Jamie Robinson

Clinical Practicum 1

October 5, 2023

Using the CT data set provided, lung treatment plans were created with the corresponding
instructions. Prescription: 60 Gy in 30 fractions to the PTV

Plan 1: Create a field directly opposed to the original field (PA). Assign equal (50/50)
weighting to each field.

Figure 1: AP/PA Field with Equal Weighting. The 100% Isodose Line shown in Red
 • What shape does the dose distribution resemble?

In plan 1 with AP/PA fields, the dose distribution reminds me of a barbell or hourglass where the
dose is distributed in the anterior, posterior and middle aspects of the body. The buildup of the
dose is most prominent in the anterior and posterior tissues of the body as well as in the tumor.

• How much of the PTV is covered entirely by the 100% isodose line?

The volume of the 100% isodose line is 11.18 cm3 with an equivalent sphere diameter of 2.2 cm.
If considering the equivalent sphere diameter of the lung PTV, 83.11 cm3 with and equivalant
square diameter of 5.4 cm, only 6.6% of the lung PTV is being covered by the 100% isodose
line. The 100% isodose volume level gives a conformity index of only 0.5894 by calculating
CI=6.58967/11.18. Ideally, it should be at or close to 1.

Figure 2: DVH of Lab Plan 1 with Coverage of PTV at 100%

• In your own words, summarize two advantages of using a parallel opposed plan?
(Review Khan, 5th ed., 11.5.A, Parallel Opposed Fields)

According to Khan, there are several advantages to using parallel opposed fields in a treatment
plan. Not only are they considered the simplest of treatment plans, but it allows for more margin
for error in treatment setups.1 As more angled beams are added to the treatment plan, it becomes
more complex and allows for an increased chance of “geometric miss.”1 With a parallel opposed
plan, such as AP/PA, a more homogenous dose results.1
Plan 2: Add a direct left lateral field to the plan and assign equal weighting to all fields.

Figure 3: AP/PA with Left Lateral Field and Equal Weighting

• How did this field addition change the isodose distribution?

With the left lateral beam added to the plan, the 100% isodose line increased in volume and most
of the dose distribution that was showing in the anterior and posterior tissue of the body is now
focused on the target and more centrally located within the body. However, in figure 4, the
image on the right shows isodose lines crossing over midline and into the left lateral tissue
indicating additional healthy tissue receiving dose totaling 30 Gy. The green isodose line
represents 18 Gy crossing over midline.
 Figure 4: Plan Evaluation of AP/PA and AP/PA with Left Lateral

• How much of the PTV is covered entirely by the 100% isodose line?

After adding the left lateral field, the volume of the 100% isodose line increased and measured
15.76 cm3 with an equivalent sphere diameter of 3.1 cm. The volume of the lung PTV measures
as 83.11 cm3 with an equivalent sphere diameter of 5.4 cm. When considering the equivalent
sphere diameter of those volumes, only 16.4% of the lung PTV is being covered by the 100%
isodose line. However, it is more than double the coverage compared to the AP/PA plan in plan
1.

Figure 5: DVH of Plan 2 with Coverage of PTV at 100%

Plan 3: Add 2 oblique fields on the affected side—1 on the anterior portion and 1 on the
posterior portion of the patient. Assign equal weighting to all fields.
 Figure 6: Lab 3.1 AP/PA, Left Lateral, LAO, and LPO with Equal Weighting

• What angles did you choose and why?

In treatment planning, dose distribution plays a big role. Once the target is established by the
physician, beams can be applied to start to create an ideal plan for the patient, maximizing dose
to the tumor volume and minimizing dose to normal tissues.1 This can be a challenging thing as
our patients are not square boxes and modifications need to be made in order to trick the machine
into thinking they are. I added two angles, a left anterior oblique and a left posterior oblique per
the plan requirements. With the intent to create an ideal plan, I tried a few different gantry angles
to see what would give the best coverage. I finally decided on a left anterior oblique (LAO) with
a gantry angle of 45 and a left posterior oblique (LPO) with a gantry angle of 150 indicated on
Lab 3.1 in the images.

Although it may be considered clinically insignificant, the first set of gantry angles chosen on
Lab 3.1, although only a 30-degree difference on the LPO (120 vs. 150 on Lab 3.2), showed
lower dose to the heart and esophagus. The dose with gantry angles 45 and 120 on Lab 3.1 also
showed less low dose outside of the target region/healthy tissue and slightly better coverage on
the D95% at 91.021% compared to 90.865% on Lab 3.2. However, it did show a higher lung
dose.
 Figure 7: Plan Evaluation of Lab Plan 3.1 vs. Lab Plan 3.2

Figure 8: ClearCheck Report Comparison of Lab Plan 3.1 and Lab Plan 3.2
 Figure 9: DVH of Lab Plan 3.1

• In your own words, summarize why beam energy is an important consideration for
lung treatments? (Review Khan, 5th ed., 12.5.B3, Lung Tissue)

