Chelsea Gehrig

772 Clinical Practicum

Prostate Plan Study

This prostate plan study consisted of creating an intensity-modulated radiation

therapy (IMRT) or volumetric-modulated arc therapy (VMAT) treatment plan for a
prostate case while utilizing a simultaneous integrated boost technique. The prescription
was given for 56 Gy to be delivered to pelvic nodes and 68 Gy to be delivered to the
prostate in 34 fractions. I planned this case to be treated on a Varian linear accelerator-
model Clinac iX. I used a VMAT treatment technique with 3 full 360° rotations, including
2 rotating clockwise from 181° to 179° and 1 rotating counterclockwise from 179° to
181°. The energy I chose for my plan was 6X, as this is standard at my clinic for all
VMAT plans (Figure 1). The collimator angles I chose for the first 2 rotations were 345°
and 10°, respectively, with each arc having a jaw setting to cover either side of the full
primary target volumes (PTVs) (Figures 2 and 3). The third arc had a collimator angle of
85° in order to have the multi-leaf collimator (MLC) cover the entire PTV while moving in
the opposite direction as the first 2 arcs (Figure 4).

Figure 1. Field settings

Figure 2. CW arc with collimator setting at 345°

Figure 3. CCW arc with collimator setting at 10°

Figure 4. CW2 arc with collimator setting at 85°

The organs at risk in this structure set included the bladder, rectum, and the right
and left femurs. As I mentioned above, there were two target volumes including a
PTV_56 covering the pelvic nodes going to 56 Gy and PTV_68 covering the prostate
and prostate bed going to 68 Gy (Figure 5). I initially began optimizing this plan prior to
creating any opt or ring structures to see how my dose distribution would look. This first
optimization placed hot spots in the rectum and did not create a very conformal plan. I
decided to utilize opt structures in order to help create a more conformal dose
distribution with the 2 different targets and dose objectives. The zPTV68_OPT2mm
structure was created by expanding the PTV_68 by 2 mm, then cropping it away from
the rectum by 2 mm (Figure 6). My zPTV56Opt structure was created by copying the
PTV_56 structure, then cropping it out to the edge of the rectum and 2 mm from the
zPTV68_OPT2mm (Figure 7). I also wanted to add ring structures to help control the
dose surrounding my targets and assist in conforming the doses. The first ring,
zHDNT_PTV68, was expanded from the zPTV_OPT2mm by 2 cm and the second ring,
zHDNT_PTV56, was expanded from the zPTV56Opt by 1.5 cm (Figure 8).

Figure 5. OAR and target structures with the color key below

Figure 6. zPTV68_OPT2mm structure in shaded magenta

Figure 7. zPTV56Opt structure in shaded magenta

Figure 8. zHDNT_PTV68 (medial and inferior) and zHDNT_PTV56 (lateral and superior)
structures in shaded yellow.

My second optimization varied from the first because I added the opt and ring
structures, therefore, resulted in a better conformal dose distribution for both targets. I
still did not reach my target objectives, though, with only 94% coverage on my PTV_68
and exceeded constraints on the bladder and rectum. I began optimization again with
higher priorities on the OAR and PTV objectives that I missed in the previous
optimization. As the optimization ran through each stage, I also paused the process and
adjusted my dose and priority numbers as needed. With this plan, all the minimum
requirements were easily met on ProKnow and there were only 4 metrics that were not
meeting the ideal score. With a total of 136.89 points, I decided to try optimizing again
to get closer with these metrics and achieve a higher score. My main focuses of change
this time were to drive the V65Gy (%) down for the bladder, lower my hot spot and
move it inside of the prostate bed, and have a higher conformation number with
PTV_68. I changed the priority and dose objectives for these structures and for the rings
around both PTVs. These final optimization objectives (Figure 9) are below.

Figure 9. Optimization objectives

After this final optimization, I reviewed my DVH analysis prior to normalization. I

covered 95.87% of the PTV_68 with 100% of the prescribed dose, however, this led to a
higher hot spot compared to normalizing my plan with 95% of the treatment volume
receiving 100% of the dose. So, I moved forward with the normalization as my coverage
remained acceptable and the OAR doses lowered slightly, proving to be the best plan
(Figures 10 and 11.) Various isodose distributions can also be viewed below.

Figure 10.
Figure 11. Dose Volume Histogram

Figure 12. Color wash isodose distribution set to show 56 Gy and above

Figure 13. Color wash isodose distribution set to show 64.6 Gy (95%) and above
Figure 14. Color wash isodose distribution set to show 68 Gy and above

In Figure 14, it is easy to see where the color wash of 68 Gy does not cover the
PTV_68 (blue). These cooler spots are acceptable as they are still covered by the 95%
isodose line seen in Figure 13. The hot spot for my plan was 71.82 Gy and was located
just inferior to the edge of the prostate bed within the PTV_68 (Figure 15). This
maximum point is acceptable because it’s location is within the PTV and is about
105.6% of the prescription dose, which is well below the maximum constraint for
ProKnow and for my clinical site.

Figure 15. Hot spot location

After uploading this plan to ProKnow, I was given a score of 144.02 out of 150
points and was happy with my metric results. Although I normalized my plan so 95% of
the volume would receive 100% of the dose, the discrepancies in ProKnow show that
only 94.75% of the volume was covered. I did go back to my plan to normalize to 96%
instead in order to reach the 95% in ProKnow, but the dose covering .03 cc of the PTV
also increased and resulted in a lower total score, so I decided to keep that first plan
normalized to 95% instead. The 4 metrics that did not reach “ideal” discussed from my
previous ProKnow score above were still not met with this plan, however, 3 of the 4
metrics moved closer to ideal and gave me more points. I was able to bring the V65Gy
(%) of the bladder down to 15.76%, the D.03cc (Gy) to 71.57 Gy, and the conformation
number up to 0.758. My final ProKnow score card can be seen below. Overall, I was
pleased with this final plan as I had adequate coverage over my PTVs and met most of
the ideal constraints on the OARs.

Figure 16.