Lee Culp

March 15, 2014

Planning Assignment (Lung)
Target organ(s) or tissue being treated:
Prescription:___180cGy 33fractions 5940cGy to tumor ________________
______________________________________________________________________
Organs at risk (OR) in the treatment area (list organs and desired objectives in the table below):
Organ at risk Desired objective(s) Achieved objective(s)

Heart

Cover PTV while meeting:

Yes

Rt & Lt Lung

Heart - V30 (volume of heart
getting 3000 below 30%)


Yes

Carina

Cord - 5% of cord & max dose
cannot exceed 4500


Yes

Cord

Lung - V20 (volume of lung
getting 2000 below 20%
volume of total lung)



Yes

Total Lung (minus PTV)





Contour all critical structures on the dataset. Place the isocenter in the center of the PTV (make
sure it isnt in air). Create a single AP field using the lowest photon energy in your clinic. Create
a block on the AP beam with a 1.5 cm margin around the PTV. From there, apply the following
changes (one at a time) to see how the changes affect the plan (copy and paste plans or create
separate trials for each change so you can look at all of them). Refer to Bentel, pp. 370-376 for
references:
Plan 1: Create a beam directly opposed to the original beam (PA) (assign 50/50 weighting to
each beam)
a. What does the dose distribution look like?
Hourglass shape
b. Is the PTV covered entirely by the 95% isodose line?
No, it is close but not entirely covered.
c. Where is the region of maximum dose (hot spot)? What is it?
Entrance location for PA beam and exit location for AP beam (same location) on the
posterior of the patient. It is 124.7% hot.
Plan 2: Increase the beam energy for each field to the highest photon energy available. (16x)
a. What happened to the isodose lines when you increased the beam energy?
The center of the hourglass shape is pinched together more. Cold sports in PTV have
increased with less homogeneity distribution.
b. Where is the region of maximum dose (hot spot)? Is it near the surface of the
patient? Why?
The hot spot is 120.2%, and is location at the posterior surface of the patient, where the
exit of the AP and entrance of the PA beam meet. It is not superficial, but approximately
mid way between the skin and lung. This would be because of the skin sparing of the
16X entrance AP beam and exit AP beam dose.
Plan 3: Adjust the weighting of the beams to try and decrease your hot spot.
a. What ratio of beam weighting decreases the hot spot the most?
AP: 55.4%
PA: 44.6%
b. How is the PTV coverage affected when you adjust the beam weights?
The cold spots have decreased but still coverage of the tumor is not 100%.
Plan 4: Using the highest photon energy available, add in a 3
rd
beam to the plan (maybe a
lateral or oblique) and assign it a weight of 20%
a. When you add the third beam, try to avoid the cord (if it is being treated with the
other 2 beams). How can you do that?
i. Adjust the gantry angle?
Yes - I started the 3rd beam as a lateral (90
o
) but there was too much
heart and cord dose, so I changed it to an oblique (110
o
).
ii. Tighter blocked margin along the cord?
With the change of gantry angle this is not needed to come off the cord
for this patient.
iii. Decrease the jaw along side of the cord?
With the change of gantry angle this is not needed to come off the cord
for this patient.
b. Alter the weights of the fields and see how the isodose lines change in response to
the weighting.
Adding more weight to the 3rd beam helps give a more uniform isodose
distribution, however, it does not decrease the hot spot (116.9%).
c. Would wedges help even out the dose distribution? If you think so, try inserting
one for at least one beam and watch how the isodose lines change.
A wedge in the AP field would help even the isodose distribution because it helps
even out the slope of the chest and also decreases the hot spot. For the AP field
wedge the toe would be medial and the heel lateral.

Which treatment plan covers the target the best? What is the hot spot for that plan?
I believe the 3rd plan with a wedge covers the target the best, and most uniformily. The
hot spot is at 115.4% and within subcutaneous tissues of the chest.

Did you achieve the OR constraints as listed above? List them in the table above.
Yes, see table above, and attached DVH.



What did you gain from this planning assignment?
I am learning how to plan treatments for lung patients with different beams, energies,
weighting, and including wedges where appropriate. I am learning how to critical look at
a plan to determine what needs to be changed and adjusted. Rather than when I began
my clinical and had no idea how to even add a field, or even change a name of a beam.

What will you do differently next time?
I would try to use a dogleg beam setup to come off the cord completely. It would be good to
test and see how a dogleg changes treatment, and isodose coverage using it, instead of 2 typical
beams (AP/PA). Perhaps this would help decrease toxicity from a third beam. Dogleg is a typical
lung setup here at CCWNY. I believe it would be neat to see how this would effect this treatment
plan.