1

Assessing dose variance from immobilization devices in VMAT head

and neck treatment planning: A retrospective analysis
Alyssa Olson, B.S., R.T.(T), Kristine Phillips, B.S., R.T.(T), Tamara Eng B.S., R.T.
(R)
ABSTRACT
Key Words: Image guided radiation therapy, intensity modulated radiation therapy, volumetric
modulated arc therapy, attenuation,
Introduction
The study of immobilization device attenuation during treatment delivery has been
studied since the early 1980s. While the purpose of immobilization devices used in radiation
treatment is to minimize daily set-up error, if left unaccounted for, they can also significantly
impact the dose distribution, increase skin dose, and decrease dose to the target.1,2 Many
institutions now prefer to use monolithic carbon fiber table tops over the conventional patient
support systems with the tennis racket insert in addition to carbon fiber immobilization
devices.1,3 Carbon fiber material has become widely used in the field of radiation oncology due
to its strong rigidity, low density, and low attenuation properties; this has become especially
important with the increased use of image guided radiation therapy (IGRT) and arc therapy
treatment techniques.
Volumetric modulated arc therapy (VMAT), a specialized branch of intensity modulated
radiation therapy (IMRT), is an innovative treatment technique capable of delivering highly
conformal dose to targets in an arc fashion.1 Arc therapy, in particular, has an increased
propensity to deliver a higher percentage of the prescribed dose through the posterior aspect of
the patient when compared to static 3D conformal techniques. To accommodate the increased
beam attenuation from the patient couch system, many manufacturers have developed standard
couch contours in which account for their appropriate attenuative properties. On the contrary,

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radiation immobilization device attenuation can often times get overlooked, ultimately
compromising the dose distribution to the desired target.
Currently, there is no standard of practice amongst institutions to include immobilization
devices within the body contour structure.1 This can be attributed to the variances in treatment
planning system (TPS) capabilities in addition to user preferences.1,4 The ultimate goal of
radiation therapy is driven by the therapeutic ratio; the ability to deliver the prescribed dose to
the target volume while minimizing the dose to the surrounding critical structures. Current
recommendations for dose delivery accuracy should be within 3%-5%; this range can be
jeopardized when immobilization devices are used to create daily reproducible positions.1 The
presence of immobilization devices in a radiation beam causes attenuation of dose at depth and
an increase in skin dose.
Beam attenuation is dependent upon energy, field size, beam geometry, and
immobilization device composition.1 Much of the current device attenuation data pertains solely
to 3D conformal or static IMRT techniques. Treatment of the head and neck, in particular,
presents frequent challenges during treatment planning as this area is tightly confined by critical
organs at risk (OR). Intensity modulated radiation therapy has gradually replaced conventional
treatment techniques as the preferred treatment planning method for cancers of the head and
neck.5 What once proved to be difficult to achieve adequate target coverage while minimizing
dose to surrounding critical structures with conventional techniques has now become more
clinically obtainable with the use of IMRT. With the increasing use of VMAT, new research data
on immobilization device attenuation must be defined.6 Therefore, the goal of this retrospective
study was to determine the dosimetric impact of head and neck immobilization on target volume
coverage using the Eclipse TPS and the Anisotropic Analytical Algorithm (AAA).
Methods and Materials
Patient Selection
This retrospective study included a random selection of 15 different patients who were
collectively treated at 3 different treatment institutions5 patients from each center. All patients
selected for this study had been diagnosed and treated for some form of cancer of the head and
neck including supraglottis, base of tongue, oropharynx, floor of mouth, and an unspecified

