Clinical Practicum II Clinical Lab Assignment

Parotid treatment technique comparison: Find one or two head and neck CT data
sets that you can use for mock plans. Look for one with the chin extended up and
one with a neutral head position, if possible. This project can be done without an
extended chin (neck flexed back) CT data set, if it is not available.
Using a head and neck CT image set, contour the parotid gland (GTV) and add a
1cm margin (PTV). Contour all surrounding critical structures.
The goal for each of the 3 plans below will be to obtain 60 Gy to the GTV with the
95% isodose surrounding the PTV.
For each plan:
1) Make a chart listing all of the surrounding critical structures and their
tolerance doses. After completing each plan, record the dose that each
structure actually received in a column next to the maximum tolerance dose.
Indicate in a 3rd column whether the structure tolerance was met or
exceeded.
2) Print or capture an image of at least one transverse slice of the plan showing
the isodose coverage of the parotid and the PTV, the maximum dose location
and the 100%, 95%, 75%, and 40% isodose lines. (Label the isodose levels).
3) Provide a DVH with the GTV, PTV and all surrounding critical structures.
4) Provide a detailed description of each plan (beam angles, energy, cone or
field size, wedges used, and any other parameters that you may have
changed: couch angle, collimator angle, etc). This can be a print out or it can
be typed in a separate document but all information required to treat this
patient must be provided for each of the 3 final plans.

Olson 2

PLAN #1 Design an ipsilateral wedged pair plan for the parotid

Wedged Pair Plan Description:
This plan was designed using two oblique fields, angled at 45-degrees and 135-degrees.
A wedged pair refers to two fields, separated by 90 degrees, using wedges with the heels
together. Creating an ipsilateral wedged pair refers to having both fields on the affected side of
the patient; in this case the fields are placed on the patients left side.
The isocenter was established in the center of the PTV volume. A beam energy of 6 MV
was chosen due to the superficial location of the parotid gland. Multi-leaf collimation (MLC)
was added and given custom margins around the PTV contour on the Y and X axis of 0.8 cm and
0.5 cm respectively. The field size was automatically adjusted to 8.8 cm (X) by 9.4 cm (Y). The
plan normalization was adjusted to achieve 95% of the dose to cover 100% of the PTV volume.
I calculated the dose without wedges to appropriately assess the correct wedge needed. As
shown in Figure 1, the dose was too hot superficially and could use some attenuation from a
wedged pair technique. In this case, I chose to use 30-degree wedges, with heels together, for
adequate coverage. This significantly reduced the hot spot from 115% to 109%.

Figure 1. A: Demonstration of dose distribution without wedges.

B: Displays attenuation of hot spots using two 30-degree
wedges with heels together.

Olson 3

Figure 2. Ipsilateral Wedged Pair Plan DVH.

Olson 4

Figure 3. Axial View of Ipsilateral Wedged Pair Plan

Olson 5

Wedged Pair Questions:

a) How would, or how does, the chin position affect the beam arrangement?
In treating a parotid tumor, the ideal patient position would be head first supine with a
slight chin extension. By doing so, this can help minimize dose to the larynx and spinal cord.
Without chin extension, it may be more difficult to utilize a true wedged pair beam
arrangementcausing the fields to be placed less than 90-degrees apart.

b) If you were not able to get adequate coverage on the parotid using the wedged pair
technique, what were your constraints?
As shown in Table 1, all constraints were met with the exception of the mandibular
maximum dose. There was some difficulty in adequately covering the PTV with the 95% isodose
line, therefore causing increased hot spot development. Because the prescription dose is 60 Gy,
the mandible is not allowed to exceed 105% of prescription dose. In order to achieve a lower
dose maximum on the mandible, I would need to sacrifice PTV coverage which is one of my top
priorities. Another option would be to add in a lightly weighted third direct lateral photon beam;
this would help decrease the peaks on the anterior and posterior aspect beyond the PTV as a
result of the wedged pair beam orientation. Reducing the anterior peak would help to minimize
the amount of mandible in the radiation beam. A small bit of field-in-field technique could also
be utilized to help further reduce the mandibular maximum dose.

Organ at Risk (OR)

Right Parotid
Spinal Cord
Oral Cavity
Mandible
R Submandibular

Tolerance Dose
(cGy)
Mean < 2600
Maximum < 4500
Mean < 3200
Maximum < 6300
Mean < 3900

Dose Received
(cGy)
123.7
2565.9
2140.3
6441.1
203.6

Table 1. A Display of Dose Constraints and the Plan Outcome

Tolerance Met?
Y/N
Y
Y
Y
N
Y

Olson 6

Even if you are not able to get an acceptable plan on this CT data set, go ahead
and add a lower anterior ipsilateral neck field that abuts the bottom of your
wedged pair fields using a half beam technique. Use the image below to design
your anterior field.

Plan this lower neck field (medial edge of the field should be off the cord) to 50.4
Gy at 1.8 Gy/day using a depth of 3.0 cm for the anterior neck nodes.
For this project turn in a plan sum showing the isodose coverage of the parotid,
the PTV, and the lower neck nodes.

