Spencer Day

DOS 772 Clinical Practicum II

ProKnow Prostate Plan

In this assignment, students were given a prostate and nodes dataset and tasked with
creating the best prostate plan to their ability. The dataset was case 1 of 5 provided by the
American Association of Physicists in Medicine (AAPM). Both CT data, organs at risk (OAR)
structures, and target structures were included in the dataset. The prescription was 68 Gy to the
prostate fossa planning target volume (PTV) and 56 Gy to the nodal region in a simultaneous
integrated boost (SIB) technique over 34 fractions. Other pertinent data such as conformality,
OAR tolerances, and global maximum dose were included in an instructional document (Figure
1).

Figure 1: ProKnow Planning Objectives

Planning Technique
I chose to approach this planning task utilizing a 3-full-arc VMAT technique with
different collimator rotations and optimization structures to shape the fluence pattern. The
treatment planning system employed was Eclipse (Varian Medical Systems version 15.6). All
arcs rotated between 181˚ and 179˚, starting with a clockwise rotation and then alternating.
Collimator rotations were 15˚, 345˚, and 90˚ for arcs 1, 2, and 3, respectively (Figures 2-4). A
beam energy of 6 MV on all arcs was selected for a Varian Truebeam linear accelerator.
Calculation model chosen was AcurosXB version 15.6.06.

Figure 2: Arc 1 collimator rotation

Figure 3: Arc 2 collimator rotation

 Figure 4: Arc 3 collimator rotation
Optimization Structures
The case 1 dataset included with both OAR and target contours. None of the original
contours were altered; however, I did add structures for the purpose of facilitating the
optimization program in computing the best fluence pattern. One such structure is my
“PTV_5600OPTI” structure (Figure 5). This contour was a duplicate of the PTV_56 structure
with PTV_68 cropped out an additional 0.3 cm margin. Later, a maximum dose of 56 Gy will be
placed on this structure to prevent dose above 56 Gy with the margin allowing distance for de-
escalation of dose outside PTV_68.

Figure 5: PTV_5600OPTI
 “PTV-PROSTATE BED” was another optimization structure created by duplicating
PTV_68 and cropping out the prostate bed contour with no margin (Figure 6). The intent of this
structure was to later help me consolidate the global maximum dose into the prostate bed, which
was one of the scoring criteria. “Rectum AVOID” was the rectum volume cropped out of the
treated volume by a margin of 0.3 cm (Figure 7). “Bladder AVOID” followed the same principle
with the treated volume cropped out of the bladder by a 0.3 cm margin (Figure 8).

Figure 6:” PTV-PROSTATE BED” structure

Figure 7: “Rectum AVOID” structure (light brown)

Figure 8: “Bladder AVOID” structure (Dark Blue)
External Beam Planning
The structure set was brought into the external beam planning window and a TrueBeam
linear accelerator along with a TrueBeam IGRT (Image-guided radiation therapy) “thick” table
were selected. I used the thickest table setting because the taper of the table is towards the head
and the position of the patient on the table (head-first, supine) located the pelvis towards the
thicker end of the table. Isocenter was then set according to the middle of PTV_56 and shifts
were rounded to the nearest whole number. Rounding was not necessary in this case but was
done out of habit to help the radiation therapists. As stated previously, arc rotation range for all 3
arcs was set and collimator rotations input. By rotating the collimator 15˚, 345˚, and 90˚, I sought
to give the optimizer a broad MLC geometry to work with (Figure 9).