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primary malignant neoplasm. Additionally, each patient was planned on the Eclipse TPS using
AAA and treated using the VMAT technique; all plans utilized either 2 to 3 full or partial arcs
with an energy of 6 MV. The PTV of 5 patients was treated to a total dose of 70 Gy, 6 treated to
a total of 60 Gy, 1 treated to a total of 66 Gy, 2 treated to a total of 66.96 Gy, and 1 treated to a
total of 30 Gy.
All 5 patients treated at clinic 1 were simulated in the head first supine position using a
Civco Type-STM Overlay Board.7 The patients head was supported with a Qfix Silverman Head
Support cup and a custom mask was molded over the patient's head and shoulder region using a
3.2 mm IMRT reinforced head and shoulder mask with neck relief.7,8 Shoulder assistance straps
were placed around each individuals wrists to help pull the shoulder region out of the treatment
area. The simulation was completed using a General Electric Lightspeed R16 computed
tomography (CT) scanner, and the treatment was completed using either a Varian IX or Varian
Trilogy linear accelerator.
Similarly, the 5 patients treated at clinic 2 were simulated in the head first supine position
using the Civco Type-STM Overlay Board.7 A Qfix Silverman Head Support cup paired with a
Civco AccuFormTM cushion was custom fitted to each patients head for comfort.7-9 A sponge
was placed under their knees for added back support. An IZI Klarity Thermoplastic Mask was
custom molded over their face and shoulders, and a CT scan was completed using a General
Electric Optima CT580 CT scanner. Treatment was completed on a Varian IX linear accelerator.
The remaining 5 patients were treated at clinic 3. All patients were simulated in the head
first supine position using a carbon fiber laminate AIO base plate. The patients head rested on
an Orfit Head Support pillow, and a custom Orfit Thermoplastic Mask was created.10 A knee
sponge was placed under the patients knees for added comfort and a CT scan was performed
using a General Electric Lightspeed R16 CT scanner. Each patient was treated on a Varian
TrueBeamTM linear accelerator and an Orfit ExactTM couch top extender was attached to the
treatment table.
Contouring
In the contouring application of Eclipse, a new CT data set was generated by duplicating
the existing approved structure set. Making changes only to the duplicated structure set, the

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body structure was copied into the newly created skin structure. This action allowed the
visualization of the body outline via the skin contour, and enabled the manipulation of the body
contour to incorporate the immobilization devices. Using the search body function of Eclipse,
the volume of interest (VOI) box was adjusted to completely encompass the body and
immobilization devices used. The range value in the search body function was adjusted to
approximately -850 which assisted the TPSs inclusion of the immobilization devices within the
body structure. Manual adjustments were made using the static two dimensional paint brush to
fill in any unwanted contour gaps of the body contour; the end result produced a body contour
which compeltely encompassed the body and immobilization system (Figure 1).
Treatment Planning
For each retrospective patient studied, a new test course was established in addition to the
pre-existing treatment course in Eclipse. The duplicated structure and CT data set were assigned
to the test course in external beam planning, and a new test treatment plan was created. For
consistency purposes, data entry into each patients dose prescription tab was kept the same to
mirror the original treatment course; this included the primary target volume, number of
fractions, total dose planned, and dose per fraction. The plan normalization value was selected
as no normalization. Finally, each field from the pre-existing plan was copied into the test plan.
To reflect the most accurate comparison of prescription dose coverage to the targets, the
test plan dose was calculated using the same number of monitor units (MU) as the initial
treatment plan. Using the newly acquired dose calculations, the two plans were analyzed and
compared for PTV dose coverage.
Plan Comparisons
Plan comparisons were performed using dose volume histograms (DVH). Target volume
coverage was assessed in the initial HN plan and the Test plan by comparing the V95% and
D100% as shown in Table 1. The V95% was chosen as a consistent point of measurement
because it was a common standard of care at each of the 3 clinics. Additionally, the initial hot
spot was recorded for both plans prior to making any adjustments in the Test plan. The Test plan
normalization was then adjusted to replicate the PTV coverage as utilized in each HN plan; both

