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Sunhee Lee

Professor Neil Joyce

Fieldwork II

July 10, 2022

RSS SBRT LtLung– ProKnow Plan review

The treatment of lung cancer with Stereotactic Body Radiation Therapy (SBRT) needs
highly conformal dose with utilizes precise targeting and dose delivery to achieve acceptable
toxicity to organs at risk (OARs). A safely deliverable and good plan quality is characterized
with highly conformal dose distribution and steep dose fall of near the target volume. Volumetric
modulated arc therapy (VMAT) is used for this plan to improve target conformality with shorter
treatment time for lung SBRT with high dose rate and Flattening Filter Free (FFF). Removing
flattening filter reduces out of field dose and improves beam accuracy.

Preplanning preparation: search body, insert support structures such as couch top and
rails, and find high density artifacts.

Structure insertion

Measure physical properties: port CT value of -1000 (air) HU

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Next, I create optimization structures: I have rings, opITV and opPTV in the beginning.

opPTV, opITV and Rings

Rings are 1cm width and 3mm away from each other, purple is opITV and red is opPTV that is
1mm away from the opITV. I add ring structures for all opPTV to reduce low dose spillage to the
surrounding healthy tissues. The rings are 1cm for outer ring and 0.3cm for inner ring, and have
four rings for lower dose PTV, 1cm for outer ring and 0.3cm for inner ring and add 1cm for each
outer rings. When I insert a new plan, I have check box for ‘Gating’ at plan property for my
department according to prescription for gating guide and MD imaging instructions. For
calculation grid size for small field SBRT case, we use 1.25mm_SRS ARC technique in
manually.
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I tried several gantry rotations to meet ProKnow metric especially Lungs-ITV and RtLung
constraints especially for this case to save lungs as much as possible. Below is ProKnow metric
guidelines.

ProKnow RSS_LtLungSBRT plan Metrics.

I ended up using two partial arcs coplanar setup. As I optimized several plans and uploaded and
reviewed with ProKnow plan evaluation, but it was hard to meet ‘Lung_Minus_ITV’ V20Gy and
V5Gy. The plans that I uploaded pass for those constraints, but I wanted to meet close to the
higher goals. At this moment, I thought about noncoplanar VMAT (n-VMAT) plan. There was
none practice for n-VMAT plan for Lung SBRT in my department. As I tried to find some
articles about n-VMAT plan research. However, there is very limited literature available for lung
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SBRT utilizing highly conformal n-VMAT planning. In this report, “a RapidPlan model is
described to generate adapt-able n‐VMAT‐based KBP treatment plans for early stage
NSCLCpatients with medically inoperable centrally located tumors that follows RTOG‐0813
dosing schemata and contouring guidelines.”1 Therefore, I decided to use coplanar VMAT
technique using two arcs with Photon Optimizer (PO) algorithm with 1.25mm calculation grid.
The partial two arcs on Truebeam Linac consisting of standard millennium 120 MLC and 6MV-
FFF, 1400MU/Min beam. The first arc starts gantry rotation from 179 degree counter clock wise
to 320 degree with collimation at 30 degree. The second arc is clockwise start from 320 gantry
angle to 179 degree with collimation 330 degree. The field size is about 7 cm by 7 cm for both
arcs, using Arc geometry cool.

Beam arrangement with two partial arcs.

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Below images are optimization setup: use automatic Normal Tissue Objective (NTO) with 75
priority number, use MU objective to control the MU with maximum 2000 for high modulation.

For the optimization process, I use higher priority to increase ITV and PTV coverages. The
optimization numbers of the targets and organs at risk (OARs) and priorities for my plan are as
below images.
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Optimization
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I put numbers to lower, upper objectives and higher priority for ITV and PTV and use lower
numbers for OARs. I use generalized Equivalent Uniform Dose (gEUD) for OAR structures that
has max dose constraints near by the PTV such as, spinalcanal, esophagus, vessels, lungs, and
heart. The gEUD numbers are dependent on the OARs. After the first optimization, I check Dose
Volume Histogram (DVH) to see the plan meets all the requirements and this gives me an idea
how to proceed the plan further. If the plan needs to be improved for coverage, I increase the
priority of PTV and ITV and lower the OARs’ priority. By editing the priority, the plan is getting
closer to the goal. If this does not helpful enough, I create other optimization structures to
increase coverage and decrease OAR dose such as, push or avoid.

Final optimization objectives

During the optimization process, I pause the process at Multi-Resolution (MR) level 1 several
times. The convergence mode calculation option at photon optimizer can be on instead of
pausing at MR. I prefer to use the MRs manually pause and go as the optimizer processed. I use
automatic intermediate dose process after all the MR levels.
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Transverse images with Isodose Colorwash with V100%>100%.

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Transverse images with Isodose Line and Dmax inside the ITV 55Gy
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Frontal images with Isodose Colorwash with V100%>100%.

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Frontal images with Isodose Line and Dmax inside the ITV55Gy.
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Sagittal images with Isodose Colorwash with V100%>100%.

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Sagittal images with Isodose Line and Dmax inside the ITV 55Gy
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Final DVH of ITV, PTV AND OAR Structures

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RadFormation ClearCheck report: Comparison of n-VMAT plan

In conclusion, the ProKnow metrics introduce the goal to achieve very clearly, and it is
helpful tool to meet the coverage while lower the OAR doses. I tried to improve the coverage
and minimize dose to the OARs. Also, tried to have Dmax inside ITV, not in PTV-ITV. I
focused to meet “Conformation Number [53.2Gy, PTV_56]” and it is better than the previous
plans, but still, it is the hardest to meet among the metrics. During the optimization process, I
push more to meet the ITV and PTV constraints than OARs’ as I use cost function while the
optimization. The hardest part for this RSS_LtLungSBRT plan was that to meet the
Lung_minus_ITV constraints. I have a comparison clearcheck report with n-VMAT plan. It is
one coplanar and two noncoplanar beams. It is also safe to deliver the plan, but overall, MU and
time are higher and especially Lung-minus-ITV is higher than coplanar plan which for this
report. This topic will be in the list of my further study. Overall plan is fine with the PTV
coverage and pass all the requirements. The plan was evaluated with ProKnow plan study: the
report is below.
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Reference:

1. Justin Visak, Ronald C. McGarry, et al. Development and clinical validation of a robust
knowledge-based planning model for stereotactic body radiotherapy treatment of
centrally located lung tumors: 07 December 2020. doi: 10.1002/acm2.13120: Accessed
July 4. 2022.

Final ProKnow score card for Submission.

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