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?

I started out this prostate plan like I normally do. I made a few different optimization
structures. Bladder inside/outside of the PTV, as well as rectum in/out of the PTV. This way I
was able to push harder on the structure outside of the PTV and ask for the organ inside of the
PTV to not receive 105% of the dose. I also created a dose limiting ring outside of the lower
PTV. This helped with conforming the dose and getting rid of unnecessary lower doses.

After a few optimizations and pushing on organs at risk and opt structures I looked at the dose
to my PTVs. I usually convert anything over my Rx to a structure to get rid of anything greater
than 105 and also make a cold structure to ask for Rx dose to the cooler areas. The only thing I
did differently than normal was ask for a little extra dose to the prostate bed to encourage the
optimizer to land the hot spot there. I always look at my hot spots before submitting a plan and
make sure that it’s not located in any OAR (bladder or bowel) or outside of the PTV, but have
yet to ask for it to be someplace specific. A new tool for my dosimetry belt!

Was there a metric you were unable to meet, and if so, how did you try to fix it?

I struggled to meet the conformation number. At first, I was unfamiliar with this term and had
to seek clarification from one of my preceptors. Essentially, the conformation number is a
measurement of how well the prescribed dose covers the target volume (PTV) compared to the
volume covered by a specific radiation dose (64.6 cGy iso-dose line).
Meeting this criterion proved challenging because I needed to prioritize the protection of
nearby organs at risk by minimizing the radiation dose they received. I chose to prioritize the
safety of the critical structures by sparing them from excessive radiation. In doing so my 95%
isodose line did bubble a tiny bit outside of the PTV where there was not organs at risk.

Did you sacrifice points on a specific metric to improve your plan in other areas? What was
your rationale?

My top priority was to ensure sufficient coverage of the PTVs while minimizing the radiation
dose to the bladder and rectum. However, due to the proximity of these organs to the PTV
volumes, I had to slightly increase the dose to these structures in order to achieve the full
prescribed dose. I explored multiple options and believe that I reached a pretty good balance of
maximizing the dose to the PTVs while keeping the dose to the organs at risk within acceptable
limits.