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?
Typically, for all VMAT planning I create a “PTV_opti” structure to help with coverage.
This structure has an outer margin of 1mm from the PTV that was created by the doctor. I have
noticed it helps with the superior/inferior coverage and helps avoid the prescription isodose line
from conforming too tightly to the PTV, where coverage could be lost. Since there are 2 dose
level PTVs I created 2 PTV_opti structures. The PTV_68_opti is created first since it has the
highest dose level. I did pull the posterior and anterior outer margin back to the drawn PTV_68
structure because I knew that the bladder and rectum were the two dose constraints to be met. I
then created the PTV_56 opti with 1mm outer margin from the PTV_56 structure. For this opti I
cropped it back out of the PTV_68 by 3mm so that the 2 opti structures did not overlap (Figure
1).

Figure 1. Demonstration of the PTV_opti structures for both the PTV_56 and PTV_68.
I also create “OAR_out” structures for each OAR that is inside any treatment volume,
then I use them in the optimizer to meet constraints. These out structures I crop 3mm out of the
PTV, this ensures that the PTV_opti and the OAR_out structures don’t overlap. I believe this
helps the optimizer to meet dose constraint requests without resulting in significant hot spots if
the cost value isn’t too high (Figure 2).

Figure 2. Bladder_out and Rectum_out structures that are used in the optimizer.
After running the plan through the optimizer, I noticed that there was prescription dose
spillage into an area without any treatment volume. To get rid of this extra dose I created an
“Avoid” structure, dark green contour (Figure 3). In the optimizer I ran this structure with 0%
volume getting 56 Gy at a priority of 85. This helped to remove the dose of 68 Gy in this area,
but there is still 56 Gy peeking out. I didn’t push very hard on this request because I didn’t want
it to cause any loss of coverage of the PTVs.

Figure 3. Avoidance structure to limit dose spillage (dark green).

Another trick I use to decrease the hot spots after the first optimization is to create a
structure by using the “convert isodose level to structure” feature. Since the plan wasn’t running
significantly hot, I created a 103% dose structure. Typically, I would use 105-108% depending
on how hot the plan is running. I ran the 103% dose structure with an optimization request for
0% volume to get 5 cGy less than the lower request of the PTV_68_opti, since it is the highest
dose. I find that this helps to decrease the volume of hot spots within the treatment plan.
Additionally, I wanted the hot spot to be inside the prostate bed to meet that metric in
ProKnow, so I created another structure to run in the optimizer. The PTV-ProstateBed structure
(Figure 4) is the PTV_68 cropped out of the prostate bed. In the optimizer I ran this structure
with 0% volume receiving slightly over the prescription of 68 Gy. This allows prescription dose
to fill the outer margin of the PTV_68 but limits the dose above 68 Gy and helps push the hot
spots into the prostate bed.

Figure 4. PTV_68-Prostate Bed structure (cyan) used to move hot spot into prostate bed.
Was there a metric you were unable to meet, and if so, how did you try to fix it?
I was unable to meet the conformation metric. I am not sure how the upload varies
between Eclipse and ProKnow, but I scored a .769 rather than the 1.0 that was needed. I tried to
follow the ProKnow instructions, but it didn’t help improve this number when the plan was
uploaded into the grading area. On Eclipse the conformity index is calculated at 1.05. I also was
unable to meet the ideal bladder constraint for the volume of 65 Gy (V65) to be at 15% or less.
To try and meet this constraint I pulled the PTV_opti structure, that typically has a 1 mm outer
expansion, back to the PTV_68 structure on the axial slices with bladder anterior to the PTV_68.
I initially tried to meet this metric by using lower objectives for the Bladder_out structure and
setting them below the requested dose constraint. I pushed on this constraint hard in the
optimizer, but it kept causing hot spots within the treatment plan or holes in PTV coverage. I
ended up relaxing on this constraint a little and my final result was 17.2% of the bladder at 65
Gy. I thought that this was a good compromise because it kept the PTVs from getting hot spots
or holes in coverage and the 50% (3400 cGy) isodose line, shown in brown below (Figure 5),
didn’t cover too much of the bladder and conformed fairly tightly to the PTVs. If I pushed hard
enough to achieve this constraint then part of the PTV_68 covering the bladder would be lacking
coverage and hot spots would multiply within the treatment volume.

Figure 5. Demonstration of the 50% isodose line and the dose to the bladder.
Did you sacrifice points on a specific metric to improve your plan in other areas? What was
your rationale?
For this plan I sacrificed points on the bladder V65 < 15% constraint. My rationale was
that sacrificing these few points would help me meet the dose constraint for 0.03 cc (D0.03cc) of
PTV_68 to be at 71.4 Gy or less, and it should also help my conformity index score because
coverage of the PTV wouldn’t be affected as much. This sacrifice made a huge difference in the
amount of hot spots inside the treatment volume. I am not sure that it affected the conformity
index much, but it did help the prescription dose cover the PTV_68 nicely. I am curious if
anyone was able to meet this metric without sacrificing significant points in ProKnow. I should
have done the math on the volume of bladder inside the PTV_68 and seen what that was. Even if
it was slightly less than 15% that does not include dose fall-off to 65 Gy which makes a larger
volume of bladder.