1

Jenny Kouri
Clinical Practicum
April 10, 2015
Non-Small Cell Lung Cancer (NSCLC) of the Left Lung
History of Present Illness: TG is a 65-year old male with stage IIIb, NSCLC of the left lung
with histology of poorly differentiated squamous cell carcinoma. This patient presented to the
Pulmonary Service in March 2015 with a 10 day history of hemoptysis in the amount of
approximately 3-4 tsp every morning and 1-2 tsp approximately 2 more times throughout the
day. TG was evaluated by his Primary Care provider and underwent a chest x-ray on 3/16/15,
which showed an increase of airspace opacity in the base of the left lung. He then underwent a
computed tomography (CT) of the chest on 3/18/15, which revealed an enlarged left hilar and
infrahilar mass with obstruction of the left lower lobe bronchus as well as enlarged mediastinal
lymph nodes. TG then proceeded to undergo a bronchoscopy on 3/23/15, which revealed a large
endobronchial lesion completely obstructing the left bronchus intermedius. A fine-needle
aspiration (FNA) biopsy was positive for squamous cell carcinoma from the left secondary
carina, bronchus intermedius. TG was presented at the Pulmonary Tumor Conference and
deemed not a surgical candidate due to the evidence of contralateral mediastinal lymph node
involvement. This patient was referred to the radiation oncology department for consultation of
radiation therapy to the left lung. The radiation oncologist recommended thoracic radiotherapy
with concurrent chemotherapy for tumor control. The radiation oncologist discussed the
importance of reduction or cessation in smoking and alcohol assumption during treatment for
better treatment tolerance. Thoracic radiation therapy side effects and risks were also explained
with the patient. TG was in understanding of the physicians recommendations and agreed to
proceed with the treatments. The patients informed written consent was obtained.
Past Medical History: TG had a past medical history of essential hypertension, continuous
tobacco use disorder, chronic posttraumatic stress disorder, benign hypertrophy of prostate
without urinary obstruction, exanthema, lipoma, obesity, rheumatoid arthritis, radiculopathy,
chronic back pain, and alcohol dependence. In addition, the patient reported of Penicillin
allergies.
Diagnostic Imaging: Further workup included a positron emission tomography-computed
tomography (PET/CT) on 3/31/15, which showed intense hypermetabolism of a left hilar mass

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that extended 4.4 cm into the left lower lobe. Hypermetabolism also appeared in an enlarged left
hilar lymph nodes and a contralateral mediastinal lymph node as well. Subtle hypermetabolism
appeared in multiple ipsilateral mediastinal lymph nodes. There was no evidence of distant
metastasis.
Family History: TG reported colon cancer in his material aunt.
Social History: TG reported a history of significant alcohol use including recently. TG would
consume 2-4 drinks of vodka per day. He had a rigorous smoking history and has reduced to
smoking 2-3 cigarettes a day over the past year to year and a half. The patient reported he is a
veteran, single, and lives alone. He was previously employed in the construction industry. The
patient reported that he is still reasonably active and rides his bike.
Medications: TG currently takes Hydrocodone, Methocarbamol, Metoprolol Tartrate,
Minocycline, Omeprazole, Paroxetine, Trazodone, Zolpidem Tartrate, and daily multivitamin
with minerals.
Radiation Oncologist Recommendations: After Pulmonary Tumor Conference, the radiation
oncologist recommended the patient to undergo a radical course of radiotherapy to the involved
sites of disease in his mediastinum and left lung. Radiation was to be given concurrently with
chemotherapy. It is not possible to cure unresectable NSCLC tumors without local disease
control.1 The radiation oncologist wanted to utilize intensity modulated radiation therapy (IMRT)
to reduce risk of pneumonitis and necrosis of the spinal cord. IMRT offered optimal planned
target volume (PTV) coverage while maximizing sparing of surrounding normal tissues,
particularly the spinal cord and the lungs. Regional tumor control decreases with conformal 3D
radiation therapy. The preferable high doses delivered by 3D-CRT combined with chemotherapy
for NSCLC is not feasible for organs at risk (OAR). 2
The Plan (Prescription): The left lung and mediastinum will be treated to a dose of 6,000cGy in
30 fractions to be given daily over 6 weeks using 6MV photons via a 5-field IMRT treatment
plan. The radiotherapy dose will be prescribed to the 95% isodose line to ensure optimal PTV
coverage.
Patient Setup/Immobilization: Following the consultation, TG underwent a CT simulation scan
for radiation therapy treatment. He was positioned supine, head to gantry on the Philips
Brilliance Big Bore simulator couch. To stress a reproducible set-up, TG was immobilized with
his arms up in a wingboard and a vaclock. A large knee sponge was utilized. A planning CT of

