April Moore

Parotid Clinical Lab

Planning Objectives/ Prescription:

The intent for this retrospective clinical lab project is to compare multiple planning options for
the treatment of parotid cancer. A head and neck CT dataset with a neutral head position was
used as one with the chin extended up was not available. The goal for each of the 3 plans below
will be to obtain 60Gy to the parotid GTV with the 95% isodose covering 100% of the PTV.
Target volumes/ Organs at risk (OR):
The Physician contoured the right parotid gland (GTV) and added a 1.0 cm margin to form the
PTV. The dosimetrist contoured all surrounding critical structures (Figure 1). These structures
included; brain stem, chiasm, left/right eye, left/right cochlea, left/right optic nerve, left/right
lens, mandible, left parotid, spinal cord and oral cavity.
Plan 1: Beam Arrangement/ Plan evaluation:
The first plan utilizes an ipsilateral wedged pair of 6 MV photons. The first beam used was an
RAO with a gantry angle of 330 and no collimator or couch rotation. The second beam used was
an RPO with a gantry angle of 210 also with no collimator or couch rotation. This beam
arrangement was chosen because the fields limited the amount of spinal cord and brain stem in
the treatment field as well only permitting exit dose to the oral cavity (Figure 2). The wedges that
were utilized were 30 heel to heel in order to move the dose buildup at the beams intersection
point inward to the deeper area of the volume.

Since the patient is in a neutral head position this did not greatly affect my beam arrangement
however an extended position would likely result in lower OR doses from moving the closest
critical structures (oral cavity, right cochlea, right eye and right lens) further away from the
treatment field. Upon reviewing the plans DVH (Figure 3), 94.5% of the right parotid GTV
received 60Gy and 95% of the PTV received 98.4Gy. Both target volumes are not in tolerance of
the desired objectives. This lack of coverage is noticed greatly toward the skin surface where the
volume extends into the dmax region. Utilizing a 0.5cm bolus would increase the superficial
coverage. Figure 4 shows a transverse slice of the plan showing the isodose coverage of the
parotid GTV, the PTV, the maximum dose location as well as the 100%, 95%, 75%, and 40%
isodose lines.
In addition to this beam arrangement, a lower anterior ipsilateral neck field that abuts the bottom
of my ispilateral wedged pair fields was used. This was accomplished using a half beam block
technique for both the wedge pair fields and the anterior field. A half beam block technique will
eliminate any beam divergence between fields so that there is no dose overlap (hot spots) or dose
gaps (cold spots). This lower neck field prescription will be 50.4Gy at 1.8Gy/day using a depth
of 5.0cm which is my clinics depth for anterior neck lymph nodes. Figure 5 shows both an
anterior neck field template with the medial edge of the field off the cord as well as an image of
my AP beams eye view. A plan sum with isodose lines of the two plans can be viewed in figure
6 to show the isodose coverage to the parotid GTV, PTV, lower neck nodes as well as a plan sum
DVH in figure 7.
Plan 2: Beam Arrangement/ Plan evaluation:
The second plan utilizes a mixed ipsilateral photon and electron beams. This is done in an
attempt of achieving the required coverage on the parotid gland and PTV. Six MeV electrons will
be used to increase the coverage of the superficial gland and 6 MV photons on the wedge pair in
an effort to reach the deeper lobe of the parotid.

The same wedge pair fields from plan one was used in this second plan with the addition of the
right lateral (270), 6 MeV electron beam prescribed to the 100% isodose line. The electron cut
out was fit with a block margin of 0.7cm around the PTV on a 10x10 cone with a source to skin
distance (SSD) of 100 cm. A collimator and couch rotation were not used for this beam.

In an axial view of the plan sum with isodose levels (Figure 8) you can see that both the
superficial and deep lobe of the parotid is covered. The plan sum DVH (Figure 9) shows that
100% of the GTV receives the prescribed 60Gy and 98% of the PTV also receives the full 60Gy
prescription. This treatment planning option shows a much higher total plan hot spot than the
other plan (8% vs 28%). This increase comes from dose gradient of the electron plan combining
with the photon plans isodose lines.

In comparing this mixed energy plan with my first wedge pair plan I can see that the superficial
GTV/PTV coverage that I was missing in the wedge pair is being covered adequately with the
addition of the lateral electron field. The only concern is the total plan hot spot was much higher
than the other plan and the OR did show an increase in dose although still in acceptable rangeswith the exception of the mandible (Figure 10). This mixed energy plan yields the same results as
my original thought of adding a 0.5cm bolus to the wedge pair plan. The main benefit of adding
the bolus to the wedge pair over the mixed energy is to reduce the total plan hot spot within
reason and lowering the max dose to the mandible.

