Treatment Planning Process

For this VMAT treatment planning assignment I chose to use the Varian Edge. This machine has extra fine MLC leaves at 2.5mm that
provide more options for the optimizer with added flexibility in leaf arrangements. The energy used in this plan consists of four
6MV beams in alternating arc patterns. The beams traveled in both the clockwise and counterclockwise directions with angles ranging
from 181-179 degrees.
I created four “Opti” structures in this plan. One Opti-PTV combining both PTV volumes together, one PTV56-68 (subtract PTV68
from the PTV56 structure), an Opti-Rectum, and an Opti-Bladder. I cropped the original OAR from extending into the PTV and added
a 0.2mm margin to create the Opti-Rectum/Bladder.
To choose the jaw size I first placed an MLC on the beams and fit the MLCs to the Opti-PTV with a 5mm margin. This auto adjusts
the jaw size to fit with the MLC’s. Then I removed the MLCs from the beams so that I was left with only the proper jaw size. I chose
collimator angles that complimented the PTV shape and were angled off of 0 or 180 to reduce leaf leakage during delivery. The couch
position was left at zero.

Optimization
To begin optimization, the NTO setting was set to automatic and jaw tracking was enabled.
I placed lower objectives on PTV-68 and PTV56-68 that were equal to their respective RX dose, with a volume of 100% and a priority
of 135. The lower objectives create the shoulder of the curve.
PTV-68 Upper Objectives: I added 100cGY to the prescription dose, placed a volume of 0% and a priority of 135.
PTV-56-68: I placed two upper objectives (due to the proximity of the PTV’s to one another). One upper constraint allowing 7% of
the volume to get 100cGY more than prescription with a priority of 135. This creates a tail on the isodose curve but allows the
optimizer to place some of the high dose in the structure because a 1200cGY immediate drop in dose would not be possible. Then to
control the length of the DVH tail, I added an upper objective of just slightly less than the high dose prescription, set the volume to
0%, and the priority to 135.
I then begin to optimize and paused optimization when it reached level 3. I jumped it back to level 2 and begin placing upper
objectives on my Oar’s. I start by evaluating the dose the optimizer is currently giving to that structure and drop that dose by about
300-400cGY with a priority of 65.
I used the posterior rectum block contour and placed a volume of 0% to receive 50% of RX with a higher priority of 90. This is to
reduce the dose contributing to the rectum.
I then allowed the optimizer to continue, slowly reducing the dose on each of the OAR’s as much as possible until the objectives were
no longer adjustable and the PTV coverage was adequate. After final optimization I noticed that an area in the rectum was being
completely covered by 3400cGY and I created a contour of this volume on only those slices. I went back into the optimizer and
increased the lower priority on the PTV volumes and placed a higher priority equal to that of the posterior rectum block on the new
“hot-spot” structure. Optimizing to this structure helped to carve dose from this area. I was unable to meet the ideal constraints on the
other OAR objectives, but I was able to meet the acceptable variation. I chose to accept this to ensure that the PTV volumes were
adequately covered. Pushing any further on these structures would have created a loss in PTV coverage due to the overlap of the
OAR/PTV’s.
The final step was to prescribe to the 96.5% to achieve the best coverage.
Isodose Coverage
The isodose lines are conformal to the target, but there is still a significant amount of low dose distributed throughout the pelvis.
PTV-68 Cold Spots

This is a color wash image scaled to Rx dose 6800cGy after normalization to 96.5%. There are no areas within the PTV-68 that are
significantly cold. Ideally the entire structure would be deep blue, however the areas that present as mostly cyan show a slight
decrease in dose because they are next to the critical Opti-structures that are attempting to drive dose down in these areas.
PTV-56 Cold Spots

This is an image of the PTV-56 in color wash scaled to 5600cGy. This volume is also adequately covered and does not have any cold
areas. In the areas abutting the PTV-68 there is increased dose as expected.
Maximum Dose & Location:
The hotspot in this plan was 102.4% and is found within the PTV-68 volume. Ideally this would have been in the prostate bed but
falling in the higher PTV-68 volume is the next best place for it to occur.