SBRT Lung Plan Final

Stereotactic Body Radiotherapy Lung Plan Study
I was very excited to be able to plan a SBRT lung this semester. My clinic is starting to
treat more SBRT patients and I will be very active in the planning of these cases. There were a
few challenges that I faced along the way with the ProKnow website but I have confidence in my
plan and I learned a lot from my instructor’s guidance and suggestions. Since there were many
changes in my planning and optimization settings to compensate for the ProKnow score I will
mostly focus on the planning modifications that I used to improve my plan quality and not the
many attempts to obtain a better ProKnow score that, in turn, reduced my plan quality.
Before I started working on this case, I looked at some of the learning materials on the
ProKnow website to get some ideas on how other people have planned this case because I have
never planned a SBRT lung clinically. This is where I got some ideas for beam arrangements,
couch kicks, number of arcs, etc. I saw a lot of similarities with what I was thinking I wanted to
do compared to some of the plans featured on the website. I also took the time to print out and
review the SBRT Lung ProKnow documents, so I could familiarize myself with the prescription
and plan metrics for the plan study.
The images, contours, and instructions came from the ProKnow 2017 Radiosurgery
Society Plan Study. The prescription was to treat the PTV to 55Gy in 5 fractions. The first thing
I thought about was what energy to use. My clinic does not have 6MV FFF, so I had to use a
6MV beam. I would like to try planning an SBRT in the future with a 6MV FFF beam to see
how different the result would be. The next thing I did was to figure out what my beam
arrangement should look like. I knew that I wanted to use at least 3 partial arcs and to avoid the
contralateral lung. After playing with the field arrangements and looking at them on the DRR, I
decided on three arcs: field 1 - CCW 179º-330º, field 2 - CW 330º-179º, and field 3 - CCW 179º-
330º. I used the arc geometry tool to help me choose an isocenter and field size for my arcs as
well. I typically will use the arc geometry tool and adjust if needed for all my VMAT plans. I
then went back to some of the learning materials on the ProKnow website and noticed that some
of the planners used couch kicks on their arcs to obtain better fall-off, so I also added 15º couch
kicks to fields 2 and 3. During the course of planning, I did not sway from this field arrangement
because I seamed to be following very closely to what I saw in the learning documents and also
with some other reference materials I obtained from my clinic on SBRT lung planning. I also
did not want to extend my arcs any more into the contralateral lung.
Once I was happy with my field arrangements, I moved on to optimization. I did not use
rings for planning but focused on using an appropriate NTO for optimization. I set the priority
the same as my ITV and used a steep fall-off of 0.5. I also set the distance from the target
boarder to 0.2cm. At first, I mostly focused on trying to get the minimum coverage needed for
my target and to have the hot spot in the ITV. The first couple of time I ran my plan I had my
PTV objectives close to the prescription dose and the ITV about 110% higher. I did have to play
around with this a few times to get good coverage and the hot spot in the ITV and I finally got
good coverage by using a PTV lower objective of 5775cGy and an upper objective of 5850cGy.
My ITV lower objective was 6000cGy and the upper objective was 6050. I did try some of the
suggestions from my instructors along the way like normalizing higher in Eclipse, looking for
overlapping structures that would affect my coverage, making a PTV expansion, and following