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the thorax without IV contrast was done and an isocenter was chosen. A 3-point set-up was
marked with tattoo ink on the patients chest for laser positioning prior daily treatment. The
physician placed the simulation isocenter. The diagnostic PET-CT was fused to the planning CT
to help facilitate contouring of radiotherapy target volume.
Anatomic Contouring: After simulation, the CT scans were imported to the Pinnacle3 9.10
radiation treatment planning system (TPS). The physician contoured a clinical target volume
(CTV) around gross disease highlighted on the PET-CT. The CTV included a 1 cm margin
around the gross disease. A 0.5 cm margin was used for the planned target volume (PTV) and for
the planning risk volume (PRV) around the spinal cord. The expansion of the target volumes
incorporated presumed microscopic extension and organ motion. If gating technique is not used,
radiation fields must cover the gross disease and allow for breathing.1 To evaluate and record
dose attenuated by the OAR during treatment, the medical dosimetrists contoured the right and
left lung, the total lung minus the PTV, heart, carina, spinal cord, and liver. The spinal cord was
expanded with a margin of 0.3cm to create a planning risk volume (PRV).
Beam Isocenter/Arrangement: TG was treated on a Varian Clinic IX linear accelerator. During
the simulation process, the radiation oncologist placed the isocenter in the lung tumor. Beam
angles were placed manually. A 5-field beam arrangement at gantry angles of 340, 20, 210,
150 and 180 were used. These angles were chosen to reduce as much dose to the contralateral
lung as possible without compromising dose to the target volume. Entrance and exit beams were
oriented at least 5 or more apart to avoid parallel opposed (POP) beams. The senior medical
physicist reviewed the beam placements before proceeding further into the treatment planning.
The collimator and couch angles were set at 0 for all of the fields. Treatments were delivered
with 6MV photons utilizing the sliding window IMRT. Figure 1 displays the 3-dimensional
beams eye view (BEV), digitally reconstructed radiograph (DRR) of all 5 beams.
Treatment Planning: The maximum number of segments was set at 40 and a direct machine
parameter optimization (DMPO) was selected. A NSCLC dose table was used to guide treatment
planning. The dose constraints from the dose table are derived from the Radiation Therapy
Oncology Group (RTOG) Protocol 0617. Figure 2 displays the NSCLC dose table. An objective
of the PTV was set for a minimum dose and uniform dose of 6100cGy. The maximum dose for
the PTV was set at 6500cGy. Each of these objectives were weighted 25%. Objectives for the

