Felicia Chu

7/19/2019

UW TG244 Case 01 Prostate Fossa Nodes Plan Study

This prostate plan study was a welcome challenge, and I enjoyed using new techniques to
achieve an optimal dose distribution. My final plan was normalized to the 98% isodose line,
covering approximately 95% of the planning target volume (PTV) low and high. Here’s a
snapshot of my final isodose distribution in all axes.

The areas lacking the majority of coverage was the periphery of the PTV low. The lack of
peripheral coverage makes sense, as there were critical structures being spared including rectum,
bladder, and bowel. The hottest point was in the prostate bed, which is ideal as it is specifically
where we are treating. This hotspot location was particularly challenging to achieve, as the
prostate bed contour overlaps with the bladder. I had to crop the prostate bed structure from the
bladder so that the hot spot would not end up in a critical structure, and give it a lower constraint
at 103% of my prescription dose. I had not previously used such a technique in order to move a
hotspot, and even then, the hotspot was not always in the prostate bed volume. I had to run the
plan a few times to move the hottest point into the prostate bed minus bladder structure.

Pictured above is my final isodose distribution. I met all minimum constraints on PTVs,
bladder, and rectum. I had the most trouble meeting the ideal constraint of V15<65 Gy on the
bladder, as there was quite a bit of bladder in the field. In order to maximize my ideal rectum
constraints my keep the hot spot to a minimum, I did sacrifice constraints on a bit of bladder. My
rationale was that in my clinic, we typically prioritize rectum sparing over bladder sparing due to
associated side effects. I still managed to keep bladder dose to a minimum, but rectum doses
were closest to ideal constraints. Striking a balance between the two constraints and overall plan
hotness was the most difficult portion of the plan study.
In terms of beam geometry, I chose to use 3 arcs, as shown below. I typically use a
185-175 degree clockwise arc and leave that 10 degree separation posterior to spare rectum. I
used 10 MV energy to push dose midline into the prostate bed and keep the plan cool.

I used a 90 degree collimator angle for my third arc in order to achieve optimal rectum
and bladder sparing. The majority of the multileaf collimators block bladder and rectum as
pictured below, but still cover the PTVs well. The 330 degree and 30 degree complement
collimator angles also balance coverage on nodes and critical structure sparing.

For my optimization constraints, I used a number of new techniques. Most notably, I used
upper generalized equivalent uniform dose (gEUD) constraints which have not been used
extensively in my clinic. I specifically made an anterior, posterior, and middle avoid structure by
adding margin in the specified direction to aid in sparing of bladder and rectum, in addition to
normal upper constraints. I cropped these structures from the PTVs so that they wouldn’t
interfere with each other in the optimization process.

The anterior and posterior gEUD volumes are pictured in lilac purple above. Below
shows the middle avoid volume.

To maximize coverage, I always begin with a 105% of prescription dose upper constraint
on my PTV high, and a 102% lower constraint. My end result will typically cover 97-98% of the
PTV. However, through the planning process, I couldn’t achieve ideal rectum and bladder
constraints while covering over 95% of the PTV, so I reduced my constraints to order to improve
sparing of critical structures.

Here’s a snapshot of my final optimization constraints. Using a mix of both gEUDs and
normal upper functions achieved a great balance of both sparing and coverage. I added in several
upper constraints from my clinic’s own dose constraint templates. These constraints are detailed
below. By adding in additional constraints to the rectum and bladder, I was able to have various
points to supplement my optimization DVH. In other words, having more constraints “pushed”
my dose down at more places on the curve.
 Overall, I intend to use the new techniques I gained from this plan study on my future
prostate plans. Although I had already been doing a few practice plans in clinic, I am excited to
produce even stronger plans in the future. I’m also looking forward to the next plan study.
Study Name: UW TG244 Case 01 Prostate Fossa Nodes

Participant Name: Felicia Chu

Participant Email: chu1569@uwlax.edu

Participant Role: dosimetrist

Participant Institution: UW La Crosse

Created: Fri Jul 19 2019 23:00:07 GMT+0000

TPS Manufacturer: Varian Medical Systems

TPS Model: Eclipse

Number of Treatment Beams: 3

Radiation Type(s): Photon

Delivery Type(s): VMAT