Sheil

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Pat Sheil

December 6th, 2017

Clinical Practicum III

Head & Neck TG244 Project

Introduction:
The assigned case by ProKnow was the TG244 Head & Neck plan challenge.
The prescribed dose was 7000cGy to be carried out in 35 fractions with a
simultaneous integrated boost (SIB) to 6300cGy and 5600cGy. I used Varians
Eclipse treatment planning system (TPS) version 13.6 to create my plan. Treatment
was planned for a Varian iX accelerator and 6MV photons were the energy of choice
for all fields. I will discuss the setup and planning process that was put into the final
product.

Setup and Fields:
The patient was positioned head first and supine. VMAT technique was used,
as it is the standard for head and neck treatments at my cancer site. Utilizing the
VMAT technique allowed me to take advantage of the inverse planning software.
VMAT was advantageous over static field IMRT due to the need for less fields and
resolving the potential problem of carriage splits due to the large target volume.1
VMAT also allows for less treatment time, which reduces patient motion and
increases patient satisfaction. Using the arc geometry tool I was able to relay to the
software that I wanted my plan to include one singular isocenter with four separate
fields employing full arcs. Fields 1 and 3 were set to rotate in the clockwise (CW)
direction starting at 181 degrees and ending at 179 degrees for a full arc. Fields 2
and 4 were set to rotate in the counter-clockwise (CCW) direction starting at 179
degrees and ending at 181 degrees for a full arc. Employing 4 full arcs for the given
plan allowed for a more homogenous dose distribution and allowed each PTV region
to achieve their desired dose. I offset the collimators for field 1 & 2 by 15 degrees so
that interleaf leakage was reduced. Fields 3 & 4 had collimator rotations of 80
degrees and 100 degrees respectively. The field parameters were manually
established due to the large target area. The field parameters for all four fields can
be found in Table 1 below.

Table 1: Field Parameters

Field Name Weight Gantry Rotation Coll X1 X2 Y1 Y2 MU

A CW Arc H&N 0.853 181.0 CW 179.0 15 7.7 9.1 7.5 10.0 171
A1 CW Arc H&N 0.866 179.0 CCW 181.0 345 9.1 7.7 7.5 10.0 173
B CW Arc H&N 0.696 181.0 CW 179.0 80 13.2 3.6 12.3 10.7 139
B1 CW Arc H&N 0.690 179.0 CCW 181.0 100 12.9 3.9 11.0 13.2 138


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Pre-Planning Process:
Before I could begin planning, I had to create optimization structures for the
PTV70, PTV63, and PTV56. My clinic utilizes OPTI structures that act as
expansions to the PTV structures to further ensure adequate coverage of the
original PTV is obtained during the optimization process. A PTV_70 OPTI structure
was created by adding 0.1cm margin in all directions to the PTV_70 structure. The
same margin expansion was done for PTV_63 OPTI and PTV_56 OPTI. The complete
list of OR structures to be cognizant of when planning were given in the data set and
included the following: brainstem, parotids, larynx, cochlea, mandible, lips, and
spinal cord. A multi-planar view of all structures can be found in Figure 1 below.

Figure 1: Multi-Planar View of the Organs at Risk

Planning Process:
The prescribed dose was 7000cGy to be carried out in 35 fractions with a
simultaneous integrated boost to 6300cGy and 5600cGy. The energy I chose to use
for this plan was 6MV for all four fields as it is the standard at my clinic when
utilizing RapidArc to avoid neutron contamination throughout gantry rotation. A
calculation point and plan normalization was not necessary as the plan was created
volumetrically.
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After my setup was complete, I was able to begin the optimization process.
For this particular plan I made my NTO priority 150 and manually adjusted the
parameters. I used manual NTO instead of the automatic configuration due to the
SIB of different doses and to improve the conformality. Once I adjusted the NTO
settings, I then removed all structures that were not pertinent for planning. My OPTI
structures that I mentioned before were most important and received the highest
priorities. For the PTV_56 OPTI I gave it an upper objective of 0% to receive
5824cGy with a priority of 135 and a lower objective of 100% to receive 5670cGy
with a priority of 135. For the PTV_63 OPTI I gave it an upper objective of 0% to
receive 6552cGy with a priority of 125 and a lower objective of 100% to receive
6400cGy with a priority of 140. For the PTV_70 OPTI I gave it an upper objective of
0% to receive 7200cGy with a priority of 140 and a lower objective of 100% to
receive 7200cGy with a priority of 145. I added upper objectives to the following
structures due to the planning goals set by ProKnow: brainstem, parotids, larynx,
cochlea, mandible, lips, post neck, and spinal cord. I pushed the priority as needed
for each structure until they satisfied the goals. I ended up with an ideal plan that
met majority of the constraints provided by ProKnow (Table 2). My final
optimization objectives can be seen on Figure 2.

