Alyssa Olson

Lung Planning Assignment

March 21, 2016

Target Organ of Interest: Right Lung

Prescription: Right lung to receive 4500 cGy in 30 fractions, BID. Goal is for 95% of the PTV
to receive 99% of prescription dose (4455 cGy).
Plan 1: AP/PA Plan with Equal Weighting using 6 MV
A. The dose distribution results in a less than ideal situation. According to Bentel,1 equally
weighted parallel-opposed beams often result in higher entrance and exit doses when
compared to the isocenter. In addition, when the isocenter is off-centered, the field with the
greater penetration depth to the isocenter will have higher hot spots than both the isocenter
and opposing field. This coincides with what is demonstrated in Figure 1; the anterior soft
tissue is receiving over 120% of prescription dose while the posterior soft tissue receives
115%. Even though 95% of the PTV is receiving 99% of prescription dose, all other
structures in the path of the beam are receiving well above what was prescribed. The
reasoning for the increased hot spots is related to the principle of tissue heterogeneity.
According to Kahn and Gibbons,2 areas of varying density, such as tissue interfaces of soft
tissue, bone, and lung, will cause a perturbance in the isodose distribution. The anterior field
in Figure 1 requires more power to penetrate a greater depth to the isocenter. The underlying
soft tissue and bone have a greater electron density than the lung; this results in an increased
absorption of dose as it penetrates these tissues prior to entering the lung.
B. I set the normalization to calculate the dose according to the prescription request: 99% of the
dose to cover 95% of the PTV. With that, one would assume that the PTV is entirely covered
by the 95% isodose line; however, when looking at the minimum dose to the PTV, it says
94.8%. The small reduction of dose below the 95% line appeared on the right lateral aspect
of the PTV. This slight discrepancy could be attributed to the higher amount of soft tissue
and bone the beam needed to traverse through on that lateral side in order to reach the PTV.
More dose was absorbed within the soft tissue and chestwall, causing an inward bowing of
isodose lines and a cooler spot on that side.
C. The region of the maximum dose can be found on both the beam entrance and exit portions
of the patient. According to Figure 1, the maximum pixel dose is 133.2% and is most likely
located on the anterior aspect of the patient. Because the AP field has a greater penetrating
depth to the isocenter, more power is needed to allow adequate dose to reach the PTV. This
occurrence is all relative to tissue heterogeneities. Soft tissue and bone have a higher
electron density and will absorb a greater amount of the traversing beam when compared to
the lung.

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Figure 1: Isodose Distribution of an AP/PA Plan with Equal Weighting using 6 MV

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Plan 2: AP/PA Plan with Equal Weighting using 15 MV
A. A change in beam energy from 6 MV to 15 MV pulled the isodose lines back towards the
surface, decreasing the overall hot spot (Figure 2). In addition, there is a more pronounced
build-up region below the skin surface when using 15 MV, due to its greater Dmax. This
build-up region does not pose any problems as the PTV is located quite deep within the
patient. As stated by Bentel,1 an increase in beam energy can be beneficial when treating
areas with a larger separation. An increased energy allows for greater penetrating ability,
ultimately decreasing the amount of power needed to deliver the prescribed dose to the PTV.
B. Increasing each fields energy from 6 MV to 15 MV resulted in a decrease in the overall hot
spot from 133.2% to 116.8% respectively (Figure 2). Despite the reduction in overall hot
spot, their location is still the same: at the anterior and posterior surfaces of the patient. As
was observed in the 6 MV plan, the larger hot spot of 116.8 is located on the anterior surface
of the patient in soft tissue and bone. Even though 15 MV provides a greater penetrating
ability, this plan is still equally weighted, which requires the anterior field to use more power
to reach the isocenter. The interacting photons more energy, but still interact with soft tissue
and bonejust not as much as previously seen with 6 MV. A neat way to visualize this
difference was an equation provided by my physicist, Daniel Lewis, MS (oral
communication, March 2016). Using a percent depth dose table at a depth of 10 cm: 6MV
delivers approximately 70% of prescription dose while 15 MV delivers approximately 80%.
1
6 MV :
=1.4 hotspot relative prescription dose
0.7
15 MV :

1
=1.2 hotspot relative prescription dose
0.8

Figure 2. Plan Evaluation of 6 MV and 15 MV AP/PA Plans with Equal Weighting

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Plan 3: AP/PA Plan with Unequal Weighting using 15 MV

A. When adjusting the weighting, the best ratio outcome with the lowest hot spot of 111.8%
resulted in contributions from the AP with 45.3% and PA with 54.7%. The tumor is located
more posteriorly, so it was more beneficial to have a higher contribution from the PA field.
Adjusting the weighting to find the lowest hot spot also created more uniformity in the
isodose distribution (Figure 3).
B. I have all plan normalizations set to achieve 99% of prescription dose to cover 95% of the
PTV. Therefore, all three plans are attempting to achieve the same coverage to the PTV.
After evaluating the maximum, minimum, and mean coverage to the PTV as shown in Table
1, I would choose plan 3 to provide the best dosimetric outcome. Plan 2 and Plan 3 are
relatively similar in comparing these values; however, the minimum coverage to the PTV is
slightly higher at 96.4% while the mean and maximum values remain relatively unchanged. I
still have to keep in mind that lung tissue is quite radiosensitive and it may still be possible to
achieve a lower hot spot than 107%.