Beam energy is an important consideration for lung treatments. When radiation is delivered, the
beam travels through many diverse types of matter including muscle, air, fat, and bone. 1 Each
structure of matter in the body has a different electron density “which affects the proportion of
beam attenuation by Compton versus photoelectric interactions.”1 When comparing the different
types of tissues, the lung has a low density (0.25-0.33 g/cm3) compared to soft tissue or bone and
will therefore attenuate less of the radiation beam.2 Bone, on the other hand, has a much higher
density (1.8 g/cm3 for compact bone) and will absorb more of the radiation.2

Within the air cavity there is a small loss of electronic equilibrium at the cavity surface, just
beyond the cavity surface or in low-density tissues resulting in a change in the electron fluence
and creating poor uniformity index.1,2 Lower density tissues such as the lung, allow for more
beam to pass through as it is unable to attenuate as much dose as the higher density structures.
This can lead to underdosing especially when using higher energy radiation.1

Plan 4: Alter the weights of the fields to achieve the best PTV coverage.
 Figure 10: Unequal Beam Weighting

• How does field weight adjustment impact a plan?

A tumor or target volume within a patient, is not always midline. Cancerous lesions can appear
anywhere within our body and not all are created equal. When beams are created, the number of
treatment beams, energy used and field size are just some of the factors that come into play and
can impact the dose distribution. It is important to consider when creating a plan how the dose
distribution affects the prescribed target volume and normal surrounding tissues. In some
instances, unequal doses need to be assigned to a beam, which is considered beam weighting. 1

By adjusting the weighting, the isodose lines showed better target coverage and sparing of
normal tissue around the perimeter of the field, particularly on the laterals where the oblique
fields were added. The orange isodose line decreased and is extending even less into the
contralateral side of the body. The final beam weighting I chose for this plan is higher on the
obliques as opposed to the anterior and posterior fields to help minimize dose to the anterior
field. The left lateral had the lowest weight in order to decrease dose spillage into the right lateral
side of the body. Modifying the beam weighting can be of benefit to reduce dose outside of the
planned tumor volume especially when multiple beams are used.2 The 100% isodose line still
does not cover the lung PTV, however, the 90% isodose line shown in green does. The absolute
dose to the PTV is 57 Gy at the 90% line.

• List your final choice for field weighting on each field.

My final choice for field weighting is as follows: AP: Gantry 0= 0.213, PA: Gantry 180= 0.184,
Left Lateral: Gantry 90= 0.124, Left Anterior Oblique: Gantry 45= 0.221, Left Posterior
Oblique: Gantry 150= 0.258

Figure 11: Weighting used for Gantry Angles

Figure 12: Dose Distribution for Unequally Weighted Fields

 Figure 13: DVH for Lab Plan 4

Plan 5: Try inserting wedges for at least one or more fields to improve PTV coverage. You
may also adjust field weighting if you feel it’s necessary.

Figure 14: Isodose Distribution after Wedged Fields

• Embed a screen capture of the beams-eye view (BEV) for each field that you used a
wedge.

a.) b.) c).

 d.) e.)

Figure 15: a.) AP EDW20Out; b.) PA EDW20IN; c.) Left Lateral EDW45IN; d.) Left Anterior
Oblique EDW45OUT; e.) Left Posterior Oblique EDW45IN

• List the wedge(s) used and the orientation in relation to the patient and describe its
purpose. (ie. Did it push dose where it was lacking or move a hotspot?)

Wedge filters often need to be added in instances of sloping surfaces. For example, when treating
the lung, the surfaces are typically rounded and the isodose curves are in turn non-uniform. By
adding a wedge filter, uniformity can be achieved. Wedges work best with multiple fields and in
the case where a hinge angle can be used to minimize hot spots within the field by tilting the
isodose curves.1,3 The wedge can “make the skin surface effectively flat and perpendicular to
each beam”1 to aid in creating an effective dose distribution.

The plan prior to adding wedges was not a very hot plan as it was 103.2% after the weighting
was changed in lab 4.With increasing the wedging on my beam angles the global dose minimum
declined reducing my dose to the PTV at the anterior aspect of the PTV. No hot spots were
created, and I wanted to push the dose so that it had better coverage. I added wedges at every
angle in this plan to see its impact.

After several attempts, the closest I could get to covering the PTV was with the following
wedges at their respective angles: AP EDW20Out, PA EDW20IN, Left Lateral EDW45IN, Left
Anterior Oblique EDW45OUT, and Left Posterior Oblique EDW45IN. This impacted my 95%
isodose line and had a total volume of 72.24cm3 with an equivalent sphere diameter of 5.2cm.
When comparing the different plans created, the D99.7% and D95% were the highest with the
final wedges described. The 3D dose max resulted in 103.5% with the minimum 3D for the PTV
totaling 82.7% and a mean of 96.8%.
 • Describe how your PTV coverage changed (relating to the 100% isodose line) with
your final wedge choice(s).

The 100% isodose line favoring the lateral aspect of the tumor was located within the lung PTV.
The 100% isodose line was measured at 2.62 cm away from the medial aspect of the lung PTV,
0.9 cm posterior, 1.2 cm superior, and 0.65 cm away from the lateral edge. Needless to say, it
was still not covering the PTV.

