1

Dosimetric Evaluation of Collimator Angles to Reduce Laryngeal Dose in Base of Tongue

Treatment Planning for Volumetric Modulated Arc Therapy
Brianna V. Niemuth BS R.T.(T); Haley M. Kroeplin BS R.T.(R)(T); Nishele Lenards, PhD,
CMD, R.T.(R)(T), FAAMD; Ashley Hunzeker, MS, CMD; Karen Lang, MS, CMD, R.T.(T);
Ashley Fellows, MS, CMD, R.T.(T); Sabrina Zeiler, MS, CMD, R.T.(T)
Medical Dosimetry Program, University of Wisconsin- La Crosse, Wisconsin
ABSTRACT
Current volumetric modulated arc therapy (VMAT) techniques result in higher laryngeal
doses that cause profound side effects such as dysphagia. Collimator angles can impact the
ability of a VMAT plan to meet dose constraints in head and neck (H&N) cancer patients. The
researchers in this study aimed to investigate if VMAT collimator angles of 90⁰ or 0⁰ could
further limit the dose to the larynx while still providing full dose coverage of the treatment
volume for base of tongue (BOT) cancer patients. Two sets of plans, containing 3 arcs, with
collimator angles of 30⁰, 330⁰ and 90⁰ or 0⁰, were made for 10 patients selected for this study.
Plans were optimized to keep all organs at risk (OAR) within ± 3% between plans, while
reducing mean laryngeal dose as much as possible and maintaining a target coverage of 95% of
the volume receiving 100% of the prescribed dose. The mean laryngeal dose was evaluated for
normality using a Shapiro-Wilk test and compared using a one-sided t-test. Statistically
significant mean laryngeal dose reduction of 8.2% (57.6 Gy vs 52.9 Gy, P<0.0005) was found in
plans utilizing a 90⁰ collimator rotation. The results suggested a collimator rotation of 90⁰ is
effective for reducing mean laryngeal dose; therefore, should be considered when planning BOT
radiotherapy patients.
Keywords: Head and Neck, VMAT, Dysphagia, Collimator Angle, Larynx, Base of Tongue
Introduction
Standard head and neck (H&N) treatments require a higher therapeutic dose of 50-70 Gy
to reduce risk of locoregional failure, however limiting dose to adjacent organs at risk (OAR) is a
primary treatment planning concern.1 The H&N region contains multiple OAR, all with varying
levels of radiosensitivity. Surrounding OAR often receive a significant amount of dose, which
can lead to a multitude of debilitating side effects. Significant dose to the larynx, even if within
dose constraints, can cause severe side effects, both acute and chronic, for patients.
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Toxicities of the larynx can have a profound impact on a patient’s quality of life.  One of
the more prevalent side effects that patients experience during and post treatment is
dysphagia. An estimated 50% of H&N cancer patients will develop some degree of acute or
chronic dysphagia.2,3 Depression, anxiety, social isolation, and malnutrition have all been linked
to radiation induced dysphagia.3,4 The impacts of dysphagia on a patient’s life can range from
percutaneous endoscopic gastrostomy (PEG) tube dependency to life threatening pneumonia due
to dysphagia related aspiration.3,4,5 Due to the severe impact dysphagia has on a patient’s quality
of life, it is essential to continue investigating ways to reduce the mean laryngeal dose in
radiation therapy treatment, such as volumetric modulated arc therapy (VMAT). 
Dysphagia, caused by VMAT technique, could potentially be diminished with different
collimator angles used during treatment.6 Ahn et al6 noted in H&N, abdominal, and chest
patients, that the ability to shape the desired dose distribution during optimization, and therefore
reduce dose to OAR, can be determined by the collimator angle. According to Kim et al,7
utilizing various collimator angles can limit the undesirable interleaf leakage during plan
optimization. Often, H&N treatment fields are long and irregular in shape, making collimator
angles even more crucial.6 Therefore, further research is required to determine if collimator
angles can reduce dose to OAR, specifically the larynx, while still allowing for full dose
coverage of the H&N target.
Radiation therapy has the feasibility to provide lifesaving treatment to those diagnosed
with base of tongue (BOT) cancer. The side effects, such as dysphagia, that patients experience
could be reduced when limiting dose to the larynx by using different collimator angles; thereby
improving their quality of life. It is recommended to reduce the mean laryngeal dose as much as
possible while delivering full dose to the BOT to reduce the chance of dysphagia.8 The problem
is current VMAT techniques result in higher laryngeal doses that cause profound side effects
such as dysphagia. The purpose of this study is to determine if VMAT collimator angles of
90° or 0° can further limit the dose to the larynx while still providing full dose coverage of the
treatment volume. The researchers tested the hypothesis (H1A) that VMAT plans with 3 arcs
utilizing collimator angles of 30°, 330° and 90° will reduce mean laryngeal dose for BOT
patients when compared to plans that utilize 30⁰, 330⁰, and 0⁰ collimator angles. 
Methods and Materials
Patient Selection & Setup
