Lung Lab Assignment

Melissa Piercey
April 12, 2023
Plan 1:
In this plan, on the coronal view, the dose distribution somewhat resembles a circle. The 100%
isodose line does not cover the PTV. On the axial and sagittal views, the dose is spread out
anterior to posterior with 100% of the dose in the anterior chest, posterior and centrally in the
PTV. Only 24.96% of the PTV is covered by the 100% isodose line. In a parallel opposed plan,
the depth dose contributions for each beam are combined which creates a homogenous dose to
the tumor. This type of setup is easy for the therapists to reproduce for daily treatment.1
Plan 1 axial Image:
Plan 1 DVH:
Plan 2:
In this plan the dose is concentrated more in the PTV and more centrally in the patient. We do
not see the 100% isodose lines at the anterior and posterior surfaces as we did on the previous
AP/PA plan. In this plan, 35.82% of the PTV is covered by the 100% isodose line.
Plan 2 axial image:
Plan 2 DVH:

Plan 3:
For this plan I added a gantry angle of 45 degrees because it was directly between the AP and LT
beams. I added the gantry angle of 135 degrees because it was directly between the LT and PA
beams. Choosing these beams gives equally distanced entrance points and creates tighter isodose
lines around the PTV.
Since lung tissue has a low density there is more scatter radiation. In energies higher than 6 MV,
the scattered electrons do not travel along the central axis, there is a loss of electronic
equilibrium and more penumbra. This wide penumbra causes the overall intensity of the beam to
be lower. This can cause under dosing at the edges of the tumor.1
Plan 3 axial image and DVH:
Plan 4: Alter the weights of the fields to achieve the best PTV coverage.
-How does field weight adjustment impact a plan?
Weighting a beam higher than another beam means that more dose will be delivered
through the higher weighted beam. Less dose will be delivered to a lower weighted beam.
Weighting the beams allows the dosimetrist to adjust the isodose distribution in the plan.
-List your final choice for field weighting on each field.
The final weightings I chose for each beam are: AP-17.89% PA- 16% Lt Lat- 28% LAO-
17.05% LPO- 21.06%
Plan 4 axial:
Plan 4 DVH:

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 for each field that you used a wedge.
Plan 5 LAO w/ wedge BEV:

LT BEV:
LPO BEV:

-List the wedges used and the orientation in relation to the patient and describe its purpose.
LAO- 30 degree, wedge heel anterior
LT Lat- 60 degree, wedge heel anterior
LPO- 35 degree, wedge heel anterior
These wedges helped move more dose medially and create a more conformal dose
distribution. There are now less hotspots and the max dose was moved more centrally in the
PTV. The wedge on the LT Lat also helps even the dose distribution due to the sloping anatomy
of the patient on the lateral side.
-Describe how your PTV coverage changed.
There is better coverage on the PTV now, 38.81% of the PTV is covered by 100% of the
dose.
Plan 5 axial image and DVH:
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?
Normalizing my plan moved my 100% isodose line out so that it is now covering
most of the PTV. Overall the plan got hotter since I am now prescribing to the 89.6%
isodose line.
-What is your final hotspot and where is it?
The hotspot is 71.5 Gy and it is located just posteriorly to the PTV. Ideally the hotspot
should be inside the PTV. Most doctors will prefer a lung plan that has a very hot center,
however the hotspot should be around 10% over the total prescription dose and this hotspot is
19% over the total dose.
-Are you satisfied with the location of the hotspot?
No, I would like the hotspot to be in the PTV.
Plan 6 axial:
Plan 6 DVH:

Plan 7:
- What energies did you use and why?
For this plan I used 6MV energy for all of my beams. I chose this energy because
when I tried higher energies I was not getting enough coverage on my PTV. This is due
to the way electrons interact with lung tissue which is mostly air. A higher energy in air
causes a wider penumbra and an overall decrease in intensity of the beam.1
- What is the final weighting of each field in the plan?
The final beam weighting is: RAO- 17.67%, RPO- 23%, Lt Lat- 17.67%, LAO-
17.67%, LPO- 24%
- Where is the region of maximum dose, what is it and is this outcome clinically
acceptable?
The max dose point in this plan is in the PTV, it is 69.5 Gy. At my clinic this is
acceptable. I talked with my preceptor and he said every doctor is different in what they
accept as a hotspot, most want the hotspot around 110% of the dose but the lung
 physician here would accept this dose since the hotspot is in the PTV and we don’t want
to sacrifice coverage of the PTV to lower that hotspot dose.
-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.
 Use the table below to list typical OAR, Critical planning objectives, and the achieved outcome.

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

Esophagus Mean Dose </= 34Gy 2.2Gy
Heart Mean Dose (10-20Gy) acceptable 1.2Gy
Lungs-IGTV Mean Dose </= 15Gy 9.7Gy
Lungs-IGTV V20Gy </= 30% 18.4% vol. @ 20Gy
Trachea </= 84Gy @ 0.1cc 7.4 Gy @ 0.1cc
Bronchus </= 84Gy @ 0.1cc 66.6 Gy @ 0.1cc
Spinal canal </= 46 Gy @0.1cc 6.8 Gy @0.1cc

References:

1
Gibbons JP. Khan’s the Physics of Radiation Therapy. Sixth. Wolters Kluwer; 2020.