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Figure 3: Isodose Distribution of an AP/PA Plan with Unequal Weighting using 15 MV

Table 1. Plan Comparison of PTV Coverage

Plan 1
Plan 2
Plan 3

Maximum Dose
Pixel for PTV
113.2%
107.0%
107.0%

Minimum Dose
Pixel for PTV
94.8%
96.1%
96.4%

Mean Dose
Pixel for PTV
107.1%
103.2%
102.9%

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Plan 4: Three-Field Lung Plan using 15 MV
A. When adding a third beam into the plan using 15 MV, it is best to position the beam at a
slight oblique to avoid the cord and minimize the dose to the healthy lung tissue.1 To do this,
I tilted the gantry to 310 (A50R). Another option could be 130 or P50L. In this case, it
would be best to utilize the A50R because of concern for table collision when considering
P50L. By doing so, the cord is avoided, and the amount of lung tissue involved is
minimized. To further decrease the amount of normal tissue involved, I also decreased the
margin along the side of the spinal cord and decreased my X2 jaw size from 4.1 cm to 3.8
cm. These things in combination also decreased the hot spot area to 104.8% at the posterior
aspect of the patient. The one concern I have is that while the PTV is receiving a mean dose
of 102.0%, a large portion of healthy lung is also receiving the same amount of prescription
dose. For this reason, it may be beneficial to adjusting the beam weighting or consider a
wedge.
B. Altering the weighting provided some excellent benefitsmore specifically to the
surrounding healthy tissue. Keeping the radiosensitivity of lung tissue in mind, I adjusted the
weighting contribution to AP with 28%, PA with 37.6%, and A50R with 34.4%. This helped
to drastically reduce dose to healthy tissue in the anterior portion of the lung, to only 50%
(Figure 4). Reducing dose to healthy lung tissue is of great importance in order to minimize
lung complications for curative or palliative treatments. Finally, other aspects of the plan
remained unchanged; the hot spot remained at 105% and the minimum dose to the PTV was
96%.
C. Addition of wedges was not as helpful as I had hoped. I was aiming to reducing some of the
prescription dose in the anterior area where the A50R and AP beam converged. I tried
different combinations of wedging with for both fields with the heel towards the anterior on
the A50R and heel towards the patients right on the AP. The wedges did not reduce the
triangle of healthy lung tissue receiving prescription dose, but rather increased the hot spot
posterior to the PTV and reduced the mean coverage to the PTV. Instead of using two
wedges, I tried using a single wedge on the AP with the heel towards the right. Since the AP
contribution was relatively low, I used a 30-degree wedge. This wedge helped to push the
prescription isodose line more medially, where I was lacking coverage. In addition, the hot
spot decreased to only 103.6%. Because my hot spot was relatively low, I finally increased
my normalization value from 293.0 to 289.5 to improve my overall coverage. My end result
achieved was 97.6% of the PTV receiving 100% of prescription dose, with a hotspot of 105%
(Figure 5).

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Figure 4. Adjusted Weighting on Plan 4 using 3-Fields and 15 MV

Figure 5. Isodose Distribution of Plan 4 using Unequal Weighting and a Wedge

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Overall Impression
The best treatment plan of all created would be Plan 4. This plan is conformed tightly to the
tumorreducing dose to normal lung tissue, and has a minimal hot spot of 105%. The area of
hot spot is located just posterior to and to the right of the PTV. As stated before, the coverage of
Plan 4 to the PTV achieved 97.6% to receive 100% of the dose.
The only constraint that was not achieved by this plan was the mean total lung dose (Table 2).
Because I have room for adjustment, I could increase my normalization value to lower the mean
dose. I could also manipulate the wedge or weighting contributions for other fields to lower lung
dose as well.
This planning assignment was very helpful in learning different ways to plan a lung treatment via
the creation of 4 different treatment plans. The lung area is such a radiosensitive structure and
care must be taken to minimize dose to the surrounding healthy tissue while targeting the lesion.
While my center plans most lung treatments using Rapid Arc, I look forward to having the
opportunity to plan the next 3D lung treatment when the occasion arises. This assignment was
extremely helpful in getting to see the different changes that occur with the addition of wedges,
energies, and altered weighting. Due to many time constraints in the real world of planning, this
assignment allowed me to take my time and fully evaluate the results of each action requested
within this assignment.
Something I would try to do differently next time is to find a way to minimize prescription dose
to the healthy lung tissue. As shown in Figure 5, I have a large diamond shape of lung tissue
healthy and tumorousreceiving full prescription dose. The portion of lung anterior to the PTV
is of most concern. I could add in right lateral field with minimal contribution to help reduce the
peaked areas of full prescription. A right lateral field would increase the dose to the esophagus
spinal cord, and total lung but based on my achieved objectives in Table 2, there may be room
for adjustment.

Table 2. Plan Objectives and Outcomes using Plan 4 Parameters

Organ at Risk (OR)
Spinal Cord
Liver
Total Lung

Desired Objective
Max < 3600 cGy
Max < 3000 cGy

Mean < 700 cGy

V20 < 15%
Heart
Mean < 1000 cGy
Pacemaker
Max < 200 cGy
Esophagus
Mean < 3400 cGy
V35 < 50%
a
Red color denotes unmet planning objects

Achieved Objective
Max: 251.9 cGy
Max: 5778.7 cGy
4.1% > 3000 cGy
Mean: 782.8 cGya
V20: 15.1%
Mean: 36.6 cGy
Max: 1.0 cGy
Mean: 42.7 cGy
V35: 0%

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References
1. Bentel GC. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996.
2. Kahn FM, Gibbons JP. Kahns The Physics of Radiation Therapy. 5th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2014.