Adam Schwartz

ProKnow Head and Neck Planning

Clinical Practicum III
November 28, 2018

ProKnow TG 244 Head and Neck Planning Study

Head and neck planning can be completed using a varying array of modalities and often

proves to be one of the more difficult planning responsibilities of a medical dosimetrist. In order

to plan multi-volume simultaneous integrated boost (SIB) cases to different dose levels, one must

possess a true understanding of patient anatomy, treatment planning software (TPS) capabilities,

and radiation physics to develop an approvable plan that limits dose to the many regional organs

at risk (OARs). Head and neck plans are difficult provided the thin, heterogeneous nature of the

neck which can limit the amount of build-up tissue. These characteristics can often make it

difficult to create customized dose distributions and limit the maximum dose to OARs and the

final treatment plan. These concerns have become more pertinent with the advent of IMRT and

new radiotherapy techniques that give the potential to increase cure rates as localizing dose to

target volumes and away from OARs decreases side effects and probability of secondary

malignancy.1

The ProKnow TG 244 head and neck study set includes 3 target volumes to receive doses

of 56Gy (PTV56), 63Gy (PTV63), and 70Gy (PTV 70). This study intends to be challenging and

test the critical thinking skills and understanding of the planner in order to achieve constraints

accepted by the ProKnow platform. I planned this case to use Volumetric Modulated Arc

Therapy (VMAT) with Elekta’s Monaco Treatment Planning Software platform, implementing 6

MV beams and the Monte Carlo dose calculation algorithm to deliver 200cGy per day for 35

fractions. Due to the size and location of the Planning Target Volumes (PTVs), I decided to start
with 2 treatment beams with 2 full 360 degree arcs. The planning process proved to be difficult

and the final plan required an increase in the number of full arcs per beam from 2 to 4 in order to

achieve the planning directives. Each beam had a collimator rotation of either 20 degrees or 340

degrees in order to limit dose streaking from leakage through multileaf collimator (MLC) leaves,

as this is currently the accepted understanding in my department.

As seen in figure 1, the Monaco TPS makes use of a unique inverse planning process

where the operator adds customized constraints, or cost functions, in order to customize dose

distribution and the dose that each target and OAR receives. Each unique cost function is entered

into the dose calculation algorithm and accounted for by the TPS during the optimization

process. A priority in this particular study was to achieve all target coverage constraints, as these

were most heavily weighted in the scoring sheet. In order to prioritize target coverage over OAR

dose, I used the Pareto function which focuses more of the systems capabilities on the cost

functions associated to the target volumes rather than OARs. In doing so, careful consideration

was taken to balance the amount of dose to OARs and target volumes by applying extra strict

cost functions to OARs close to the target volumes.

The final statistics, as seen in dose volume histogram format in figure 2, indicated that

target coverage was met for each of the PTVs and clinical tumor volumes (CTVs). Prescription

dose was mostly conformal and confined within designated target volumes as seen in figures 3-

5. The most difficulty I encountered in this plan was when attempting to limit dose to the larynx

and right parotid, along with the PTV56-PTV 63 and PTV63-PTV70 volumes. A trick I used to

increase my score was to create 1cm rings surrounding target volumes (figures 6-8). These rings

were pushed by the optimizer by using a maximum dose of approximately 108% with no shrink

margin and a maximum dose of the prescription value with 0.3cm shrink margin. In doing so, I
was able to create a rapid dose fall-off from adjacent targets which also aided in limiting dose to

nearby OARs. As I pushed harder, I began losing target coverage, increasing maximum dose,

and decreasing the conformation number of 53.2Gy to PTV56. After several tweaks and a

number of optimizations, I was able to find a balance of how hard to push the ring structures and

created a plan that would have been deemed clinically acceptable at my facility, as shown in the

ProKnow score-sheet in figure 9. This technique is very effective as it allows the planner to use

fewer structures in the optimizer and create complex treatments with more simple plans.
References

1. Tolentino Ede S. Oral adverse effects of head and neck radiotherapy: literature review
and suggestion of a clinical oral care guideline for irradiated patients. NCBI.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3984189/. Published September 2011.
Accessed November 27, 2018.
Figure 1. Cost functions are used in Elekta’s Monaco TPS to customize dose distributions. Note
that the weight column indicates how hard the planning system had to work to achieve the
desired parameters.

Figure 2. Indicated is a dose volume histogram with volume in percent listed in the Y-axis and
Dose in cGy in the X-axis. This tool is a very useful gauge of plan quality.
Figure 3. Axial slice image of plan dose distribution and target coverage.

Figure 4. Coronal slice image of plan dose distribution and target coverage.

Figure 5. Sagittal slice image of plan dose distribution and target coverage.
Figure 6. Axial image demonstrating Ring70 in orange surrounding PTV70 in red. This structure
was created by adding a 1 cm margin to PTV70.

Figure 7. Axial image demonstrating Ring63 in aqua surrounding PTV63 in pink. This structure
was created by adding a 1 cm margin to PTV63 and subtracting Ring70 from the volume.
Figure 8. Axial image demonstrating Ring56 in yellow surrounding PTV56 in green. This
structure was created by adding a 1 cm margin to PTV56 and subtracting Ring70 and Ring63
from the volume.

Figure 9. ProKnow metric score card indicating the achieved scores for each of the planning
metrics. Note that target coverage was prioritized and achieved within the ideal value for each of
the requested metrics.