Plan 1 6x: 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 looks like an hourglass axially due to the tissue inhomogeneity
from soft tissue, muscle, bone and the lung tissue. The beams deposit higher dose to the tissue upon entry and the dose gradient that is
created provides dose to the tumor. There is higher dose being deposited upon entry and to the tumor area versus the lung tissue. This
occurs because the lung tissue has an inhomogeneity value of 0.3, which alters the dose distribution due to loss of electronic equilibrium.
Dose is attenuated upon entry into the soft tissue due to the 1.0 inhomogeneity value and then again at the tumor.
 How much of the PTV is covered entirely by the 100% isodose line? 6.5% 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, 5 th ed., 11.5.A, Parallel Opposed Fields)
There is a homogenous dose coverage to the tumor because of the conformity or dose gradient that is created with parallel opposed
beams.1 This is because the two beams intersect one another eliminating fall off. The field size should be large enough so the lateral portion
of the tumor is not missed. If the field size is right, with parallel opposed fields, there is less chance of missing the tumor during treatment. 1
The other advantage is a reproducible setup that is simple for the patient.

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Plan 2 6x: 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?
 How much of the PTV is covered entirely by the 100% isodose line? 16% of the PTV is now covered. This additional field allowed me to take
dose and weight away from the AP/PA. When more field angles are added and weight is pulled, the dose can be distributed from more
angles reducing the surface dose.
 How did this field addition change the isodose distribution? This changes the isodose distribution by reducing surface and entry dose and
providing more coverage to the PTV.

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Plan 3 6x: 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 45 and 135 so the angles are evenly all 45 degrees apart to provide equal coverage around
the PTV. I added the angles only to the left side of the patient where the tumor is located because it is not justifiable to come from the right
side. If dose was coming from the right, unaffected organs would now be irradiated such as the right lung, esophagus, trachea, and more of
the heart. Yes, there is some exit dose from the current beam arrangement, but it is not contributing the excessive unnecessary amount of
dose that would occur if the beams came from the patient’s right/unaffected side.
 In your own words, summarize why beam energy is an important consideration for lung treatments? (Review Khan, 5 th ed., 12.5.B3, Lung
Tissue)
Beam energy is important to consider for lung treatment because in and around air cavities such as lung tissue, electronic equilibrium can be lost.
This means the dose is lost. Scatter increases with increased beam energy and so with a lower energy, we get more dose to the target and less dose
to the lungs. The maximum dose is obtained when electron equilibrium is reached. Lungs have a low density and when dose is calculated here,
there are deviations.

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Plan 4 6x: Alter the weights of the fields to achieve the best PTV coverage.
 How does field weight adjustment impact a plan? Field weight shifts the dose coverage around the PTV. More weight equals more dose
from that beam angle. As weights are adjusting so are the isodose lines. More weight provides more coverage from that particular beam.
 List your final choice for field weighting on each field. I notice minor changes to the coverage as the plan is currently. There is less surface
dose now.
My final weights are:

This allowed me to get as close to an evenly distributed amount of coverage as possible

around the PTV.

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Plan 5, 6x, with wedge: 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?) To decide where to place a wedge, I looked at the patient’s anatomy. Wedges can be used to compensate for tissue
differences. I used a 45 degree wedge in the AP field. The AP field is weighted the heaviest. The heel of the wedge is superior and the toe
inferior due to the patient’s surface anatomy as seen above. I wanted more dose attenuated at the thicker part of the wedge where the
patient has less surface/skin present. This allows the dose to be distributed more evenly. This angle increased the dose coverage of the PTV
but also increased the hot spot. I tested wedges from 15-25 degrees and they did not provide an increase in coverage.

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 Describe how your PTV coverage changed (relating to the 100% isodose line) with your final wedge choice(s). The PTV coverage is now at
28.5% versus 14% without tx

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Plan 6, 6x, with wedge: 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? The PTV is now covered with 100% of the dose. But the plan is hot with a dose
max. of 128.8% (77.3Gy).
 What is your final hotspot and where is it? My hotspot is 77.3Gy within the PTV volume. It is slightly inferior and posterior within the PTV.
 Are you satisfied with the location of the hotspot? Yes because it is in my PTV. It is preferred to have the hotpost located here instead of
within a critical structure or OAR. If a critical structure is overdosed this will cause long term negative effects, possible lack of function and
even death depending on the structure.

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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 used 6x because I was able to spare skin and entry dose by using the three fields. I was also able
to provide coverage to the tumor. I did try 10x and the difference in coverage and dose to organs at risk were minimally changed. I did learn
6x is preferred over higher energies for multiple reasons. Lung tissue has a low density and high energy beams interact with low densities
such as air or lung tissue, electronic equilibrium is lost, specifically laterally due to an increase in penumbra width. 2
 What is the final weighting of each field in the plan? The final weighting is shown below. The PA field is weighted the most. I started with
all the fields at equal weighting and then added my FiF to the left lateral field. I chose this field to have FiF because my coverage of the PTV
was less effected. I started to lose coverage because of the FiF and I had to adjust the weight from the PA field to enhance my coverage
more and to make sure the dose was being distributed as equal as possible. Adding the left lateral field cooled off the surface dose because
dose is now distributed more. Having parallel opposed fields only created a dose gradient.

AP=27.8%, PA=33%,LT LAT=30.3%

 Where is the region of maximum dose (“hot spot”), what is it, and is this outcome clinically acceptable? Technically a hot spot is an area
outside of the target that receives a higher dose that the specified target dose.1 In this case the hot spot is located within the posterior
portion of the PTV at 66.5 Gy or 110.8%. The hot spot located in the PTV is acceptable because in this case critical structures and OAR are
not affected by overdosing. Clinically we would like the hot spot under 110%. However, if I try to reduce the hot spot any more in this case, I
lose coverage to the PTV.

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 Embed a screen cap of your final plan’s isodose distribution in the axial, sagittal and coronal views.

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 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.

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  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

Left Lung Mean ≤ 8Gy

Right Lung Mean ≤ 8Gy

Heart Mean ≤ 20-31Gy &

V40Gy ≤ 40%

Spinal Cord Max ≤ 45-47Gy

Esophagus Max ≤ 63Gy &

Mean ≤ 30Gy

Total Lung-ITV

Per Orlando Health Cancer Institute templates based from TG and RTOG constraints.
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 References

1. Gibbons, J. Khan’s the Physics of Radiation Therapy. Wolter Kluwer. 2020.

2. Wang, L., Yorke, E., Desobry, G., Chui, C. 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 Winter;3(1):51-9. doi: 10.1120/jacmp.v3i1.2592

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