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Michelle Rocque
Final Clinical Project
October 24, 2015
Head and Neck Treatment Planning with IMRT and VMAT Techniques
History of Present Illness: Patient WM is an 88 year old with squamous cell carcinoma of
facial skin with metastasis to the left parotid glad. The cancer is a stage IV, T0N2aM0, status
post superficial parotidectomy performed in August of 2015. Post-operative radiation therapy is
prescribed to decrease the chance of loco-regional recurrence.
The Plan (Prescription): After fully discussing the treatment options with the patient, he
agreed to begin external beam irradiation to minimize the chance of loco-regional recurrence.
The radiation oncologist scheduled a PET/CT scan to aid with treatment planning. The treatment
will include remaining parotid tissue, 2 cm superior margin, and regional lymphatics. The
prescription would consist of a simultaneous integrated boost (SIB) technique. A planning target
volume (PTV) consisting of the left parotid and facial skin would receive 200 cGy for 35
fractions to a total dose of 7000 cGy. PTVs indicating the areas of high risk and low risk were
drawn and would concurrently receive 180 cGy totaling 6300 cGy and 160 cGy totaling 5600
cGy, respectively, for 35 fractions. Bolus was also prescribed to be used daily in the treatment.
The patient would have one treatment daily.
Patient Setup/Immobilization: In late August 2015, WM underwent a computed tomography
(CT) simulation scan. The patient was placed in the supine position on a rigid immobilization
board on the CT simulation couch. His hands were on his abdomen and holding a cushioned
ring. An aquaplast mask was made for daily immobilization of the head and neck area (Figure
1). A cushion was placed under the knees for support and comfort. The oncologist placed a wire
around the area of interest to better delineate the volume on the scan (Figure 2). In addition BBs
were placed on the mask to indicate the CT origin: longitudinal, lateral, and vertical.

Figure 1: CT simulation position

Figure 2: Wire delineation of involved volume

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Anatomical Contouring: The radiation oncologist requested for the patients PET/CT scan to
be fused with the planning CT scan. Both scans were sent to the Varian Eclipse 11.0 treatment
planning system (TPS) and fused by the medical physicist. The structures that were drawn by
the oncologist included: PTV70Gy, PTV63Gy, and PTV 56Gy. The radiation oncology resident
contoured critical organs at risk (OR) that included: right parotid, pharyngeal constrictors,
mandible, and the left parotid. Other structures contoured by the medical dosimetry student were
bilateral eyes with lens, optic nerves, spinal canal, brainstem, and a density override structure for
dental scatter. In order to optimize on the multiple PTVs, an optimization structure was created
for the PTV63Gy which was named PTV63 Opt. This contour was a copy of the original PTV
63Gy from the physician. The 70Gy and 56Gy were cropped out of the structure with an
additional 2mm subtracted. This would enable constraints to be set in the optimizer for each
PTV without asking it to deliver conflicting doses within each one. Otherwise, the optimizer
would be confused because of overlapping coverage within the same volumes: coverage of 70Gy
within the 63Gy, and 63Gy within the 56Gy volumes (Figure 3). Also created was an avoidance
structure for the larynx and the oral cavity (Figure 4). The prescribing physician desires the doses
to be conformed around these areas so full dose is not being delivered to these areas where there
is no disease. A brainstem/spinal cord planning at risk volume (BS_SC PRV) was created to
constrain the dose to the structures where they were close to the PTV volumes (Figure 5). For
the original optimization of the VMAT plan there was no ring used to constrain dose. After the
first optimization, a ring was added to further push the dose to conform.

Figure 3 PTV Opt of 63Gy (Purple) cropped with an extra 2mm from PTV 70Gy

Figure 4 Avoidance of oral cavity (Blue) and larynx (Magenta)

Figure 5 PTVs (Red/Purple) shown with BS_SC PRV (Blue)

Beam Isocenter/Arrangement: A Varian 23IX linear accelerator was used for treating this
patient. A volumetric arc technique (VMAT) was chosen for the first plan. The PTV volumes
were located on the right side of the patient so partial arcs were set up to begin. The first arc was
in the clockwise direction with the angle beginning at 180 degrees and ending at 40 degrees
(Figure 6). A counterclockwise direction utilizing the same angles was set up. This technique
requires that the field size be determined prior to entering the optimizer for planning. When
using an arc technique, the collimator is required to be turned a minimum of 10 degrees. This
minimizes leakage occurring in the same area through the MLCs as the gantry is rotating during
treatment delivery. The collimator angle for the clockwise rotation was set to 345 degrees while
the counterclockwise rotation had a 15 degree rotation. After setting the field size, collimator
angles, and ensuring the PTV would be covered throughout the arcs, the VMAT optimization
was entered to begin setting the objectives.

