Joseph Spencer

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.

Figure 1: Plan 1 axial, coronal, sagittal views of the dose distribution of AP/PA plan using 6MV
and equal weighting.
  What shape does the dose distribution resemble?
The dose distribution of a typical opposing AP/PA plan would resemble an hourglass shape
when the tissue being treated is homogenous. In this case, lung tissue has a much lower tissue
density than the target lesion and chest-wall. This unique combination of tissue densities alters
the 90% isodose line (blue) to resemble what I would describe as a bean-pod shaped. The dose
is wide at both entry points in the AP and PA fields but then narrows through the normal lung
tissue only to widen back out at the target. The isodose lines lower than 70% appear to create a
straight column connecting the two fields.

 How much of the PTV is covered entirely by the 100% isodose line?
The DVH shows that only 7.7% of the PTV is receiving 100% of the prescribed dose of 60Gy.

Figure 2: Plan 1 DVH of the PTV coverage at 100%.

 In your own words, summarize two advantages of using a parallel opposed plan?
(Review Khan, 5th ed., 11.5.A, Parallel Opposed Fields)
One of the advantages to a parallel opposed plan is the dose distribution to the target being
more homogenous and predictable with just two fields. This setup makes it easier to apply
beam weighting to get adequate target coverage. Another advantage to a parallel opposed plan
is the simplicity and reproducibility of the setup. This is especially true when using generic
AP/PA fields. Reducing the complexity of a plan will also minimize the chance of treatment
error that comes with multifield treatments.

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?
Adding a third lateral field improved the dose distribution and coverage by a good margin.
While the 100% coverage (yellow) on the PTV only improved by 10%, the higher isodose lines
have better conformed around the target area. This is seen well by the 70% line (light blue)
creating a nice box shape around the target (red). The AP/PA plan placed the max dose on the
PA field along the patient’s posterior side, but both the AP and PA fields had doses above 105%
of the prescribed dose. This high entrance dose was greatly reduced when adding the third
lateral field of equal weighting with only a max entrance dose of 70% in the AP and PA and only
50% on the left lateral field.

Figure 3: Plan 2 axial, coronal, sagittal views of the dose distribution of AP/PA/Left Lateral plan
using 6MV and equal weighting.

 How much of the PTV is covered entirely by the 100% isodose line?
The DVH shows that 17.7% of the PTV is receiving 100% of the prescribed dose of 60Gy. A 10%
increase from Plan 1. (See Fig.4)

Figure 4: Plan 2 DVH of the PTV coverage at 100%.

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.

Figure 5: Plan 3 axial, coronal, sagittal views of the dose distribution of AP/PA/Left
Lateral/LAO/LPO plan using 6MV and equal weighting.

Figure 6: Plan 3 DVH of the PTV coverage at 100%. The DVH shows that 16.4% of the PTV is
receiving 100% of the prescribed dose of 60Gy.
  What angles did you choose and why?
I experimented with different oblique angles. I wanted to get my beam angles to be as “en
face” with the patient’s skin surface as possible for a more even dose distribution. By doing so, I
noticed that the beam angles of 60° and 140° were pointing right at the heart and great vessels.
I created comparison plans of a plan with en face oblique fields (60°, 140°) to a plan that angled
the obliques away from the mediastinum area (35°, 150°) and compared each plan’s DVH. Both
plans had similar PTV coverage with very similar max and min coverage. Surprisingly, the heart
dose was similar in both plans. The biggest difference I noticed came from dose sparing to the
spinal canal, trachea, bronchus, and esophagus. Ultimately, I chose to use the plan with added
oblique angles of 35° and 150° because of the dose sparing to OAR. See Figure 7 to see DVH
comparison between the two plans I made for this section of the assignment to make my
decision on which beam angles to use.

Figure 7: Dose Volume Histogram of two comparison plans created to assess appropriate LAO
and LPO angles to use for OAR sparing in the Plan 3 assignment. The line with the square
represents oblique angles of 60° and 140° and the line with the triangle represents angles of 35°
and 150°.

 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 an important consideration when treating lung tumors because there is a loss of
lateral electronic equilibrium and build up with higher energies due to the lower lung tissue
densities. The lower lung tissue densities allow electrons to scatter laterally causing a reduction
in overall dose along the central beam axis. This loss of electronic equilibrium could result in
under dosage of the areas surrounding the tumor. This is especially true in combination of
higher energies with smaller field sizes.1
Plan 4: Alter the weights of the fields to achieve the best PTV coverage.

Figure 8: Plan 4 axial, coronal, sagittal views of the dose distribution of AP/PA/Left
Lateral/LAO/LPO plan using 6MV and beam weighting applied to each field.

Figure 9: Plan 4 DVH of the PTV coverage at 100%. The DVH shows that 18.3% of the PTV is
receiving 100% of the prescribed dose of 60Gy.
  How does field weight adjustment impact a plan?
Field weighting impacts a multifield plan by allowing the Dosimetrist to determine how much
dose each field contributes to the whole target to achieve desired dose distribution outcomes.
This technique can be used to manipulate the dose and to push and pull isodose lines or
hotspots. It can also be used for skin sparing or to lower doses to OAR. Field weighting can be a
very effective technique when targets are at unequal depths or in challenging locations
throughout the body. In the case of this project, I weighted the fields to minimize entrance
dose and to keep dose around the target conformal.

 List your final choice for field weighting on each field.

Figure 10: Field weighting for Plan 4.

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.