Figure 9: Field Arrangements

I also created a clinical protocol reference utilizing the ProKnow objectives so that the
objectives populated the plan objectives tab in the external beam planning window (Figure 10).
This generated a quick reference guide for me to evaluate the plan in a timely manner before
submitting it to ProKnow. I only input the minimum requirements and not the ideal requirements
into the clinical Protocol. In hindsight, the ideal objectives would have been more useful since I
easily met all the minimum requirements and spent most of my time on the ideal specifications.
Figure 10: Clinical protocol objectives (values shown demonstrate the final plan)
Initial Optimization
In the optimization window, jaw tracking was toggled on and manual normal tissue
objective (NTO) selected. Table 1 includes the NTO parameter. Optimization objectives were
prostate bed, PTV_56, PTV_68, Bladder AVOID, left femoral head, penile bulb,
PTV_5600OPTI, PTV-PROSTATE BED, Rectum AVOID, and right femoral head. PTV_56 was
given just a lower boundary of 5600 centi-gray (cGy) since it overlapped with PTV_68. I input
an upper and lower boundary for PTV_68 since it was the highest dose PTV structure.
PTV_5600OPTI was then labeled with an upper boundary due to PTV_56 covering the lower
boundary and the upper boundary prevented higher doses from PTV_68 permeating into the
nodal PTV volumes. Table 2 contains my initial optimization objectives.
Table 1: Initial NTO Parameters
Parameter Value
Priority 100
Distance from Target Border 1.0 cm
Start Dose 105.0 %
End Dose 60.0%
Fall-Off 0.05

Table 2: Initial Optimization Objectives

Structure % Volume Limit Dose (cGy) Priority
PTV_68 0 upper 6810 150
PTV_68 100 lower 6800 150
PTV_56 100 lower 5600 150
PTV_5600OPTI 0 upper 5610 150
Prostate Bed 100 lower 6800 100
PTV-PROSTATE 0 upper 6800 150
Lt Femoral Head 0 upper 3500 50
Rt Femoral Head 0 upper 3500 50
Penile Bulb -- mean 800 30
Rectum AVOID -- mean 2000 80
Bladder AVOID -- mean 2800 80

