Patrick Melby

DOS772
Parotid Lab
Parotid gland radiation therapy is a fairly rare treatment. This gives an excellent
opportunity for students to practice a treatment in which they have not done in the past and
compare and evaluate the different techniques used for treatments. Three different techniques
were compared, a standard wedge pair, mixed photons/electrons and intensity modulated
radiation therapy (IMRT) plans. All of the plans used the same prescription of 60 Gy, with a
normalization of 100% of the dose going to 95% of the planning treatment volume (PTV). The
PTV was created with a 1 cm margin around the parotid gland (gross tumor volume, GTV).
The first plan that was evaluated used a wedge pair. The details of the wedge pair are
contained in Table 1. Because of the size and shape of the PTV mixed energies were used to
penetrated deep enough to cover the PTV. Also, even though the beams were 90 degrees apart, a
45 and 60 degree beam proved to give the best isodose distribution. Bolus was also used in
order to bring the prescription dose closer to the skin's surface. Figure 1. displays the isodose
distribution around the PTV and GTV. To evaluate the plan a dose volume histogram (DVH)
was created and is shown in Figure 2. Using the DVH the isodose levels to the PTV, GTV and
critical structures were charted in Table 2. This table showed what restraints from the physician
were achievable. The end results for this treatment showed that the only restraints that were not
met were the max dose and the dose to the inner ear.
Additionally, the wedge pair needed to be evaluated with a supraclavicular (SCLV) field
used to treat lymph nodes. This plan was created using a half-beam block below the fields of the
wedge pair so that no hot spots were created. Details of the beams are displayed in Table 3.
Images showing the fields along with their isodose lines and DVH can be viewed in Figures 3-6.
The DVH showed that although the beams never crossed, the scatter from the SCLV field did
contribute to the overall dose of the original wedge pair.
The second plan the was created was a mixed beam treatment with photons and electrons.
This type of treatment was completely new to me, so I did some research to help guide me to
how this procedure was done. One study showed that the most beneficial energies used for this
plan was 16 MeV for the electrons and 6 MV for the photons.1 The details of these beams are
shown in Table 3 and Figures 7 and 8 display the isodose lines and the DVH. This plan did a
great job of sparing the critical structures that surrounded the PTV, but PTV had much larger hot

spots with a max dose of over 115%. Addition info about the dose the PTV and critical
structures can be found in Table 4.
Lastly, I did an IMRT plan using 7 different beam angles in order to cover the PTV. This
plan showed the most conformal isodose lines when compared to the previous two plans. The
isodose line distribution is displayed in Figure 9 and in Figure 10 the DVH is shown. The 7
beams were positioned by trying to avoid the critical structures. This plan was able to meet all of
the requirements made by the doctor. Another IMRT plan using 5 beams was also created, but
with this plan, I was unable to get as conformal of a dose. The hot spots were larger than the 7
beam IMRT and minimum dose was smaller. These are the main reasons why the 7 beam IMRT
plan was better.
After comparing the three different plans, the plan with the best isodose distribution was
the 7 field IMRT plan. The worst of the three plans ended up being the mixed energy plan.
Although it did a very good job of sparing all of the critical structures, it created hot spots that
were greater than 115% when the physician required less than 107%. The wedge pair surprised
me with how well it covered the PTV. The only constraints that were not met included the max
dose and the inner ear dose, so it is understandable that this was a common treatment for the
parotids in the past. I was only able to use a CT scan that had an extended chin, but I found the
extended chin to be very helpful in planning. One reasons is that with the chin extended it
allowed the SCLV field to not clip the chin and create a possible unwanted skin reaction.
Another reason for the extended chin is it allowed some critical structures to get out of the
treatment field. By extending the eyes and lens were not included in the treatment. Positioning
the patient with an extended chin using IMRT created the most optimal treatment plan for the
patient.

Referecnces
1. 1. Yaparpalvi M.S. R, Fontenla Ph.D. D, Tyerech M.D. S, Boselli M.D. L, Beitler M.D., MBA.
J. Parotid Gland Tumors: A Comparison of Postoperative Radiotherapy Techniques Using Three
Dimensional (3D) Dose Distributions and Dose-Volume Histograms (DVHs). International
Journal of Radiation OncologyBiologyPhysics. 1998;40(1):43-49. doi:10.1016/s03603016(97)00484-7
Figures

Figure1. Axial view of the parotid gland treatment using a wedge pair.

Figure 2. Dose volume histogram of the wedge pair plan.

Figure 3. Beam angles used in the SCLV and wedge pair

Figure 4. Axial view of the parotid gland treatment using sum of the SCLV and wedge pair.

Figure 5. Axial view of the parotid gland treatment using sum of the SCLV and wedge pair.

Figure 6. Dose volume histogram of the SCLV and wedge pair plan.

Figure 7. Axial view of the parotid gland treatment using photons and electrons.

Figure 8. Dose volume histogram of the photon and electron plan.

