ProKnow VMAT Prostate Plan

Normalized Plan
A VMAT prostate was created as a SIB, Rx normalized ≥ 95% coverage. PTV56 ≥ 56 Gy; PTV68 ≥ 68 Gy.

Beam Arrangement
I chose 4 full beam dynamic arcs using 10MV energy. 2 beams in a both clockwise/counterclockwise direction
have alternating 45-degree collimator angle; 2 beams in both clockwise/counterclockwise directions have
alternating 60-degree collimator angle. My clinic will not allow any more than a 60-degree collimator rotation with
VMAT planning technique. I planned the collimator angles to help spare dose to the bladder and rectum.

The details of the beam geometry is provided in the image below.

Plan Isodose Lines

Cold Spots

I had cold spots around the periphery of my target volumes initially. I often create and use coldPTV structures to
resolve this and gain coverage. I make these by creating an ROI of the isodose lines and then use it to make the
coldPTV structures by using the PTV structure as my source and avoiding the interior of the isodose line ROI. In
the case of this plan, I created 2 structures, coldPTV56 and coldPTV68. I would often edit this structure while
going through my optimizations by creating the ROI of the current 5600 and 6800 isodose lines.

Maximum Dose Point

The global maximum dose point is within the prostate bed. Initially it was not. The way I fixed this was pretty
simple- on 1 slice in the center of the prostate bed (or wherever I wanted the max point to be, I added an ROI
structure that looks like this:

I named the ROI max pt and set a minimum dose optimizing objective equal to what the current max dose was. The
max pt moved directly to the slice and inside the max pt ROI structure.

This is the 3-panel view in Pinnacle TPS of my structure:

Global Max Dose view in ProKnow

To increase coverage to target volumes and minimize hot spots or lower dose to OAR constraints, I often use rings
that help to push dose toward the planning target volumes and away from OAR. I will decrease the max dose limits
in optimization objectives as well as increase/decrease the weighting for these objectives.

I previously mentioned the way I improve coverage after each optimization attempt by using coldPTV structures. I
also use this to minimize hot spots by creating a hotPTV structure. When I create this structure, I create the hot
isodose line ROI. Using the PTV as a source, I avoid the exterior of the PTV. This way I can use the hotPTV as a
dose limiting structure in my planning objectives.

Metrics unable to meet

While I met all of the planning metrics, I had the most difficult time getting the V40 of the Rectum to an ideal or
less than the minimum requirement. I found that I had to keep lowering the dose and increase the weighting for this
planning objective, as well as use the coldPTV structures often after optimizations.
DVH

Prostate Bed

PTV68
PTV56

Bladder

Rectum
ProKnow Scorecard