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Homogeneity index, hot spot areas, the maximum dose, and the lung constraints were significantly reduced in the prone position (p < 0.05).
In our practice, the lung constraints were set as V20 < 22% and MLD <12 Gy.
The lung constraints consisted of a central lung distance below 3 cm, the mean lung dose had to be <7.5 Gy, the heart constraints consisted of a maximum heart distance below 1 cm, the heart volume receiving >10 Gy had to be <5 %, and the heart volume receiving >5 Gy had to be <10%%.
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The patient had a very large tumor and we had to limit the total dose delivered because of lungs constraint.
In this study, we considered VILI in the framework of lung anatomical constraints and physical forces.
The lung dose constraint was specified such that no more than 35% of the pulmonary parenchyma (defined as total lung volume minus PTV) received ≥20 Gy.
If lung or heart constraints cannot be met, some underdose in the thoracic wall target volume can be accepted to reach the constraints, provided that the quadrant where the primary tumour was localized is adequately covered.
Critical structures and constraint-lung volume dose constraints were set in the optimization procedure.
For joint lungs excluding PTV, constraints of V5Gy < 30%, V10Gy < 20%, V20Gy < 10 were set and a mean dose <4Gy was accepted.
We could not scan the whole lung due to time constraints and radiation exposure, so we chose to limit CT images to a representative lung fraction, from the carina to the diaphragm.
Whenever possible, the following constraints were respected: lung dose (volume of the two lungs – PTV) receiving >20 Gy (V20) <20% of the total lung volume.
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