Kearla Bentz Lung Clinical Lab 1

Lung Clinical Lab Assignment

*Prescription: 60 Gy in 30 Fractions to PTV

*Plan 1: 6MV (AP/PA) 50/50 Weighting

1. What shape does the dose distribution resemble?

The dose distribution in this AP/PA plan resembles an hour glass. It is fairly columnar
shaped but the 80-95% (48-57 Gy) isodose lines are concave in the lung. This creates wider areas
of increased dose on the anterior and posterior ends with a thinner area of dose in the lung. There
is also a somewhat circular shape of dose around the PTV in the middle of the beams.
2. How much of the PTV is covered by the 100% isodose line?
There is only 29.1% of the PTV is receiving the prescription dose of 60 Gy in this AP/PA
6 MV plan. There are also areas of dose greater than the prescription on both the anterior and
posterior surfaces where the beams enter.
3. What are two advantages of using a parallel opposed plan?
One advantage of parallel opposed plans is that they are simple to set up and
reproducible. They also provide a homogenous dose to the tumor with little chance of a
geometric miss if the field size is large enough to cover the lateral aspects of the tumor volume.1

*Plan 2: 6MV (AP, PA & L Lat) Equal Weighting

1. How much of the PTV is covered by the 100% isodose line?

In this plan using 6 MV and three fields (AP, PA, and L Lat) equally weighted, 46.86%
of the PTV is receiving the prescription dose of 60 Gy. The prescription isodose line is now
Kearla Bentz Lung Clinical Lab 2

around the PTV and is no longer present in the anterior and posterior tissue like it was in the
AP/PA plan. Additionally, there are now only areas of 50-70% (30-42 Gy) dose in the superficial
tissues where the beams enter.

*Plan 3: 6MV (AP, PA, L Lat, A45L, P45L), Equal Weighting

1. What angles were chosen?

I chose 45 degree angles because the PTV is fairly circular in shape. I thought that the 45
degree angles would help conform the dose around the PTV by using the jaws of each field to
shape the isodose lines. Arranging the beams at 45 degree angles did move the esophagus, heart,
and spinal canal into the field on the oblique beams, but I verified that the organs were still well
within typical dose constraints.
2. Why is beam energy an important consideration for lung treatments?
Beam energy is important to consider in lung treatments because of the low density of the
lungs. The low density of the lung in conjunction with high-energy photon beams can cause
increased dose within and past the lung. When high-energy photon beams cross the lungs, more
electrons are able to go further than the geometric limits of the beam, which causes loss of
sharpness. There is also a loss of lateral electronic equilibrium with high-energy beams which
reduces the dose on the beam axis. These effects are exaggerated with smaller field sizes (<6cm
x 6cm2) and higher energies (>6MV) and can result in under dosage to the periphery of the
tumor.1

*Plan 4: 6MV (AP, PA, L Lat, A45L, P45L), Altered Weighting

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1. How do field-weight adjustments impact a plan?

Adjusting field weights alters the percent contribution of that field to the plan. If a field
weight is increased, it will contribute an increased percentage of the dose, and if it is decreased it
will contribute less. Increasing a field’s contribution pulls the isodose lines in the direction of the
beam origin because the other fields contribution is simultaneously being decreased. Too much
weight of a specific field can cause areas of increased dose towards that beam’s entry.
2. What is the final choice for field weighting on each field?
I chose to weight the plan almost equally between the five fields. The AP beam I
weighted at 23.8%, the P45L at 21.5%, the L Lateral at 20.7%, the PA at 19.5%, and the A45L at
14.5%. I thought this arrangement offered the most conformal coverage. I tried different
arrangements of weighting, but I liked this one the most because there was not a lot of 50% dose
in the skin at any beam entrance and the 95% isodose line covered the PTV the best.

*Plan 5: 6MV (AP, PA, L Lat, A45L, P45L), Weighting, Wedges

BEVs for each field

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1. What wedge(s) were used, the orientation in relation to the patient, and the purpose?
I used two 20-degree wedges and a 45-degree wedge on this plan to push dose to the
medial and superior aspects of the PTV and remove the areas of 105% dose on the lateral side of
the PTV. The 20-degree wedges were added to the AP and PA beams with the heels toward the
patient’s left side and the toes pointing medially. I noticed that the addition of these wedges
removed the lateral hot spots and adjusted the dose more medially. This helped reduce dose into
the lung laterally outside the PTV and helped cover the PTV medially. The 45-degree wedge on
the lateral beam was positioned with the heel towards the patient’s feet (inferiorly) and the toe
pointing to the patient’s head (superiorly). This wedge was placed to help push the abundance of
dose on the inferior PTV superiorly where dose was missing.
2. How did the PTV coverage change (100% isodose line) w/ final wedge choice(s)?
There is now about 43% of the PTV receiving 60 Gy. The wedges helped to remove
prescription dose extending laterally past the PTV and pushed prescription dose medially and
superiorly where it was missing.

