Jenna Payne

UWLAX Lung Lab

Plan 1: 6MV – AP/PA Parallel Opposed

Figure 1.1. Plan 1 – 6 MV Parallel Opposed AP/PA Beams

1. What shape does the dose distribution resemble?

The dose distribution in this plan resembles the shape of an hourglass (Figure 1.1). The
isodose lines are wider at each beam’s entrance point, then narrow as they near the tumor in
the left lung. The isodose lines representing 50-80% of the prescription (Rx) dose (30-48Gy)
maintain more of a column shape rather than narrowing with depth. This shape is due to the
vast difference in density of the tissue that the beams must traverse as they travel through
lung (air), bone, and soft tissue prior to reaching the target. The lack of dose buildup in the
lung also causes hotspots (60Gy+) to occur in the soft tissue/bones at the beam entrance sites.
This plan’s hotspot is in the posterior soft tissue and is 114.6% of the Rx dose (6875.4cGy).

2. How much of the PTV is covered entirely by the 100% isodose line?
The DVH for this AP/PA plan shows that only 7.8% of the PTV is receiving the Rx dose of
60Gy (Figure 1.2).

3. In your own words, summarize two advantages of using a parallel opposed plan?
(Review Khan, 5th ed., 11.5.A, Parallel Opposed Fields)
The use of parallel opposed fields in RT is the simplest technique for combining beams,
which results in favorable reproducibility of the treatment setup. This is advantageous
because reducing setup/treatment complexity helps minimize errors that may occur and can
reduce the time a patient spends on the table. Another benefit of parallel opposed beams is
the improved homogeneity of the dose distribution surrounding the target because there are
 two beams contributing dose opposite one another. Field weighting can also be applied to
these beams to adjust the contribution from each, further improving target coverage.

Figure 1.2. Plan 1 – DVH

PTV

7.82%

6000cGy

Plan 2: 6MV – AP/PA/LL

Figure 2.1. Plan 2 – 6 MV AP/PA/LLat
1. How did this field addition change the isodose distribution?
Adding in a left lateral field pulled the isodose curves toward the PTV, increasing Rx
coverage (Figure 2.1). This third beam also removed the high dose regions greater than 70%
(4200cGy) that were previously being deposited superficially from the AP and PA beams.
The max dose point decreased significantly in this plan as well, down to 103.2% of the Rx
dose (6191.3cGy) and moved to within the PTV.

2. How much of the PTV is covered entirely by the 100% isodose line?
There is now 18.8% of the PTV being covered by the prescribed dose of 60Gy (Figure 2.2).

Figure 2.2. Plan 2 – DVH

PTV

18.8%

6000cGy
 Plan 3: 6MV – 5 Field (equal weighting)
Figure 3.1. Plan 3 – 6 MV, 5 Field

1. What angles did you choose and why?

I initially chose to add oblique beams equidistant from the previous beams, so the LAO at
45° and the LPO at 135°. The isodose curves were still reaching away from the target in the
AP/PA directions the most, so I decided to try different angles. I changed the LAO to 60° and
the LPO to 120°. This improved Rx coverage from 19% to 21.3% of PTV and the dose
distribution also began to better conform around the PTV. However, I did notice this change
caused an increase in OAR dose. I decided to split the options I had already tried and chose
angles of 50° for the LAO beam and 130° for the LPO, which gave 20.5% Rx coverage of
the PTV and was only 3.7% hot (Figure 3.1 and Figure 3.2).

2. In your own words, summarize why beam energy is an important consideration for lung
treatments? (Review Khan, 5th ed., 12.5.B3, Lung Tissue)
Treating tumors in the lungs can create challenges in radiation therapy due to the Compton
effect being the predominant interaction in RT and the vast difference in tissue density
between the lung (air), tumor, and tissues surrounding the lungs. The electron density of a
material is directly related to its beam attenuation ability, so less density results in less beam
attenuation and a loss of lateral electronic equilibrium. This will occur as a treatment beam
travels through lung tissue. Then, when the beam eventually reaches a material of higher
density (i.e. tumor), a re-buildup region occurs at that interface, creating a second dmax and a
significantly lower dose delivered to the periphery of the tumor. As beam energy is increased
(and field size decreases), the loss of lateral electronic equilibrium will escalate, worsening
this phenomenon and decreasing target coverage. This is why lower energy beams are
typically preferred when treating tumors within the lungs.
Figure 3.2. Plan 3 – DVH

PTV

20.5%

6000cGy

Plan 4: 6MV – 5 Field (unequal weighting)

Figure 4.1. Plan 4 – 6 MV 5-Field with weighting
1. How does field weight adjustment impact a plan?
Field weighting allows for the manipulation of a treatment plan by assigning each beam a
different percentage, or value, of the total dose contribution. This results in the alteration of
the overall dose distribution with the goal of achieving more optimal target coverage (Figure
4.1). Changing a beam’s weight will result in a shift of the isodose curves either toward or
away from the source. Field weighting can also be used in the sparing of OAR and is
especially beneficial when the tumor depth differs for each beam, such as in SAD (isocentric)
plans.

