Planning Assignment (Lung)

Target organ(s) or tissue being treated:

Prescription: 4500cGy with a 180cGy/day for 25 fractions
Organs at risk (OR) in the treatment area (list organs and desired objectives
in the table below):
Organ at risk
Bi-lateral Lung

Desired objective(s)
< 30% receiving 20.8Gy

Achieved objective(s
<30% at 17.48Gy

Heart

<50% receiving 31.3Gy

<50% at 7.95Gy

Spinal Cord

45Gy

39.78Gy

Esophagus

Mean Dose <36.5Gy

Mean Dose of 13.63Gy

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
is sort-of broken up-not conformal and hourglass shaped.
b. Is the PTV covered entirely by the 95% isodose line? NO
c. Where is the region of maximum dose (hot spot)? What is it? The
maximum dose is posterior to the PTV, about 1.4cm from the
posterior surface of the patient. The maximum dose is 115.1%.

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 isodose lines are not as broken up. The coverage
of the PTV is better. The isodose levels spread out and are no
longer hour-glass shaped.
b. Where is the region of maximum dose (hot spot)? Is it near the
surface of the patient? Why? The hotspot is Posterior to the PTV,
near the surface of the patient because the maximum dose is
deposited at 3.2 cm. The hotspot is further from the surface
than the 6MV plan due to the dmax of 23MV being greater
(1.5cm vs 3.2 cm). The hotspot is 2.36cm from the posterior
surface 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?
AP=55.4%, Pa=44.6%
b. How is the PTV coverage affected when you adjust the beam
weights? As the weight is adjusted more anterior, the coverage
to the PTV is improved with the 95% isodose line covering
most of the PTV. The 100% isodose is now posterior, anterior,
and midline though it is breaking up. The 100% isodose is more
anterior than posterior. The hotspot is inside the PTV.
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 added a
third field and adjusted the gantry angle to 50 to avoid the
cord. Decreasing the margin or moving the jaw in could also
reduce dose to the cord, however it was not necessary for me
to do this.

i. Adjust the gantry angle? Yes- I did this

ii. Tighter blocked margin along the cord Yes- I did not have
to do this
iii. Decrease the jaw along side of the cord Yes- I did not
have to do this.
b. Alter the weights of the fields and see how the isodose lines
change in response to the weighting. The dose is distributed
more laterally. Increasing the AP weighting improves the
Medial target coverage.
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 thought that wedges would help even out the
dose distribution so I added wedges to different angles
until I got the desired coverage. I then adjusted the
weighting to move the hotspot to the center of the PTV.

Which treatment plan covers the target the best? What is the hot spot
for that plan? The 3-field plan offers the best coverage of the
target. The hotspot is 106.1% for that plan.

Did you achieve the OR constraints as listed above? List them in the table
above. Yes, I achieved the OR constraints.
What did you gain from this planning assignment? I gained experience
in field weighting and wedge placement. I began by placing the
wedge on the AP and Oblique fields in order to change my target
coverage. I ended up with a wedged pair (sort of) in the PA and
LPO positions.

What will you do differently next time? Next time, I would begin with
a wedged pair instead of attempting a wedge in the AP field. I
would also normalize my dose distribution so that 100% covers
95% of the target after calculation and then work to reduce my
hotspots.

AP/PA field with 50/50 weighting with 6MV

Best Plan

Plan comparison of 3-field with and without wedges