Dustin Melancon

Planning Assignment (Lung)

Target organ(s) or tissue being treated: Right lung Prescription: Right lung tumor treatment using three-dimensional conformal radiation therapy (3D-CRT) with anterior and posterior fields. Laterals may be used. One fraction per day with a daily dose of 200 centigray (cGy) over 25 fractions. The target will receive a total dose of 5000 cGy with a source to axis distance (SAD) of 100 cm. Organs at risk (OR) in the treatment area (list organs and desired objectives in the table below):

Organ at risk Total Lung Heart Spinal cord

Desired objective(s) Maximum dose of 1750 cGy Maximum dose of 4000 cGy Maximum dose of 4500 cGy

Achieved objective(s) 416.2 cGy 8.8 cGy 28.1 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: 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? The dose distribution for 6 megavolts (MV) is higher for the posterior-anterior (PA) field with a 127.4% hot spot. b. Is the PTV covered entirely by the 95% isodose line? No, the 95% isodose line covers most of the planning target volume (PTV). It is entirely covered by the 90% isodose line. c. Where is the region of maximum dose (hot spot)? What is it? The maximum dose region is in the patients tissue between the surface and posterior lung. It is in PA field with a 127.4% hot spot, or 6369.7 centiGray (cGy).

Dustin Melancon 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? The available energies on the Varian TrueBeam linear accelerator include 6 MV and 10 MV. Increasing the energy to 10 MV shifted the isodose lines to greater depths. b. Where is the region of maximum dose (hot spot)? Is it near the surface of the patient? Why? The 10 MVs region of maximum dose is deeper with isodose lines shifting further into subcutaneous tissue. There is an increase in depth dose with higher energies. The hot spot decreased to 120.8%.

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? I weighted the anterior-posterior (AP) beam 57.9% and the PA beam 42.1% to decrease the hot spot to 114.3%. b. How is the PTV coverage affected when you adjust the beam weights? Changing the beam weights increased the PTV coverage. The PTV was receiving 4895.7 cGy (97.9%) mean dose and is now receiving 4903.1 (98.1%) mean dose. 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 The spinal cord is not in any of the fields. b. Alter the weights of the fields and see how the isodose lines change in response to the weighting. The isodose lines are more conformed around the PTV. I gave the AP field 32.0% weighting, PA field with 48.0%, and a right lateral field with 20.0% weighting of the beam. The hot spot went down to 104.0%. 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. I inserted a 15-degree wedge for the AP field and a 30-degree wedge for the right lateral field. This helped even out the dose distribution around the PTV.

Which treatment plan covers the target the best? What is the hot spot for that plan? The treatment plan that best covers the target is the three-field plan with unequal weighting and two wedged fields, the AP and right lateral. The hot spot for this plan is

Dustin Melancon 101.9%. I weighted the AP field with 34.5% of the beam, the PA field with 45.5%, and the right lateral field at 20%.

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

What did you gain from this planning assignment? Adding fields can sometimes benefit the patient. Its important to remember the prescribed target dose and the dose constraints to critical structures. Caution is advised when using extra fields. This increases lung dose and possible dose increase to critical structures, such as the heart and spinal cord. I also learned that energies around 6 MV and 10 MV are better for lung patients and are commonly treated on the Varian TrueBeam linear accelerator. I think this lab helped me visualize lung dose distribution before making changes to the plan. I was less familiar at the beginning of the semester how beam energy and tissue heterogeneities can influence a lung plan. What will you do differently next time? First, I will look at the prescription and the target location. Based on this information, I can add the necessary fields appropriately. I will consider using additional fields in various arrangements and/or wedges to achieve the best treatment plan. I will also attempt planning with unequal beam weighting and see if I can achieve better results.