After my initial optimization was complete, I normalized my plan to 100% of the

prescription dose to 95% of the target volume. I then exported the plan to ProKnow to get an
idea of how the two compared on normalization and interpreting objectives. ProKnow
normalized cooler than Eclipse so I set normalization in Eclipse to 100% to 95.9% which
brought the Proknow normalization just above 100% to 95%. I kept this normalization for the
remainder of my planning iterations.
My first iteration met all minimum objectives but fell short on all rectum and bladder
ideal objectives as well as the ideal maximum dose to 0.03 cc of PTV_68 and conformation
number.
Subsequent Optimizations
My next iteration focused on rectum and bladder objectives. I decided to push on bladder
and rectum avoid structures to find the limit where I sacrificed another objective. I lower rectum
avoid down to a mean of 1800 cGy and upped the priority to 100. For bladder avoid I lowered
the mean to 2400 and upped the priority to 100. This iteration did decrease the dose to the
bladder and rectum and met the bladder ideal objective of V40<40%. I decided to push harder on
both structures one more time to try and meet more objectives.
I ran a few consecutive iterations continuing off the previous plan to try and meet more
bladder and rectum constraints. When optimizing using previous plans, I set the MR level back
to 3 to give the optimizer more time to run different fluence patterns. Since the bladder avoid
structure met one ideal objective, I pushed harder on this structure decreasing the mean value to
eventually 2200 cGY and a priority of 100. Since I had not met any ideal rectum constraints, I
brought in the rectum contour, with the thinking I could push inside the PTV a little bit to help
meet objectives. I started with a mean 2700 cGy and a priority of 80. This did aid me to meet the
objective of less than 10 cc of rectum receiving 68 Gy. Consequently, I continued to push on the
rectum and rectum avoid. My most constrictive objectives were 1800 cGy mean and a priority of
110 on rectum avoid and 2000 cGy mean with a priority of 100 on the rectum. After about 3 re-
optimizations of slowly constricting the bladder and rectum objectives, I submitted to ProKnow
to see what I had gained and lost.
Subsequent optimizations did decrease bladder and rectum dose, but no more ideal
objectives had been met. However, I had lost considerable points on conformality, 0.03 cc
maximum dose to PTV_68 (maximum dose), and my global maximum point was now outside
the prostate bed. This was the point where I decided to make sacrifices. I knew further
constraints on the bladder and rectum would not meet any more criteria, and my total score was
suffering from points lost in maximum dose and conformality. Therefore, I determined it was a
balancing act between maximum dose, the global maximum point, conformality, and all
parameters. I decided to re-examine my priorities.
Cold spots were never a problem in my plans. My 100% isodose line (IDL) distribution
remained homogenous in both PTVs, with hotspots being the main concern. My global
maximum was now outside the prostate bed and adjacent to the rectum border inside the PTV.
Other 105% IDLs surrounded the rectum border and between the PTV and bladder avoid. My
maximum dose point was close to 7300 cGy. This meant that I was pushing too hard on the
bladder and rectum structures. Conformality had fallen to 77%, which was probably also due in
part to dose being forced out of the PTV in directions other than the bladder and rectum.
 My following plan sought to decrease maximum dose, increase conformality, and ease
my bladder avoid, rectum, and rectum avoid constraints while keeping the ideal bladder and
rectum objective I had met. Femoral heads had no point value in scoring, so I now sought to keep
them below 45 Gy. Maximum values for both femoral heads were set to 4100 cGy and a priority
of 30. Since the 0.03 maximum dose point was occurring in PTV_68, I boosted the lower and
upper objective to a priority of 170. Bladder avoid was changed to 2400 cGy mean and a priority
of 100. Rectum avoid was modified to 2300 cGy mean and a priority of 100 along with the
rectum contour becoming 2500 cGy mean and a priority of 100. To encourage the optimizer to
move the global hotspot back into the prostate bed I increased the priority of the prostate bed to
150 and the PTV-PROSTATE BED contour to 225. Examining this plan iteration, I had eased up
on the bladder and rectum constraints while keeping the objectives I had met. The 0.03
maximum dose decreased to just above 7200 cGy. However, the global maximum point was still
outside the prostate bed, so I first tried contouring 105% IDLs and optimizing with constraints on
these regions. However, the 105% volumes now just moved to new locations outside the prostate
bed. I now chose a brute-force approach and kicked the priority of the PTV-PROSTATE BED
contour up to 250, which the global maximum finally yielded to be inside the prostate bed.
Final Optimization
The most current plan I had was exported to ProKnow where I got a score of 144.6. I now
set the goal of trying to break 145 so I looked for a parameter where I could gain the most points.
About four points were still available in conformality with other objectives only tenths of a point
away from maximum, thus I decided to try and push conformality.
Back in optimization, I placed new inputs in the manual NTO function (Table 3) and
reoptimized off the old plan. This brought conformality from 77% to 78%, so I ran the optimizer
off the old plan one more time changing no inputs but setting the optimizer back to MR level 3 to
allow more time for the optimizer to work. This finally brought conformality up to 80% and the
extra optimization time also lowered my maximum dose down to 7151 cGy. The ProKnow score
for this plan broke 145 points and decided to end my planning.
Below is Table 4, which depicts my final objectives.

Table 3: Final NTO Parameters

Parameter Value
Priority 100
Distance from Target Border 0.5 cm
Start Dose 90.0 %
End Dose 50.0 %
Fall-Off 0.01
Table 4: Final Optimization Objectives
Structure % Volume Limit Dose (cGy) Priority
PTV_68 0 upper 6810 170
PTV_68 100 lower 6800 170
PTV_56 100 lower 5600 150
PTV_5600OPTI 0 upper 5610 150
Prostate Bed 100 lower 6800 150
PTV-PROSTATE 0 upper 6800 250
Lt Femoral Head 0 upper 4100 30
Rt Femoral Head 0 upper 4100 30
Penile Bulb -- mean 800 30
Rectum AVOID -- mean 2300 100
Bladder AVOID -- mean 2400 110
Rectum -- mean 2500 100

Figure 11: Dose distribution at isocenter

Figure 12: Dose distribution at the global maximum point (inferior of the isocenter)

Figure 13: Dose distribution (axial plane roughly at the level of the obturator foramina)
Figure 14: DVH of the final plan

Figure 15: ProKnow score card of the final plan