Makelle Barski

Clinical Practicum II
July 17, 2019
Proknow Prostate Plan Study
Prescription: 68 Gy to “PTV_68” (includes prostate bed)
56 Gy to “PTV_56” (includes lymph nodes)
34 fractions (SIB) x 200cGy

Organs at risk: Rectum, Bladder, Penile Bulb, Rt Femoral Head, and Lt Femoral Head.

Instructions: Proknow’s criteria needed for the plan.

Treatment Planning:
 Isocenter: I combined the PTV_56 and PTV_68 to make a PTV total and autoplaced the
isocenter in the center of the PTV total.

 VMAT: I used VMAT to achieve conformity and it was especially helpful to conform to
two different PTVs. Also, VMAT was used so there would be a decrease treatment time.
This decreases the risk of patient movement.
 Machine: Elekta Agility (machine in the department with VMAT and CBCT
capabilities)
 Beams: I chose two full arcs to get the best conformity. Collimator angles were used to
reduce tounge and groove effect.
o 1 Clockwise (181-179); Collimator 45; Couch 0
o 1 Counterclockwise (179-183); Collimator 315; Couch 0
 Energy: Both beams were 6 MV energy. I typically always try first with 6 MV first with
most cases and if the plan I am not achieving coverage or the patient is bigger, I would
try 10 MV. 6 MV worked out well.
 Dose Grid: Included all of the target volumes and the ROIs.

 Prescription: The prescription was set to 200 cGy x 34 Fractions. The percentage is
100%. The percentage is of point dose for the isocenter. I did add monitor units to a total
of 690 to get at least 95% for both PTV_68 and PTV_56.

 Auto-plan: I used Pinnacle’s auto- planning. Auto-planning creates its own optimization
structures and rings. Pictures below are the objectives I put in. Not pictured is the Dose
Fall-Off Margin which is 2.6 cm and the Hot-Spot Maximum goal which was 103%.
After the first optimization, I normalized the dose so that at least 95% of the PTV_56 was
covered by 56 Gy and that 95% of the PTV_68 was covered by 68 Gy. I did this by adding more
monitor units. I did add one more optimization manually to reduce dose to the rectum.

This helped tremendously reduce dose to the rectum. I did try pushing on the bladder and rectum
more but it was making me lose target coverage.
It is interesting to see what structures and optimization objectives auto-plan creates. (Refer to
picture below). It created the PTV56, PTV68, and Prostate bed to not overlap with any other
target structure. So PTV_56 was carved from the PTV_68. The PTV_68 carved out the PTV_56
and surprisingly the prostate bed. These then were heavily weighted and contained a minimum
and maximum dose constraint. Auto-plan made rectum and bladder structures that avoided the
PTV and put a low dose but low weighted constraint on that. Auto-plan made a 2 cm ring
(seashell) 2 cm away from the PTV. Another structure was the body avoiding the interior of that
ring and everything inside was created too. These were weighted the heaviest with a low dose
constraint. Auto-plan also makes cold and hot spots for each of the target structures to try and
lower the hot spots or bring more dose to the cold spots by putting a minimum (cold) or
maximum (hot) dose on them. It then put low dose constraints and heavy weights on the rectum,
bladder, and posterior portion of the rectum.
• Isodose Lines: Isodose lines are shown below: We can see that the lower dose isodose lines
such as the 50% scoops in anteriorly for the rectum and the scoops in posteriorly for the bladder
to avoid those structures as much as possible.

PTV_56: 98.95% of the volume is receiving 100% of the dose

5600 isodose line- hugs the majority of the PTV but misses on a couple slices on
of the PTV posteriorly near the rectum. This isodose line extends around the
PTV_68 as well but does not hug it because of the higher dose.
PTV_56: 99.77% of the volume is receiving 95% of the dose
5320 isodose line- nearly encompasses the total volume. The portion it does miss
is on a couple slices is on PTV posteriorly near the rectum. This isodose line
extends around the PTV_68 as well but is not hugging it because of the higher
dose.
PTV_68: 95.20% of the volume is receiving 100% of the dose
 6800 isodose line- hugs the PTV for the most part laterally. Scoops in posteriorly
and medially to miss some of the PTV and anteriorly slightly and misses some of
the PTV.
PTV_68: 99.41% of the volume is receiving 95% of the dose
6460 isodose line- covers all the PTV except for the posterior medial portion.
Prostate_bed: 100% of the volume is receiving 100% of the dose
Picture: PTV_56 isodose lines (95% and 100%)

Picture: PTV_68 isodose lines (95% and 100%)

 Coldspots: There were coldspots medially on the PTV_68 both anteriorly and posteriorly
(pictured above). This is acceptable because of the dose constraints on the rectum and the
bladder. In regards to the PTV_56, there was a cold spot where the rectum overlapped the
PTV so that was also acceptable because of the dose constraint (pictured below).

 Max Point Dose: (Pictured below) It is 7238.5 cGy and it is within the PTV_68. It is
posterior and to the right side in the PTV. The placement is acceptable; however, it is not
ideal because it is not within the prostate bed outlined in red.
 DVH:
 Pinnacle Scorecard:

 Proknow Scorecard: These do differ slightly than the pinnacle scorecard which is to be
expected.

 DISCUSS the following:

o If you were able to improve coverage or minimize hot spots after each optimization
attempt – what was your process? Did you try any new tricks?
o To improve the coverage I just bumped up the MU to get at least 95% to both
PTVs. I had a few “specks” of 105% and I tried contouring them and optimizing;
the plan ended up getting hotter. I also tried uniform dosing the PTVs but that was
unsuccessful too (I found that this usually helps bring down the maximum).
o I did try new tricks but it was not pertaining to hot spots. I tried auto-planning for
the first time after I was not satisfied with the plan after manually planning it.
This worked out very well for me. I also made a structure (“3500 rec”) where I
contracted the rectum only anteriorly by .7 cm. Then I was able to set a max dose
of 3400 to the posterior portion of the rectum so I could meet objective of no 3500
isodose line crossing the rectum. I struggled with this when I manually was doing
the plan and it was the biggest problem.
o Was there a metric you were unable to meet, and if so, how did you try to fix it?
o I was unable to meet the bladder constraints ideally; however, I was very close to
meeting it ideally and it was in the acceptable range. I did try pushing on the
bladder by optimizing to it even more but it would put my rectum constraints in
the acceptable range (knocking them out of ideal) and I figured the rectum was
worth more points so I stayed content with not pushing on the bladder. I did try
making the plan more conformal by making a 50% isodose structure and
optimizing it to have a lower dose. This lowered my coverage and when I tried
bumping up the MUs to increase coverage the plan got hotter. I did not meet the
.03 cc ideally, but what I did to try to fix that is in the question above regarding
the hotspots. Lastly, my max dose was not ideal but it was acceptable. I did try to
relocate it but putting a high dose objective in the prostate bed but that knocked
out some other objectives. I was satisfied with the plan I had even though not
everything was ideal, it was a give and take on what I thought was more
important. Target coverage was the biggest priority.
o Did you sacrifice points on a specific metric to improve your plan in other areas?
What was your rationale?
o I did sacrifice meeting ideal bladder coverage so that I could get ideal rectum
coverage. It seemed to be of more importance on the metric scale we were
provided. When I attempted to get ideal coverage on bladder, it would take the
rectum out of ideal. Also, attempting to lower the hot spots, moving the max point
dose, and making it conformal were all acceptable but when I tried to make them
ideal, I was sacrificing target coverage so I did not push on those because
coverage was more important.