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ProKnow SBRT Lung Plan Study

I will be first to say that upon beginning this plan study, I was a bit apprehensive,

as I personally am not the main person who plans our SBRT. In most cases, a medical

physicist does the SBRT planning in our clinic as their specialty, but I was excited to get

the opportunity to give this a try. Upon downloading the plan, the first thing that I noticed

was that the ITV, in which our goal was to get our full prescription dose, was over 4cm in

radial size. In our clinic, if the GTV is 4cm or greater, it is likely that the physician would

choose standard fractionation rather than IMRT. So, immediately, with the size and

location of the tumor near critical structures with varying heterogeneity, I knew this

challenge would be difficult.

First, in contour mode, I created some additional structures to help my planning

be more successful. I decided to create a 2mm margin on my ITV and a 2mm margin on

my PTV for dose escalation. Then, I created some dose control structures, such as a left

lung – PTV2mm, and a PTV-PBT. I also decided to create a PTV-ITV and a Body-ITV

in order to help force my hot spot into my ITV. Finally, I made my way into treatment

mode to begin creating my plan.

I kept the treatment isocenter as created and decided to create 3 partial ARC,

VMAT beams: gantry 330-179 with collimator at 45 and couch at 0, gantry 179-330 with

collimator at 315 and couch at 0, gantry 330-179 with collimator at 90 and couch at 0. I

set up these fields as if we were in the clinic, so I had too many concerns about clearance

issues to be comfortable with doing full ARCs, though that would have been my

preference. I decided that since this was an SBRT Lung plan, I went with 10mV
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flattening filter free beams at a dose rate of 2400MU/min with a 2.5mm dose grid and

Acuros dose calculation algorithm. I began with lower limits on my PTV, ITV,

PTV_2mm, ITV_2mm and PTV-PBT with upper limits on my critical structures,

including the newly created Lung-PTV2mm, PTV-ITV and Body-ITV. I also utilized an

Normal Tissue Objective (NTO) of priority 125, distance of 0.2cm, start dose of 101%,

end dose of 30% and fall-off of 0.15. Of course, this plan, as all of our clinic SBRT plans,

was normalized to 100% in Target Maximum. During my initial attempt, I found that this

was just not going to work, missing a lot of constraints on the score card. So, I made

some beam modifications. I decided to keep my 3 beams, but to extend their right sided

angle a bit more and add 3 more beams that were non-coplanar. So, my 6 partial ARC,

VMAT beams were as follows: CW gantry 320-179 with collimator at 45 and couch at 0,

CCW gantry 179-320 with collimator at 315 and couch at 0, CW gantry 320-179 with

collimator at 90 and couch at 0, CCW gantry 179-320 with collimator at 330 and couch at

345, CW gantry 320-179 with collimator at 30 and couch at 15, and CW gantry 310-30

with collimator at 0 and couch at 90 (this gantry may not work depending on table height,

but that would have to be tested on the machine). I kept my optimization parameters

essentially the same, but decided to focus a little harder on my NTO with a priority of

150, distance of 0.1cm, start dose of 100%, end dose of 35% and fall-off of 0.15. Finally,

I had an acceptable plan, normalized to 100% in Target Maximum to a prescribed

percentage of 89.1%. I finished with the DVH and score card as shown below.
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Figure 1. DVH including all structures used in score card criteria.

Figure 2. Proknow Score card of a final score of 121.98/150.00

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Since gaining these results, I tried multiple tricks and ran more plans than I would like to

admit in order to make my plan even better, such as creating “cold spots” in my PTV, but

I could not get coverage to improve without sacrificing additional parameters. As

suggested by Professor Joyce, I even attempted to let my hot spot get out of control, but I

still was not achieving the desired results. With this, I could improve my conformity, but

I would still have issues with PTV coverage, controlling the hot spot location and

excessive dose to lung minus ITV. I ultimately found this plan to be very acceptable due

to the fact that my clinic often wants 95% of the PTV to be covered by the prescription.

So, with 98% of the prescription covering 100% of the PTV and 100% of the ITV being

covered by the prescription, I was quite satisfied with the results (but not satisfied with

my score). I was also happy to keep my hot spot isolated within my tumor volume, as

shown in figure 3.

Figure 3. Maximum dose point of 6172.8cGy located inside of the ITV.

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I would have liked to have talked to some of the physicists about ideas in my clinic, but

with COVID 19 and increased patient load, there has been little to no down time for

anyone these past few weeks. However, if anyone may have additional SBRT tips and

tricks up their sleeves that may help with plans such as this in my future, I would greatly

appreciate it! I look forward to playing with and learning more about SBRT as my career

continues.