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Ten patients from a single institution were selected for this retrospective study. Inclusion
criteria was squamous cell carcinoma (SCC) of the BOT, stage III-IVc, planning treatment
volume (PTV) length of 23 cm or less, and simultaneous integrated boost (SIB). Exclusion
criteria consisted of post-surgical patients, BID, sequential boosts, previous radiation therapy, or
plans requiring bolus. The patient data was collected retrospectively with all patients prescribed a
dose of 70 Gy to the primary target and 63 Gy to the nodal volume at 2 Gy and 1.8 Gy per
fraction, respectively.
All patients were simulated in the head-first supine position using a custom Klarity neck
rest and a 5-point Orfit H&N mask. Patients were positioned with arms at their sides grasping
handles or on their lower abdomen holding a ring and a knee cushion under their knees. Eight of
10 patients utilized bite immobilization. The isocenter was placed by the radiation oncologist
with a sternal tattoo for proper alignment in conjunction with marks on their mask. All CT
simulation scans were performed on a Siemens CT scanner using 2 mm slice thickness with
scans extending from the top of the immobilization through the lung volume. Dental iterative
metal artifact reduction (iMAR) was utilized for all simulation scans.
Contours
The CT simulation scans were exported to Eclipse treatment planning system (TPS) for
contouring. Eight of 10 patients had CT simulation scan fused with a positron emission
tomography (PET) scan to assist with target delineation. The clinical target volume (CTV) was
contoured by the physician with a 0.5 cm expansion to create the PTV. All PTVs were cropped
0.5 cm from the skin surface. Organs at risk were delineated by the physician, medical resident,
and medical dosimetrist according to department protocol.
The OAR contoured in this study were taken from Radiation Therapy Oncology Group
1016 (RTOG 1016) and RTOG 0619 and included the spinal cord, spinal cord planning organ at
risk volume (PRV), brainstem, brainstem PRV, parotids, lips, oral cavity, pharynx, larynx,
mandible, esophagus, and the brachial plexus.9,10 The spinal cord PRV was created using a 5 mm
margin and the brainstem PRV utilized a 3 mm margin from the brainstem. In all cases the
submandibular glands were entirely encompassed by the PTVs and were excluded from the OAR
list.
Treatment Planning
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All patients were planned with curative intent using Eclipse (Version 15.1.51). Plan dose
was calculated using the Anisotropic Analytical Algorithm (AAA) (Version 11.1.31). All plans
were optimized using 6 MV photons for Varian TrueBeam linear accelerators.
Two plans for each patient were created using 1 isocenter and 3 full VMAT arcs (Table
1). Collimator angles consisted of 30⁰, 330⁰ and 0⁰ or 90⁰ (Figure 1 and 2). A target margin of
0.5 cm was used to create the field size with jaw tracking utilized on all fields. Arcs 1 and 2 had
an X jaw size reduced to 20 cm (X1 =10 cm and X2 = 10 cm) while arc 3 had an X jaw size
limited to 30 cm.
The plan with the collimator at 0⁰ (Plan 1) was optimized first followed by the 90⁰
collimator plan (Plan 2). In all plans, the larynx dose was reduced as much as possible while still
meeting target objectives and attempting to meet other OAR dose constraints. An automatic
normal tissue objective (NTO) was utilized for all plans to control dose distribution outside of
the target structures. Plans were optimized with the goal of keeping all OAR, excluding the
larynx, within ± 3% between Plan 1 and Plan 2. Upon completion of Plan 1 for each patient, a ±
3% difference was calculated for each OAR. Optimization for Plan 2 aimed to keep all OAR
doses within this 3% limit while also reducing the laryngeal dose as much as possible. After
normalization, the planning target volume receiving 70 Gy (PTV70) had 95% of the volume
receiving 100% of the prescribed dose and the planning target volume receiving 63 Gy (PTV63)
had 95% of the volume receiving at least 100% of the prescribed dose.
Plan Comparison
The mean larynx dose was compared between Plan 1 and Plan 2. The OAR for each plan
were also evaluated using dose metrics from RTOG 1016, RTOG 0619 and departmental
standards which consisted of the mean dose for the uninvolved oral cavity, parotid glands, lips,
OARpharynx (uninvolved posterior pharyngeal wall and pharyngeal constrictors), and
esophagus. The maximum dose was evaluated for the mandible, brachial plexus and uninvolved
oral cavity. The spinal cord and brainstem PRV were evaluated by the dose received by 0.03cc of
each structure (D0.03 cc) < 50 and 52 Gy, respectively. The metrics were used to attempt to keep
Plan 1 and Plan 2 within ± 3% for each OAR. The target objectives that were evaluated included
95% of the PTV70 and PTV63 receiving 100% of the prescription dose and the maximum dose
to the PTV70 to be < 82 Gy, which was considered acceptable per RTOG 1016 protocol.
Statistical Analysis
