Proknow Prostate

Brianna Niemuth
Clinical Practicum II
7/17/20
Proknow Prostate Plan

Prescription: The prostate was prescribed 68 gray (Gy) in 34 fractions and the nodal volume
was prescribed 56 Gy in 34 fractions. This plan was to use simultaneous integrated boost
technique.
Contours: The data set was contoured with prostate, lymph nodes, rectum, bladder, bilateral
femoral heads, and penile bulb. It also contained two target volumes: PTV68 and PTV 56. The
first thing I did was add optimization structures. I created a 1mm expansion off each PTV. I
then created optimization structures for the bladder and rectum which were cropped 2mm outside
of the expansion structures. After this I created two ring structures one at 1.0cm and one at
2.0cm from the PTV expansions. I also created bladder and rectum avoidance structures; just in
case I had a hard time limiting dose to these structures. For the bladder avoidance I contoured the
area anterior of the bladder and cropped it from the body at zero. I did the same with the rectal
avoidance except it was posterior to the rectum.
Figure 1: Contours- Ring1cm, Ring2cm, Optibladder, Optirectum, Bladderavoid, Rectumavoid,
PTV68exp, and PtV56exp
Planning: Planning was done in Eclipse treatment planning system with the plan to be delivered
on a Truebeam linear accelerator. Isocenter was placed in the center of the two targets. The plan
consisted of 3 VMAT arcs. The first and third arcs went clockwise from 181⁰-179⁰ with
collimator angles of 30⁰ and 95⁰. The second arc was counterclockwise from 179⁰-181⁰ with a
collimator angle of 330⁰. All arcs utilized 10 MV energy due to the thickness of the patient.
Optimization: After my first optimization I normalized the plan so 95% of PTV68 was getting
100% of the dose. I had a pretty good plan with a hot spot of 105.1%. However, I felt I could do
better with the rectum, bladder and conformality. I continued to optimize, pushing on the rectum
and bladder until I saw it start to affect the PTV coverage and the max dose.
Figure 2: Optimization objectives- these were used for the 1st optimization and then I adjusted
them as needed to reduce dose to the bladder and rectum.
Figure 3: Isodose lines after first optimization. Still need to work to reduce bladder and rectal
dose and into improve conformality.
Final Plan: I normalized my final plan to 95% of PTV68 receiving 100% of the prescription
dose. I had a global max dose of 107.4% and mean dose for PTV68 of 103.4. The global max
dose fell within the PTV, so I was okay with it. (Figure 3A) I would prefer that it fall in the
prostate bed, however being in the PTV is acceptable. When looking for “cold” spots within the
rectum I noticed they were all in the rectum. (Figure 3B) This is to be expected because I pushed
hard to reduce the rectal dose. Figure 5 shows my final score card. Figure 6 is a final DVH and
figure 7 shows multiple axial views to demonstrate the conformality through the plan. Overall, I
think this plan is acceptable. It was nice being able to try different techniques and see how hard I
could push before it started having a negative affect on the overall plan.
Figure 4A Global hot spot and 4B Global cold spots
4A 4B
Figure 5: Final Score Card
Figure 6: Final DVH

Figure 7: Isodose lines throughout plan
Failed objectives: There were a few objectives that I did not meet with this plan.
Conformality: My conformality was 0.765. I used two rings and optimization structures to help
make my plan conformal. I decided to stop pushing for the plan to be more conformal when it
started increasing my maximum dose.
Hot Spot: This was an objective that I compromised on. I let this go a little higher in order to
reduce my bladder and rectum dose. The plan mean was still under 105, however by pushing on
the bladder and rectum I did make this plan hotter than I would normally like to see.
V65 Rectum: After the first 2 optimizations I calculated how much of the rectum was in the
PTV68. There was 9.19% of the rectum in the PTV68. I did not want to keep pushing to meet
this goal as it was causing a cold spot in my PTV. I would rather see good coverage on a PTV
and an acceptable dose to OAR than risk underdosing any part of the PTV.
V40 Rectum: Again, with some of the rectum being in the PTV68 I did my best to push the dose
in around the rectum. I lowered this to 25% but as I pushed harder, I was wither creating a cold
spot in the PTV or pushing dose to other areas that I was not happy with.
V65 Bladder: I also calculated how much of the bladder was within the PTV68 and PTV56.
This was 8.47 and 17% respectively. I pushed on this to reduce it as much as I could without
negatively affecting the PTV or rectal dose. I was able to reduce this to 18% which was 3% away
from the goal.
Hot spot in Prostate Bed: My hot spot was in the PTV but outside the prostate bed. When
optimizing I put the minimum dose and maximum dose slightly higher in my CTV than my PTV.
In many cases this will help to push the hot spot into the CTV. It did not help after a few
optimizations, so I left it where it was and focused on other objectives.

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Brianna Niemuth

Proknow Prostate Plan

Figure 4A Global hot spot and 4B Global cold spots

Figure 6: Final DVH

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