Planning Assignment (Lung)

Target organ(s) or tissue being treated:

Prescription: 39.6 Gy @ 180cGy per fraction (22 fractions)

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 Max Dose<45Gy 42.38 Gy @ Max Dose

Heart <40Gy @ 100% 40Gy @1.77%

790cGy Mean Dose
Left Lung <20Gy @37% 153.5cGy Max Dose

Right Lung <20Gy @37% 37.5Gy@37%

Failed
Total Lung (V20) Mean Dose <20Gy 15.8Gy @ Mean Dose

Esophagus Mean Dose <35Gy 745cGy @ Mean Dose

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).

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 distribution appears rectangular primarily with an hour glass effect as

you scroll through the slides. Covers most of the GTV (98%) and PTV (87%)
b. Is the PTV covered entirely by the 95% isodose line? No, it clips
along the medial portion of the PTV.
c. Where is the region of maximum dose (hot spot)? What is it? A
hot spot occurs along the posterior portion of the patient outside the
lung field. It is 4,745cGy.
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?

Coverage along the medial border of the PTV improved. However, coverage
along the lateral, inferior and superior borders decreased. The result is
about 100% GTV coverage and 86% PTV coverage.
b. Where is the region of maximum dose (hot spot)? Is it near the
surface of the patient? Why? It remains in the posterior portion of the
 patient, but it is located more medial and lies in close proximity to the
spine @ 4,442cGy. The 6x hot spot lies closer to the surface of the
patient when compared to the 18x beam. The higher energy beams
have a slight sparing effect on the superior tissues of the patient
because these photons penetrate deeper.
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=54% PA=46%. The hot spot decreases from 4,442cGy to
4,350cGy.
b. How is the PTV coverage affected when you adjust the beam
weights? The PTV coverage favors whatever beam has the most weight
distributed to it.
Plan 4: Using the highest photon energy available, add in a 3rd 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?
ii. Tighter blocked margin along the cord
iii. Decrease the jaw along side of the cord
Applying a combination of gantry angles, tighter margins and bringing the
jaws in can help spare the cord. It appears changing the beam angle is most
effective.
b. Alter the weights of the fields and see how the isodose lines
change in response to the weighting.
As the weight of the lateral beam increases, the isodose lines pull
toward it and the anterior/posterior isodose lines pull in towards the
PTV.
 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.
Inserting a wedge could help even out the dose distribution. The
patients chest is slanted. Placing a wedge with the heel facing the
patients head could help with uniformity on the superior portion of
the PTV. In this case, it helped very little and compromised the
dose on the lateral portions of the PTV.

Which treatment plan covers the target the best? What is the hot spot
for that plan?
I found that plan 2 was the most efficient way to cover the target. The
hot spot was 4,442cGy. However, plan 4 was most effective in limiting
dose to the organs at risk.

Did you achieve the OR constraints as listed above? List them in the table
above.
Unfortunately no, the dose to the right lung was too high. The cord was
also high, but within tolerance. I missed the primary objective in achieving
95% coverage of the PTV.

What did you gain from this planning assignment? I am a visual learner,
so this assignment was very beneficial. Expanding my knowledge on
manipulating dosimetry concepts to achieve isodose coverage, has
helped me make a connection to some of the material we have been
going over. Now that I understand how the isodose lines react to certain
manipulations, I can be more effective in treatment planning.

What will you do differently next time? I believe I could have made plan 4
work. If I had it to do all over again. I would play with the margins and jaw
symmetry in attempt to increase PTV coverage to the superior and inferior
portions.