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Statistical analysis was performed using a one-sided t-test to compare mean laryngeal
dose to all BOT patients between Plan 1 and Plan 2. The sample of differences was examined for
normality both graphically and with a Shapiro-Wilk normality test and clearly met the criteria for
the use of the paired t-test, with P<0.05 considered statistically significant. Statistical analysis
was performed using the R (R Core Team, 2020).
Results
For all cases in this study, the mean dose to the larynx was evaluated for VMAT Plans 1
and 2. The overall mean population dose to the larynx for Plan 1 was 57.6 Gy. When the
collimator was rotated to 90⁰ for Plan 2, an 8.2% reduction in dose was observed, with an overall
mean population dose of 52.9 Gy (Figure 3). Optimization aimed to keep all OAR within ± 3%
between Plan 1 and 2 for each patient. In total, 5 OAR did not meet the ± 3% deviation in at least
1 set of plans (Table 2). The target objectives were met for all treatment plans. The one-sided t-
test demonstrated statistically significant differences for mean larynx dose (P<0.0005). The null
hypothesis (H10) was rejected as data analysis did show a significant correlation between the
collimator rotation and mean larynx dose.
Discussion
The goal of this retrospective study was to determine if collimator angles, specifically
90⁰, could reduce the mean dose to the larynx for BOT radiation therapy patients. Adequate
target coverage is essential to reduce the risk of recurrence, however reducing dose to
surrounding OAR is also of critical importance. Results of the study indicated that 3 arc VMAT
plans which utilize a collimator angle of 90⁰ can provide adequate target coverage while also
reducing the mean laryngeal dose when compared to plans that utilize a 0⁰ collimator angle. All
plans were normalized to 95% of the PTV70 volume receiving 100% of the prescription dose,
which ensured the PTV coverage was not compromised to lower OAR dose.
 Throughout this retrospective study, plans containing a collimator angle of 90⁰
demonstrated a lower mean dose to the larynx. One explanation for this dose reduction could be
decreased interleaf leakage or transmission of radiation between the multileaf collimator (MLC)
leaves. A mechanical limitation of the Varian Truebeam MLC is the physical length of the MLC
being 15 cm. Any field larger than 15 cm in the X-jaw aperture results in a single MLC not being
able to travel the entire width of the field. Due to this limitation, a large field size results in
reduced MLC modulation, causing dose distributions to the targets and OAR in this region to be
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unsatisfactory.11 Integral dose resulting from interleaf leakage can be lessened using jaw tracking
and a smaller overall field size. A smaller field size affords the MLC a shorter travel distance,
resulting in higher modulation and more desirable dose distributions.12,13 Although the X-jaws
were limited to 30 cm for the 90⁰ and 0⁰ collimator arcs in this study, the 90⁰ collimator arc had
a smaller average maximum field size of 20.82 cm compared to 25.81 cm for the 0⁰ arc,
resulting in reduced dose from MLC leakage. In addition, the dose reduction may also be
explained by examining the effects of collimator rotation on the MLC modulation at different
control points. Kim et al14 determined that a 90⁰ collimator rotation could potentially reduce the
burden of MLC control for modulating photon beam intensity due to the maximum leaf travel at
specific collimator angles.
Another explanation for the dose reduction could be the 90⁰ collimator rotation allows
the MLC to run parallel with the long nodal targets and long axis of the larynx, providing the
ability to treat both sides of the volume, while effectively blocking the central larynx. A study
about paraspinal stereotactic body radiation therapy (SBRT) revealed that aligning the collimator
angle with the primary axis of the spinal cord allowed the cord to be shielded at each control
point, thus effectively reducing the cord dose.15 MacDonald et al15 also concluded that for
treatments with irregular target volumes, such as H&N patients, collimator angle is a strong
function of the MLC’s ability to conform to the target while still sparing OAR.
Researchers also noted in the current study that centrally located OAR, such as the oral
cavity, esophagus, spinal cord, and brainstem also experienced a dose reduction most of the time,
while OAR on the periphery, such as the parotid glands, brachial plexus, and mandible of the
patients seemed to be less affected by the collimator angle of 90⁰. By examining the beams eye
view (BEV) projections for targets at each control point, Li et al16 noted that collimator angle is
especially important for sparing OAR in plans containing convex or split targets, due to the MLC
being limited to travel in a single direction. Split target volumes are common with H&N and
pelvic treatments involving bilateral lymph nodes. A previous study about collimator angles used
in VMAT prostate plans revealed superior rectal sparing with the use of a 90⁰ collimator angle.17
