PROSTATE FOSSA PLAN STUDY 1

ProKnow TG244 Prostate Fossa Plan Study

William A. Deere

University of Wisconsin – La Crosse

PROSTATE FOSSA PLAN STUDY 2

The final plan submission, with isodose lines in three planes.

This plan study was a challenging but rewarding experience, allowing me to explore

some newly acquired skills and techniques. I would like even more time to improve my score,
PROSTATE FOSSA PLAN STUDY 3

but I am ultimately satisfied with my final submission. For beam arrangement, I used a two arc

Voumetric Modulated Arc Therapy (VMAT) arrangement that is standard in my department.

Both arcs are co-planar and utilize a rotation of 350 degrees, with collimator rotations of 10 and

350 degrees respectively. The collimator rotation in this instance is to both give the optimizer

more potential solutions and accounts for the mild tongue and groove effect of the MLCs in the

Elekta VersaHD linear accelerator which the plan was generated for. I utilized 6MV energy, but

I experimented with 10MV for this assignment and did not immediately notice a benefit. Beam

weighting is virtually equal, at 51.60% of MU weight for beam 1A and 48.60% for beam 1B.

I generated my own optimization structures, which include Bladder-PTVs_5mm and

RectumPost_5mm, which are their respective original structures minus a 5mm expansion of both

PTV_56 and PTV_68, as well as PTV56opti which is PTV56 minus a 5mm expansion of

PTV68. I also generated a PTV_reduce structure which was a posterior portion of PTV_68 that I

selected based on this areas propensity for higher dose build up. The final structure I created was

prostatebed_min, is a contraction of the given prostate_bed structure. I generated both of these

structures based on tips from my preceptor.

The optimizer was set to perform 30 iterations before computing final dose. The resulting

optimization does not take very long, no more than a few minutes; this allows for quick

adjustments to the objectives and quicker overall optimization. When viewing the objectives

table, keep in mind that the weight listed for each function is almost entirely relative. So even

though the number seem high, the absolute number is not relevant. The top three functions as
PROSTATE FOSSA PLAN STUDY 4

well as the Max EUD function for the NT (normal tissue) structure were the first objectives I

utilized. This put the focus on conformality and coverage first before using the organs at risk to

affect the optimization directly. The first function listed, Uniform Dose, equally penalizes dose

that is both below and above the specified level. I used this for both PTV_68 and PTV56opti to

ensure that both PTVs would get adequate coverage. The Dose Fall-Off function for the external

contour (BODY) is fulfilling the same function as rings, if you are familiar with that technique. It

aims to reduce the dose from the specified high level of 6800 cGy to 3400 cGy at a 1cm distance

from the target. This function also has an option to adapt to target dose levels, so this works even

with the second PTV with a target level of 5600 cGy. Max EUD (Equivalent Uniform Dose) is a

function that works especially well to spare organs at risk and normal tissue. First you must a

maximum EUD that you are willing to accept for that structure, then you must set a Parameter A

value. If this number is 1, cold and hot spots are given equal weight. If this parameter is greater

than 1, higher doses are given higher weight. This is particularly effective for serial structures

like the spinal cord. By using this function for optimization structures which accounted for

overlap of the PTV, I avoided asking too much of the optimizer. The Max Dose function placed
PROSTATE FOSSA PLAN STUDY 5

on PTV_reduce aimed to keep the dose from building up in the posterior portion of PTV_68, the

same region which tended to overlap with the rectum.

For plan normalization, I normalized my plan to a 96.35% coverage to PTV_68 in

RayStation in order to meet ProKnow’s ideal result of 95% for the PTV_68 coverage metric. I

believe this is not unique to RayStation as a TPS but related to ProKnow’s method of analysis.

As for the areas where both PTV structures were not full receiving prescription dose, these cold

spots tended to be adjacent to the rectum and the bladder at the superior end of the PTV_68

structure. Having only the assistance of my clinical preceptor and the scoring system with

ProKnow, I believe that location of the cold spots for both PTVs are acceptable as they are a

result of improving the sparing of the rectum and bladder.

PROSTATE FOSSA PLAN STUDY 6

I initially found it difficult keep the higher dose regions of the plan within the prostate

bed. My preceptor demonstrated two techniques to attack this problem, and I utilized both in

different ways. One is the dose brush function of RayStaton, which allows for a customized

increase or decrease of a given dose to a given area, if dose is already present. I used this when I

was near my final optimization to cool down aspects of the plan. To keep the global dose max of

7196 cGy within the prostate_bed structure, I used the second technique which involves

generating a structure within a target and assigning it a minimum dose function. I named this

structure prostatebed_min and applied an objective function of min dose set to 6900 cGy. This

told the optimizer that I would like a higher than prescribed dose to be given to this specific area.

You may think this would make the plan itself hotter, but in this case it just pushed the higher

dose region (105% of prescribed dose) to the prostate_bed. From the dose volume histogram, we
PROSTATE FOSSA PLAN STUDY 7

can see that a meaningful portion of PTV_56 is receiving more than 6000cGy, since the higher

dose PTV was prioritized. This aspect of the plan may have room for improvement, but for the

sake of this challenge I did not focus on minimizing doses higher than 5600 cGy to the PTV_56

structure. Additionally, the rectum and bladder follow similar curves since I had multiple

objectives of focus for each OAR. Only 2.85 cm3 of the PTV_68 is receiving 105% or more of

the prescription dose. Notice the max dose given from RayStation is 7222 cGy while the same

plan submitted to ProKnow results in a maximum dose of 7196.4 cGy. It is within the central

aspect of the prostate bed structure which is ideal. I made a set of clinical goals which mimicked

the plan study goals given by ProKnow.

PROSTATE FOSSA PLAN STUDY 8

All of my clinical goals were met except for keeping the maximum dose below 7140

cGy. No matter what I changed during the optimization process the highest conformity index I

could achieve is .84. I was also never able to reduce the V65 of the bladder to less than 16% or

the V40 of the rectum less than 20%. The final plan I developed was not only the plan that

highest scoring plan I generated but I think the most clinically optimal plan as well. The total

monitor units of this plan were however on the higher side, which would likely lead to a

theoretical increase in integral dose. I would ask one of my physicists for further guidance in this

area. With my final plan, I ultimately decided to accept a V40 greater than 20% for the rectum

and a max dose over 7140 cGy within the prostate bed. If I continued working on this plan

challenge, I would aim to further reduce to the V40 and V65 of the rectum. I would like to

improve my conformity index as well as bring the bladder V65 to below 15%. I also believe I

could further decrease the maximum dose. I look forward to working on the additional plan

challenges ProKnow has to offer. I think having an independent scoring of my plan submissions

will significantly enhance my VMAT optimization and planning skills.

PROSTATE FOSSA PLAN STUDY 9

The scorecard for my highest scoring plan.