some of their upper and lower objective constraints, but I found that these suggestions did not
make a significant improvement in my plan in Eclipse and gave me a worst score in ProKnow or
just made my plan too hot. The only structure that was really overlapping with my PTV was the
PBT and I had no problem getting that to an ideal metric, so I did not crop that out of the PTV
for optimization.
Once I was satisfied with my PTV coverage I went back and ran the plan multiple time to
get my OARs down as much as possible and to try to improve my ProKnow score. When I run
plan optimizations I really like to watch it in real time and build a plan during the phase 1
optimization. I go back and work on the OARs as needed. I eventually hit diminishing returns
on the ProKnow score and focused more on trying to improve my plan quality in Eclipse.
There were many things I learned while working on this project. First, I had to spend a
lot of time going over job aids to help in the SBRT planning process. This was a great way to
show my employer that I would really like to be involved in the new SBRT program we will be
starting at my clinic and I had a lot of insight to share while I was researching SBRT planning.
In my research I learned a lot about the immobilization techniques used while treating these
patients and I look forward to seeing what technique we will choose for our program. I did step
out of my box when it comes to optimization techniques because it is uncomfortable to see such
a high plan maximum point, but I have learned that it is okay to go as high as 150% in some
cases. My plan had a 3D dose max of 135%. I did take advantage of the very helpful
Cyberknife physicists at my clinic in talking through a lot of concerns I had for my plan and they
helped me see the differences in conventional fractionated VMAT lung planning verses SBRT
lung planning.
There were a couple of things I struggled with during this project. My biggest struggle
was figuring out the grading system for ProKnow and trying to evaluate my plan in both Eclipse
and ProKnow. I attached a comparison sheet of my metrics from Eclipse and ProKnow, so you
can see the difference between the two. This also taught me how to calculate the conformation
number and the conformality index values. I used the formulas listed on the ProKnow website
for consistency. Another metric that I struggled with was getting the hot spot inside of the ITV.
I did eventually figure this out by playing with different optimization techniques for the upper
and lower objectives suggested to me by the dosimetrists at my clinic and my instructors. There
was some confusion on the metric Dose (Gy) covering whole PTV minus 0.03 (cc). My
instructors gave me some guidance on this metric and I did reach out to ProKnow for guidance
as well. I took this information and evaluated my plan to the best of my ability with the metrics
given.
Overall, I did learn a lot about SBRT planning while working on this project. I had to
deal with some other struggles that were out of my control along the way, but I spent a lot of
time researching SBRT planning, the ProKnow system, and trying to make my plan as clinically
deliverable as possible. Once my plan was completed, I had some peer review within my
department and I was very happy with their critique of my plan. I look forward to planning more
SBRT plans in the future and I will take the lessons I learned from this project and apply them to
future planning.
RSS, PlanStudy (RSS2017)
Printed on Saturday, March 24, 2018 10:32:18 AM by JCS136 Franklin Square Radiation Oncology Center, Radamerica II LLC
Patient Name: RSS, PlanStudy (RSS2017) Course: C1 Plan normalization value: 85.5 %
Hospital: Franklin Square Radiation Oncology Center, Radamerica II LLC Plan: SBRT LUNG 6* Calculation grid: 2.5 mm