Figure 16: ClearCheck Report for First Two Plans

Figure 17: ClearCheck Report Comparison for Final Wedged Plan No Normalization

Figure 18. Lab Plan 5.5 DVH

Plan 6: Normalize your plan so that 95% of the PTV is receiving 100% of the prescription
dose.

Figure 19: Plan Normalized to 95% of the PTV Receiving 100% of the Prescription Dose

• What impact did normalization have on your final plan?

In Eclipse, I normalized so that 100% of the prescription dose was covering 95% of the target.
Normalization made a huge impact on my final plan. Throughout the lab, I really struggled with
coverage to the full extent of the PTV. Regardless of what I added, new beam angles, unequal
beam weighting, or wedges, I still was unable to achieve an optimal plan.

• What is your final hotspot and where is it?

With normalization, the 3D Max dose changed and increased from 103.5% to 111.4%. The
minimum 3D and mean for the PTV also increased totaling 91.69% and 105.4% respectively.
The hotspot location spread out more evenly and landed within the PTV covering the full extent
of the tumor volume.
 Figure 20: Hotspot Location Shown in Pink and Located Around the Tumor

• Are you satisfied with the location of the hotspot?

I am very satisfied with the location of the hotspot. If the hotspot was outside of the PTV, I
would need to re-evaluate my plan to see what changes can be made.

Figure 21: Lab Plan 6 DVH

Plan 7: There are many ways to approach a treatment plan and what you just designed was
just one idea. Using the tools of your TPS, your current knowledge of planning, and the
help of your preceptor, adjust or design your own ideal 3D lung treatment plan. Get
creative! You may adjust the beam energy, beam weighting, wedges, add field-in-field, etc.
Normalize your final plan so that 95% of the PTV is receiving 100% of the dose.
 • What energy(ies) did you use and why?

For my final plan, I used 6 MV for all of the treatment fields. Based on the size of the patient, I
did not feel it was necessary to use a higher energy. When treating the lung, lower energy
photons beams are the preferred choice among the photon energies to provide optimal coverage
to the PTV.
• What is the final weighting of each field in the plan?
For this final lung lab, I altered the angles so that there were three treatment beams. The final
beams were a RAO with gantry angle 355, a LAO with a gantry angle of 60, and a LPO with a
gantry angle of 124. The final weighting of my plan was 0.273 for the RAO, 0.371 for the LPO
and 0.356 for the LPO.

• Where is the region of maximum dose (“hot spot”), what is it, and is this outcome
clinically acceptable?

The region of maximum dose was located within the Lung PTV and was considered clinically
acceptable.

• Embed a screen cap of your final plan’s isodose distribution in the axial, sagittal and
coronal views.
 Figure 22: Final Plan for Lab 7

• Include a final screen capture of your DVH and embed it within this assignment.
Make it big enough to see (use a full page if needed). Be sure to provide clear labels
on the DVH of each structure versus including a legend. *Tip: Import the screen
capture into the Paint program and add labels. See example in Canvas.

Figure 23: Final DVH

 • Use the table below to list typical OAR, critical planning objectives, and the
achieved outcome. Please provide a reference for your planning objectives.

Organ at Risk (OAR) Desired Planning Objective Planning Objective Outcome

Spinal Cord D5cc<4400cGy 1801.6 cGy
Spinal Cord D0.035cc<4500-5000cGy 2030.8cGy
Lungs V2000cGy<30% 28.549%
Lungs V500<50-100% 46.154%
Lungs Mean<2000cGy 1411.2cGy
Heart D15cc<6000cGy 1521.6cGy
Heart D20%<4000cGy 165.6cGy
Heart D0.035cc<6800cGy 4251.6cGy
Heart Mean<2600cGy 166.9cGy
Esophagus D0.035cc<6000cGy 2182.1cGy
Esophagus D5cc<5100cGy 1913.2cGy
Esophagus V5000cGy<40% 0%
Esophagus V3500cGy<50% 0%
Esophagus Mean<2400cGy 521.4cGy
Larynx D3cc<4000cGy 1499.3cGy
Larynx D0.035cc<4600cGy 2327.7cGy

All planning objectives were referenced from our ClearCheck program where QUANTEC values
were used.
 Figure 24: ClearCheck Report for Final Lung Lab 7

Sources:

1. Gibbons JP. Khan's The Physics of Radiation Therapy, 6th Edition. Philadelphia, PA:
Lippincott, Williams, and Wilkins; 2020.
2. Bentel G. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hills; 1992.
3. Vann A. Beam Modifiers in Treatment Planning. [SoftChalk]. La Crosse, WI: University
of Wisconsin-La Crosse. Tissue Compensation (softchalkcloud.com) Last updated
December 5, 2022. Accessed April 6, 2023.
4. Khan F, Gibbons J, Sperduto P. Khan’s Treatment Planning in Radiation Oncology,
fourth edition. Philadelphia, PA: Wolters Kluwer; 2020.