Planning Assignment (Lung)

Target organ(s) or tissue being treated: Right lung

Prescription: 400 cGy x 5 fx = 2000

cGy______________________________________________

Organs at risk (OR) in the treatment area (list organs and desired
objectives in the table below):

Organ at risk Desired objective Achieved objective

Heart Dmean < 2800 cGy 223 cGy
Left lung Dmean < 1800 cGy 182 cGy
Right lung Dmean < 1800 cGy 924 cGy
Spinal cord Dmean < 1800 cGy 510 cGy
Esophagus Dmean < 3200 cGy 854 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).

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?

- hot spots near skin surface, both anteriorly and posteriorly

- only about 50% of the PTV is getting the prescribed dose

- the dose is higher in lung than in other soft tissues

b. Is the PTV covered entirely by the 95% isodose line?

- No; the 95% isodose line encompasses about 95% of the PTV
c. Where is the region of maximum dose (hot spot)? What is it?

- The region of max dose is very posterior and to the right side of the patient.
This is where the

beams travel through the most lung.

- hot spot: 2436.2 cGy

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?

- isodose lines became more heavily weighted near patients posterior

b. Where is the region of maximum dose (hot spot)? Is it near the

surface of the

patient? Why?

- The hot spot is a little deeper into the patient but still posterior and near to
the surface of the

patient. The dmax depth for 18 MV photons (the highest energy available) is
about 3.3 cm. Lung

tissue (air) leads to higher deposition of energy after a photon passes

through. The PA beam

didnt reach the lung at 3.3 cm, so it deposited max dose in the posterior part
of the patient. The

AP beam went through lung right away, so it deposited max dose after
passing through the lung.

The combination of the 2 beams led to a hot spot in the posterior part of the
patient.

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?
 - Weighting the AP beam slightly more heavily than the PA beam decreased
the hot spot the

most, with a ratio of 1.3:1.

b. How is the PTV coverage affected when you adjust the beam weights?

- PTV coverage is better (increasing to 96% of PTV covered by (5% isodose

line) but still not

great.

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?

-This is the way that worked best for me. Using the other techniques (tighter
blocked margin,

decreased jaw alongside of the cord) I lost ample PTV coverage.

ii. Tighter blocked margin along the cord

iii. Decrease the jaw alongside of the cord

b. Alter the weights of the fields and see how the isodose lines change in
response to

the weighting.

- much more conformal dose and even distribution with the addition of an
oblique beam

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.

- A wedge (22 degrees) on the AP field helped to eliminate some hot spots
and even out the
 dose.

Which treatment plan covers the target the best? What is the hot spot
for that plan?

-The plan with the best target coverage was the last plan, AP/PA and one
oblique. The hot spot

for this plan is 2109 cGy.

Did you achieve the OR constraints as listed above? List them in the table
above.

- Yes, see above.

What did you gain from this planning assignment?

- Choosing appropriate energy is important. After I asked my preceptor to

look at the plan, he

suggested using 6 MV photons for the AP and oblique beams due to the small
amount of tissue

the beams traveled through before entering the lung. The dose distribution
might be better

using mixed energies in this way.

- appreciate difficulty of achieving conformal dose to targets within the lungs

due to different

electron densities of lung and surrounding soft tissue

- beam weighting and wedges are important tools to understand

What will you do differently next time?

-try different gantry angles to conform dose better and stay off critical
structures

- weight AP more than PA right away

 - try using different photon energies based on how much soft tissue the beam
needs to go

through before entering lung tissue