Plan last modified: Thursday, March 22, 2018 12:34 PM by JCS136 Image: AS Edited July 2 Maximum dose: 7426.3 cGy
Save Status Not saved! Maximum dose in PTV: 7426.3 cGy
Minimum dose in PTV: 4732.6 cGy
Mean dose in PTV: 6582.3 cGy
Hidden field and field accessory outlines not included in the printout
Patient Name: RSS, PlanStudy (RSS2017) Z: 9.20 cm External Beam Planning 13.5.37
Course: C1 Scaling Factor: 65% Printed Saturday, March 24, 2018 10:33 AM by JCS136
Plan: SBRT LUNG 6* - Unapproved Head First-Supine Page 1/1
User origin DICOM offset = (0.00cm, 0.00cm, 0.00cm)
Patient Name: RSS, PlanStudy (RSS2017) Y: 7.46 cm External Beam Planning 13.5.37
Patient Name: RSS, PlanStudy (RSS2017) X: 5.33 cm External Beam Planning 13.5.37
Patient Name: RSS, PlanStudy (RSS2017) Scaling Factor: 30% External Beam Planning 13.5.37
Course: C1 Head First-Supine Printed Saturday, March 24, 2018 10:35 AM by JCS136
Plan: SBRT LUNG 6* - Unapproved User origin DICOM offset = (0.00cm, 0.00cm, 0.00cm) Page 1/1
External Beam Planning
External Beam Planning 13.5.37 Franklin Square Radiation Oncology Center, Radamerica II LLC
Patient: RSS, PlanStudy Plan ID Plan Status Course ID Plan Last Modified
Patient IDs: RSS2017 SBRT LUNG 6* Unapproved: Monday, March 19, 2018 2:14:24 PM by JCS136 C1 Thursday, March 22, 2018 12:34:19 PM by JCS136
Comment:
DVH Structure Structure Status Coverage [%/%] Volume Min Dose Max Dose Mean Dose Modal Dose Median Dose Std Dev
PTV Unapproved 100.0 / 100.0 83.1 cm³ 4732.6 cGy 7426.3 cGy 6582.3 cGy 7122.2 cGy 6678.7 cGy 519.0 cGy
BODY Unapproved 100.0 / 99.9 22123.6 cm³ 0.0 cGy 7426.3 cGy 259.1 cGy 1.5 cGy 38.4 cGy 656.7 cGy
LPLEXUS Unapproved 100.0 / 100.0 12.3 cm³ 37.1 cGy 105.9 cGy 61.0 cGy 53.0 cGy 59.1 cGy 11.0 cGy
ITV Unapproved 100.0 / 100.0 35.7 cm³ 6191.2 cGy 7426.3 cGy 7048.8 cGy 7122.2 cGy 7088.0 cGy 166.1 cGy
TRACHEA Unapproved 100.0 / 100.0 36.3 cm³ 23.4 cGy 1313.8 cGy 224.8 cGy 31.4 cGy 75.7 cGy 278.5 cGy
PBT Unapproved 100.0 / 100.0 39.0 cm³ 217.7 cGy 7147.5 cGy 1425.0 cGy 284.5 cGy 1231.1 cGy 1037.4 cGy
ESOPHAGUS Unapproved 100.0 / 100.0 48.7 cm³ 9.8 cGy 1598.3 cGy 281.0 cGy 14.0 cGy 47.1 cGy 402.2 cGy
SPINALCANAL Unapproved 100.0 / 100.2 56.1 cm³ 6.9 cGy 864.4 cGy 220.0 cGy 14.0 cGy 46.3 cGy 271.5 cGy
Patient: RSS, PlanStudy (RSS2017) Printed Saturday, March 24, 2018 10:36:56 AM by JCS136
Course: C1
Plan: SBRT LUNG 6* - Unapproved Page: 1/2
External Beam Planning
External Beam Planning 13.5.37 Franklin Square Radiation Oncology Center, Radamerica II LLC
DVH Structure Structure Status Coverage [%/%] Volume Min Dose Max Dose Mean Dose Modal Dose Median Dose Std Dev
PBT+3mm Unapproved 100.0 / 100.0 94.3 cm³ 203.7 cGy 7249.3 cGy 1439.5 cGy 257.3 cGy 1105.4 cGy 1280.6 cGy
PRVSPINALCANAL Unapproved 100.0 / 100.1 123.2 cm³ 5.7 cGy 967.3 cGy 220.7 cGy 13.0 cGy 45.9 cGy 278.2 cGy
RIBS Unapproved 100.0 / 100.1 146.6 cm³ 25.1 cGy 2760.1 cGy 635.2 cGy 44.7 cGy 352.9 cGy 669.5 cGy
VESSELS Unapproved 100.0 / 100.0 159.2 cm³ 103.0 cGy 5147.6 cGy 1196.2 cGy 714.8 cGy 926.2 cGy 790.7 cGy
THORACICWALL Unapproved 100.0 / 100.0 319.2 cm³ 24.8 cGy 3061.2 cGy 706.9 cGy 45.9 cGy 404.6 cGy 753.2 cGy
HEART Unapproved 100.0 / 100.0 815.3 cm³ 11.3 cGy 1285.7 cGy 103.0 cGy 16.6 cGy 44.8 cGy 133.9 cGy
RLUNG Unapproved 100.0 / 100.0 1718.0 cm³ 8.3 cGy 942.8 cGy 210.5 cGy 23.4 cGy 186.1 cGy 160.9 cGy
SKIN Unapproved 100.0 / 98.9 2219.1 cm³ 0.0 cGy 1730.6 cGy 79.8 cGy 1.2 cGy 14.7 cGy 172.6 cGy
LLUNG Unapproved 100.0 / 100.0 2384.7 cm³ 9.1 cGy 7240.3 cGy 861.2 cGy 28.5 cGy 197.1 cGy 1275.4 cGy
LUNG_MINUS_ITV Unapproved 100.0 / 100.0 4102.7 cm³ 8.3 cGy 7240.3 cGy 588.7 cGy 28.5 cGy 190.0 cGy 1029.3 cGy
Patient: RSS, PlanStudy (RSS2017) Printed Saturday, March 24, 2018 10:36:56 AM by JCS136
Course: C1
Plan: SBRT LUNG 6* - Unapproved Page: 2/2
Fields in plan 'SBRT LUNG 6*' of course 'C1'