It is evident that collimator angle has an impact on a plan’s ability to provide adequate target
coverage while still sparing adjacent OAR, however further investigation is needed to determine
an optimal angle.
Conclusion
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Current VMAT techniques result in higher laryngeal doses that cause profound side
effects such as dysphagia. Collimator angles can impact the ability of a VMAT plan to meet dose
constraints in H&N cancer patients. The purpose of this retrospective study was to evaluate if
VMAT plans containing collimator angle of 90⁰ in primary BOT cancer, could reduce the mean
dose to the larynx, while maintaining adequate target coverage. Plans containing an arc with a
90⁰ collimator rotation were shown to reduce the mean laryngeal dose, with a population mean
dose reduction of 8.2%. Consequently, a significant correlation between mean laryngeal dose
and collimator rotation was found. The dose reduction was found to be statistically significant
(P< 0.0005). Coverage to all PTVs was kept at or above 95% of the volume receiving 100% of
the prescribed dose and optimization attempted to keep additional OAR within ± 3% between
Plans 1 and 2.
The limitations of this study included data collection occurring at a single institution and
using a single TPS and calculation algorithm. A larger population from multiple institutions may
provide additional results to determine significance. Also, treatment planning using multiple
TPSs and calculation algorithms may provide additional information on the significance of dose
reduction. Despite advancements in radiation therapy treatments, such as VMAT, have been
proven to increase OAR sparing, such as the larynx, researchers should continue looking at ways
to further this dose reduction, possibly through the use of collimator angles.18,19 Although
evaluation of other laryngeal volumetric or maximum dose metrics were beyond the scope of this
study, further evaluation of these dose objectives may also be impacted by collimator angles and
therefore should be evaluated in future studies. Additional research on dose reduction to other
OAR within the H&N region or other primary H&N tumor locations may prove to be beneficial.
Moreover, reviewing a 90⁰ collimator rotation and its effect on other dosimetric constraints, such
as the Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC), may be
warranted. Furthermore, research to evaluate additional collimator angles against 90⁰ may
provide an optimal collimator angle for dose reduction to the larynx in BOT radiotherapy.
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Acknowledgements
We would like to thank Dr. Reineke and the Statistical Consulting Center at UW-La Crosse for
assistance with the statistical analysis of the data; however, any errors of fact or interpretation
remain the sole responsibility of the authors.
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References 
1. Yeh SA. Radiotherapy for head and neck cancer. Semin Plast Surg. 2010;24(2):127–136.
https://doi.org/10.1055/s-0030-1255330
2. Kumar R, Gupta H, Konwar K, Sharma R, Anand AK, Sachdeva S. Impact of early
dysphagia intervention on swallowing function and quality of life in head and neck
cancer patients treated with intensity-modulated radiation therapy or image guided
radiation therapy with or without surgery/chemotherapy. Asian J Oncol. 2015;1(1):37-43.
https://doi.org/10.4103/2454-6798.165109
3. Hutchison AR, Cartmill B, Wall LR, Ward EC. Dysphagia optimized radiotherapy to
reduce swallowing dysfunction severity in patients undergoing treatment for head and
neck cancer: A systematized scoping review. Head Neck. 2019;41(6):2024-2033.
https://doi.org/10.1002/hed.25688
4. Kaae JK, Spejlborg ML, Spork U, Bjorndal K, Eriksen JG. Reducing late dysphagia for
head and neck cancer survivors with oral gel: A feasibility study. Dysphagia.
2019;35(2):231-241. https://doi.org/10.1007/s00455-019-10018-9
5. Prameela C, Ravind R, Renil Mon R, Sheejamol VS, Dinesh M. Radiation dose to
dysphagia aspiration-related structures and its effect on swallowing: Comparison of
three-dimensional conformal radiotherapy and intensity modulated radiation therapy
plans. J Cancer Res Ther. 2016;12(2):845-851. https://doi.org/10.4103/0973-
1482.163676
6. Ahn BS, Park SY, Park JM, Choi CH, Chun M, Kim J. Dosimetric effects of sectional
adjustments of collimator angles on volumetric modulated arc therapy for irregularly-
shaped targets. PLoS One. 2017;12(4):1-14.
https://doi.org/10.1371/journal.pone.0174924
7. Kim YH, Park HR, Kim WT, et al. Effect of the collimator angle on Dosimetric
verification of volumetric modulated arc therapy. J Korean Phys Soc. 2015;67(1):243-
247. https://doi.org/10.3938/jkps.67.243
8. Brodin NP, Kabarriti R, Garg MK, Guha C, Tome WA. Systemic review of normal tissue
complication models relevant to standard fractionation radiation therapy of the head and
neck region published after the QUANTEC reports. Int J Radiat Oncol Biol Phys.
2018;100(2):391-407. https://doi.org/10.1016/j.ijrobp.2017.09.041
 10