2. List your final choice for field weighting on each field.

My final field weighting for each field in this plan is shown below and resulted in a 105.2%
hotspot (6314.2cGy) that lies within the PTV, and Rx dose coverage of 30.4% of the PTV
(Figure 4.2).
• AP = 17%
• PA = 14%
• LLat = 38%
• LAO = 16%
• LPO = 15%

Figure 4.2. Plan 4 – DVH and field weights

PTV

30.4%

6000cGy
 Plan 5: 6MV – 5 Field (unequal weighting with wedges)
Figure 5.1. Plan 5 – 6 MV 5-Field with wedges

1. Embed a screen capture of the beams-eye view (BEV) for each field that you used a
wedge.
See Figure 5.2 below.

Figure 5.2. Plan 5 – 6 MV, BEV of AP field (a), PA field (b), and LLat field (c) with wedge orientation

(a) (b) (c)

2. 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?)
For the AP and the PA beams, I utilized 30° enhanced dynamic wedges (EDW) with the heel
toward the inferior of the patient and the toe at the superior. My reasoning for this was to
increase dose to the superior aspect of the PTV as I had noticed in my previous plans that
 coverage was lacking the most in that area. The 95% isodose line did showed improved
coverage to this area, decreasing its distance by half when compared to Plan 4.

For the left lateral beam (LLat), I added a 45° EDW oriented with the heel toward the
anterior part of the patient’s body and the toe toward the posterior. I chose to use this wedge
as a compensator with the heel side acting as an additional attenuator in the portion of the
beam’s path encountering less tissue. This helped create a more homogenous dose
distribution along the lateral aspect of the PTV.

3. Describe how your PTV coverage changed (relating to the 100% isodose line) with your
final wedge choice(s).
The prescription dose coverage of the PTV decreased with the addition of wedges, from
30.4% PTV coverage in Plan 4 down to 21.1% in this plan (Figure 5.3). However, I chose to
continue with this arrangement because I was able to increase the dose that 95% of the PTV
was receiving, from 5437.2cGy (Plan 4) vs 5601.5cGy (Plan 5), the hotspot was decreased
from 105.2% (Plan 4) to 103.1% (Plan 5), and I liked the dose distribution that was provided
by the wedges as well (Figure 5.1).

Figure 5.3. Plan 5 – DVH and field weights

PTV

21.1%

6000cGy
 Plan 6: 6MV – 5 Field (plan normalized - 100% Rx to 95% PTV)
Figure 6.1. Plan 6 – 6 MV 5-Field with normalization

1. What impact did normalization have on your final plan?

Normalizing my plan to have 100% of the Rx dose covering 95% of the PTV resulted in an
overall increase of dose in this plan (Figure 6.1). This was seen by the isodose curves each
expanding to cover larger volumes of normal and target tissue. The higher isodose curves
(95%+) expanded more than those representing lower doses (50-90%), which meant more
dose was being pushed into the target region to reach the desired normalization goal (Figures
6.2 and 6.3).

2. What is your final hotspot and where is it?

The final hotspot increased with normalization to 110.4% (6623.7cGy) of the Rx dose and is
located superiorly in the anterolateral aspect of the ITV (Figure 6.1).

3. Are you satisfied with the location of the hotspot?

I was satisfied with having the hotspot in this location because it was not only within the
PTV, but also within the given ITV. I would have preferred for this point to be more central
in the tumor, but ultimately, the hottest area of the plan was hitting the actual disease site
rather than being in normal tissue, which is one of the goals at my clinical site.
Figure 6.2. Comparison of Plan 5 (left) and Plan 6 (right) – distance of 50% isodose line from PTV is displayed

Figure 6.3. Plan 6 – DVH

95%

PTV

6000cGy
 Plan 7: 6MV – Final 3D Lung Treatment Plan
Figure 7.1. Plan 7 – 6 MV Final Plan with normal structure contours

1. What energy(ies) did you use and why?

I continued to use 6MV beams for my final 3D lung treatment plan, which is the lowest
energy option at my clinical site. I chose this energy because the tumor was surrounded
mostly by low density lung tissue (Figure 7.1) and I did not want to risk reducing PTV
coverage by increasing beam energy, which would have caused a wider penumbra and a
secondary build-up region at the lung-tumor interface.

