.
 What shape does the dose distribution resemble?
The dose shape resembles an hourglass isodose distribution. The hourglass shape is a classic
isodose distribution for parallel opposed fields. This simplistic beam arrangement is
advantageous in that it reduces the chance for a geometric miss and gives a homogenous dose
to the tumor.1 The downfall of a parallel opposed beam arrangement is the unnecessary dose
given to the normal tissues in the entrance and exit of the beams.
  How much of the PTV is covered entirely by the 100% isodose line?
6.9% of the PTV is covered by the 100% isodose line.

 In your own words, summarize two advantages of using a parallel opposed plan?
(Review Khan, 5th ed., 11.5.A, Parallel Opposed Fields)
According to Khan1, parallel opposed beams offer advantages in regard to setup and
reproducibility. Due to the forgiving nature of this isodose distribution, there is less of a chance
to miss the target. Parallel opposed fields also offer a more homogenous dose distribution to
the target tissue compared to a single field. The negative element of a parallel opposed beam
arrangement is the unnecessary doses give to the normal tissues in the entrance and exit of the
two beams. The skin sparing effect can be increased by increasing the energy of the photon
beam.1

Plan 2: Add a direct left lateral field to the plan and assign equal weighting to all fields. How
did this field addition change the isodose distribution?

The addition of the left lateral beam changed the isodose distribution to form a box around the
PTV. The PTV coverage increased from 6.9% to 14.8%. The hot spots on the anterior and
posterior side of the patient are lessened. However, the heart and contralateral lung are now
receiving exit dose from the left lateral beam.
  How much of the PTV is covered entirely by the 100% isodose line? 14.8%

Plan 3: Add 2 oblique fields on the affected side—1 on the anterior portion and 1 on the
posterior portion of the patient. Assign equal weighting to all fields.
 What angles did you choose and why?

I chose an A30R for my anterior oblique beam and P20L as the posterior oblique beam angle. I
chose these beam angles by looking at the organs at risk in the beam’s eye view. In selecting
the anterior oblique beam angle, I focused on avoiding the esophagus, heart, spinal cord, and
contralateral lung. The contralateral lung and heart were the main organs at risk taken into
consideration for the posterior oblique beam. By utilizing a 160 degree posterior oblique, I was
able to keep the heart mean to 91 cGy. Also, I wanted to keep a reasonable separation between
the oblique beams from the anterior and posterior beam as to limit the amount of entrance
and exit dose the beams would contribute to one another.

 In your own words, summarize why beam energy is an important consideration for lung
treatments? (Review Khan, 5th ed., 12.5.B3, Lung Tissue)
Beam energy is important due to the lateral scatter of secondary electrons in the lung tissue.
The dose distribution is affected by the electron density of the tissues in the beam path and the
low electron density of the lung compared to other tissues of the body. The secondary
electrons from a Compton interaction are scattered further in the low density lung tissue
compared to other tissue types and more electrons are scattered outside the field boundaries. 1
That is, there is a loss of electronic equilibrium which can result in a reduction in dose,
particularly along the periphery of the beam.1, 4, 5 There is also increased penumbra due to the
increased range of the secondary electrons. These effects are greater as photon energy
increases and field size decreases. The loss of scattered secondary electrons also results in a
decreased dose along the beam axis.1
Plan 4: Alter the weights of the fields to achieve the best PTV coverage.
 How does field weight adjustment impact a plan?

After altering the weights of the fields, the PTV coverage improved from 13.5% on plan 3 to
90.4% of the PTV covered by 100% of the dose in plan 4. I chose the AP and PA beams to carry a
majority of the weight to help minimize the V20 of the lung. The anterior and posterior oblique
beam weight was decreased slightly to minimize dose to the heart, esophagus, contralateral
lung, and spinal cord. I also did not want to put too much weight on the left lateral beam in
being mindful of the dose to the heart, esophagus or contralateral lung.
When selecting beam weighting, I was conscious of the dose received by the soft tissue in
the entrance and exit of the anterior and posterior beams. Overall, my goal in setting my beam
weighting was to achieve the best target coverage while still minimizing dose to the ipsilateral
and contralateral lung, as well as sparing the esophagus, spinal cord, and heart. It is common
practice at my clinical site for the beam weighting to add up to greater than 1. The intention is
to balance the base weighting to be in a position to effectively add field in field to add in or take
away dose as necessary. We do not typically normalize our plans using the normalization tool in
Eclipse.
  List your final choice for field weighting on each field.