Show the max dose location and the 100%, 95%, 75%, and 40% isodose lines.
(Label the isodose levels).
Show your DVH with the GTV, PTV and all surrounding critical structures.

Olson 7

Figure 3. Axial View of Parotid Isodose Lines in Plan Sum

Olson 8

Figure 4. Axial View of Neck Node Isodose Lines in Plan Sum

Olson 9

Figure 4. Coronal View of Parotid and Neck Node Plan Sum

Olson 10

Figure 5. Plan Sum Global Dose Maximum

Organ at Risk (OR)

Right Parotid
Spinal Cord
Oral Cavity
Mandible
R Submandibular

Tolerance Dose
(cGy)
Mean < 2600
Maximum < 4500
Mean < 3200
Maximum < 6300
Mean < 3900

Dose Received
(cGy)
133.4
2927.1
2579.9
6462.5
283.5

Tolerance Met?
Y/N
Y
Y
Y
N
Y

Table 2. Dose Statistics of Parotid and Neck Node Plan Sum. All constraints were met with the exception
of the maximum mandibular dose.

Olson 11

Figure 6. Parotid and Neck Node Plan Sum DVH

Olson 12

PLAN #2
Plan Description:
Mixed energy treatment plans can provide sufficient coverage to a superficially located
target while minimizing dose to surrounding critical structures; this technique can be beneficial
when treating a structure such as the parotid gland. According to Vann et al, 1 a photon field can
be used to target the deep aspect of the parotid gland while an additional electron field can be
utilized to encompass the superficial aspect of the parotid.
This plan was designed using a 90-degree left lateral 6MV photon beam paired with a
direct left lateral 12 MeV electron beam. The photon field had custom MLC shaped around the
PTV volume with a 0.8cm margin on the superior and inferior aspect and a 0.5cm margin on the
lateral aspect of the PTV. The field size of the photon field measured 9.6 cm by 9.4 cm.
The electron field block was created using a 1.5 cm circular margin around the PTV
structure; this required the use of a 15cm by 15 cm cone size. Our current clinic practice is to
treat all electrons at a distance of 110 cm for collision purposes. To follow suit, this field was set
up at 110cm SSD while the photon field was planned at 100 cm SAD. The final weighted result
was 82.6% photons and 17.4% electrons.
The mixed energy plan provided good coverage but at the cost of significant hot spots. I
think there are better techniques that could be used to treat this structure that can provide similar
results with a lower maximum dose.

Figure 7. Axial View of Mixed Energy Beam Plan Isodose Coverage and Global Dose Maximum

Olson 13

Figure 8. Mixed Energy Beam Plan Sum DVH

Olson 14

Plan #2: Mixed Energy Beam Questions

1. How does this plan compare to your wedged pair plan?
Compared to the wedged pair plan, the outcome of the mixed energy beam plan was less
effective. The wedged pair plan met all constraints except the maximum mandibular dose while
the mixed energy plan did not meet any of the required constraints. In order to achieve the
required target coverage, the mixed energy plan needed to be quite a bit hotter. For that reason,
all constraints were exceeded beyond acceptable tolerances. With the use of a direct lateral
photon beam, the contralateral submandibular and parotid gland received quite a bit more dose
than with a wedged pair. The wedged pair was able to successfully avoid direct beam exit dose
through those structures, therefore minimizing the dose to unwanted structures.
2. Were there any dose constraints not met?
As stated above and as shown in Table 4, all dose constraints were exceeded beyond their
accepted values. The direct left lateral photon beam included the contralateral parotid and
submandibular gland, resulting in an increased amount of exit dose. According to QUANTEC
data as stated by Vann et al,1 if sparing of the contralateral parotid gland is desired, the mean
dose should not exceed 20 Gy. In the case of the mixed energy beams, the mean dose reported
was 29.9 Gy. In addition, since the mandible and oral cavity lie within close proximity to the
parotid gland, they are in direct line of oncoming primary or scattered radiation; this causes these
structures to receive dose close to full prescription.

Organ at Risk (OR)

Right Parotid
Spinal Cord
Oral Cavity
Mandible
R Submandibular

Tolerance Dose
(cGy)
Mean < 2600
Maximum < 4500
Mean < 3200
Maximum < 6300
Mean < 3900

