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 a bat or bowtie, as there is more dose at the entry
points and in the center, where the tumor is located.
• How much of the PTV is covered entirely by the 100% isodose line? 82%
• In your own words, summarize two advantages of using a parallel opposed plan?
(Review Khan, 5th ed., 11.5.A, Parallel Opposed Fields)
Two advantages of using a parallel opposed plan are that it is a straightforward setup that can
be easily replicated, and also minimizes the likelihood of missing the tumor, as compared to
obliquely oriented beams.
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?
The coverage of the tumor has improved, and entrance dose from the AP and PA beams has
decreased.
• How much of the PTV is covered entirely by the 100% isodose line? 83%
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?
I chose 45 and 135 degrees, just for the sake of being equidistant from the AP, Left
Lateral, and PA 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)
Due to the reduction in density as a beam permeates the lung tissue, there is an increase in
electron scatter results in a more dull dose profile. This is intensified by higher energy beams
and could result in an inadequate dose reaching the external margins of the tumor.
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 primary components of creating an acceptable treatment
plan. Utilization of this tool can result in a much more uniform dose coverage of the
tumor as well as improved sparing of proximal healthy tissues.
• 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.
I used a 60 OUT EDW on the posterior beam (coll. At 90 degrees) to direct the dose toward the
medial aspect.
I also used a 30IN wedge on the LAO (coll. At 90 degrees), which further increased the dose
deposition in the medial aspect of the patient.
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 normalization increased my max dose from 107% to 118.9%. Although the overall
coverage improved, the max dose is considered too high at my clinical site.
• What is your final hotspot and where is it?
7133.8 cGy is found at the inferior medial aspect of the PTV.
• Are you satisfied with the location of the hotspot?
Yes, the hotspot is located within the PTV, which is desired at my clinical site.
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?
6MV energies were used, as is the standard with lung treatments. Due to reduced beam
attenuation of the lung, there is the possibility of underdosing the tumor with a higher energy
beam. It is notable that we decided to remove the left lateral field in order to spare the
opposing lung from its exit dose.
• 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 max dose is 6758.7 cGy, in the inferior portion of the PTV. Although higher than the ideal,
this is a clinically acceptable outcome.
• 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
Spinal Cord Max Dose= 1461.7cGy
Max 50 Gy (full cord
section)
Liver Not assessed
Mean Liver < 32 Gy
(normal liver minus gross
disease)
Heart Mean dose < 26 Gy Mean dose = 312cGy
Healthy Lung Tissue V20=20%
Mean 20-23 Gy, V20<30%-
35%
Esophagus Mean dose < 34 Gy Not assessed
Brachial Plexus Max 66 Gy, V60 < 5% Not assessed
References:
1.Marks LB, Yorke ED, Jackson A, et al. The Use of Normal Tissue Complication Probability
(NTCP) Models in the Clinic. International journal of radiation oncology, biology, physics.
2010;76(3 0):S10-S19. doi:https://doi.org/10.1016/j.ijrobp.2009.07.1754
2. Yan M, Kong W, Kerr A, Brundage M. The radiation dose tolerance of the brachial plexus: A
systematic review and meta-analysis. Clinical and Translational Radiation Oncology.
2019;18:23-31. doi:https://doi.org/10.1016/j.ctro.2019.06.006