Figure 2: Optimization Objectives
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Table 2: ProKnow Scorecard

Plan Analysis:
My final plan had a global max of 7418.5cGy (106%). The hot spot was
located within the PTV70 structure, which passed the ProKnow ideal goal (Figure
3). Upon review I deemed this to be an ideal location for the hot spot and it is
located within the target.
My upper objectives for my OPTI structures had to be pushed very hard
during optimization, as coverage was failing to meet the ideal goals provided. My
final product still came up short by only having 94.57% of PTV70 covered by the
70Gy. Overall, the upper objectives were very useful in keeping adequate coverage
for all three PTVs. The tight coverage and conformality was obtained due to the
dynamic MLCs movement as the gantry continuously rotated around the patient.
The dynamic MLCs were able to modulate beam intensity to structures that I
prioritized while lowering dose to ORs based on the objectives that I placed during
the optimization portion. The isodose coverage displayed in color wash of the plan
can be seen in Figure 4. The DVH for the OARS and target structure can be seen in
Figures 5 and 6.
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Figure 3: Hot Spot located in the cranium
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Figure 4: Colorwash Dose (Red=6500cGy and up, Green/Yellow=3500-
6500cGy, Blue/Cyan=0-3500cGy)
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Figure 5: DVH OARs

Figure 6: DVH Targets

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Issues Encountered:
This plan challenge posed many difficulties while trying to achieve the goals
set forth by ProKnow. The first and biggest issue I encountered was setting the
appropriate field parameters. Initially, I manually set my field sizes for all 4 arcs but
as my first few plans came out, I was severely lacking coverage to my PTV56. After
some analysis of the field sizes, I determined that I needed to bring fields 3 and 4
inferior borders down more to encompass the PTV56. This took some balancing
because our rule is to not have our X field be greater than 16.8cm and this large
target volume was hard to encompass within those parameters. After some
tweaking, I was able to get all 4 fields to encompass the PTV56, PTV63, and PTV70
and the final plan resulted in great coverage for all target volumes.
The other big issue that I had was that I was not able to achieve the goal of
95% of the PTV70 covered by 70Gy. My end result was just short of the goal at
94.57%. I tried to increase the priority on my PTV70 lower objective, but the
consequence of that was my plan would increase in hot spot to roughly 110%. My
lower and upper objective ended up both being 7200 and I believe that could have
played a role in the lack of coverage and increase in hot spot. Adjusting the
collimator rotations could have helped with the coverage of the PTV70 more and
also helped with the cold shoulder. I could have also increased the field size in the Y-
axis to encompass more target volume, which also could have resolved the lack of
coverage (Figure 7 and 8).
Lastly, I struggled the most with reducing the volume of the PTV63-PTV70
covered by 66.15cGy to be covered by 20%. When I placed a higher priority to
achieve this goal, it would make my PTV70 lose coverage that I could not afford. The
PTV63-PTV70 and PTV70 target structures went hand in hand, what you did to one
affected the other in the same manner. So ultimately I was left with the decision of
having adequate PTV70 coverage or achieving the 20% of the PTV63-PTV70
covered by 66.15Gy. I tried many plans to fix this problem but to no avail. Next time
I would again change the collimators and maybe even try a slight couch kick to see if
more of the target could be encompassed so that coverage is met.

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Figure 7: Field Size Encompassing PTV56

Figure 8: Field Size Encompassing PTV70

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References:

1. Schofield, D; Court, L; and Chuck, M. Review and Guidelnes for Treating
Head and Neck Tumors using IMRT and VMAT. AAPM 2010. Retrieved
December 1st, 2017. Web accessed.
<http://www.aapm.org/meetings/amos2/pdf/49-14474-44091-
567.pdf>