Plan 3: Beam Arrangement/ Plan evaluation:

The third beam arrangement was an IMRT plan of the planners choice. I used static IMRT
fields. The plan consisted of 5 right sided beamlets to stay off of the left sided critical structures
such as the left parotid and left cochlea. The angles of fields used were 0, 330 , 300 , 240 ,
220 and 180 all without a collimator or couch angle. This beam arrangement (30-40 apart)
was useful in reducing left sided structures as well as the spinal cord and brain stem. All target
volumes and OR were entered into the Eclipse TPS. The target volumes received upper and
lower limits to ensure that the GTV and 95% of the PTV would receive full prescription dose.
The OR had lower limits entered to ensure that the dose constraints would be met, see table 1 for
OR dose constraints. Once the optimization process completed the plans dose coverage (Figure
11) and DVH (Figure 12) were viewed to ensure all objectives were met.
A comparison DVH (Figure 13) was generated of all 3 treatment planning techniques used in this
clinical lab study as well as a table (table 1) showing the target volumes, ORs, dose objectives
and whether the achieved doses met or did not met the goals. After reviewing the statistics on the
table it seems the most optimal plan is the IMRT static fields. Since I was able to enter the dose
constraints into the optimizer the TPS was able to keep all limits in tolerance while meeting the
target objectives. The wedge pair plan also met all OR constraints but was lacking on superficial
coverage of the GTV and PTV. A suggestion to improve this plan if IMRT is not available would
be to add a 0.5cm bolus to the treatment area. The mixed energy plan did cover the target
volumes as requested but the dose to the mandible exceeded limits. The plan itself was also much
hotter than the others.

Figure 1: CT data set in neutral head position with contoured organs at risk (OR); PTV (orange),
right parotid GTV (red), mandible (green), oral cavity (white), brain stem (brown), spinal cord
(cyan).

Figure 2: Plan 1 axial view of beam arrangement and RAO and RPO beams eye view.

Figure 3: Ipsilateral wedge pair plans dose volume histogram (DVH).

Figure 4: Transverse CT slice of wedge pair plans isodose coverage of the parotid and the PTV,
the maximum dose location and the 100% (yellow), 95% (green), 75% (blue), and 40% (light
green) isodose lines.

Figure 5: A lower half beam blocked anterior ipsilateral neck field template and a beams eye
view of my anterior field.

Figure 6: Wedge pair and AP neck plan sums isodose coverage of the parotid and the PTV, the
maximum dose location and the 60 Gy (100% yellow), 57 Gy (95% green), 45 Gy (75% blue),
and 24 Gy (40% light green) isodose lines.

Figure 7: Sum dose volume histogram (DVH) of the wedge pair arrangement (plan 1) and AP
neck field.

Figure 8: Plan sum of isodose coverage of the parotid and the PTV, the maximum dose location
and the 60 Gy (100% yellow), 57 Gy (95% green), 45 Gy (75% blue), and 24 Gy (40% light
green) isodose lines for mixed energy plans.

Figure 9: Sum dose volume histogram (DVH) of the mixed energy plans.

Figure 10: Plan Comparison of mixed energy versus the wedge pair dose volume histogram
(DVH).

Figure 11: Transverse CT slice of IMRT plans isodose coverage of the parotid and the PTV, the
maximum dose location and the 100% (yellow), 95% (green), 75% (blue), and 40% (light green)
isodose lines.

Figure 12: IMRT plans dose volume histogram (DVH).

Figure 13: Comparison DVH of all 3 plans highlighting the dose to the GTV (red), PTV
(orange), mandible (green), oral cavity (white), spinal cord (cyan), brain stem(brown) and right
cochlea (brown).

Table 1: A chart listing all the surrounding critical structures with their respective tolerance doses
and doses achieved in each plan.
Organ:

Desired

Plan 1:Wedge Pair

Objectives:

Plan 2: Mixed

Plan 3: IMRT

Energy
Met (M) or Not Met (NM)

Met (M) or Not Met (NM)

Met (M) or Not Met (NM)

right parotid

100% 60Gy

94.5%= 60Gy (NM)

100%=60Gy (M)

100%= 60Gy (M)

(GTV)
PTV

95% 60Gy

95%= 57Gy (NM)

95%=60Gy (M)

95%=60Gy (M)

spinal cord

Max45Gy

Max=23.7Gy (M)

Max=24.06Gy (M)

Max= 20.77Gy (M)

brain stem

Max 54Gy

Max= 22.2Gy (M)

Max=22.3Gy (M)

Max=18.83Gy (M)

oral cavity

Mean 40Gy

Mean= 13.4Gy (M)

Mean=13.5Gy (M)

Mean=10.5Gy (M)

mandible

Max 70Gy

Max= 64.8Gy (M)

Max=110.3 (NM)

Max=64.1Gy (M)

left cochlea

5% 55Gy

5%= 0.86Gy (M)

5%=0.93Gy (M)

5%=5.08Gy (M)

left lens

Max 25Gy

Max=0.86Gy (M)

Max=0.92Gy (M)

Max=0.56Gy (M)

left eye

Max 50Gy

Max= 1.02Gy (M)

Max=1.11Gy (M)

Max= 0.77Gy (M)

left optic nerve

Max 54Gy

Max=0.92Gy (M)

Max=1.02Gy (M)

Max= 0.61Gy (M)

right cochlea

5% 55Gy

5%= 7.48Gy (M)

5%=9.63Gy (M)

5%= 2.64Gy (M)

right lens

Max 25Gy

Max=1.4Gy (M)

Max= 1.41Gy (M)

Max= 0.61Gy (M)

right eye

Max 50Gy

Max= 1.7Gy (M)

Max=1.8Gy (M)

Max= 1.09Gy (M)

right optic nerve

Max 54Gy

Max= 1.24Gy (M)

Max= 1.31Gy (M)

Max= 0.65Gy (M)

left parotid

50% 30Gy

50%= 0.66Gy (M)

50%= 0.76Gy (M)

50%= 0.76Gy (M)