Figure 6: Clockwise Arc

Although the VMAT plan was used for the patients treatment, I later chose to complete an
intensity modulated radiation therapy (IMRT) plan for my own comparison. This plan consisted
of five separate fields with all of the fields entering on the affected right side of the patient. The
angles that were used for the gantry were: 0, 320, 280, 240, and 200 degrees. Upon choosing
each of these angles, the organs at risk (OR) were looked at in each angle to decide which would
spare the greatest extent of the spinal cord, eyes, brainstem and the entrance into the shoulder.
Treatment Planning: The treatment planning system Eclipse version 11 was used. The plan
objective was to normalize the PTV70Gy with 100% to cover 95% of the target volume.
Understanding the optimization process was my personal objective for this case study. In the
TPS optimizer, I first looked at the contoured structures that I could exclude so that it would
work only on critical structures that needed to be constrained. Then the process of setting upper
and lower objectives and their priorities was begun. An easy way to think of these was taught by
my preceptor. For the lower objective: you want at least ___ % of the volume of the structure to
receive____ dose. For the upper objective: you want at most ____% of the volume to receive
____ dose. Generally, the lower objective for the PTVs that I have learned to use is 100%
volume to receive 20-30 cGy over the prescribed dose and 0% to receive 150 cGy above the
lower objective dose. For the OR structures, I usually begin by looking at QUANTEC data and

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use those values to begin. The avoidance structures required an educated guess of the upper
objective dose to begin the optimization. The physician who would be evaluating this plan has
specific dose objectives for the avoidance structures that were created. He looks at these areas to
evaluate that the dose stays within his objectives. The final optimization objectives of the
VMAT plan are listed in Figure 7.

Figure 7 VMAT Objective

The IMRT optimization objectives that were used were very similar to the VMAT. Because
automatic normal tissue sparing is not an option in the IMRT plan, the normal tissue sparing has
to be set prior to optimizing. This will tell the optimizer how quickly to drop off the dose around
the PTV volumes. Also, the upper and lower objective doses were set slightly higher because of
my previous working knowledge of creating an effective plan. The optimization objectives are
shown for the IMRT plan in Figure 8.

Figure 8 IMRT Objectives

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After the optimization was complete, evaluation of the plan was needed. This was done by
looking at the hotspot location, dose coverage of the three PTVs, and DVH measurements of the
PTVs and OR. Figure 9 represents the PTV coverage comparison of both plans.

Figure 9 DVH comparison of plans PTV coverage

By comparing both plans in plan evaluation, 2 very similar and treatable plans were observed
(Figures 10, 11, 12). The VMAT plan was slightly more conformal than the IMRT plan. The
OR doses were under tolerance for both plans, but the IMRT showed slightly lower doses to the
left lens, right lens, and brainstem. The VMAT plan enabled the patient to be on the table for a
shorter period of time which helped because he was claustrophobic. The hotspot on the VMAT
plan was located in the high dose PTV and was 7352.3 cGy or 105% (Figure 13). The OR doses
for the treated VMAT plan were met except for the left and right lenses. Although they were
higher than the objective of 2 Gy maximum in both plans, the physician still accepted the VMAT
plan for treatment (Table 1).

Figure 10 56Gy Lt=IMRT Rt=VMAT Isodose lines for 56Gy: Turquoise=5600cGy,

Orange=5320cGy, Blue=3520cGy, Green=1750cGy

Figure 11 63Gy: Turquoise=6300cGy, Orange=5985cGy, Blue=3520cGy, Green=1750cGy

Figure 12 70Gy: Yellow 7000cGy, Magenta 6650cGy, Blue 3520cGy, Green 1750cGy

Figure 13 Location of the hotspot of the plan in the 70Gy PTV

OR Structure
Spinal Canal

Planning Objectives
Max Dose 45Gy

Dose
Met 37.44Gy

Optic Nerves Lt/Rt

Max Dose 55Gy each

Met Lt 13.58Gy Rt 21.14Gy

Lens Lt/Rt

Max Dose 2Gy

Brainstem

54Gy Whole organ

Contralateral Parotid

Mean <24Gy
V40 <33%
V65 <10%

Mandible

Not Met Lt 4Gy Rt 11Gy

Met 25.85Gy
Met 9.3Gy
Met 0
Met 8.7%

Table 1 OR structures

Conclusion: Understanding the optimization process is very important when creating IMRT or
VMAT treatment plans. Before beginning the plan, it is important to look at the PTV and think
about what the objectives are and what may be difficult to spare. The more thought that is given
to use contours such as PRVs, rings, and avoidance structures will be beneficial as planning
begins. These things are very useful to use to constrain dose in the optimizer and especially
useful during VMAT planning. VMAT planning offers a dosimetrist less options for
manipulating things such as hot spot placement. Also, VMAT planning is a longer optimization
process. All the planning prior to starting the process can lead to a better plan the first run
through rather than having to optimize time after time. With this project, I have come to
understand the optimizer better for the treatment of head and neck cancers. I learned to watch
the optimizer more closely as it was running and to adjust the objectives and priorities during the

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optimization. Previously, I would wait to manipulate the values after the optimization was
complete which caused me to have to run the entire process again. My efficiency in the
IMRT/VMAT planning process has improved.