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Brittany Bird
Clinical Practicum III
December 6, 2017
ProKnow TG 244 Head and Neck Plan Study Challenge
Cancer involving the head and neck region can oftentimes present several complex
challenges during the treatment planning process. Planning and prescription doses can vary
depending on whether the patient will be having surgery or if they will only be receiving external
beam radiation therapy (EBRT). At Maury Regional Medical Center, if a patient is pre-operative
three separate treatment plans will be created and the daily dose will be at 200 cGy per fraction.
For a patient that is not having surgery, one plan is created with the daily dose at 180
cGy per fraction. The majority of the work is performed on the front end of the planning,
ensuring that all of the target volumes dont overlap or are cropped out from one another. This is
important during the optimization process, so that the optimizer doesnt get confused by the
conflicting values that are being input.
The TG 244 head and neck case dataset provided by ProKnow was imported into an
Eclipse treatment planning system (TPS). The prescription dose was set to 200 cGy per fraction
for 35 fractions for a cumulative dose of 7000 cGy. The plan comprised three target volumes
including a PTV 70, PTV 63, and a PTV 56 reflecting the various dose levels to be achieved.
The TrueBeam linear accelerator was selected as the beam delivery device utilizing a
volumetric-modulated radiation therapy (VMAT) technique. A total of three full arcs were used
for this particular treatment plan along with a 6 MV photon beam energy (Figure 1). Three arcs
would allow for better target volume coverage for this plan. There are two clockwise (CW) arcs
rotating from 181 to 179, and the counter-clockwise (CCW) arc is rotating from 179 to 181.
The CW arc consists of a collimator angle of 10 and the CCW has a collimator angle of 350 to
avoid overlapping interleaf transmission. The couch rotation was set to 0. Organs at risk (OR)
incorporated into the ProKnow PlanIQ scoring system included the brainstem, larynx, left and
right cochlea, lips, mandible, posterior neck, right parotid gland, and the spinal cord. Initially,
visualizing the target volumes, I knew the mandible and right parotid were going to be difficult
to achieve a high score on.

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Figure 1. A coronal, axial, and sagittal view of the dose distribution of the head and neck
treatment plan.

For this plan challenge I added three dose rings, one around each PTV. Each individual
dose ring had to be cropped out of one another. This helped me to focus on the dose fall-off
between each dose level. Almost half of the ProKnow score sheet evaluated target volume
coverage, so this was something that I primarily focused on. This was a difficult task, because
sometimes I would tighten certain constraints and achieve a value for certain target volumes, but
then this could alter other volumes and lower the score on them. After the initial optimization
process was completed, I created PTV optimization structures to increase my coverage to the
target volumes. In the optimization window, I placed an upper and a lower objective on the
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PTVopt structure that was similar to the PTV objective, except with a higher lower objective.
This allowed a little extra focus to this specific structure. I also excluded any structures that I
wasnt using from the optimization window, so the optimizer didnt have to work harder. My
biggest challenge throughout the entire process was trying to raise the conformation number to
one. I never really could get my score to change for this, and so this was a struggle.
A few tricks that I used to help improve the plan besides using dose rings is that I
expanded my posterior neck and spinal cord region to help block extra dose to that region. I
even created an avoidance structure in the posterior area. Due to the right parotid gland receiving
an extensive amount of dose, I decided to subtract the volume of the gland that wasnt in the
target volume and use this as a structure in the optimizer. A dose-volume histogram (DVH)
depicting the final outcome of the head and neck treatment plan is shown in Figure 2.
Overall, the ProKnow TG 244 head and neck plan challenge proved to be exactly that, a
challenge. This project helped me utilize a variety of treatment planning tricks that I have
learned over the progression of my clinical rotation and also made me aware of what I can
improve on. I would have liked to have reached a higher score on my target volumes, however, I
believe with more experience and practice I will gain the skills that I need to be able to achieve
this. My final plan challenge results can be viewed in Figure 3. I plan on participating in more
ProKnow plan challenges to keep my skills updated and to learn new tips and tricks from other
users. I also plan to discuss different methods that other medical dosimetrists or medical
physicists would have utilized for this head and neck plan.
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Figure 2. A DVH of the target volumes and OR.

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Figure 3. ProKnow TG 244 head and neck plan challenge results.