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 distribution resembles an hourglass. This is because of the differences in
density between bony anatomy and the air in the lung or heterogeneity of the tissues.
The hourglass appears in purple color (90% isodose line). The hotspot is around
116.3% (6983 cGy)
 How much of the PTV is covered entirely by the 100% isodose line?
About 30% of the PTV is covered by 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)
1) A parallel opposed plan is simple and quick in both planning and setup, easy to
reproduce. With only two treatment fields, less treatment time, less movement of
gantry, collimator therefore reduces the chance of mistake(s) during treatment.
2) Homogenous dose to the tumor: the fields are parallel and equally weighed.
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?
With the Left Lateral added, the isodose distribution becomes more conformal to the
target. It helps reduce dose to the normal tissue in the left lung; however now there is
an exiting dose to the Right lung.

 How much of the PTV is covered entirely by the 100% isodose line?
About 51% of the PTV is covered by 100% isodose line.
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?

The LAO is at 35 degree gantry angle. I chose this angle because I want to try to avoid
placing dose in the Right Lung while trying to avoid the heart also. However, the beam
goes through the spinal cord (the only beam).

The LPO is at 155 degree gantry angle. I chose this angle because I want to try to avoid
giving dose in the Right Lung and limiting dose to the heart.
  In your own words, summarize why beam energy is an important consideration for lung
treatments? (Review Khan, 5th ed., 12.5.B3, Lung Tissue)
There are different tissue densities within the lung treatment area. The density inside
the lungs is lower compared to other tissues like fat, muscle, bone etc. According to
Khan, Higher energy decreases in ionization interactions in the lower density and have
less scatter in higher density tissue.1 With higher energies, as the radiation travel
through lung tissue, it will have a decrease in interaction due to the low level of
density, less interaction-> less scatter-> less dose.

Plan 4: Alter the weights of the fields to achieve the best PTV coverage.
 How does field weight adjustment impact a plan?
Field weighting is one of the fundamental methods to manipulate dose conformality
as well as reduce dose to normal tissue surrounding the target. Weighting can also be
used to move or reduce hotspot.
 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?)

I use wedges in three of the fields (LAO, LPO, LLAT). The orientations are as shown on
the picture. With LAO 45 degree with toe toward midline and anterior, LPO 45 degree
with toe toward midline and posterior, and LLAT 30 degree with toe toward posterior.
 The wedges help push the dose to where it is lacking and in the toe direction like
expected. Having the wedges also move and reduce the hotspot.
 Describe how your PTV coverage changed (relating to the 100% isodose line) with your
final wedge choice(s).

About 50% of the PTV is covered by 100% isodose line compared to about 43% of the
PTV is covered by 100% isodose line when wedges weren’t used. The Isodose lines
from 90% to 100% become more conformal to the PTV and reduce the hotspot to
104.1% instead of 104.9%

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?
Normalization scales the dose distribution from one level to another. After
normalization, 95% of the PTV is receiving 100% of the prescription dose; the hotspot
increases from 104.1% to 114.4%.
 What is your final hotspot and where is it?
The final hotspot is 114.4% and located in the PTV.
  Are you satisfied with the location of the hotspot?
Yes, because it is within the PTV and not the OARs or normal tissue.

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 use 6MV because the higher energies 10Mv or 15MV will be affected by the
inhomogeneity of lung tissue and high energy might also produce neutron
contamination. I use the same fields arrangement with the same wedges and
weighting as plan 6; however, for AP and PA I use Field in field to help cool the plan
and the hotspot.

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

 Where is the region of maximum dose (“hot spot”), what is it, and is this outcome
clinically acceptable?
The hotspot is 112.8% (6769 cGy) which is acceptable for a 3D conformal plan, the
hotspot is also within the PTV and iTV. The hotspot clinically prefers to be located in
the PTV.

 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.

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

Esophagus2 V35Gy < 50% V35=0%, Max≈2065 cGy (pass)

Heart2 V25Gy < 10% V25≈0%(pass)

Lungs2 V20G < 35-37% V20≈18% (pass)
Primary Bronchus2 Max < 80Gy Max dose =6548cGy (pass)
Spinal Canal2 Max < 45 Gy Max dose =1202cGy (pass)
 Reference

1. Khan FM, Gibson JP. The Physics of Radiation Therapy. 6th ed. Philadelphia, PA: Lippincott
Williams and Wilkins; 2020
2. RadiationOncology/Toxicity/QUANTEC. Wikibooks.
http://enwikibooks.org/wiki/Radiation_Oncology/Toxicity/QUANTEC. Accessed March 27, 2023.