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of these normalization values were recorded and compared. Upon adjusting the Test plan
normalization, the adjusted MU and new maximum hot spot was recorded and evaluated against
the initial HN plan outcome. The variances between the initial and new hot spot, normalization
values, and adjusted MUs were noted and compared in percentile form. (Will create a table)
Results target coverage percentage analyzing what percentage covers 95% of the PTV and 100%
of the PTV. Still in progress...
The question we proposed was: Does the prescription dose provide coverage to 95% of
the PTV? All of the initial plans, calculated without immobilization devices, all meet standard of
care and provide coverage to 95% of the PTV. Through calculation of the same plan with the
same MU values and addition of the immobilization devices, one will see how much target
coverage is compromised. The second plan is displayed in the second row of every patient,
labeled test plan. Target coverage no longer meets standard of care had we accounted for
immobilization devices keeping with the same MUs. Also, one can see that 100% of the
prescription dose drastically changes once we introduce immobilization devices ranging from
93.8% PTV coverage to 31.5% PTV coverage. The attenuating effects of immobilization devices
decrease the dose coverage of the PTV and further increase the risk for recurrence if not
accounted for. When we incorporate immobilization devices, we need to increase the MU per
field/per fraction in order to make up for the lost dose attenuated by such devices. This change in
MU is displayed in Table 1.
Discussion Limiting factor of eclipse treatment planning system, AAA calculation model, and
the use of further immobilization devices for head and neck treatment not studied in this
research.
AAA only captures structures that fall within the body contour in the dose calculations.
Thus, any structures falling outside of the body contour, namely immobilization devices will not
be accounted for within the dose calculation. In order to take into account the effect of these
immobilization devices on the dose to the target, the dosimetrist must contour. name device

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Conclusions
References
1. Dosimetric effects caused by couch tops and immobilization devices; Report of AAPM Task
Group 176. Olch AJ, Gerig L, Li H, Mihaylov I, Morgan A. Med Phys. 2014;41(6):061501061530. doi:http://dx.doi.org/10.1118/1.4876299
2. Olch AJ, Lavey RS. Reproducibility and treatment planning advantages of a carbon fiber
relocatable head fixation system. Radiat Oncol. 2002;65(3):165-168.
doi:http://dx.doi.org/10.1016/S0167-8140(02)00282-7
3. DeMooy LG. The use of carbon fibres in radiotherapy. Radiat Oncol. 1991;22(2):140-143.
ISSN:01678140.
4. Munjal RK, Negi PS, Babu AG, Sinha SN, Anand AK, Kataria T. Impact of 6MV beam
attenuation by carbon fiber couch and immobilization devices in IMRT planning and dose
delivery. J Med Phys. 2006;31(2):67-71. doi:http://dx.doi.org/10.4103/0971-6203.26690
5. Lee N, Chuang C, Quivey JM, et al. Skin toxicity due to intensity-modulated radiotherapy for
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doi:http://dx.doi.org/10.1016/S0360-3016(02)02756-6
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doi:http://dx.doi.org/10.1259/bjr/22373346
7. Solutions guide 2.0: comprehensive motion management solutions. Civco Medical Solutions
Web site. http://www.civco.com/ro/resources/brochures/solutionsguide.pdf. Updated 2014.
Accessed July 5, 2016.
8. Silverman head supports. Qfix Positioning for Life Web site. http://www.qfix.com/qfixproducts/intracranial-head-and-neck.asp?CID=2&PLID= 48. Updated 2016. Accessed July 5,
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Figures

Figure 1. Display of the adjusted body contour (green) to include immobilization devices in the
axial (A) and sagittal view (B). The couch contour is displayed in pink.

Tables

Table 1. Patients 1 through 5 were treated at clinic 1; patients 6-10 were treated at clinic 2;
patients 11-15 were treated at clinic 3. HN represents the initial treatment plan without inclusion
of immobilization devices in the body contour while the Test plan incorporates immobilization
devices within the body contour. Current hot spot represents the maximum dose of the initial HN
plan and Test plan prior to adjustments. Adjusted normalization represents the value needed to
achieve the same target coverage as the initial Test plan. The adjusted MU and new hot spot
represent the change that occurred as a result of normalization adjustment of the Test plan.