ProKnow Prostate VMAT Plan

Dylan Kozlowski

1. How was your plan normalized?

o My plan did not require any normalization. I noticed with previous optimizations that when I
normalized to a normalization value like the 99.7%, though it looked good in eclipse, this did
not translate to proknow. Therefore, once I observed this, I made sure my plans looked
good without any normalization before I uploaded them to proknow.

2. Images of the plan showing the isodose coverage of your volumes

o At iso:
o Good view of PTV68 and Prostate Bed coverage:
o Good view of PTV56 coverage:
o Transverse view:

o Frontal view:
 o Sagittal view:

3. Identify any cold spots, where are they located, and explain if its location was acceptable

o
 ▪ Here you can see the dark blue line that represents the PTV56 coverage. There are
multiple cold spots for this volume and this picture is a good representation of that.
As you can see these cold spots are near the rectum. Being that the rectum had
some high priority constraints and proknow wanted very little high dose in this area,
the cold spots represent the dose being pulled away from this area. This is
acceptable because from the start I was struggling to keep the rectum from
receiving too much dose, and this shows how I achieved that constraint. With this
plan, the PTV56 is receiving 97.04% coverage which is above the recommended 95%
coverage, even with the cold spots.

4. Identify the maximum dose location and explain if its location was acceptable

o
▪ The hotspot position is in the prostate bed which was a requirement for the
proknow constraints. It is away from the bladder and is in an acceptable location.
From the start, I was struggling to get the hotspot within the prostate bed. Originally
it was showing up in the bladder, near the rectum, and within only the PTV68. To
help control the location of the hotspot I created a structure called HotPTV68. For
this, I drew over every current hot location that I did not want the hot spot to show
up. I placed an optimization objective of 0% of this structure receiving around 105%
of the 6800 PTV or 7150cGy. This pushed the hotspot in the current location above
and within the prostate bed. The hotspot was also lowered to 108.5%. An image of
the HotPTV68 structure is represented below by the magenta circles:
 •

5. Provide a DVH with the target volume(s) and important surrounding critical structures with clear
labels

o Here you can see that the targets are receiving good coverage. I placed the crosshair on the
PTV68 to show that it is receiving 95.75% coverage which is just above the recommended
95%. I was able to keep all my OARs pretty low, with the exception of the bladder receiving
slightly more dose than “ideal.” This is better represented on the proknow scorecard.
6. Embed your ProKnow plan scorecard within your assignment

o I am pretty pleased with the score that I received. The very first plan that I submitted had a
score of 117 out of 150, so getting my score up to 140.25 was very satisfying. With that
being said, I found this plan to be very challenging. These plan objectives are very different
than the ones set here at VCU. Therefore, I had to get creative and change my plan multiple
times.

7. 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?
o To start my plan was very hot and the dose to the bladder and rectum were not meeting the
plan metrics set for proknow. My main struggle was the rectum. The constraint above states
that the serial slice dose to the rectum should not receive 34Gy. With 2 full arc rotations and
additional planning structures, I was not able to meet this constraint no matter what I did in
the optimizer. For this I decided to not do 2 full arcs, instead, I placed a 20-degree
separation on the start and end of each arc. I set the NTO at 85 priority to make the dose
more conformal and included some additional hot/cold structures to fill any holes and help
shape the dose.
 ▪
• Here you can see the start and end of the arcs being 20-degrees apart. I did
this to reduce the entrance dose to the rectum. Each arc also had a
complementary rotation of 15-degrees to reduce MLC spillage and help with
dose conformity.
o Here are my optimization objectives:

8. Was there a metric you were unable to meet, and if so, how did you try to fix it?
o Once again, the bladder and rectum were the hardest structures to meet. This is
understandable being that they are both within the PTV structures. For the bladder, I did a
 bladder-PTV structure to keep the dose low in this area and to allow the bladder within the
PTV to receive more dose. I did this for the rectum as well, but this did not fully help remove
the 34Gy out of this area. For the rectum, I needed to create additional structures to
significantly remove the dose out of this area.
▪ You can see these separations below:

o Below you can see the additional structures I added to control the 34Gy isodose line. While
this was mainly used to remove the 34Gy from entering the rectum, I did draw this structure
on some areas of the bladder to further reduce the dose in this area as well. I had to put a
very hard max on this, 0% receiving 3145cGy and a priority of 100% and this was the
structure that finally helped me meet the constraint in proknow.

▪
9. Did you sacrifice points on a specific metric to improve your plan in other areas? What was your
rationale?
o I was able to meet all the constraints, with four only meeting the acceptable variation.

▪ As you can see above, I was very close to meeting these two objectives. Even though
they were so close, I found that when I met these objectives I lost coverage to my
PTV68 and prostate bed. That is why these only meet their minimum requirement,
which is an acceptable outcome. Though in eclipse the PTV68 coverage showed
95.75%, the PTV68 dose in proknow was 95.093% and I could not afford to lose any
more coverage. All in all, this was a fun patient to plan. I enjoyed seeing what
different planning objectives could look like, and how we as dosimetrists can find
multiple ways to reach the desired outcome.