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Beverly Meyer
DOS 773
ProKnow Head and Neck Discussion
The ProKnow Head and Neck Plan Challenge proved quite difficult to achieve the
required goals. The contours, prescription, and fractionation details were provided by ProKnow,
a contouring accuracy program. The VMAT arrangement consisted of 3 full arcs with collimator
turns of 15 degrees and 345 degrees, which is standard protocol for head and neck treatments at
my clinical facility in order to obtain better conformality (Figure 1). I used the planning tips
provided in D2L and also discussed them with my preceptor before beginning the challenge.

Figure 1. First plan VMAT beam arrangement

The normal tissue objective was given a priority of 150 and I typically begin the
optimization process by only including the targets initially. I feel this gives me a better overall
impression of what needs to be constrained and by how much. However, this challenge had me
perplexed. I struggled through 4 plans, constraining the OARs while trying to achieve coverage
for the targets. The next plan received my highest score thus far of 125/155 but the mean dose to
the right parotid remained too high to receive any points. I then tried to constrain the right
parotid by giving it a lower mean objective and a higher priority in the VMAT optimization
(Figure 2), only to fail miserably by landing dose in the spinal cord over 48 Gy. This in turn
provided me a score of -24/155 by losing 150 points by overdosing the spinal cord.
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Figure 2. Initial optimization objectives.

Continuing the same path as the first six plans, I was unable to both maintain coverage in
the PTV70 and restrict dose to the right parotid. I was also struggling with coverage on the
contralateral side. After another consultation with my preceptor, I decided to make some
changes in my planning approach as I had reached a stalemate. I changed the collimator to 15
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and 345 degrees in the two clockwise arcs, providing coverage laterally to the PTV56, since we
limit the X to a maximum of 16 cm at my clinical site. Next, I changed the collimator in the
counter clockwise arc to 70 degrees, which provided the MLCs with more channels of
modulation over the PTV70, while limiting channels to the right parotid (Figures 3-5).

Figure 3. Collimator changes.

Figure 4. Collimator and X field size changes for clockwise arcs, PTV56 in green.
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Figure 5. PA view of Field 2 CCW arc showing PTV70 (red) and right parotid (gold).
In addition to changing the collimators, I lowered the NTO priority from 150 to 80 and
left the optimization objectives as they were. This allowed for the dose to fall off less
symmetrically around the right parotid in particular. In addition, I converted the 7000cGy dose
line as a control structure which helped constrain the dose within the PTV70, not outside it. I
optimized the seventh plan with these goals, and scored a 130/155. I scrutinized the scoresheet
and decided I could optimize once more, adding in the left cochlea constraints to earn a few more
points (Figure 6).
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Figure 6. Optimization objectives for submitted plan.

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The eighth and final plan I submitted to ProKnow earned 133/150 points. I am uncertain
that I could improve on this plan anymore. In the clinical setting, a medical dosimetrist would
not have the time to devote to one patient as I did with this challenge. I feel like I learned a
tremendous amount by participating in this challenge and hope to continue to hone my skills as a
medical dosimetrist and keep participating in learning opportunities like this in the future. The
final DVH for the plan challenge can be seen in Figure 7. Finally, there is one discrepancy
between eclipse and ProKnow, the volume of PTV70 which is covered by 73.5Gy. According to
the ProKnow scoresheet (Figure 8), the volume is 0.357% coverage, where I found it to be much
less at 0.0357% volume (Figure 9).

Figure 7. Final DVH.

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Figure 8. ProKnow Scorecard.

Figure 9. Percent volume of PTV70 covered by 73.5Gy.