9. U.S. National Library of Medicine. RTOG 1016: Phase III trial of radiotherapy plus
cetuzimab versus chemoradiotherapy in HPV-associated oropharynx cancer.
https://clinicaltrials.gov/ProvidedDocs/34/NCT01302834/Prot_SAP_001.pdf. Updated
February 23, 2016. Accessed April 1, 2020.
10. RTOG 0619: A Randomized phase II trial of chemoradiotherapy versus
chemoradiotherapy and vandetanib for high-risk postoperative advance squamous cell
carcinoma of the head and neck.
https://pdfs.semanticscholar.org/9ce6/b604748034855dc6797891020c7b76039f5b.pdf?
_ga=2.120078216.1894391104.1592792325-1376015872.1592792325. March 25, 2010.
Accessed May 26, 2020
11. Zhang W. Z., Lu J. Y., Chen J. Z., Zhai T. T., Huang B. T., Li D. R., et al. (2016) A
Dosimetric Study of Using Fixed-Jaw Volumetric Modulated Arc Therapy for the
Treatment of Nasopharyngeal Carcinoma with Cervical Lymph Node Metastasis. PLOS
ONE 11(5): e0156675. https://doi.org/10.1371/journal.pone.0156675
12. Thongsawad S, Khamfongkhruea C, Tannanonta C. Dosimetric Effect of Jaw Tracking in
Volumetric-Modulated Arc Therapy. J Med Phys. 2018;43(1):52-57.
doi:10.4103/jmp.JMP_75_17
13. Ugurlu BT, Temelli O. The impact of the field width on VMAT plan quality and the
assessment of half field method. Med Phys. 2020;21(3)115-122.
https://doi.org/10.1002/acm2.12834
14. Kim, J., Ahn, B. S., Choi, C. H., Park, J. M., & Park, S.-Y. (2018). Optimal collimator
rotation based on the outline of multiple brain targets in VMAT. Radiat Oncol. 13(1),
88. https://doi.org/10.1186/s13014-018-1039-5
15. MacDonald RL, Thomas CG, Syme A. Dynamic collimator trajectory algorithm for
multiple metastases dynamic conformal arc treatment planning. Med Phys. 2018;45(1):5-
17. https://doi.org/10.1002/mp.12648
16. Li X, Wu J, Palta M, et al. A Collimator Setting Optimization Algorithm for Dual-Arc
Volumetric Modulated Arc Therapy in Pancreas Stereotactic Body Radiation
Therapy. Technol Cancer Res Treat. 2019;18:1533033819870767.
https://doi:10.1177/1533033819870767
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17. Isa M, Rehman J, Afzal M, Chow J. Dependence of Collimator Angle on Prostate

