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James 1

Shands James
4/29/2016
DOS 771 Clinical Practicum I
Planning Assignment (Lung)
Target organ(s) or tissue being treated: Lung tumor located near midline of right lung
Prescription: 200 cGy x 30 fractions = 6000 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:
*Organ at risk chart was developed for each plan variation and can be found in each plan section.
Patient was simulated supine with a headrest and knee cushion for patient comfort and
immobilization.

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Plan 1: Create a beam directly opposed to the original beam (PA) (assign 50/50 weighting to
each beam)

Figure 1: Plan 1 isodose lines from all planes. 100% line is yellow.
Organ at risk

Desired objective(s)

Achieved objective(s)

Spinal Cord1

Max Dose = 5000 cGy

Max Dose= 5652.8 cGy

Heart2

Mean Dose= 4000 cGy

Mean Dose = 995.6 cGy

V45<66%

V45 = 12.6%

V60<33%
Mean Dose = 3400 cGy2

V60 = 0%
Mean Dose = 1640.4 cGy

V35<50%

V35 = 26%

V50<40%
V5<65%

V50 = 10.4%
V5 = 92%

Left Lung(Contralateral)3

V5<60%

V5 = 0%

Total Lung (minus CTV)2

V20<37%

V20 = 39.7%

Esophagus

Right Lung(Ipsilateral)

Table 1: Dose statistics for Plan 1.

James 3

a. What does the dose distribution look like?


The first thing that I noticed about the isodose distribution is that it is not conformal
around the target. A large amount of the critical structures are being irradiated past
tolerance. The coverage for the PTV is also not very good.
b. Is the PTV covered entirely by the 95% isodose line?
No, the 95% line (Green) does not cover the entire PTV. The isodose line that does cover
the whole PTV is the 80% line (baby blue).
c. Where is the region of maximum dose (hot spot)? What is it?
The hotspot is located posteriorly on the patients back before the rib cage. The hotspot is
7129.4 cGy which is a 118.8% hotspot. This is located more posteriorly because the PA
beam has more tissue to penetrate before reaching the target.
Plan 2: Increase the beam energy for each field to the highest photon energy available.

Figure 2: Plan 2 isodose lines from all planes. 100% line is yellow. All beam energies
changed to 23 MV.

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Organ at risk

Desired objective(s)

Achieved objective(s)

Spinal Cord1

Max Dose = 5000 cGy

Max Dose= 5765.9 cGy

Heart2

Mean Dose= 4000 cGy

Mean Dose = 998.1 cGy

V45<66%

V45 = 12.5%

V60<33%
Mean Dose = 3400 cGy2

V60 = 0%
Mean Dose = 1676.7 cGy

V35<50%

V35 = 26.2%

Right Lung(Ipsilateral)3

V50<40%
V5<65%

V50 = 14.5%
V5 = 93.4%

Left Lung(Contralateral)3

V5<60%

V5 = 0%

Total Lung (minus CTV)2

V20<37%

V20 = 39.9%

Esophagus

Table 2: Dose statistics for Plan 2.


a. What happened to the isodose lines when you increased the beam energy?
I switched to a 23 MV beam which caused the isodose lines shifted towards midline
which resulted in a lower hotspot and better PTV coverage. This shift is due to the 23
MV beam being more penetrating (dmax= 3.8 cm) compared to a 6 MV beam (dmax=
1.5cm).
b. Where is the region of maximum dose (hot spot)? Is it near the surface of
the patient? Why?
The hotspot is located posteriorly just before the start of the rib cage. The hotspot is
located here because there is more tissue that the PA beam has to penetrate than the
AP beam. So to deliver the prescription dose to the target more monitor units from the
PA beam are needed. However, the hotspot of plan 2 is located more anteriorly than
plan 1 because of the greater penetration of the 23 MV beam.

Plan 3: Adjust the weighting of the beams to try and decrease your hot spot.

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Figure 3: Plan 3 isodose lines from all planes. 100% line is yellow. Weighting of each beam
was changed to reduce hotspot.
Organ at risk

Desired objective(s)

Achieved objective(s)

Spinal Cord1

Max Dose = 5000 cGy

Max Dose= 6061.2

Heart2

Mean Dose= 4000 cGy

Mean Dose = 711.3 cGy

V45<66%

V45 =5.8 %

V60<33%
Mean Dose = 3400 cGy2

V60 = 0%
Mean Dose = cGy

V35<50%

V35 = 6.7%

V50<40%
V5<65%

V50 = 0.9%
V5 = 91.5%

Left Lung(Contralateral)3

V5<60%

V5 =0 %

Total Lung (minus CTV)2

V20<37%

V20 = 38.3%

Esophagus

Right Lung(Ipsilateral)

Table 3:Dose statistics for Plan 3.


a. What ratio of beam weighting decreases the hot spot the most?

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The beam weighting that reduced the hotspot the most was 54.5% from the AP beam and
45.5% from the PA beam. The hotspot was reduced to 105.9% from 109% (Plan 2) as
result of changing the weights of the beams.
b. How is the PTV coverage affected when you adjust the beam weights?
The PTV coverage of Plan 3 was not as good as Plan 2. In this case, the changing the
beam weighting reduced the coverage, but reduced the hotspot. This change in PTV
coverage is not what I expected to see when changing the beam weights.

