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Alecia Eliason
ProKnow Head & Neck Planning
Clinical Practicum III
December 6, 2017
ProKnow TG 244 IMRT Head & Neck Planning
Planning head and neck radiation treatments, especially those with multiple planning
target volumes (PTVs), has proven to be one of the greatest challenges Ive encountered as a
medical dosimetry student. The numerous organs at risk (OARs) near and/or within PTVs in the
head and neck region, along with avoiding entrance dose to a patients face for most situations,
force medical dosimetrists to use critical thinking skills and creativity to meet objectives
requested by physicians. The relatively thin separation of a patients neck can pose an issue as
well, not only limiting build-up tissue but also leading to a higher dose of radiation received by
much of the neck, possibly increasing the likelihood and severity of side effects.
The ProKnow TG 244 IMRT Head & Neck case proved a challenge regarding all of the
above criteria, making it an exceptionally difficult plan. I chose to plan using a volumetric-
modulated arc therapy (VMAT) technique on an Elekta Infinity linear accelerator. Initially I used
just 2 beams with 2-360 degree arcs each, but after struggling to meet many constraints, my final
plan had 3 beams with 3-360 degree arcs each, all with 6 MV. The collimator was turned to
either 20 or 340 degrees for each beam to spread the dose leakage between multileaf collimator
(MLC) leaves. In terms of treatment planning constraints, I put maximum dose limitations on the
spinal cord, brainstem, left cochlea and right cochlea. I used a serial constraint on the lips,
mandible, larynx and parotid, effectively lowering specific volume doses to each of these organs.
As for the target volumes, I put target doses on each to their respective prescriptions, along with
a high dose-limiting constraint on each to prohibit large volumes of these doses within each
PTV.
Delivering the prescribed doses of 70 Gy, 63 Gy, and 56 Gy to each relative PTV using a
simultaneous integrated boost technique was somewhat challenging, but the area of most
struggle for me was in limiting the higher doses within each volume as required by the treatment
objectives. Firstly, a dose of 71.3 Gy to 0.03 cc or less of the PTV was a very difficult
requirement. This case was planned using an Elekta Monaco treatment planning system with a
Monte Carlo algorithm, which although is very accurate, makes meeting goals like this
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maximum dose nearly impossible. The physicians at my clinical site typically will accept a
maximum dose of 108-110% the prescribed dose for head and neck IMRT plans, so I was very
pleased to keep my maximum dose to 105% (Figure 1), even though this didnt meet the ideal
goal of 71.3 Gy (101.9%). The maximum point dose ended up in the PTV70 rather than the
CTV70, which was not ideal but a metric with which I felt ok.
In order to keep the high dose regions within the ProKnow plan requirements (i.e. volume
of PTV63-PTV70 covered by 66.15 Gy), I created PTV structures with which to optimize rather
than using those provided. I expanded the PTV70 by 2 mm and used this as my optimization
structure for the 70 Gy prescription dose. I also expanded the PTV63-PTV70 structure by 2 mm
and then left a 2 mm gap between this expansion and the PTV70 expansion, using this structure
for optimization of the area to receive 63 Gy. I did not expand the PTV56-PTV63 volume at all,
but I did create another optimization structure leaving a 2 mm gap between this and the PTV63-
PTV70 optimization structure. These new structures helped me achieve 95% coverage for all
target volumes while limiting some of the high-dose regions within each, although I did not meet
the ideal metric for the PTV63-PTV70 or the PTV56-PTV63 high-doses. However, these high-
dose limitations did affect my conformation number, resulting in a score of 0.714 rather than the
ideal 1 (Figure 1).
As for OARs, I didnt meet the mandible ideal metric but was close at 11% covered by 70
Gy (ideal was 10%), which I was extremely happy with seeing as 15% of the mandible was
within PTV70. I was very close to meeting the ideal metrics for both the right parotid and the
larynx (Figure 1), but I found that pushing these structures too hard drastically affected my target
coverage. Both mean doses received by these OARs were well within the range provided, so I
was content with letting up a little on my constraints in order to achieve 95% target coverage.
This is an area that I would definitely review with the treating physician so I could be sure to
meet his/her wishes (allow for less target coverage or allow for more dose to be received by the
OARs).
My plan was obviously not perfect, but I do feel that it would be acceptable for treatment
and that the physicians I work with would agree. I wanted to try planning this case using
Accuray Precision for Radixact (previously Tomotherapy), but the treatment machine and
software was being upgraded for a period of time, and even when it was back up and running the
medical dosimetrists needed the workstations for the planning of actual patients. I think I could
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definitely get a cooler plan using Precision, and Id be curious to see in which other areas my
plan might improve. Directional blocks are tools that may be utilized on Precision but not on
Monaco, so using this may lower the right parotid dose. I suspect the conformation may also
improve using Precision. Overall, I feel my final plan is one that could be safely and effectively
delivered (see Figures 2-5 for the dose volume histogram and plane screenshots).

Figure 1. ProKnow metrics. Note that at least 95% coverage for each target volume was
achieved in the treatment planning system and is inaccurately reported here.
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Figure 2. Dose volume histogram with volume (%) on vertical axis and dose (cGy) on horizontal
axis.

Figure 3. Axial screenshot of final plan.

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Figure 4. Sagittal screenshot of final plan.

Figure 5. Coronal screenshot of final plan.