Figure 9. Axial view of the parotid gland treatment using sum of the IMRT plan

Figure 10. Dose volume histogram of the IMRT plan.

Tables
Table 1. Details about the beams used for the wedge pair plan.
Beam

Energy

Angle

Weighting

1
2

6x
10x

315
225

.555
.450

Collimator/Couc
h
0
0

Field
Wedge
Size
8.9 x 9.5 45
8.0 x 9.5 60

Bolus
0.5cm
0.5cm

Table 2. Dose constraints achieved in the wedge pair plan.

Structure
R Parotid PTV

Spinal Cord+5mm
Brainstem +3mm
Oral
Cavity/Oropharynx
L Parotid Gland
L Submandibular
Gland
Mandible

Constraints
V60Gy>95%
Max dose<107%=
6420cGy
Max dose < 40Gy to no
more than 0.03cc volume
Max dose < 50Gy to no
more than 0.03cc volume
Mean Dose < 20 Gy

Lips
Inner Ear

Actual
60Gy = 95%
Max = 6542cGy

Achieved
Yes
No

Max = 3054cGy

Yes

Max = 2774cGy

Yes

Mean = 1823cGy

Yes

Mean Dose < 10 Gy

Mean Dose < 15 Gy

Mean = 108cGy
Mean = 168cGy

Yes
Yes

Max dose < 73Gy to

0.03cc
Mean<20 Gy
Max dose < 26 Gy
Mean < 20 Gy

Max = 6543cGy

Yes

Mean = 1322cGy
Max = 3124cGy
Mean = 2489cGy

Yes
No
No

Table 3. Details about the beams used for the SCLV and wedge pair plan.
Beam

Energy

Angle

Weighting

1
2
3

6x
10x
6x

315
225
15

.555
.450
1.0

Collimator/Couc
h
0
0
0

Field
Size
8.9 x 9.5
8.0 x 9.5
9.3 x 9.6

Wedge

Bolus

45
60
15

0.5cm
0.5cm
N/A

Cone

Bolus

Table 4. Details about the beams used for the photon and electron plan.
Beam

Energy

Angle

Weighting

Collimator/Couc
h

Field
Size

1
16E
270
.80
0
2
6x
270
.20
0
Table 5. Dose constraints achieved in the photon and electron plan.
Structure
R Parotid PTV
Spinal Cord+5mm

Brainstem +3mm

Oral
Cavity/Oropharynx
L Parotid Gland
L Submandibular
Gland
Mandible
Lips
Inner Ear

14 x 14
8.4 x 9.0

10
N/A

Constraints
V60Gy>95%
Max dose <107%
Max dose < 40Gy to
no more than 0.03cc
volume
Max dose < 50Gy to
no more than 0.03cc
volume
Mean Dose < 20 Gy

Actual
60Gy = 95%
Max = 7088 cGy
Max = 3992 cGy to
0.03cc

Achieved
Yes
No
Yes

Max = 2426 cGy

Yes

Mean = 156 cGy

Yes

Mean Dose < 10 Gy

Mean Dose < 15 Gy

Mean = 765 cGy

Mean = 1265 cGy

Yes
Yes

Max dose < 73Gy to

0.03cc
Mean<20 Gy
Max dose < 26 Gy
Mean < 20 Gy

Max = 6540 cGy

Yes

Mean = 27 cGy
Max = 3082 cGy
Mean = 1369 cGy

Yes
Yes
Yes

Table 6. Details about the beams used for the IMRT plan.
Beam

Energy

Angle

1
2
3
4
5
6
7

6x
6x
6x
6x
6x
6x
6x

0
50
115
170
220
280
320

Collimator/Couc
h
0
0
0
0
0
0
0

Field
Size
8.1 x 8.8
8.0 x 8.8
8.3 x 8.8
8.3 x 8.8
7.8 x 9.0
8.3 x 9.0
8.5 x 9.0

N/A
N/A

Table 7. Dose constraints achieved in the IMRT plan.

Structure
R Parotid PTV

Constraints
V60Gy>95%
Max dose<107%= 6420 cGy

Actual
60Gy = 95%
Max = 6402 cGy

Achieved
Yes
Yes

Spinal Cord+5mm

Max dose < 40Gy to no

more than 0.03cc volume
Max dose < 50Gy to no
more than 0.03 cc volume
Mean Dose < 20 Gy

Max = 3978 cGy

to 0.03cc
Max = 3408 cGy

Yes

Mean = 1334 cGy

Yes

Mean Dose < 10 Gy

Mean Dose < 15 Gy

Mean = 634 cGy

Mean = 458 cGy

Yes
Yes

Max dose < 73Gy to 0.03 cc

Mean< 20 Gy
Max dose < 26 Gy
Mean < 20 Gy

Max = 6258 cGy

Mean = 730 cGy
Max = 2488 cGy
Mean = 1220 cGy

Yes
Yes
Yes
Yes

Brainstem +3mm
Oral
Cavity/Oropharynx
L Parotid Gland
L Submandibular
Gland
Mandible
Lips
Inner Ear

Yes