2. What is the final weighting of each field in the plan?

I added field in fields to the LAO and the LPO beams to help reduce the hotspots in the
hotspots. After reevaluating the dose distribution, I chose to also adjust the wedges that I
used in this final plan. I used 15° EDWs for the AP and PA, with the heels oriented at the
lateral aspect of the fields and I changed the LLat wedge to a 45° EDW oriented with the heel
at the inferior border of the field to assist with dose to the superior portion of PTV. This area
of PTV was the most difficult to get adequate coverage at, so after discussing this plan with
my preceptor, it was suggested that I open the superior MLC margin on my beams to 1.5cm,
which helped improve coverage of that area due to the increased scatter.
The final field weighting chosen for this plan after merging subfields was (Figure 7.2):
• AP = 22.4%
• PA = 22.3%
• LLat = 14.7%
• LAO with FiF = 20.3%
• LPO with FiF = 20.3%
Figure 7.2. Plan 7 – 6 MV Final Plan – showing field weights and hot spot

3. Where is the region of maximum dose (“hot spot”), what is it, and is this outcome
clinically acceptable?
The final maximum dose was located centrally and slightly posteriorly within both the PTV
and ITV contours (Figure 7.2). The hotspot was 106.8% of the Rx dose, or 6410cGy, which
would be considered clinically acceptable because it is less than the traditionally allowed
maximum dose of 110%.

4. Embed a screen cap of your final plan’s isodose distribution in the axial, sagittal and
coronal views.
See Figure 7.1 above.

5. 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.
See Figure 7.3.
Figure 7.3. Plan 7 – Final DVH with all structures

ITV

PTV
Primary
Bronchus

Lt Lung
Trachea

Heart Esophagus Total Lung - ITV

Rt Lung Body
Spinal Canal

6. Use the table below to list typical OAR, critical planning objectives, and the achieved
outcome. Please provide a reference for your planning objectives.

Figure 7.4. Combination of RTOG 0623, 06172, and Timmerman3 Dose Constraints
Planning Objective
Organ at Risk (OAR) Desired Planning Objective Met?
Outcome
Spinal Canal (Cord) D0.03cc < 4500cGy 842.14cGy Y
Esophagus D0.03cc < 6300cGy 1714.97cGy Y
Esophagus Mean Dose < 3400cGy 424.9cGy Y
Heart V60Gy < 33% 0% Y
Heart V45Gy < 67% 0.05% Y
Heart V40Gy < 100% 0.11% Y
Heart Mean Dose < 4000cGy 289.2cGy Y
Total Lung – ITV* V20Gy < 37% 22.7% Y
Total Lung – ITV* Mean Dose < 2000cGy 1171.2cGy Y
Trachea3 V44Gy < 5cc 0.00cc Y
Trachea3 D0.035 < 6000cGy 1585.3cGy Y
Primary Bronchus3 V44Gy < 5cc 8.1cc N
Primary Bronchus3 D0.035 < 6000cGy 6237.3cGy N
*RTOG 0623 defines constraints for Total Lung – GTV.
 Extra Plan: 6MV – Lung DCA
My preceptor sometimes prefers to use dynamic conformal arcs (DCAs) for a treatment instead
of static beams, especially in palliative pain cases, for a reduced treatment time. For this reason, I
wanted to attempt a plan with the DCA technique as well, which can be seen below (Figure 8.1).

Figure 8.1. Plan 8 – 6 MV Lung DCA

Figure 8.2. Comparison of Plan 7 (left) and Plan 8 (right) with the hotspots displayed
Figure 8.3. Plan 8 – DVH Lung DCA
ITV
PTV

Primary
Bronchus

Lt Lung
Trachea

Heart Esophagus Total Lung - ITV

Rt Lung Body
Spinal Canal

It was interesting to see the differences between Plan 7 and Plan 8 (Figure 8.2). Both plans met
required constraints and would be considered acceptable for treatment. However, Plan 7 was less
hot and had better sparing for all contoured OAR, except for the heart. This was not surprising
seeing as the DCA plan delivers beam around the patient’s entire circumference without blocking
for normal structures when possible. The OAR that received the highest increase in dose from
Plan 8 included the spinal canal, trachea, and esophagus (Figure 8.3).

References:

1. Gibbons JP. Khan’s the Physics of Radiation Therapy. 6th ed. Wolters Kluwer; 2020:222-230.

2. Kavanaugh Ja, Holler S, DeWees TA, et al. Multi-institutional validation of a knowledge-

based planning model for patients enrolled in RTOG 0617: implications for plan quality
controls in cooperative group trials. Pract Radiat Oncol. 2019; 9(2):218-227.
https://doi.org/10.1016/j.prro.2018.11.007

3. Timmerman R, Choy H, Gerber D, et al. Accelerated hypofractionated image-guided vs

conventional radiotherapy for patients with stage II/III non-small cell lung cancer and poor
performance status. JAMA Oncol. 2021; 7(10):1497-1505.
https://doi.org/10.1001/jamaoncol.2021.3186