VMAT: A Treatment Planning Study. World Congress Med Phys Biomed Eng. 2015;51
https://doi.org/10.1007/978-3-319-19387-8_93

18. Cilla S, Deodato F, Macchia G, et al. Volumetric modulated arc therapy (VMAT) and
simultaneous integrated boost in head-and-neck cancer: is there a place for critical
swallowing structures dose sparing? Br J Radiol.
2016;89(1059):20150764. https://doi.org/10.1259/bjr.20150764 
19. Hawkins PG, Kadam AS, Jackson WC, Eisbruch A. Organ-sparing in radiotherapy for
head-and-neck cancer: Improving quality of life. Semin Radiat Oncol. 2018;28(1):46-52.
https://doi.org/10.1016/j.semradonc.2017.08.002
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Figures

Figure 1. The collimator configuration utilized for Arc 1 and Arc 2. Figure (A) demonstrates the
collimator angle of 30⁰ and Figure (B) displays the collimator angle of 330⁰. PTV70 is outlined
in magenta, PTV63 is outlined in cyan, and larynx is outlined in red.

Figure 2. The collimator configuration utilized for Arc 3. Figure (A) demonstrates the collimator
angle of 0⁰ and Figure (B) displays the collimator angle of 90⁰. PTV70 is outlined in magenta,
PTV63 is outlined in cyan, and larynx is outlined in red.
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Figure 3. The 4.7 Gy reduction in mean population laryngeal dose between Plan 1 (0⁰) and Plan
2 (90⁰).
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Tables

Table 1. Arc geometry for Plan 1 and 2 with gantry and collimator angles.
Gantry Start Gantry Stop Gantry Rotation Collimator
Arc Plana,b
Angle (⁰) Angle (⁰) Direction Angle (⁰)
1 1,2 181.0 179.0 Clockwise 30
2 1,2 179.0 181.0 Counter-clockwise 330
3 1 181.0 179.0 Clockwise 0
3 2 181.0 179.0 Clockwise 90
a
Plan 1 utilized the 0⁰ collimator
b
Plan 2 utilized the 90⁰ collimator

Table 2. Patient optimization outcomes of the organs at risk (OAR) that fell within and outside
of the 3% tolerance between Plan 1 and Plan 2.
Number of
Number of
Patients
Patients Percentage of
Number of Showing a
OAR Dose Showing an Deviation
Patients Decrease in
Parameters Increase in Dose Between Plan 1
Within 3% Dose by >3%
by >3% from and Plan 2 (%)
from Plan 1 to
Plan 1 to Plan 2
Plan 2
Lips Dmean 9 1 0 3.3

Mandible Dmax 9 1 0 4.9

Oral Cavity,
9 0 1 3.1
Uninvolved Dmean
Parotid Gland, Left
9 1 0 10.1
Dmean
Parotid Gland, Right
9 1 0 10.3
Dmean
OAR= Organs at Risk; Dmean=the mean dose the OAR received; Dmax= the maximum dose the OAR received