Planning Assignment (Lung)

Target organ(s) or tissue being treated: GTV/PTV in Rt Lung

Prescription:__200cGy, 33fxn for total of 6600cGy_________________________________
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)
Cord

1/3 of organ - 5,000cGy 33% = 142 cGy
Heart

1/3 6000cGy 33% = 2374 cGy
Lt Lung 1/3 4500cGy 33% = 552 cGy
Esophagus 1/3 6000cGy 33% = 1185 cGy

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?
Dose is hot anterior and posterior of PTV near surface of patient, and also more
laterally to the PTV where there is more air in the field
b. Is the PTV covered entirely by the 95% isodose line?
No
c. Where is the region of maximum dose (hot spot)? What is it?
Anterior part of the chest at the thickest part of the patient (where chest slopes up)
160.3%

Plan 2: Increase the beam energy for each field to the highest photon energy available.
a. What happened to the isodose lines when you increased the beam energy?
The dose is higher more centrally (hot spots are extended so the previous ant and post
hot areas are nearly meeting). The dose is still high where the field includes more air.
b. Where is the region of maximum dose (hot spot)? Is it near the surface of the
patient? Why?
The hottest part has a max of 129.7%. This is near the surface of the patient
anteriorly. This hot spot occurs with the high beam energy traveling through a thicker
part of the patient (this hot spot occurs posteriorly to the peak of the slope on the
patients chest) when dose needs to reach a more central part of the patient.
Compared to the plan using a lower energy however, the hot spot is located slightly
deeper because of the difference of the dmax of the energies (higher the energy,
deeper the dmax).
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?
41.3% from AP, 58.2% from PA
b. How is the PTV coverage affected when you adjust the beam weights?
The hot spots that were extended centrally now move back to be primarily in the
ANT/POST directions depending on which field is weighted more. The isodose curves
follow this dose distribution. PTV coverage by the 100% line breaks up and dose
moves more anteriorly.
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? First tried 215 degrees, then tried 240 degrees
ii. Tighter blocked margin along the cord Used 1cm margin along the side
of spinal cord
iii. Decrease the jaw along the side of the cord Brought jaws in to meet
block
b. Alter the weights of the fields and see how the isodose lines change in response to
the weighting. By weighting RPO field to ~25%, the anterior hot spot is decreased
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.
I added several wedges to PA field and it reduced the hot spot posteriorly, but as
wedge angle increased, a hot spot anteriorly was added again. At this point, I
decided a larger gantry angle was needed so the fields did not overlap too much
anteriorly.

Which treatment plan covers the target the best? What is the hot spot for that plan?

A three field technique with a larger gantry angle works best. There was almost no
overlap of the PA and RPO beams anteriorly when the angle was adjusted, allowing for a
larger wedge on the PA field which reduced the posterior hot spot effectively.

Did you achieve the OR constraints as listed above? List them in the table above.
Yes
What did you gain from this planning assignment?
It was interesting to see how the air in the lung volume affected the dose distribution and
isodose curves so drastically. The slope of a persons chest will also help decide if a
wedge would be helpful in creating the plan.

What will you do differently next time?
Most of the physicians here typically use 6X for the treatment of lung or chest volumes. I
think next time I would start with 3 fields right away (AP/PA and an off axis beam) and
use the lower energy. We also tried normalizing a three field plan and that also helped
coverage of the GTV with the 100% isodose line. Our goal was to have the PTV covered by
95%, and the GTV by 100%. Having a lower energy but normalizing to increase dose was
very effective.