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 Isodose distribution of Plan 1

Figure 2 DVH showing PTV coverage on Plan 1

  What shape does the dose distribution resemble?
The shape resembles an hourglass. There is high intensity in both anterior and posterior
soft tissue. The dose then slightly converges until it reaches the higher material density
of the tumor and the pulmonary artery and expands out slightly.
 How much of the PTV is covered entirely by the 100% isodose line?
30.3 percent 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, 5th ed., 11.5.A, Parallel Opposed Fields)
One advantage of using opposing PA and AP beams is that there is not contribution to
the contralateral lung as well as the far medial and lateral of the ipsilateral lung.
Another advantage of using this simple arrangement is the quickness of the plan for the
patient during treatment which can help the patient be more compliant.

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?
There is no prescription dose outside of the lung field causing the plan to look much more
conformal. There is no prescription dose on the medial side of the PTV due to no beams
directly contribution to the quadrant.
 How much of the PTV is covered entirely by the 100% isodose line?
The DVH shows that 61 percent of the PTV is receiving 100 percent of the dose.

Figure 3 Isodose distribution for Plan 2

Figure 4 DVH showing PTV coverage on Plan 2

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 Isodose distribution for Plan 3

Figure 6 DVH showing PTV coverage on Plan 3

 What angles did you choose and why?
The angles I picked were 45 and 135. This is due to them being directly in between 0, 90
and 180 degrees to try to minimize any specific areas where there will be unnecessary
hot spots due to excess overlap between 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)
When treating lung patients, laterally scattered electrons can fall outside of the beams
due to the low material density of the lung. This gets progressively worse as the beams
energy is increased. Also increasing the energy to the lateral and oblique beams will
cause more dose to go to the contralateral lung, which can have a negative affect on the
patient’s quality of life after treatment.

Plan 4: Alter the weights of the fields to achieve the best PTV coverage.
 How does field weight adjustment impact a plan?
Adjusting field weighting will alter the plan by evening out the dose distribution. This
can pull hot spots in one direction to allow for better coverage and a lower total hot
spot.
 List your final choice for field weighting on each field.
 Figure 7, Field weighting for Plan 4

I had larger contributions to the AP and PA beams due to not having any direct contribution the
medial portion of the PTV and these beams being the closest to this area. My direct lateral
beam is weighted slightly higher than the oblique beams to limit the amount of prescription
dose that is going anterior and posterior to the PTV.

Figure 8 Isodose distribution for Plan 4

Figure 9, DVH showing PTV coverage on 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.
 Embed a screen capture of the beams-eye view (BEV) for each field that you used a
wedge.
 Figure 10, BEV for G0 with 20 degree wedge

Figure 11, BEV for G90 with 20 degree wedge

Figure 12, BEV for G180 with 25 degree 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?)
The wedges for G0 and G180 were used to help push dose to the medial portion of the
PTV. In this area prior to the wedges there was not a lot of 100% dose in that area. The
area in the superior portion of the PTV had less dose than the inferior portion so I used a
wedge on G90 to help push the dose superiorly.
 Describe how your PTV coverage changed (relating to the 100% isodose line) with your
final wedge choice(s).
The coverage of the PTV was raised to to 58.8 percent

Figure 13, DVH showing PTV coverage for Plan 5

Figure 14 Isodose distribution for Plan 5

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?
The plan normalized down from 100% plan normalization to 93.3%. Normalizing the
plan down 6.7% caused the hot spot to rise approximately 6.7% to 112.5%. After
adjusting weighting I was able to get the hot spot to 111.5%.
 What is your final hotspot and where is it?
After adjusting weighting I was able to get the hot spot to 111.5%. The hot spot is
towards the bottom of the PTV.
 Are you satisfied with the location of the hotspot?
Yes I am, the hot spot is fairly far away from the edges of the PTV.
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 for all beams. I originally tried to use 10x for my G0 and G180 beams but the
plan was hot due to the difficulty of build up on the edges of the PTV. Switching to 6x
helped with this. I wanted to keep the lateral fields at 6x to prevent dose going into the
contralateral lung. I used this arrangement to get rid of a beam to help with patient’s
treatment time.
 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 hot spot is in the middle of the PTV and the 3D max is 114.6%. It is below 115% so it
is clinically acceptable and the fact it is in the middle of the PTV helps to due to set up
inconsistencies and patient movement.
 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.
I am using the OSU_Lung_Standard_30Fx OSU constraints for my OARs. All of my OARs
meant the constraints.

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

Spinal Cord D0.03cc < 50000 cGy 1289.6 cGy
Esophagus Mean <3400 cGy 245.7 cGy
Esophagus V6000<cGy 0%
Heart Mean < 200-3500 cGy 100.7 cGy
Heart V3000< 50% 0.019%
Lung- CTV Mean 2000-2200 cGy 904 cGy