Destiny Jacobs

DOS 791- Clinical Lab I

March 6, 2016
Non-Small Cell Lung Cancer (NSCLC)- RTOG 0839
Patient GP is a 71 year old female patient presented with a mass in her lungs while getting a preoperative chest x-ray before spine surgery. Patient was treated with antibiotics because this was
thought to be infection. After completing the course of antibiotics no notable change was
represented on the CT. GP underwent an initial biopsy which revealed inconclusive results. A
second biopsy revealed poorly differentiated carcinoma. A PET/CT was obtained which showed
a 3.0cm x 2.8cm right lower lobe mass with right hilar adenopathy. She will receive concurrent
chemo radiation to the lung.
Simulation and Target volumes: Patient GP was simulated on a CT simulator. The patient was
immobilized during simulation using the Vac.Lock system positioned on top of an indexed wing
board. The patients hands were position above the head to give optimal clearance of beams
around the chest. She was asked to breathe normally while attaining the treatment planning CT
images. The simulation was done using a free breathing technique. Since the free breathing
technique was used, the contouring tumor margins were based on the Free-Breathing CT +
Free-breathing delivery +daily IGRT specified in RTOG 0839 protocol. (See Table 1 and
Figure 1) GTV_6000 was initially drawn by the physician and includes gross tumor volume and
positive lymph nodes. Next I drew the CTV_6000 which included GTV plus 1cm superiorinferior and 0.5 axial margins in accordance with the protocol requirements. Lastly, the
PTV_6000 margin was created, which included CTV plus 1.2cm superior-inferior margin and
0.7cm axial margin.

Prescription and Objectives: According to the protocol GP was planned to 60Gy over 30 total
fractions. 100% of the PTV_6000 volume was to receive 95% of the dose. The organs at risk
included Esophagus, heart, lungs and esophagus. Spinal cord constraints were to be kept at a
maximum dose less than 50.5Gy. The V20 of the sum lung volume was to be less than 30%. The
esophagus and heart were to meet all qualifications as outlined by the protocol. (Table 3)
Beam Arrangement and Planning Technique: A 9 field IMRT technique was generated in
order to meet the constraints of the protocol. The beams chosen were dependent upon organs at
risk based on the positioning of the tumor. Beam angles 175 and 350 first were setup first
because those angles oppose one another at the optimal position to spare the cord. After the first
two angles were positioned, seven more equidistant beams were positioned between angles 175
and 350. These nine angles, [175, 196, 218, 240, 26, 284, 306, 328 and 350] allow for
diversification of dose. All beam angle entrances were kept through the right lung in order to
avoid entrance through the contra-lateral lung as much as possible.
The PTV_6000 optimization technique was set to 100% of the prescription dose since 100% of
the volume was to get 95% of the dose. After setting up the tumor volume dose constraint, spinal
cord constraints follow. The upper limit constraint of the spinal cord is set to 4400cGy. Then
the Spinal Cord margin volume, which is defined as a 1cm axial margin and 3cm posterior
margin, was used to guide the dose to the area around the cord. The Lung V20 constraint for the
sum lung was set to 25%-30%. Then multiple upper constraints are set to help lower the dose to
the lung. The final organs constrained are the Esophagus and the heart. These constraints were
based off the limits within the protocol and then adjust accordingly. Lastly, the normal tissue
optimizer (NTO) was set. The NTO was set to start at 0.8cm distance from the target volume.

The start dose was set at 100%, the end dose at 65% and a 0.15 fall off. Constraints were
adjusted as the plan actively optimized.
Plan Outcome: Upon final review of the plan, in order to receive the outlined objective for the
PTV_6000, I normalized the plan to 98.5%. 100% of the PTV_6000 volume received 95% of
the dose. All organs at risk objectives were met as outlined in the protocol. (See Table 3 and
Figure 3)

GTV_6000

Gross Tumor with Positive Lymph

nodes
CTV_6000
GTV plus 1cm superior-inferior; 0.5
axial margins
PTV_6000
CTV+ 1.2 superior-inferior margin; 0.7
axial margin
Table 1: Target Volume Margins

Figure 1: Visual Target Volume Margins

Figure 2: Beam Arrangement

Upper
Lower
GTV_6000 6500cGy
6120cGy
CTV_6000 6500cGy
6115cGy
PTV_6000 6500cGy
6000cGy
Table 2: Tumor Volume Constraints

Table 3: OR Objectives

Figure 3: DVH