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heart, total lung minus CTV, spinal cord PRV, and esophagus were determined. The objectives
for the regions of interest (ROI) are shown in Figure 3.
To reduce dose streaking at the 50% isodose line, two rings were created. Ring 60 was
made by expanding the PTV by 1.5 cm. Ring 35 was a PTV expansion of 3 cm. Ring 60 and
ring 35 were assigned a maximum dose of 5700cGy and 3500cGy, respectively. The weight of
ring 60 was 17%, ring 35 was 9%. These initially were weighted lower, but to reduce streaking
and to create a more conformal dose distribution around the PTV, the weighting was increased
during planning. Figure 4 displays the ring contours in the sagittal, coronal, and axial view.
Despite the weighting of the rings, unwelcomed hot spots still presented on the plan. The hot
spots were contoured. In effort to cool the hot spots, they were assigned a maximum dose of
3000cGy with a weighting of 1%.
The finalized plan had a maximum dose of 7095.2cGy. The hot spot was located within
the PTV. The majority of the 95% isodose line covered the PTV. Dose to the OARs met all the
goals required by the RTOG 0617. Figure 5 shows the completed NSCLC dose table. The final
plan was carefully analyzed by the medical oncologist and was approved for treatment. Figure 6
displays the sagittal, axial, and coronal view of dose distribution. Figure 7 demonstrates the dose
volume histogram (DVH) of the finalized plan.
Monitor Unit (MU) Checks: Tissue inhomogeneity corrections were applied to all dose
calculations. Pinnacle3 9.10 calculated the finalized plan with a total of 616 MU. MuCheck
preformed a second calculation check. MU calculations must be within a +/-5% deviation for all
IMRT plans. Computed MU outside of +/- 5% must be recalculated and reviewed by the medical
physicist. All 5 fields were within tolerance. Figures 8 and 9 displays the calculated MU
computed by MuCheck.
Quality Assurance (QA) Checks: A plan validation was performed by ion chamber in solid
water and ArcCheck diodes. The ion chamber plan percentage difference was -0.85% and the
average percentage of ArcCheck diodes passed was 99.9%. The summary of the test was charted
and double checked by the medical physicist. An IMRT note was documented and signed by the
medical dosimetrist and radiation oncologist. This note stated the plan prescription, maximum
dose, and the results of the quality assurance tests.
Conclusion: Typically at my clinical site, 3-dimensional conformal radiation therapy (3DCRT)
is used for lung treatment planning, rarely IMRT. This particular lung tumor inhabited the

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majority of the left lung. As I scrolled through the CT slices, I studied the extensiveness of the
tumor, which presented from the inferior aspect of the lung and stretched almost to the apex.
Due to the dimensions of the tumor, this plan was a challenge to cover the PTV while trying
deliver little dose as possible to the OARs. Working alongside the physicist, I learned the
contralateral lung could be spared with appropriate orientation of the beam angles.

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Figures

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Figure 1: BEV DRR of treatment fields

ROI

PTV= CTV + 0.5cm

Vol
(cc)

Hard Constraints

Soft Constraints

Min PTV dose >

93% px dose

Min PTV dose >

95% prescribed
dose

D90 > px dose

D0.03cc < 125% px
dose

Min dose is for vol

of 0.03cc
D0.03 < 120% px
dose

Min Dose=

Y/N

D90=

Y/N

D0.03cc=

Y/N

V120%=

Y/N

D0.03cc=

Y/N

V120=

Y/N

Mean dose=

Y/N

Mean dose=

Y/N

V60=

Y/N

D0.03cc=

Y/N

V60 < 33%

V60=

Y/N

V45 < 66%

V45=

Y/N

V40 < 100%

V40=

Y/N

Mean dose < 25Gy

Mean dose=

Y/N

Hot Spot (vol. outside

of PTV)
Spinal Cord PRV
(5mm)

V120% < 1cc

Max dose (0.03) <
50.5Gy

Total Lung Vol-CTV

V20 < 37%

V20 < 32%

Mean dose < 20Gy

Esophagus

Mean dose < 34 Gy

Brachial Plexus
Heart

Liver

Meets
Goal

Max dose < 66 Gy

Figure 2: NSCLC Dose Table was used to guide treatment planning and aid in assigning
objectives.

ROI
External
GTV SIM
TableH20_EQ
GTVp-JS
Carina
CTV_6000_10JS
PTV_6000_05JS
Esophagus
RT Lung
LT Lung
Heart
Spinal Cord
Spinal Cord
PRV
Liver
Total Lung-CTV
Ring 60 PTV
3cm exp
Ring 35
Cool
UST

