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Lymphoma VMAT treatment summary

1. The treatment site was at head and neck with mediastinum for Hodgkin
lymphoma stage IIB. The prescription was 1.75 Gy/day x12 Fractions=21 Gy
total. The radiation oncologist gave the dose intent based on RTOG 0839
reference. VMAT was used for planning.
2. The dose origin was set to zero at isocenter based on the simulation images
and measurement, and a reference point was created as primary reference
point for dose tracking.
3. Dose was prescribed to 100% without normalization point in VMAT.
4. While waiting for the physician drawing the CTV and PTV volumes, I started
contouring the OARs. Per the preceptors preference, I added an opti PTV
structure with 0.3 cm margin from the PTV drawn by physician, and cropped
0.5 cm off body contouring. The original PTV was extended beyond the body
structure at neck area. Another structure called NS_ring excluding the PTV
with 1.0 cm margin from opti PTV was created to allow dose fall off and
improve dose conformity. Some dosimetrists may prefer creating three rings
around PTV with certain margins for the same goal.
5. After the entire settings were done, I started working on the fields. I planned
to add two full arc beams with reverse arc directions which were arc 1
clockwise (CW) from 181 to 179 degrees and arc 2 counter-clockwise (CCW)
from 179 to 181 degrees. Under the Arc Geometry tool in planning menu,
there was default option of one isocenter for two full rotations. After selected
the target, two full arcs with MLC were automatically created with
corresponding collimator angles too. However, the collimator angles should
be evaluated and carefully adjusted as needed.
6. Under each field properties, I renamed each beam with the range and
direction of rotation, and set up the beam energy as 6 MV at 600 MU/min rate
and ARC technique for VMAT setting. New DRR for each beam was added with
bones parameter.
7. Prescription dose with number of fractions was filled out. The algorithm
AcurosXB_13.5 was selected under calculation models and under physical
material table in structure properties.
8. Then the plan was ready for optimization.
9. Under plan optimization, I first set up the normal tissue objective with 120%
priority, 0.3 cm distance from target border, 100% start dose and 65% end
dose, and 0.15 fall-off to better view the trends of the lines. I then added
upper and lower levels to opti_PTV to constrain the dose with 1.04% of
prescription dose at upper level, and 1.02% of the dose at lower level with
100% priorities. I also added a lower level with prescription dose at zero
priority as a reference line to track the dose constrain in PTV.
10.Based on the dose intent and dose tolerance of organs, I added upper levels
to the critical OARs to constrain the maximum dose to those structures.
Priorities were added at low levels to each dose constrain.

11.After checking the automatic optimization mode and automatic intermediate

dose, I started the optimization process. I observed the line changes in DVH,
and the isodose lines in transversal view of the body while watching the
optimization process. I eventually increased the priority to opti PTV and OARs
to achieve the dose constrains given in dose intent. As the total dose was
only 21 Gy which was within most OARs tolerance, the major focus was to
constrain the dose to PTV for good coverage. So I gave the opti PTV the
highest priority, and then the NS_Ring structure secondly to push the most
doses to target. The other OARs priorities were slowly increased for as low as
possible dose to the structure.
12.Sometimes, I paused the optimization for more changes. When I was satisfied
with the dose constrains in opti PTV and OARs, I let the optimization process
continue and the plan was calculated automatically.
13.Under external beam planning, I again evaluated the plan by checking the
dose coverage of PTV in DVH and isodose lines, and hot spot location.
14.I ended to re-optimize the plan to improve the PTV coverage and cool down
the plan.
15.Per the dose intent, 95% of PTV volume covered by 21 Gy of the prescription
dose was achieved. The OAR dose constrains were all met too. Because some
portion of the PTV was out of body contour, the PTV coverage may be
affected. However, in this case, the PTV coverage was great. My plan was
9.2% hotter.
16.So I stopped at this point and had the dosimetrist to evaluate it. The
dosimetrist agreed with my plan.
17. I compared my plan with my preceptors and found his plan had better
coverage of PTV with 11.4% hotter. I was nervous to exceed 10% of
prescription dose. However, per my preceptors experience, he was confident
to heat the plan for better coverage.
18.I will follow up this plan for QA and treatment observation.