Plan 5: Try inserting wedges for at least one or more fields to improve PTV coverage. You may
also adjust field weighting if you feel it’s necessary.
 Embed a screen capture of the beams-eye view (BEV) for each field that you used a
wedge.
  List the wedge(s) used and the orientation in relation to the patient and describe its
purpose. (ie. Did it push dose where it was lacking or move a hotspot?)

On the anterior field, I used a 30 degree wedge with the heel positioned inferiorly. This helped
push dose superiorly where the target was lacking dose. With the addition of this wedge, the
coverage improved by 1.1%. Additionally, the area of 110% on the inferior aspect of the PTV
decreased in size.

On the lateral field, I selected a 15 degree wedge with the heel positioned anteriorly. This
assisted in pushing dose posteriorly to improve posterior target coverage. It is understandable
that the dose was lacking on the edges of the target. This is typical during lung planning due to
the low electron density of the lung.

 Describe how your PTV coverage changed (relating to the 100% isodose line) with your
final wedge choice(s).

Overall, my PTV coverage increased from 90.4% in plan 4 to 92.1% of the PTV covered by 100%
of the dose with the addition of the 2 wedges. The maximum dose in plan 5 decreased from
6712.9 cGy in plan4 to 6648.1 cGy in plan 5.

Plan 6: Normalize your plan so that 95% of the PTV is receiving 100% of the prescription dose.
  What impact did normalization have on your final plan?

Without normalization, the plan was slightly shy of achieving 95% coverage of the PTV with
100% of the prescription dose. Therefore, after normalization, the entire plan warmed up by a
small amount in order to achieve this constraint. The plan normalization value was 99.14%,
which means the entire plan’s dose was increased by 0.86% in order to meet the coverage
requests.

 What is your final hotspot and where is it?

The final hotspot is 6705.9cGy (111.8%) and is located within the internal target margin (ITV) of
the target. The ITV encompasses the CTV plus an additional margin to account for internal
organ motion associated with respiration.1
 Are you satisfied with the location of the hotspot?

The ITV is an acceptable area for the hot spot to be. Additionally, the hot spot is located in
target tissue that is not of particular radiosensitive concern that could cause unfavorable side
effects such as the esophagus. The QUANTEC data report advises the amount of esophagus
receiving greater than 50 Gy increases the risk of acute esophagitis. 2

Plan 7: There are many ways to approach a treatment plan and what you just designed was just
one idea. Using the tools of your TPS, your current knowledge of planning, and the help of your
preceptor, adjust or design your own ideal 3D lung treatment plan. Get creative! You may
adjust the beam energy, beam weighting, wedges, add field-in-field, etc. Normalize your final
plan so that 95% of the PTV is receiving 100% of the dose.
 What energy(ies) did you use and why?

I chose to use 10 MV beams in this plan due to the deeply seated target and to eliminate hot
entrance and exit doses. The drawback of using 10 MV in the lung is due to the low electron
density of the lung tissue and the secondary build up region after traversing through the low
density lung and penetrating the tumor tissue. The secondary buildup region is larger for a 10
MV beam than for a lower energy. Typically, a 6 MV beam would be preferred to allow for
better PTV coverage at the interface of the lung and soft tissue.3 Being aware of the benefits
and drawbacks of higher energy beams in the low density lung tissue is important. Having said
that, 10 MV beams is what dosimetrists at my clinical site routinely use. When evaluating 6 MV
versus 10 MV in the setting of VMAT SBRT lung plans, Tchelebi et al 6 found that 10 MV should
at least be considered due to its significant reduction in monitor units. This ultimately means
less treatment time and therefore, less time for possible intrafraction motion.

 What is the final weighting of each field in the plan?

The final field weighting for my plan adds up to 1.205, which is greater than 100%. This is
common practice at my clinical site. We utilize this method of field weighting and do not utilize
the normalization mode in Eclipse.
Ant: 0.36 A50L: 0.24
Post: 0.385 P45R: 0.22

 Where is the region of maximum dose (“hot spot”), what is it, and is this outcome
clinically acceptable?
The point of maximum dose of 109.9% is located in the middle of the internal target volume in
the target tissue. This would be acceptable at my clinical site as it is less than 110% and not
located in any normal organs at risk, but rather located within the target.

