Sara Muellerleile

Prof. Neil Joyce

Fieldwork II
July 20, 2021
Lung SBRT ProKnow Plan Study

The goal for treating this ProKnow case is to achieve prescription dose coverage to the

PTV with rapid fall off for an SBRT treatment of 55Gy in five fractions (11Gy/fx). Eclipse

treatment planning system for a TrueBeam Linac will be used for this case. While a 3D treatment

technique is still used at my clinic at times, we almost always use VMAT for SBRT treatments

now, especially when the target is near a critical structure. Depending on the location of the

target, I will use a partial or full arcs. In this case, I chose to use partial arcs, largely staying on

the left side of the patient to reduce as much dose as possible to the contralateral lung and avoid

treating through the bronchus as much as possible. I used opposing arcs in the clockwise and

counterclockwise direction with gantry angles from 340º-179º and collimator angles at 30º and

85º to have the leaves moving in two different directions. After running the plan a couple of

times, I decided to add two additional arcs (starting a half of a degree off from the others just to

have different control points) with couch angles at 5º and 355º. I wanted have more arc variety,

but without going further into the other lung. This lead to a total of four partial arcs as seen

below.
 Partial arc beam arrangement
The isocenter for this plan was placed in the middle of the PTV and gantry clearance of

the table was verified. Jaw tracking was turned on. The calculation grid size was set to 0.1. The

energy used was 6X FFF. Flattening filter free beams can be delivered at a much faster dose rate

which is especially nice for patients with longer treatment times. We don’t typically prescribe to

a different IDL unless 3DCRT is used, so this plan was set to “no normalization”.

Several optimization structures were created to aid in optimal dose distribution. I started

by creating a zITV in which the ITV was cropped inside of itself by 1mm. The goal of this

structure is to control where the hot spots occur and to allow higher dose in this region

depending on physician preference. At my current clinic, when using VMAT for SBRT, the

physicians still prefer the plan have the “look” of a 3D plan with a hot spot of 120-130% in the

middle of the target with rapid fall off.

 ITV-1mm
Next, I created a cheater PTV (zPTV) which was the PTV +2mm to account for the

inability of the treatment algorithm (AAA) to get dose to the edges of the target especially in air

spaces. Additionally, a couple of ring structures were contoured. First, a zPTV-ITV was created

to help with dose fall off from the hotter center of the ITV to the prescription dose at the edges of

the PTV. Next, two low dose normal tissue structures were created. One at 1.5cm outside of the

zPTV to try to aid in the control of the low dose conformity (50% isodose) and one at 1mm from

the zPTV to help with the conformity of the 52.25Gy IDL.

 zPTV (PTV+1mm), zPTV-ITV (red), zLDNT (magenta)

In checking the overlap region of the PBT and the zPTV, it was found that the volume of

this “structure” was only 0.7cc, so I decided only to keep hot spots out of the PBT, without

trying to lose coverage initially. In doing this, I took the PBT out of my zPTVs by 1mm and out

of my zITV by 2mm to add as a structure to keep out any hot spots and lower the dose to this

structure as much as possible.

Initial optimization objectives were set according to ideal goals from ProKnow, weighted

such that the targets were of most importance. The Normal Tissue Objective (NTO) was set with

very tight constraints for rapid fall off.

 NTO settings
Upon initial review of the plan, the biggest issues were with conformation number

for the 52Gy IDL and the volume of the LUNG_MINUS_ITV covered by 5Gy. The PTV was

nicely covered and most other objectives seemed to be decently within the ranges allowed. I

played with this plan many times, adjusting different weights of objectives and changing dose

requirements in the optimizer. I contoured in some areas where I wanted to heat things up and

contoured some areas where I wanted to reduce dose for the conformity score. I found this plan

to be quite tricky in the sense that several of the ProKnow “ideal goals”, especially for the lungs,

were difficult to meet depending on which way things were prioritized. I even attempted a 3D

plan with 12 angles to try to reduce lung dose, with extra focus on the contralateral lung.

Knowing that VMAT spreads low dose around quite a bit, I thought that the 3D plan might be a

good option, but it really didn’t gain much on the lungs and the tradeoff was higher doses to

critical structures near the PTV, so I went with the VMAT option for a higher pointed scorecard.
 Final optimization objectives

While I would have liked to have gained more points through ProKnow, this plan

is very conformal and would be totally acceptable to treat in clinic. The dose distribution looks

really nice with the 100%IDL hugging the PTV, a hot center in the ITV, and rapid fall off. The

gradient index also looks decent with the shape of the 50%IDL in a ring around the PTV.

Dose distribution
 DVH

ProKnow Scorecard, Score: 126.08

 Overall, I found this plan to be quite challenging as there were so many different

ways to go with how one could prioritize objectives. It would certainly be impossible to achieve

“ideal” for every category, so there was a lot of going back and forth with optimizing. It seemed

that most points were awarded for PTV/ITV coverage and conformity so that is where I focused

the most. The area I would have liked to see more improvement was with the 52.25Gy

conformation number, but I struggled to gain in this without losing PTV coverage. I am

interested to see how others achieved a lower lung dose as well.