Dose Received
(cGy)
3486.3
4541.9
4860.0
7224.7
3994.2

Table 4. Dose Statistics for Mixed Energy Beam Plan of OR

Tolerance Met?
Y/N
N
N
N
N
N

Olson 15

PLAN #3
Using an IMRT technique of your choice find the beam arrangement needed to achieve the
required coverage on the parotid gland while sparing the critical structures.
Plan Description:
For plan 3, I chose a VMAT technique using 2 partial arcs on the patients left side. The
collimator was offset by 10 degrees on both the clockwise and counterclockwise arc to minimize
interleaf leakage. In the contouring application of Eclipse, I created a PTV opti structure by
adding a 1 mm margin around the original PTV; this structure was used for dose manipulation in
the optimizer. Because the parotid gland is so superficial, I cropped the PTV opti 5mm away
from the body contour surface. In addition, I also created edit structures of both the mandible
and left submandibular gland which were encompassed in the PTV volume. These edit
structures were cropped out of the PTV opti with a margin of 3mm; this action allows for better
control of the dose to organs at risk (OR) beyond the PTV. Finally, the arc geometry tool
helped me to find the ideal isocenter placement and the field size was adjusted accordingly;
clockwise utilized a field size of 8.1 cm by 8.8 cm while the counterclockwise arc utilized 8.9 cm
by 8.6 cm.
In the optimizing window, I evaluated the DVH of the right parotid, spinal cord, oral
cavity, mandible, right submandibular gland, all edit structures and the PTV opti. I gave my
PTV opti an upper and lower constraint with 0% receiving 6180 cGy at a priority of 99 and
100% receiving 6000 cGy at a priority of 100. I ran the plan first with just the target constraints
only so I could assess for future improvements. The plan was normalized at 100% of the dose to
cover 95% of the volume, which resulted in an insufficient amount of 105% and holes in the
prescription isodose line within the PTV. Upon evaluation of the OR constraints, all were
successfully achieved, but I knew I could do better.
To better fill in the prescription isodose line holes within the PTV, I gave the GTV an
upper and lower constraint of 6180 cGy and 6050 cGy respectively. To help control the low
dose scattered outside the PTV, I also put a few upper constraints on the mandible between the
2000 cGy and 4000 cGy dose area. The final plan was normalized at 100% of the dose covering
95% of the target. The final hot spot was recorded as 106% or 6358.5 cGy (Figure 9-11). All
dose constraints and their final outcome was reported in Table 5.
I also ran a static IMRT plan using the same opti and edit structures. My beam angles
were set at AP, A45L, L Lat, and P45L; the collimator and couch remained at zero. All
constraints and upper and lower limits remained the same in the optimizer. The final plan hot
spot was recorded as 104.8% or 6285.3 cGy when 100% of the dose covered 95% of the volume
(Figure 12-14). Again, all constraints and their final outcomes were recorded in Table 6 and
compared to the VMAT plan.

Olson 16

Figure 9. Axial View of VMAT Plan and Isodose Lines

Figure 10. Point of Global Dose Maximum in VMAT Plan

Olson 17

Figure 11. DVH of VMAT Plan

Olson 18

Figure 12. Axial View of Isodose Distribution Using Static IMRT

Figure 13. Global Dose Maximum of Static IMRT Plan

Olson 19

Figure 14. DVH Display for Static IMRT Treatment Plan

Olson 20

Plan 3 IMRT Questions:

What beam arrangements did you try?
For the VMAT plan, I designed the plan using 2 partial arcs starting at 0-degrees
(anterior aspect of the patient) and ending at 179.9-degrees (posterior aspect of the
patient). I did not adjust the arc rotation past 0-degrees to minimize the amount of
mandible included in the treatment arcs.
For the static IMRT plan, I designed the plan using 4 different beams: AP, A45L, L
Lat, and P45L. I chose this arrangement based on trying to minimize the amount of
mandible and other normal tissue in the treatment fields.
Why did you decide on your final one?
I was pleasantly surprised at how comparable the static IMRT plan was to the VMAT
plan. Ultimately I would decide to treat this patient using the VMAT plan because, as shown in
Table 5, the achieved constraints are still considerably lower than the static IMRT outcomes in
Table 6. The constraints in which static IMRT proved to be superior were the maximum
mandibular dose and mean oral cavity dose. I would need to work harder on the mandibular
constraint in the optimizer to decrease the overall maximum dose in the VMAT plan.
With the use of VMAT, it allows the TPS to deliver dose with more modulation
throughout the entire arc rather than to be confined by specified static angles; this helps to lower
the dose to surrounding critical structures such as the spinal cord and ipsilateral parotid and
submandibular glands.

Organ at Risk (OR)

Right Parotid
Spinal Cord
Oral Cavity
Mandible
R Submandibular

Tolerance Dose
(cGy)
Mean < 2600
Maximum < 4500
Mean < 3200
Maximum < 6300
Mean < 3900

Dose Received
(cGy)
711.4
2782.2
988.9
6327.6
580.1

Tolerance Met?
Y/N
Y
Y
Y
N
Y

Table 5. Dose Constraints and Dose Achieved using VMAT Planning

Organ at Risk (OR)

Right Parotid
Spinal Cord
Oral Cavity
Mandible
R Submandibular

Tolerance Dose
(cGy)
Mean < 2600
Maximum < 4500
Mean < 3200
Maximum < 6300
Mean < 3900

Dose Received
(cGy)
1397.7
3037.1
583.6
6235.5
1836.9

Table 6. Dose Constraints and Dose Achieved using Static IMRT Planning

Tolerance Met?
Y/N
Y
Y
Y
Y
Y

Olson 21
References
1. Vann AM, Dasher BG, Wiggers NH, Chestnut SK. Portal Design in Radiation Therapy. 3rd ed.
Augusta, GA: Phoenix Printing; 2013:49-52.