 Embed a screen cap of your final plan’s isodose distribution in the axial, sagittal and
coronal views.
 Include a final screen capture of your DVH and embed it within this assignment. Make it big enough to see (use a full page if
needed). Be sure to provide clear labels on the DVH of each structure versus including a legend. *Tip: Import the screen
capture into the Paint program and add labels. See example in Canvas.
  Use the table below to list typical OAR, critical planning objectives, and the achieved
outcome. Please provide a reference for your planning objectives.

The following table lists typical organs at risk for a lung plan. The planning objectives are taken
from my departmental planning template for a conventional lung regimen. I also compared
these constraints to the RTOG and QUANTEC data found in the literature.7 I was able to achieve
all desired planning objectives with my plan by a considerable margin.

Organ at Risk (OAR) Desired Planning Objective Planning Objective Outcome

Lung_R Mean[Gy] Report 0.96 Gy
DC500cc [cGy] Report 0.19 Gy
DC1000cc [cGy] Report 0.39 Gy
V10Gy [%] Report 0.2%
V20Gy [%] Report 0%
Lung_L Mean[Gy] Report 15.28 Gy
DC500cc [cGy] Report 0.62 Gy
DC1000cc [cGy] Report 2.32 Gy
V10Gy [%] Report 39.1%
V20Gy [%] Report 29.7%
Lung_total Mean[Gy] Report 9.28 Gy
V5Gy [%] Report 30.2%
V10Gy [%] < 42% 22.8%
V13Gy [%] Report 20.5%
V20Gy [%] < 25% 17.3%
V30Gy [%] Report 13.8%
Heart Max [Gy] < 62 Gy 32.27 Gy
Mean [Gy] < 20 Gy 0.82 Gy
V5Gy [%] Report 3.8%
V30Gy [%] < 46% 0%
V40Gy [%] < 33% 0%
Cord Max [Gy] < 50Gy 12.27 Gy
Cord_prv Max [Gy] < 55 Gy 12.55 Gy
V55Gy[cc] < 10cc 0 cc
Esophagus Max [Gy] Report 13.12 Gy
Min [Gy] Report 0.05 Gy
Mean [Gy] < 20Gy 2.40 Gy
D0.03cc [Gy] Report 12.93 Gy
DC0.03cc [Gy] Report 0.05 Gy
V35Gy [%] < 35% 0%
 V50Gy [%] < 20% 0%
V55Gy [%] < 5% 0%
V60Gy [%] < 1% 0%
PTV_Lung Max[%] Report 109.9%
D0.03cc [Gy] Report 65.93 Gy
D95% ≥ 100% 100.7 %
D99 ≥ 93% 99.1%
DC0.03cc [Gy] Report 57.79 Gy
V95% Report 100%
V110% < 1% 0%

References:

1. Khan FM, Gibbons JP. Khan's The Physics of Radiation Therapy. 6th Ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2020.
2. Werner-Wasik M, Yorke E, Deasy J, Nam J, Marks LB. Radiation dose-volume effects in
the esophagus. Int J Radiat Oncol Biol Phys. 2010;76(3 Suppl):S86-S93.
http://doi.org/10.1016/j.ijrobp.2009.05.070
3. Khan FM, Gibbons JP, Sperduto PW. Khan's Treatment Planning in Radiation Oncology.
4th Ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2016.
4. Wang L, Yorke E, Desobry G, Chui CS. Dosimetric advantage of using 6 MV over 15 MV
photons in conformal therapy of lung cancer: Monte Carlo studies in patient
geometries. J Appl Clin Med Phys. 2002;3(1):51-59.
http://doi.org/10.1120/jacmp.v3i1.2592
5. White PJ, Zwicker RD, Huang DT. Comparison of dose homogeneity effects due to
electron equilibrium loss in lung for 6 MV and 18 MV photons. Int J Radiat Oncol Biol
Phys. 1996;34(5):1141-1146. http://doi.org/10.1016/0360-3016(95)02384-4
6. Tchelebi l, Chen D, Ikoro N, Guirguis A, Kyriacou A, Parameriti J, Viswahathan R,
Katsoulakis E, Mokhtar B, Ashamalla, Hani. The Dosimetric Effects of Photon Energy on
the Quality of Volumetric Modulated Arc Therapy for Lung Stereotactic Body Radiation
Therapy. World J Oncol. 2016;3:27-35. http://doi.org/10.15379/2413-7308.2016.03.04
7. Marks LB, Yorke ED, Jackson A, et al. Use of normal tissue complication probability
models in the clinic. Int J Radiat Oncol Biol Phys. 2010;76(3 Suppl):S10-S19.
http://doi.org/10.1016/j.ijrobp.2009.07.1754