Stephanie Sanford

Clinical Practicum III

Head and Neck Planning Discussion

This planning challenge was of tremendous value to me. Of all the clinical competencies
that were required for this program I have found head and neck planning to be of the more
complex and challenging cases. Several dose levels and closely surrounding critical structures
make each case a bit of a problem to be solved. I need to consider how I can setup a plan to
deliver optimal coverage within the constraints set by the physician. Learning from others their
tricks to achieving the objectives of the planning directive has been very advantageous. I
know I will continue to develop my planning skills but Id like to discuss some of the concerns I
addressed while working on this planning challenge.

I began by setting up my VMAT arcs as all of the target and critical structures were
already provided through the plan challenge. In this case I decided to try to keep the plan to two
arcs if possible as if it were to be treated clinically the therapists would prefer a two arc approach
to ensure there is less opportunity for the patient to move in the mask and less opportunity to
miss the treatment volumes. Also many times patients are required to have stents in their mount
or other treatment devices that can be quite painful so I try to make my plan delivery a quick and
reproducible as possible. In this challenge we were asked to keep beam on time to less than 2
minutes. I was nearly able to make this objective but did go just beyond this time constraint.

The arcs were setup to first rotate clockwise from 182 to 178 including at 15 degree
offset of the collimator. The second arc was setup to rotate in the counterclockwise direction for
workflow in the treatment room and went from 176 to 184 with a 15 degree offset in the opposite
direction of the collimator. The collimator rotation was picked to limit interleaf leakage to the
patient. I did choose to limit the field size of each of these beams to improve the ability of the
machines MLCs to keep up with the motion during each arc. We have found that Pinnacle will
create a plan that requires the MLCs to move far more quickly than they truly are able to do and
by restricting the field width I help this to be a more reasonable distance that the MLC will have
to traverse during the arc. We have found that this improves our QA pass rate. One arc was
limited in the affected side direction laterally and the other was limited to under 14 cm wide
across.

Figure 1. Arc 1 and Arc 2 collimator settings showing limiting maximum jaw size.

I then added in my planning structures that I anticipated would be needed for adding to
the optimizer to aid in meeting objectives. I began by adding a false structure in the posterior
neck to limit the dose from entering posteriorly.

Figure 2. Purple false structure posterior avoid used to limit dose to the cord and posterior neck.
 I additionally added a normal tissue avoidance structure that was created by making an
expansion of the total PTV structures by 3mm to the external of the body throughout the entire
length of the total PTV structure. I also made a second structure for normal tissue avoidance that
was 1.5 cm away from the total PTV structure to the external of the patient extending through the
entire length of the total PTV structure. By having two different normal tissue structures I am
able to be stricter with the one that has a greater distance from the PTVs. I also created an
anterior avoidance structure to limit dose to the lips and mouth wherever possible. Finally, I
created some planning PTV structures subtracted the higher dose levels from each PTV with a
1mm moat as well. This helps to use max dose goals in the optimizer for the lower dose levels
and not compromise the higher level structures coverage.

I was now ready to setup my optimizer with goals to begin the planning process.
Generally I start by focusing almost all of my efforts on getting coverage to the targets then I
gradually add in the limiting structures but because there are so many critical structures near the
targets in this case I decided to add in some of these structures as well with a lower weighting. I
started by giving each dose level a min dose of the prescribed dose, a uniform dose of the
prescription dose plus 50 cGy, and a max dose of next higher dose level or 105% of the highest
dose level. I additionally added a goal fo the posterior avoidance structure of max dose of 5700
cGy. I also added a goal of limiting my normal tissues structure (3mm from total PTV) to 2000
cGy mean dose and the normal tissue structure (1.5 cm from the total PTV) to 1000 cGy mean
dose. These were adjusted as I planned but I felt this was a good place to start. I ran the plan for
100 iterations and reassessed the plan. In this process I found that the normal tissue structures
worked well to keep the plan conformal but I may have been a bit too aggressive with the dose
limits as I found it difficult to get good coverage throughout the entire planning process. Ideally
I try to stay around 98% normalization but in the final plan I needed to normalize down to 97%
in this case to get the coverage. As shown below in my final scorecard I ended up having a very
hot plan because I was trying to use the normalization to obtain coverage.
Figure 3. Final plan scorecard

While I feel the plan ended up being pretty conformal there were a couple of areas that I
would like to have improve more but found to be quite challenging. These were not specifically
items listed on the plan challenge but they are areas that I know our physicians would prefer so I
tried to consider this when completing this plan. In the area around the larynx there are two
lateral structures that were creating a bridge across the esophagus of dose that wasnt necessary.
I used dose painting structures to push dose out of this small area but ideally I would have liked
to push more out. Patients receiving head and neck treatments are already having troubles with
swallowing and eating and we dont want them to lose a lot of weight while on treatment. In
order to help them to keep eating as consistently as possible its important to limit dose to the
esophagus as possible. If they lose weight adaptive plans are necessary so by taking the time to
limit dose in the initial plan, I may help the patient to keep a consistent weight limiting the
opportunity for a re-plan. I save myself time in the long run.
Figure 4. Area where dose was bridging across the throat.

One other area I found to not be as conformal as I would have preferred was around the
right parotid. Because I was pushing dose out of the mandible and the right parotid I found that
the dose was spraying out more than I would have preferred. Because it was more important to
limit dose to these structures this was something I was willing to compromise on.

Figure 5. Dose spray around the mandible and right parotid

Limiting the dose to the mandible was another thing that I found to be difficult. I think
this was primarily because the high dose target was covering quite a bit of the mandible. In
order to keep the dose at or below 70 I was fighting the optimizer for dose to the PTV 70
structure. In the end I feel I got as close as I could with the percentage of the mandible receiving
the 70Gy dose level at 11.7%. Again if I had been able to normalize lower perhaps I would have
been able to improve on this as well.

I found this plan challenge to be a very good learning tool and I have discussed the
challenges I faced with my preceptors to come up with other methods to achieve the objectives
for future plans. I look forward to learning from my classmates as well.