*Plan 6: 6MV (AP, PA, L Lat, A45L, P45L), Weighting, Wedges, Normalized

1. What impact did normalization have on the final plan?

Normalizing the plan so that 95% of the PTV is receiving 60 Gy caused an increased in
dose and hot spots. The prescription isodose line is now almost completely encompassing the
PTV. There are now areas of dose above the prescription and the 50% dose has increased in the
surrounding lung and skin, with a couple areas of 70% dose appearing outside the lung in tissue.
2. What is the final hotspot and where is it?
The final hot spot is 113.1% (6785.1 cGy) and it is located on the anterior and lateral side
of the PTV about midway between the superior and inferior borders. There is also a large spot of
110% dose inside the PTV surrounding the lateral, superior, and inferior borders. Also, there is
105% dose almost completely covering the PTV with extension laterally and inferiorly outside
the PTV.
Kearla Bentz Lung Clinical Lab 5

3. Is the hotspot in a satisfactory location?

The area of 110-113% dose is inside the ITV and is in a satisfactory location. Although,
the area 105% dose is very large and extends outside the PTV. I would work on reducing the
max dose and the cloud of 105% dose so that it is not so large and no longer appears outside the
PTV in the surrounding tissues if possible.

*Plan 7: 6MV, 7-Field, Wedged, Weighted, EZ-Fluence, Normalized

1. What energy(ies) were used?
For this lab I only used 6MV beams. The reason for this is because it is clinic policy at my
location that all lung treatments be treated with the lowest energy beam (6MV). This is due to the
interactions that occur with high energy photon beams and lung tissue. It is also necessary to use Acuros
instead of AAA at my clinical site because it visually demonstrates a more realistic interaction of photons
and the isodose lines in lung tissue.
2. What was the final weighting of each field in the plan?

3. Where is the region of maximum dose? What is it, and is it acceptable?

The maximum dose in this plan is 108.6% of the prescription (6513.6 cGy). It is mainly located
on the lateral side of the PTV, with just a little hanging out laterally past the margin of the PTV. This
would be acceptable plan because the prescription conforms to the PTV very well, and the area of
increased dose (>105%) is primarily in the PTV and ITV and not in other OAR. Although, there is one
spot of 105% dose that is touching the primary bronchus, but this spot is within the ITV. Typically, at my
clinical site they look for plans with 105-108% dose maximum, but to reduce the hot spot the dose to the
PTV (95% getting 60 Gy) becomes compromised.
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Organ at Risk (OAR) Desired Planning Outcome Planning Objective Outcome

PTV_Lung D95 > 6000 cGy2 6000.22 cGy
SpinalCanal D0.03cc < 5000 cGy 2
2374.79 cGy
Lungs V5 Gy < 65%2 32.47%
Lungs V20 Gy < 30%2 17.81%
Esophagus V35 Gy < 50% 2
0.0%
Esophagus V60 Gy < 20%2 0.0%
Heart D0.03cc < 7000 cGy2 2211.20 cGy
Heart V30 Gy < 50%2 0.0%
Heart V45 Gy < 35%2 0.0%
SpinalCanal D5.00cc < 4740cGy3 2123.03 cGy
Esophagus D5.00cc < 5100 cGy3 1646.14 cGy
Heart D20 < 4000 cGy 3
111.38 cGy
Heart D15.00cc < 6000 cGy3 823.85 cGy
Primary Bronchus D5.00cc < 6000 cGy3 4279.43 cGy
Total Lung-ITV D950.00cc < 1800 cGy3 1010.20 cGy
Total Lung-ITV V20 Gy < 37%3 17.81%
PTV_Lung Max dose < 6600 cGy* 6513.6 cGy
PTV_Lung Max dose <7200 cGy2 6513.6 cGy
Lungs Mean dose < 2000 cGy 2
878.3 cGy
Esophagus Mean dose < 3400 cGy2 397.5 cGy
Heart Mean dose < 1000 cGy* 110.3 cGy
SpinalCanal Max dose < 5280 cGy 3
2407.8 cGy
Esophagus Max dose < 6000 cGy3 1906.2 cGy
Heart Max dose < 6800 cGy3 2596.8 cGy
Primary Bronchus Max dose < 6900 cGy3 6343.1 cGy
* These are per my clinical site, physician preference on maximum dose and heart mean dose allowed.

References
1. Gibbons JP. Khan’s the Physics of Radiation Therapy. 6th ed. Wolters Kluwer Health: 2020.
2. RTOG. RTOG 3505: randomized, double blinded phase III trial of cisplatin and etoposide plus thoracic
radiation therapy followed by nivolumab/placebo for locally advance non-small cell lung cancer.
https://clinicaltrials.gov/ProvidedDocs/58/NCT02768558/Prot_SAP_000.pdf. Revised January 30, 2017.
Effective February 22, 2017. Accessed March 18, 2023.
3. Timmerman R. A story of hypofractionation and the table on the wall. Int J Radiation Oncol Biol Phys.
2021; 112(1): 4-21. https:/doi.org/10.1016/j.ijrobp.2021.09.027.