Volume
(cm^3)
30048.4
1.63395
1529.33
139.323
18.4866

Min
Value
0.1
6225.0
0.0
5956.0
963.4

Max
Value
7066.7
6638.1
2607.0
6923.2
6768.6

Mean
Value
848.9
6442.8
27.4
6384.2
5792.1

Std.
Dev.
1629.8
86.0
180.0
130.3
1218.1

Unit
s
cGy
cGy
cGy
cGy
cGy

% Outside
Volume
1.63%
0.00%
4.17%
0.00%
0.00%

457.888

5825.9

7066.7

6375.2

130.1

cGy

0.00%

699.968
51.1137
2439.54
1294.18
726.596
58.0701

4481.3
77.5
24.5
64.6
104.0
25.4

7066.7
6646.7
6584.0
6810.2
6700.1
4619.9

6309.4
2200.1
816.1
3927.8
1587.8
1411.5

192.1
2538.8
1280.0
2052.8
1817.9
1660.5

cGy
cGy
cGy
cGy
cGy
cGy

0.00%
0.00%
0.00%
0.00%
0.00%
2.46%

186.406
2086.16
3583.19
258.738
3790.07
666.966
1.43017
22525.9

23.8
2.1
24.5
1497.9
148.6
0.0
3019.7
0.1

4880.0
156.4
6784.4
6787.3
7066.7
6473.4
3569.8
6787.3

1414.3
42.3
1707.3
5374.2
3661.7
1710.9
3162.9
603.8

1658.5
25.0
2012.8
849.9
2187.6
1687.5
75.4
1284.5

cGy
cGy
cGy
cGy
cGy
cGy
cGy
cGy

2.57%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
2.15%

Figure 3: Region of Interest Dose Statistics

Figure 4: A sagittal, axial, and coronal view of Ring 60 (red color-wash) and Ring 35 (orange
color-wash). The PTV is shown in blue color-wash.

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ROI

PTV= CTV + 0.5cm

Vol (cc)

699.95

Meets
Goal

Hard Constraints

Soft Constraints

Min PTV dose >

93% px dose

Min PTV dose >

95% prescribed
dose

Min Dose= 6040cGy

Y/N

D90 > px dose

Min dose is for vol

of 0.03cc

D90=4788cGy

Y/N

D0.03cc < 125% px

dose

D0.03 < 120% px

dose

D0.03cc=6890cGy

Y/N

Hot Spot (vol. outside

of PTV)

V120% < 1cc

V120%=0%

Y/N

Spinal Cord PRV

(5mm)

Max dose(0.03) <

50.5Gy

D0.03cc=4812cGy

Y/N

Total LungVol-CTV

V20 < 37%

V20=34%

Y/N

Mean dose=1710cGy

Y/N

Mean
dose=2200.1cGy

Y/N

V60=15%

Y/N

V20 < 32%

Mean dose < 20Gy

Esophagus

Mean dose < 34 Gy

Brachial Plexus
Heart

Liver

Max dose < 66 Gy

D0.03cc=NA

V60 < 33%

V60=4%

Y/N

V45 < 66%

V45=10%

Y/N

V40 < 100%

V40=13%

Y/N

Mean dose < 25Gy

Mean dose=42.5cGy

Y/N

Figure 5: Completed, finalized NSCLC Dose Table

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Figure 6: A sagittal, axial, and coronal view of the dose distribution. The PTV is barely clipped
by the 95% isodose line (green).

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Figure 7: DVH for finalized plan

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Figure 8: Fields 1-4 MuCheck

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Figure 9: Field 5 MuCheck

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References
1. Bradley J. A randomized phase III comparison of standard-dose (60Gy) versus high-dose
(74Gy) conformal radiotherapy with concurrent and consolidation carboplatin/paclitaxel
+/- cetuximab (ind #103444) in patients with stage IIIA/IIIB non-small cell lung cancer:
RTOG 0617. Radiation Therapy Oncology Group (RTOG).
http://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=0617.
Published March 6, 2014. Accessed April 19, 2015.
2. Bree I, van Hinsberg M, van Veelen LR, et al. High-dose radiotherapy in inoperable
nonsmall cell lung cancer: comparison of volumetric modulated arc therapy, dynamic
IMRT, and 3D conformal radiotherapy. Med Dosim. 2012; 37(4): 353-357.
http://dx.doi.org/10.1016/j.meddos.2011.12.002.