Michal Liu

DOS 772 Clinical Practicum II

ProKnow Prostate Plan Study

Provide an in-depth description of your treatment planning process (energy, gantry, couch,
collimator angles, technique, etc.). Provide references, if any were used to determine your
technique (references are not required). Give a detailed summary of your plan outcome and
evaluation process.
For my prostate plan I created a VMAT plan with two Arcs. Arc 1 had a gantry rotation of
181 -179 o moving clockwise. Arc 2 had a gantry rotation of 178 o -182 o moving
o

counterclockwise. Both arcs were 10MV photon energies. Arc 1 had a collimator angle of 90 o to
better block the rectum with the MLC’s. Arc 2 had a collimator angle 5 o to reduce dose
accumulating from interleaf leakage from the MLC’s. Prescription was for a PTV68 = 6800 cGy
and a PTV56 = 5600 cGy, simultaneous boost in 34 fractions.

Planning structures created:

_56PTVIN: 1cm inner margin from PTV56. Bladder and rectum cropped out. Cropped 5mm
away from PTV68
_56PTVOUT: _56PTVIN, bladder, and rectum cropped out. Cropped 5mm away from PTV68
_56PTVOAR: portion of bladder & rectum inside of PTV56. (used to keep hotspot out of OAR)
_68PTVIN: 1cm inner margin from PTV68. Bladder and rectum cropped out.
_68PTVOUT: _68PTVIN, bladder, and rectum cropped out.
_68PTVOAR: portion of bladder & rectum inside of PTV68. (used to keep hotspot out of OAR)
_95%Ring: created for both PTV68 and PTV56. _95%Ring for PTV56 was cropped away from
PTV68 _95%Ring to avoid conflicting objectives in optimizer. _95%Ring used to help
conformality of plan.
_50%Ring: created to control 50%isodose line.
_Midavoid: used to keep isodose lines from connecting in the middle of the patient.
_Bladder-PTV: Cropped 3mm away from both PTVs.
_RectumAvoid: Cropped 3mm away from both PTVs and expanded posteriorly 5cm.

How your plan was normalized

 I normalized my plan so that 96.5% of the target volume was receiving 100% of the
dose. Typically, I would normalize so that 95% of the target volume was receiving 100%, but for
some reason when I loaded my plan in ProKnow it would show that less than 95% was being
covered, so I increased it to 96.5% so that I would meet Proknow’s objectives.

Here are some images showing isodose coverage:

The Magenta colored structure is the PTV68
The Segmented Red structure is the PTV56
Images of the plan showing the isodose coverage of your volumes

Yellow is the 6800cGy isodose line. Magenta structure is PTV68

Cyan is the 5600cGy isodose line. Segmented red structure is PTV56
Identify any cold spots, where are they located, and explain if its location was acceptable.
Cold spot in my plan were in areas where the PTV abutted or overlapped an OAR. The locations
of the cold spots are acceptable because the target volume is still receiving the prescribed
objective of 95% of the target volume receiving 100% of the dose. These cold spots are in or
near OAR and are a result of trying to spare the OAR.

Below is a cold spot in PTV56. The cold spot is located where the rectum and PTV56 overlap.
(Red=PTV56, Cyan=5600cGy, Brown= Rectum)

Below is a cold spot in PTV68. The cold spot is located where the rectum and PTV68 overlap.
(Magenta=PTV68, Yellow=6800cGy, Brown=Rectum)
Identify the maximum dose location and explain if its location was acceptable.
The Global max dose point was located within the PTV68 inside the prostate bed. This location
is acceptable. It is one of ProKnow’s objectives to have the max hot spot within the prostate
bed.
Provide a DVH with the target volume(s) and important surrounding critical structures with clear
labels.

Embed your ProKnow plan score card within your assignment.

DISCUSS the following:

 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?
 Was there a metric you were unable to meet, and if so, how did you try to fix it?
 Did you sacrifice points on a specific metric to improve your plan in other areas?
What was your rationale?

To improve coverage after my first run of the optimizer, I scrolled though my plan and
contoured areas of the PTV that was missing coverage. When I reran the optimizer, I
entered a new objective under this contour and pushed dose there to ensure adequate
coverage of the PTV. To reduce my hot spot, I converted my 108% isodose line into a
contour structure and placed an objective on the structure in the optimizer to reduce the
dose there.

I was able to meet all minimum requirements for this case study. I met 9 out of 12 ideal
requirements. The objective that I didn’t do great on was the dose covering 0.03(cc) of the
PTV_68. My hot spot was 111%, which was a result of my pushing very hard to reduce dose
to the bladder, rectum, and femurs. I created my hot spot contour in order to try to reduce
the hot spot.
I sacrificed point on my hot spot objective. I ran a couple of plans that where I was able to
bring the hotspot down to 106-107%, however in those plans I was not sparing as much OAR
and didn’t meet as many ideal objectives. In the end I decided to go with my hotter plan
because it was still meeting the minimal requirement and was sparing the most OAR.