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Renee Jackson
Clinical Practicum III
October 9, 2019

CSI Plan Study

Plan 1: Brain

Prescription: 36Gy at 1.8 Gy/day

Target: PTV_Brain

Patient Position: Supine

Organs at Risk
The organs at risk include: Spinal cord, Left and Right Optic Nerves, Left and Right
Submandibular glands, Thyroid, Left and Right Eye Globes, Esophagus, Brainstem, and Left and
Right Lens.

Figure 1. Demonstrates the organs at risk.

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TrueBeam Linear Accelerator

Field Energy Field Size Collimator Gantry Angle
ARC 1 6MV 21.5 x 19.1 0 181 CW 179
ARC 2 6MV 21.5 x 19.1 0 179 CCW 181
Figure 2. Fields for Brain PTV
Asymmetrical jaws using half beam technique.

Figure 3. Jaw Settings for Brain PTV

First, I created a field using the half beam technique. I closed the Y1 jaw to zero and only
included the brain and spine PTV (Brain/Spine PTV) until slice -10.00 on the CT, this will be my
new PTV that I will optimize to. I combined the brain and spine PTV’s using the Boolean feature
under Contouring tab. Slice -10.00 will also serve as my match line for the Cervical/thoracic
spine field.

Figure 4. Brain/Spine PTV contoured in yellow.

Using the Brain/Spine PTV, I added MLC’s with a 0.5cm margin.

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Plan Optimization
The plan was normalized so that 95% of the target is receiving 100% of the prescription dose.

Figure 5. Optimization for Brain PTV.

Global Max Dose
The Global max dose was 111.4%. It is located on the left side of the patient’s skull.

Figure 6. Global Max Dose of 111.4%

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Dose Volume Histogram

Figure 7. Dose Volume Histogram for Brain PTV

Plan 2: Spine

Prescription: 36Gy at 1.8 Gy/day

Target: PTV_Spine

TrueBeam Linear Accelerator

Organs at Risk
The organs at risk include: Spinal cord, Left and Right Kidneys, Left and Right Lungs, Thyroid,
Heart, Esophagus, Liver, Rectum, Left and Right Femoral Heads, Stomach, and Bowel.
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Figure 8. Organs at risk for Spine PTV.

The Spine PTV is too long to treat in one field, so I split the field into two isocenters.

Cervical/Thoracic Spine Field

Field Energy Field Size Collimator Gantry Angle
ARC 1 6MV 11.1 x 20 0 181 CW 179
ARC 2 6MV 11.1 x 20 0 179 CCW 181
Figure 9. Fields for Cervical/Thoracic Spine Field.
For this field, I also used the half beam technique by closing Y2 to zero and placed the isocenter
at slice -10.50cm. I extended the Y1 jaw to slice -32.00cm. The Spine PTV that is included in
this field is labeled PTV Spine 1. MLC’s were added with a 0.5cm margin.
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Figure 10. Cervical/Thoracic Spine Field

Lumbar Spine Field

Field Energy Field Size Collimator Gantry Angle
ARC 1 6MV 16.2 x 19.3 0 181 CW 179
ARC 2 6MV 16.2 x 19.3 0 179 CCW 181
Figure 11. Lumbar PTV fields.
A second spine field was created to treat the remainder of spine PTV. The new PTV for this
field was labeled Lumbar Spine PTV. MLC’s of 0.5cm was added to the PTV.
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Figure 12. Field for Lumbar Spine

Both treatment areas were added into the same plan by ungrouping the fields to allow two
different isocenters. My physicists suggested overlapping the Y2 jaw of the Lumbar fields with
the Y1 jaw of the Cervical/Thoracic fields, by 3.0cm to allow necessary coverage of the PTV.
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Figure 13. Demonstrates the overlapping of fields.

Jaw Settings

Figure 14. Jaw Settings for both Cervical/Thoracic and Lumbar Spine fields.
Plan Optimization
The plan was normalized so that 95% of the target is receiving 100% of the prescription dose.
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Figure 15. Optimization for Spine PTV

During optimization, the only structures that I had to really push were the right and left kidneys.
I set a dose of 90cGy with a priority of 150 to bring the mean dose into range. The Spine PTV
was set a priority of 170 for the upper limit and 150 for the lower limit. The upper priority was
set higher to lower the dose where the two fields overlapped.

Global Max Dose

The Global max dose was 112.4%. It is located on the left side of the PTV near the cervical
spine.
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Figure 16. Hot spot for Spine PTV 112.4%

Dose Volume Histogram

Figure 17. Dose Volume Histogram for Spine PTV

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Plan Sum
A plan sum was created with all three fields.

Figure 18. Demonstration of the Brain and Spine PTV fields.

Constraints

Structure Objective Result

PTV - Brain 95% of volume ≥ Rx dose 95% = 36 Gy
PTV Spine 95% of volume ≥ Rx dose 95% = 35.9 Gy
Spinal Cord V45 < 100% Max dose = 42.4 Gy
Brainstem V60 < 0.9 cc / V54 < 100% V60 = 0 cc / V54 = 0 %
Rt Optic Nerve Maximum < 55 Gy to 0.1 cc Max dose = 34.7 Gy / 0.1 cc = 32 Gy
Lt Optic Nerve Maximum < 55 Gy to 0.1 cc Max dose = 34.8 Gy / 0.1 cc = 32 Gy
Rt Globe of Eye < 50 Gy to 0.1 cc Max dose = 35.5 Gy / 0.1 cc = 33.5 Gy
Lt Globe of Eye < 50 Gy to 0.1 cc Max dose = 35.4 Gy / 0.1 cc = 33.5 Gy
Thyroid V26< 20% V26 = 0 Gy
Rt Lens < 12 Gy Max dose = 7.2 Gy
Lt Lens < 12 Gy to 0.1 cc Max dose = 7.1 Gy
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Left Parotid Mean dose < 26 Gy Mean dose = 12.6 Gy

Right Parotid Mean dose < 26 Gy Mean dose = 12.5 Gy
Mandible < 70 Gy, if not possible, then Max dose = 37 Gy

R Submandibular Mean dose < 35 Gy Max Dose = 7 Gy

L Submandibular Mean dose < 35 Gy Max Dose = 8Gy
Bowel V50 < 1% V50 = 0%
V40 < 30% V40 = 0%
Rt Kidney Median dose < 17.5 Gy Median dose = 8.3 Gy
Lt Kidney Median dose < 17.5 Gy Median dose = 7.9 Gy
Rt Femoral Head < 45 Gy Max dose = 0.7 Gy
Lt Femoral Head < 45 Gy Max dose = 1.3 Gy
Bladder Max dose = 1.9 Gy
Rectum Max dose = 23 Gy
Right Lung MLD < 20 Gy Mean dose = 7.6 Gy
Left Lung MLD < 20 Gy Mean dose = 7.6 Gy

Esophagus Mean dose < 34 Gy Mean dose = 11.8 Gy

Stomach Max dose = 45 Gy Max dose = 12.7 Gy

Heart Mean Dose Mean dose = 6 Gy

Liver Mean dose < 25 Gy Mean dose = 6.9 Gy

Figure 19. Constraints Sheet

During the planning process, I also tried using the Alignment feature through Eclipse treatment
planning system. For some reason we could not get the function to work properly with using all
three fields. The physicist suggested using VMAT to give an evenly distributed dose while
sparing the critical organs.
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References
1. Quantec Normal Tissue Constraints Guide.