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?
o The dose distribution resembles an hour glass shape, and moving more laterally
the 70% isodose line is shaped more like a rectangle.
How much of the PTV is covered entirely by the 100% isodose line?
o A very small percentage of the PTV is covered by the 100% line, and by looking at
the DVH only 7.7% of the PTV is receiving 100% of the prescription dose.
In your own words, summarize two advantages of using a parallel opposed plan?
(Review Khan, 5th ed., 11.5.A, Parallel Opposed Fields)
o Some advantages of using a parallel opposed plan is the simplicity and
reproducibility of the setup. This technique gives a lot of dose to healthy tissue
around the tumor but there is an advantage within the homogenous dose
distribution to the tumor. The uniformity of the dose distribution within the PTV
is dependent on beam energy, patient thickness, and beam flatness. Parallel
opposed plans are easy to do quickly in case of an emergency.
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?
o The distribution changed from an hourglass shape to more of a box with the
addition of the left lateral field. With the AP/PA arrangement there was higher
dose concentration in soft tissue close to beam entry for both of those fields.
With the addition of the lateral and equal weighting to all 3 beams, the dose at
the entry of PA/AP beams have dropped from doses of 115% or 110%, to 70%.
The 90% isodose line is covering the PTV and is more conformal to the PTV
instead of being drawn out into healthy tissue like in the AP/PA plan. The 98%
isodose line moved to be more central within the PTV and is covering slightly
more with this plan.
How much of the PTV is covered entirely by the 100% isodose line?
o 8.95% of the PTV is covered by the 100% isodose line. This is a small increase in
coverage from the AP/PA plan.
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?
o I chose to add an LAO and LPO to the plan. I chose these fields because they
were directly between the other fields (AP-LT, and LT-PA), and I thought these
fields would give better coverage to the PTV, a more even coverage, and
minimize the hot spots from overlapping of my existing fields.
In your own words, summarize why beam energy is an important consideration for lung
treatments? (Review Khan, 5th ed., 12.5.B3, Lung Tissue)
o Beam energy for lung treatments is important because of the effect of tissue
inhomogeneities. The density of the tissue in the lung is low and because of this
there is higher dose regions within and beyond the lung. The tumor within lung
tissue is more effected by scatter, and regions beyond the tumor are effected by
the primary beam.
Plan 4: Alter the weights of the fields to achieve the best PTV coverage.
How does field weight adjustment impact a plan?
o Changing the weighting of the fields helped to eliminate unwanted dose outside
of the PTV and gain better coverage on my PTV. Changing the field weight can
allow more coverage to your PTV, allow an OAR to receive less dose, or make
your coverage more uniform. Manually changing your fields weighting can shift
isodose lines to or away from structures depending on what your planning goal
is.
List your final choice for field weighting on each field.
o AP: 25.6%
o LAO: 11.4%
o LT LAT: 22.3%
o LPO: 15.2%
o PA: 25.6%
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?)
o AP: I used a 30 degree wedge with the heel of the wedge facing lateral to the
patient and the toe medial, toe towards the sternum. This wedge eliminated
dose from overlap between the AP and LAO field. It also helped push dose
medially to where I needed more coverage.
o PA: I used a 30 degree wedge with the heel of the wedge facing lateral to the
patient and the toe medial, toe towards the sternum. This wedge eliminated
dose from overlap between the PA and LPO field. It also helped push dose
medially to where I needed more coverage.
o LPO: I used a 15 degree wedge with the heel of the wedge facing posterior to the
patient and the toe more lateral. This wedge eliminated dose from overlap
between the PA and LPO field.
o LAO: I used a 15 degree wedge with the heel of the wedge facing medial to the
patient and the toe laterally. This wedge eliminated dose from overlap between
the AP and LAO field. It also helped push dose medially where the coverage was
not as good.
Describe how your PTV coverage changed (relating to the 100% isodose line) with your
final wedge choice(s).
o Before I amended the plan with wedges only 70.9% of the PTV was being
covered by 100% of the prescription dose. After I utilized the wedges, 72.6% my
PTV is covered with 100% of the prescription dose. The wedges helped me
eliminate the overlap dose in the soft tissue in the chest wall from field overlap,
and my plan with the wedges has a more even distribution. The heels of the AP
and PA wedges helped me push dose towards the medial side of the PTV,
allowing me better coverage.
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?
o To be expected, normalization heated up the plan. Before normalizing my max
dose was 108.4%, and after it was 112.9%. After normalizing, the 100% isodose
line now covers the PTV where before it was not covering as well. The 105%
isodose line now covers most of the PTV where before it was not.
What is your final hotspot and where is it?
o My final hot spot was 112.9%, located in the center of the PTV. Anatomically the
max dose is located to the left and slightly inferior of the carina, within the
tumor in the left lung.
Are you satisfied with the location of the hotspot?
o I am. I would prefer the hot spot at least be within the PTV instead of healthy
tissue outside of the treatment area. If the plan is meant to be ablative, then
that is a perfect spot for the max dose.
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?
o I used 6X for all beams. I believed this would allow for the best coverage. With
my preceptor, we chose to use conformal dynamic arcs. We utilize this technique
at clinic a lot for 3D cases because it gives great conformality without using
IMRT. I used an AP/PA field as well with 15 degree wedges on both to even out
the distribution and eliminate hot spots. I ran my plan with all 15X to see the
difference, and there was not a large difference in coverage or distribution. The
OARs had higher max and mean doses.
What is the final weighting of each field in the plan?
o AP: 16.7%
o PA: 16.7%
o CDA 1: 33.3%
o CDA 2: 33.3%
Where is the region of maximum dose (“hot spot”), what is it, and is this outcome
clinically acceptable?
o The max dose is 116.2%, or 6974 cGy. The hot spot is located within the PTV.
Anatomically this max dose is located anterior and to the left of the carina, and
left of the primary bronchus. The location of the hot spot being within the PTV is
acceptable, but I think our physicians would say 116% is a little too hot and ask
me to cool it off a little bit. I would do that by changing the normalization since I
think the field arrangements and distribution is clinically acceptable. If the goal
of the treatment was ablative, then it would be found clinically acceptable
according to our physician.
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. Please provide a reference for your planning objectives.
Organ at Risk (OAR) Desired Planning Objective Planning Objective Outcome
Spinal Cord D.03cc max < 50Gy D.03cc max=9.5Gy
Heart V50 < 25% V50=0%
V30 < 50% V30= 0%
Mean <20Gy Mean= 9.6Gy
D.03cc max < 75 Gy D.03cc max= 17Gy
Esophagus Dmean < 34 Gy Dmean= 2.9Gy
D2cc < 68 Gy D2cc= 12.5Gy
Total Lung V20 < 35% V20= 15.9%
V5 < 65% V5= 28%
Vmean< 20Gy Vmean= 8.5Gy
Reference:
My clinical site uses RTOG 0623 protocols for our thorax constraints and planning objectives.
1. Radiation Therapy Oncology Group . RTOG protocol table
[Internet] Philadelphia, PA: Radiation Therapy Oncology Group; c2016 [cited
2024 Mar 18]. Available
from: http://www.rtog.org/ClinicalTrials/ProtocolTable.aspx. [Google
Scholar]