Field ID Technique Machine Energy Scale Wedge ID Weight X1 X2 Y1 Y2 Gantry Rtn Coll Rtn Couch Rtn X Y Z SSD MU
[cm] [cm] [cm] [cm] [deg] [deg] [deg] [cm] [cm] [cm] [cm]
1 ARC-I FSROCTB 6X IEC61217 0.685 -3.7 +3.5 -3.7 +3.7 179.0 - 330.0 15.0 0.0 5.3 6.8 6.3 87.7 881
Patient Name: RSS, PlanStudy (RSS2017) Field '1' plotted at 65.0 cm External Beam Planning 13.5.37
Course: C1 Arc Segment: 1/114 - 179.00 [deg] Printed Saturday, March 24, 2018 10:37 AM by JCS136


Study Name: 2017 SBRT Lung
Participant Name: Jeanette Smith
Participant Email: smith1403@uwlax.edu
Participant Role: student
Participant Institution: University of Wisconsin
Created: Sat Mar 24 2018 12:34:12 GMT+0000
TPS Manufacturer: Varian Medical Systems
TPS Model: Eclipse
Number of Treatment Beams: 3
Radiation Type(s): Photon
Delivery Type(s): VMAT

ProKnow SBRT LUNG Minimum Ideal ProKnow Score Eclipse Score
Dose (Gy) covering 98 (%) of the PTV 52.25 55 54.669 54.98

Dose (Gy) covering whole PTV minus 0.03 (cc) 49.5 55 47.497 50.8
Conformation Number [52.25 (Gy), PTV] 0.75 0.95 0.868 0.88
Conformality Index [55 Gy), PTV] 5 4 3.558 1.03
Minimum dose (Gy) to the ITV 52.25 55 61.683 61.91
Structures containging the global max dose point PTV ITV ITV ITV
Volume (cc) of the HEART covered by 10 (Gy) 10 0 0.614 0.42
Dose (Gy) covering 0.03 (cc) of the PRVSPINALCANAL 20 7.5 9.479 9.46
Dose (Gy) covering 0.03 (cc) of the TRACHEA 40 10 12.591 12.16
Volume (%) of the LUNG_MINUS_ITV covered by 20 (Gy) 15 5 8.803 8.82
Volume (%) of the LUNG_MINUS_ITV covered by 5 (Gy) 30 10 25.079 25.12
Mean dose (Gy) to the LUNG_MINUS_ITV 10 5 5.878 5.88
Volume (%) of the RLUNG covered by 5 (Gy) 30 0 5.53 5.52
Volume (cc) of the THORACICWALL covered by 30 (Gy) 10 0 0.064 0.02
Dose (Gy) covering 4 (cc) of the ESOPHAGUS 32.5 10 10.503 10.49
Dose (Gy) covering 0.03 (cc) of the ESOPHAGUS 40 10 15.207 15.13
Dose (Gy) covering 0.03 (cc) of the VESSELS 57.75 50 49.333 49.04
Dose (Gy) covering 4 (cc) of the PBT 50 20 24.781 24.19
Dose (Gy) covering 1.5 (cc) of the PBT 55 40 39.671 38.18
Dose (Gy) covering 0.03 (cc) of the SKIN 30 10 16.257 16.21
* Although I lose some of my ideal scoring in the Eclipse Not meeting Criteria
plan, I am getting better results with PTV coverage, Meeting Minimum
Conformation number and Conformation Index. There are Meeting Ideal
also a few other metrics that are better with the Eclipse Plan.

SBRT Lung Plan Final

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Stereotactic Body Radiotherapy Lung Plan Study

and plan metrics for the plan study.

Fields in plan 'SBRT LUNG 6*' of course 'C1'

Fields in plan 'SBRT LUNG 6*' of course 'C1'

Fields in plan 'SBRT LUNG 6*' of course 'C1'

Participant Name: Jeanette Smith

Participant Email: smith1403@uwlax.edu

Participant Role: student

Participant Institution: University of Wisconsin

Created: Sat Mar 24 2018 12:34:12 GMT+0000

TPS Manufacturer: Varian Medical Systems

TPS Model: Eclipse

Number of Treatment Beams: 3

Radiation Type(s): Photon

Delivery Type(s): VMAT

Dose (Gy) covering 98 (%) of the PTV 52.25 55 54.669 54.98

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