Figure 4: DVH comparison of Plan 2 versus Plan 3.

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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%

Figure 5: Plan 1 isodose lines from all planes. An RPO beam was added to see the change in hotspot and PTV
coverage.

Organ at risk
Spinal Cord1

Desired objective(s)
Max Dose = 5000 cGy

Achieved objective(s)
Max Dose= 4354.9

Mean Dose= 4000 cGy

Mean Dose = 1167

V45<66%

V45 =12.9%

V60<33%
Mean Dose = 3400 cGy2

V60 = 0%
Mean Dose = 1723.4 cGy

V35<50%

V35 = 26.3%

V50<40%
V5<65%

V50 = 13.4%
V5 = 93.7%

Left Lung(Contralateral)3

V5<60%

V5 =0.21%

Total Lung (minus CTV)2

V20<37%

V20 = 40.2%

Heart2

Esophagus

Right Lung(Ipsilateral)

Table 4: Dose statistics for Plan 4.

James 8

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? I used an RPO beam at an angle of 210 degrees
which avoided an entrance and an exit on the cord. I also turned the
collimator so that the X jaw would better block the cord.
ii. Tighter blocked margin along the cord? On the side of the spinal cord
(X1), I changed the auto margin from 1.5 cm to a margin of 1 cm which
blocks the cord to a greater degree.
iii. Decrease the jaw alongside of the cord. After decreasing the margin
around the PTV, I adjusted the X1 jaw to fit snugly against the MLC to
further decrease the dose to the spinal cord by preventing leakage from the
MLC.

Figure 6: Beams eye view of RPO beam to improved blocking of the spinal cord.

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b. Alter the weights of the fields and see how the isodose lines change in response
to the weighting. The lines conformed to the PTV better and the hotspot improved
as I adjusted the weight.
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. After
reviewing the locations of the hotspots, I dont think that a wedge would be helpful
in this case. Below is a picture of the AP beams eye view (BEV). The orange cloud
is the 105% location and does not fall to either side of the PTV.

Figure 7: BEV of AP beam showing areas of high dose(orange dose cloud) to determine
need for a wedge.

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Which treatment plan covers the target the best? What is the hot spot for that plan?
Out of the 4 plans that were created during this project, Plan 4 had the best overall PTV
coverage and plan. Plan 2 was very close to the coverage that Plan 4 achieved however, Plan
4 was better overall. The hotspot for Plan 4 was 106.4% as opposed to 109% for Plan 2.

Did you achieve the OR constraints as listed above? List them in the table above.
None of the 4 plans achieved all of the dose constraints. The only plan to meet the spinal cord
constraint was Plan 4. The trade-off was higher lung, heart, and esophagus dose due to the
third beams entrance and exit locations.

What did you gain from this planning assignment?


This assignment helped me to see how adjusting the beam energies, angles, and weighting
can improve a plan. However, I noticed that there is a trade off when adjusting these factors.
For example, adjusting the beam weighting in Plan 3 decreased the hotspot, but the PTV
coverage got worse. Another thing that I noticed was the more beams that you add the more
conformal the isodose lines are and the hotspot decreases further.

What will you do differently next time?


The biggest change I would make would be in the beam arrangement. I would add more
beams to the plan so the dose will be more conformal. One drawback to the dataset that I
performed this assignment on was that the patient was simulated with their arms down
instead of in a wing board. Having the arms down means I cant have a lateral beam entrance
and limits the possible beam angles. Had the patient been simulated in a wing board a 5 field
beam arrangement may have been more appropriate and efficient at sparing the lung and
spinal cord. Having a 5 field beam arrangement will provide the opportunity of weighting the
fields in a different way with the goal being better conformity and a lower hotspot.
Another thing that I could change is the collimator rotations on all of the fields and not just
the RPO. I would angle the collimator to better block the spinal cord with the jaw. Also, I
would decrease the MLC margin along the side of the spinal cord to better preserve it.
Rotating the collimator so that the Y-jaw is perpendicular with the hotspot also provides the
possibility of using dynamic wedges that can improve coverage and the hotspot.

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One last possibility of improving the plan is using a mixed energy beam arrangement. My
center only has 6MV and 23 MV on the machine that I planned on, but an energy somewhere
in between may be more appropriate. So using a combination of 6 MV of 23MV can give a
dose distribution of that is more suitable.
References
1. Kirkpatrick JP, van der Kogel AJ, Schultheiss TE. Radiation dose-volume effects in the
spinal cord. In J Radiat Oncol Biol Phys. 2010; 76 (3 Suppl): S42-9.
Http://10.1016/j.ijrobp.2009.04.095.
2. Videtic GMM, Woody NM. Handbook of Treatment Planning in Radiation Oncology. 2nd
ed. New York, NY: Demos Medical Publishing, LLC; 2015: 85-100.
3. Song CH, Pyo H, Moon SH, Kim TH, Kim DW, Cho KH. Treatment-related pneumonitis
and acute esophagitis in non-small-cell lung cancer patients treated with chemotherapy
and helical tomotherapy. Int J of Radiat Oncol Biol Phys. 2010; 78(3):651-8.