● What was the most difficult metric to meet and why?

● What things did you try to improve your score?

● What was one neat planning trick you learned from this experience?

I found that the most difficult metric to meet was the 25 Gy conformality index. In this particular
plan, the conformality index was calculated based upon the ratio of the total volume receiving 25
Gy over the PTV volume. While I was able to easily meet the 50 Gy conformality index, the
volume receiving 25 Gy was more difficult to constrain. The volume receiving 25 Gy was 291.8
cm3 and the volume of the PTV was 83.1 cm3. This means that the conformality index was 3.455
and the “ideal” measure was 3.4. This was the only metric which I was not able to meet the ideal
measure. I did use a ring to reduce the volume receiving 25 Gy, but to meet this ideal constraint,
it caused other targets to fall outside of the ideal range. For this reason, I chose to leave this
metric just shy of the ideal mark.

This plan looked pretty good after a single optimization, but I knew that I could improve my
score. The PBT was one structure that needed to be given a higher priority in order for the
optimizer to reduce the maximum dose that it received. There was a fine balance of reducing
the dose of the PBT while maintaining conformality and good target coverage. Another strategy
I used during the planning process was optimizer rings. These structures allowed me to push
the higher areas of dose closer to the target and make the isodose lines tighter. The effect of
these rings is seen by my scores for the conformality index for 50 Gy and 25 Gy. In addition, I
adjusted the NTO priority and adjusted the rate of dose falloff in the manual NTO settings. This
helped to draw the isodose lines closer together, protect the OAR, and increase the conformality
of the overall dose.

I learned how important it is to use optimization structures like rings, to reduce the total volume
of tissue receiving all doses, but especially the higher dose levels. I also used the PTV D2c
structure to reduce the overall volume of the body receiving a dose greater than 25 Gy. We use
a similar technique at our clinical site by using ring, PTV+2cm and PTV+4cm structures. This
allowed me to monitor the dose that was falling outside a 2 cm sphere around the PTV and
constrain it to an acceptable level. I will definitely take the tricks I learned during this lab into the
clinical setting to make the best treatment plans possible.