Figure 11: Plan 5 axial, coronal, sagittal views of the dose distribution of AP/PA/Left
Lateral/LAO/LPO plan using 6MV and weighting applied to each field. 45-degree wedges added
to the AP, LAO, LPO, and PA fields. The DVH in the upper right window for Plan 5 shows that
20% of the PTV is receiving 100% of the prescribed dose of 60Gy.

 Embed a screen capture of the beams-eye view (BEV) for each field that you used a
wedge.
Figure 12: Beams-eye view images of the AP, LAO, PA, and LPO fields after adding 45-degree
wedges to each.

 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?)
At first, I only added two wedges to the oblique fields to try and make up for the slope of the
chest-wall, but it didn’t look as good as I was hoping. I ended up adding 45-degree wedges on
the obliques, AP, and PA fields. While looking in the axial view, the wedge heels are together for
the PA and LPO fields and the wedge heels are together for the AP and LAO fields. Overall, this
change didn’t seem to push dose or move the hotspot that was already located in the PTV. The
wedges did help to minimize the streaking dose that appears to come outward were the AP,
LAO, LPO, and PA overlap. Four wedges were better than two wedges because it lowered the
max dose while also increasing the minimum dose coverage on the PTV and still maintaining
conformity of dose coverage around the PTV.

 Describe how your PTV coverage changed (relating to the 100% isodose line) with your
final wedge choice(s).
The PTV coverage didn’t have a significant change with the addition of wedges. When
comparing Plan 4 and Plan 5, the 100% isodose line looks very similar with almost identical PTV
coverage. There is a slight 1.7% increase in Plan 5 of 100% coverage to the PTV. There is a
subtle improvement in lower anterior dose in the periphery of the target. This can be seen in
the 70% isodose line (light blue) becoming more conformal to the PTV target. (See Fig. 13)
Figure 13: Side-by-side comparison axial views of Plan 4 (left) and Plan 5 (right).

Plan 6: Normalize your plan so that 95% of the PTV is receiving 100% of the prescription dose.

Figure 14: Axial, coronal, sagittal views of Plan 6 with normalization of 95% of the PTV receiving
100% of the prescription dose.
 What impact did normalization have on your final plan?
Normalizing the plan made the plan much hotter than before. The maximum dose changed
from 103.1% in Plan 5 to 112.9% in Plan 6. This is very impressive considering that only 17.2% of
the PTV in Plan 5 had 100% prescription dose and there was only 9.8% increase in the maximum
dose to reach the normalized plan of 100% prescription to cover 95% of the PTV. All the isodose
levels had to increase to reach the requested 100% prescription coverage to cover at least 95%
of the PTV. If this was an actual clinical case, I would try to lower the maximum dose to get it
below 110%.

 What is your final hotspot and where is it?

With normalization, the hotspot in Plan 6 is 112.9%. It is located within the PTV along the
inferior portion of the target. (See Fig.15)

Figure 15: Hotspot in Plan 6 with normalization. 113.4% or 6801.2 cGy.

 Are you satisfied with the location of the hotspot?

I am satisfied with the location of the hotspot because it is within the PTV target margin and it’s
within the denser tumor tissue rather than normal lung tissue. I would prefer the hotspot to be
more in the center of the target rather than the on the edge.

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 made two comparison plans using 6MV for one and 10MV for the other. Both plans were very
similar in target coverage and dose to OAR structures in the higher dose range. I chose to use
6MV for my final plan for all fields because I noticed that 6MV had lower overall dose to the
OAR structures in the low dose ranges while still delivering good PTV coverage. This difference
in the low dose range is because there is a loss of lateral electronic equilibrium and increased
peripheral scatter with higher energies due to the lower lung tissue densities.

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

Figure 16: Field weighting for Plan 7.

 Where is the region of maximum dose (“hot spot”), what is it, and is this outcome
clinically acceptable?
The hotspot is in the same place as in Plan 6. It is in the PTV and at the inferior edge of the
denser tumor tissue but appears to be right on the edge. The hotspot is 106.1% of the
prescription dose or 6364.7 cGy. I was able to lower the hotspot by 7% by using field-n-field
planning. This hotspot would be clinically acceptable for this case. Many 3D cases would be
clinically acceptable with hotspots under 110%.
Figure 17: Hotspot in Plan 7. 106.1% or 6364.7 cGy.
 Embed a screen cap of your final plan’s isodose distribution in the axial, sagittal and coronal
views.

Figure 18: Axial, coronal, sagittal views of Plan 7 using 5 fields normalized to 100% of the
prescription dose covering 95% of the PTV.

 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.

Figure 19: DVH of Plan 7 including PTV and OAR.

  Use the table below to list typical OAR, critical planning objectives, and the achieved
outcome. Please provide a reference for your planning objectives.

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

Esophagus <5 cm3 51 Gy 5cm3 = 11.9 Gy
Heart <15 cm3 60 Gy 15cm3 = 9.9 Gy
<20% of total heart vol. 40 Gy 40 Gy = <1%
Bronchus <5 cm3 60 Gy 5cm3 = 52.3 Gy
Lung Total 950cm3 <18 Gy 950cm3 = 10.1 Gy
V-20 Gy <37% V-20 GY = 18%
Spinal Canal <5 cm3 47.4 Gy 5cm3 = 9.3 Gy
Trachea <5 cm3 60 Gy 5cm3 = 10 Gy

References:

1. Khan FM. The Physics of Radiation Therapy. 4th ed. Philadelphia, PA: Wolters Kluwer;
2011.
2. Timmerman, R. A Story of Hypofractionation and the Table on the Wall. Int J Radiat
Oncol Biol Phys. 2021; 112(1), 4–21. https://doi.org/10.1016/j.ijrobp.2021.09.027