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Taisa Polishchuk
DOS 772 Clinical Practicum II
Clinical Lab Assignment (Parotid)
The patient was simulated supine head first on pad, with the Q3 timo and an accuform under his
head. The chin was extended with the mask and the shoulders pulled down. The right parotid was
outlined and labeled GTV (in pink), and PTV was created by adding 1 cm margin around it (in
red). The expansion outside of the patients body was subtracted and labeled PTV Planning, and
was utilized for planning in all of the treatment plans.

The goal for treatment was to obtain 60 Gy (100% of dose) to the GTV with the 95% isodose
surrounding the PTV. In addition, different organs at risk were outlined to monitor their tolerance
doses.

The dose constraints to the critical structures were outlined by the physician and displayed below
in the table:

Multiple plans were created to compare GTV and PTV coverage and accomplish the critical
structure tolerances:
I. Plan 1a parotid treatment plan utilizing a wedged pair technique and bolus; Plan 1b parotid
treatment plan with lower neck nodes involvement.
II. Plan 2 Photon/Electron mixed beam parotid treatment plan.
III. Plan 3 parotid IMRT treatment plan.

I. Plan 1a:
For my first plan, I used 2 beams (1.1 RAO and 1.2 RPO) utilizing 6 MV energy. RAO was at
310 degrees and RPO was at 220 degrees, which created a 90 degree hinge angle and therefore I
was able to use a 45 degree wedges on both fields. Due to the patient being positioned with the
chin extended, no couch and no collimator angles were needed on this plan. The weight was
distributed equally with 100cGy assigned to each of the 2 beams.

In order to achieve adequate coverage, 5 mm bolus (in orange) was used in this treatment plan.
Utilization of bolus was necessary to receive better coverage of the PTV due to PTV being very
superficial.

Prescription was normalized to 90% and absolute doses were used to evaluate plan 1a:
a hot spot of 110% - 6600 cGy was displayed in orange,
100% of dose 6000 cGy was displayed in yellow,
95% of dose 5700 cGy was displayed in red,
75% of dose 4500 cGy was displayed in purple,
40% of dose 2400 cGy was displayed in green.

DVH for the Plan 1a showed GTV receiving 100% of the dose, and PTV receiving only 92.5%
of the dose. This was due to the PTV being very superficial, as well as being limited by utilizing
only 2 fields and using wedges only.

Most of the other dose constraints were met and displayed in the table below.

I. Plan 1b:
For this plan I added a lower anterior ipsilateral neck field that abutted the bottom of the wedged
pair field using a half beam block technique. The medial edge of the lower neck field was
designed to be off cord and the dose of 50.4 Gy at 1.8 Gy/day was utilized to that anterior field.
6MV energy was used on the AP field to cover the lower neck nodes.
Absolute doses were used to evaluate parotid dose in plan 1b:
a hot spot of 111% - 6700 cGy was displayed in orange,
100% of parotid dose 6000 cGy was displayed in yellow,
95% of parotid dose 5700 cGy was displayed in red,

75% of parotid dose 4500 cGy was displayed in purple,

40% of parotid dose 2400 cGy was displayed in green.

Absolute doses were used to evaluate nodal dose in plan 1b:

100% of nodal dose 5040 cGy was displayed in green,
95% of nodal dose 4788 cGy was displayed in pink,
75% of nodal dose 3780 cGy was displayed in light blue,
40% of nodal dose 2016 cGy was displayed in blue.

DVH for the Plan 1b shows GTV receiving 100% of the dose, and PTV receiving only 96% of
the dose.

All of the other dose constraints were met and displayed in the table below.

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II. Plan 2:
For this plan, I used a mixed beam technique. Two beams were assigned to this treatment plan:
1.1 Rt Lat Photon beam with 6MV energy, and 1.2 Rt Lat Electron beam with 20MeV energy.
Both beams were positioned at 270 degrees and no other modification devices were used. Due to
the patient being positioned with the chin extended, no couch and no collimator angles were
needed on this plan. 80 cGy per fraction was assigned to the photon beam and 120 cGy per
fraction was assigned to the electron beam.

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Prescription was normalized to 95% for the photon beam and 90% for the electron beam.
Absolute doses were used to evaluate plan 2:
a hot spot of 120% - 7200 cGy was displayed in orange,
100% of dose 6000 cGy was displayed in yellow,
95% of dose 5700 cGy was displayed in red,
75% of dose 4500 cGy was displayed in purple,
40% of dose 2400 cGy was displayed in green.

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The coverage of tumor volume was not as good when comparing it to the wedged pair plan. GTV
was receiving 94% of the dose, and PTV was receiving 78.3%. This was due to the fact that there
was no bolus on this plan and there was a lack of coverage superficially. Photon field helped with
covering the depth of the tumor, however lacked delivering dose superficially. 20 MeV electrons
were utilized to adequately cover 5 cm deep lesion, however it was not enough to contribute to
the dose superficially. GTV, PTV and the cord dose criteria were not met by the mixed beam
plan.

The summary of doses received by all of the structures was displayed in the DVH and a table
below.

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III. Plan 3:
For IMRT plan I used volumetric modulated arc therapy (VMAT) technique consisting of 2 arcs
with opposite rotation (clockwise and counter-clockwise). The path length of each arc was 160
degrees (190-350 degrees) with the collimator rotated 345 degrees in the clockwise arc and 15
degrees in the counter-clockwise arc.

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Absolute doses were used to evaluate plan 3:

a hot spot of 111% - 6680 cGy was displayed in orange,
100% of dose 6000 cGy was displayed in yellow,
95% of dose 5700 cGy was displayed in red,
75% of dose 4500 cGy was displayed in purple,
40% of dose 2400 cGy was displayed in green.

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DVH for the Plan 3 shows GTV receiving 100% of the dose, and PTV receiving 96.8% of the
dose.

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Dose constraints were displayed in the table below. All of the dose constraints were met.

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When evaluating all of the plans performed on this patient, the best choice would be IMRT plan.
In addition to meeting all of the dose constraints, there was a better coverage of the GTV and the
PTV. Doses to some critical structures like brainstem, spinal cord, optic nerves, and eyes were
higher in VMAT plan versus the wedged pair plan. However, doses to mandible, both lenses, and
left parotid were lower in VMAT plan. When treating lesions in the head and neck region there is
a lot of critical structures to consider, and VMAT plan was able to achieve all of the dose
constraints as well as keep an adequate coverage to the tumor volume.