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Evgenia Nigay
H&N ProKnow Plan Assignment

Planning Technique
For this three level SIB H&N plan a 6MV VMAT technique with three full arcs was used
(Figure 1). The field sizes of each arc were set to only cover the PTV partially, due to a large
target volume. Figure 2 shows the field size arrangement and dimensions.

Figure 1. VMAT beam arrangement

Figure 2. Field sizes for each arc

Optimization and Results

The PTV optimization structures used were PTV70, PTV63-70, and PTV56-63; each
level was cropped 1mm from the next. A 3mm margin structure was created around the spinal
cord to help minimize the dose to the cord. After the initial optimization, the maximum dose was
outside the CTV70. The 105% isodose line was converted into structure and cropped out of
CTV70 optimizing this structure reduced the volume of high doses throughout the target while
pushing the maximum dose into CTV70. To get rid of the tail on the DVH as well as reduce
the volume of the maximum dose, 107% isodose line was converted into structure and optimized
using a high priority. An upper limit objective for the Body was also set at high priority to help
reduce the maximum dose. The final DVH and the ProKnow scoring sheet are shown in figures 3
and 4. There were some discrepancies between the values from the Eclipse TPS and ProKnow,
shown in figure 5.
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Figure 3. Cumulative DVH

Figure 4. ProKnow score sheet

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Figure 5. Discrepancies between ProKnow (left) and Eclipse (right)

Planning Issues
The most challenging part of the planning process was to reduce the 105% doses for the
middle and lower levels. To reduce the doses as much as possible multiple upper limit objectives
were set during the optimization process. Dose levels of 6615 cGy and 5880 cGy were converted
into structures and optimized with upper limits in attempts to reduce their volumes.
Another tough objective was to reduce the volume of mandible covered by 70 Gy to 10%
without sacrificing the PTV coverage. To reduce the volume as much as possible in addition to
pushing the upper limit for the mandible structure an optimization structure was created to
include the overlapping PTV70 and mandible region; the lower limit helped maintain the PTV
coverage while the upper limit helped reduce the volume of mandible receiving the target dose.
An optimization structure was also created for the mandible region outside of PTV70 to push the
70Gy isodose line away from it.
If I were to re-do the plan from the start, in attempt to reduce the 105% doses for the
lower dose levels I would increase the optimizer priority for the upper limit and loosen up the
objective for the lower limit, allowing lesser coverage. To improve the confirmation number, I
would create a ring around the PTV, trying to draw the dose in.