Lung Clinical Lab 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). Create a single AP field using the lowest photon energy in your clinic. Create an MLC
block on the AP beam with a uniform 1.5 cm margin around the PTV. Apply the following
changes (one at a time) as listed in each plan exercise below. After making the adjustments
requested for each plan, answer the provided questions. Tip: Copy and paste each plan after
making the requested changes so you can compare all of them as needed.

Plan 1: Create a beam directly opposed to the original beam (PA). Assign equal (50/50)
weighting to each beam.
 What does the dose distribution look like?
Hourglass shaped, with the hottest region on the anterior and posterior lung. Lung
tissue density creates this heterogenous dose distribution.
 Is the PTV covered entirely by the 95% isodose line?
No. The lateral side of the PTV is not covered by the 95% isodose line.
 Where is the region of maximum dose (“hot spot”) and what is it?
There are hot spot at both anterior and posterior region, but more pronounced near the
posterior ribs. Being equal beam weighting of 50/50, posterior region receives more
dose due to shorter SSD compared to anterior (AP SSD 89.55 cm, PA SSD = 83.19).
Hot spot – 7006 cGy, 117% at posterior ribs.
 What do you think caused the hot spot in this location?
6MV with Dmax of 1.5cm and the PA beam travels further to the isocenter than the AP
beam produce higher dose at the skin surface, which then creates less uniform dose
distribution as a function of depth.

Plan 2: Adjust the weighting of the beams to try and decrease your “hot spot.”
 What ratio of beam weighting decreases the “hot spot” the most?
AP 53.4%, PA 46.6%
Hot spots are still seen on both anterior and posterior region, but they appear even.
Hot spot = 6857 cGy, 114%, at the anterior region because of heavier AP beam
weighting.
 How is the PTV coverage affected when you adjust the beam weights?
Adjusting the beam weights did not affect the PTV coverage that much.

Plan 3: Add a 3rd beam to the plan (a lateral or oblique) and assign it a weight of 20%. Try to
avoid the spinal cord.
 How did you decide on the location of your 3rd beam?
 The 67° LPO to avoid the spinal cord.
 Did you do anything special to avoid the spinal cord? (ie. Adjust the gantry angle, tighter
blocked margin, decrease the jaw alongside of the cord)
Adjusted the gantry angle.
 What does the dose distribution look like?
Adding the third beam changes the shape of the dose distribution from hourglass
shaped to an irregular square-shaped. The dose distribution became more conformal
around the PTV.
 Is the PTV covered entirely by the 95% isodose line?
No. The 95% isodose line does not cover the superior, lateral and inferior portion of the
PTV.
 Where is the region of maximum dose (“hot spot”) and what is it?
Hot spot = 6251 cGy, 104%, located in the center of PTV.
 What do you think caused the hot spot in this location?
The addition of LPO beam causes isodose build-up around the PTV.

Plan 4: Alter the weights of the fields and see how the isodose lines change in response to the
weighting.
 Describe the ideal beam weighting to achieve the best PTV coverage.
AP 42.20%, PA 39.63%, LPO 18.17%
 Where is the region of maximum dose (“hot spot”) and what is it?
Hot spot = 6223 cGy, 104%, located in the center of PTV.
 What do you think caused the hot spot in this location?
The LPO beam.

Plan 5: Try inserting wedges for at least one or more beams to improve PTV coverage.
 List the wedge(s) used and the orientation in relation to the patient.
30° wedge, the heel on the cephalic position on the LPO beam
 Describe how the isodose lines changed.
The addition of 30° wedge altered the PTV coverage slightly.
 Where is the region of maximum dose (“hot spot”) and what is it?
Hot spot = 6238 cGy, 104%, located in the center of PTV.
 What do you think caused the hot spot in this location?
LPO beam. By applying a wedge in cephalic position, the hot spot shifted slightly toward
the heel of the wedge.

Plan 6: At this point you may adjust the beam energy, beam weighting, and/or wedges to achieve the
best PTV coverage. Once you have obtained the best plan possible, normalize your final plan so
that 95% of the PTV is receiving 100% of the dose.
  What energy(ies) did you use and why?
All three beams used 6 MV because lung tissue is less dense and filled with air. I also
used:
AP: EDW 25 Collimator 275
PA: EDW 20 Collimator 270
LPO: EDW 45 Collimator 90

I used EDW on all three beams so that the PTV is covered by the 95% isodose line.
 What is the final weighting of your plan?
AP 37.98%, PA 37.00%, LPO 25.02%
 Where is the region of maximum dose (“hot spot”) and what is it?
Hot spot = 6727 cGy, 112%, located within the PTV.
 What do you think caused the hot spot in this location?
All the three beams intersected at this point.
 What impact did you see after normalization? Why?
Dmax increases, from 6238 cGy to 6727 cGy
 Embed a screen cap of your final plan’s isodose distribution in the axial, sagittal and
coronal views. Show the PTV and any OAR’s.
 If this patient is treated to 60 Gy, use the table below to list typical organs at risk, 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 References
Total Lung – ITV Mean <20-23 Gy 1252 cGy QUANTEC
V20 <30-35% 4056 cGy
Left Lung V20 <= 30% 3786 cGy QUANTEC
Heart V25 <10% 0.2 Gy QUANTEC
Spinal Cord Max dose 50 Gy 5.28 Gy QUANTEC
Esophagus Mean <34 Gy 2.02 Gy QUANTEC

 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.