Peter Hirschi

Parotid Treatment Technique Comparison

July 30, 2015
Treating the Left Parotid to 60Gy with 30 fractions of 2 Gy a day.
Structures

Dose

Plan 1

Plan 2

Plan 3

Contoured

Constraints

Ipsilateral

Ipsilateral

3 Field IMRT

Brain Stem

Max 6000

wedge pair
2500 cGy

Photon/Electron
5012cGy

3074 cGy

All

Cord

cGy
Max 4500

2745 cGy

4252 cGy

3469 cGy

All

Cord Margin

cGY
Max 5000

2886 cGy

4748 cGy

3736 cGy

All

Left Retinea

cGy
Max 5000

158 cGy

142 cGy

115 cGy

All

Right Retinea

cGy
Max 5000

185 cGy

183 cGy

106 cGy

All

Left Lens

cGy
Max 2000

96 cGy

59 cGy

67 cGy

All

Right Lens

cGy
Max 2000

89 cGy

65 cGy

59 cGy

All

Left Optic

cGy
Max 5500

123 cGy

156 cGy

101 cGy

All

Nerve
Right Optic

cGy
Max 5500

156 cGy

264 cGy

108 cGy

All

Nerve
Mandible

cGy
30% vol.

13.5% vol.

14.2% vol.

10.5% vol.

All

Left Parotid

6000 cGy
Mean 2600

Mean 96 cGy

Mean 1731cGy

Mean 482

All

cGy

Met Constraint

cGy

30% vol.

30% vol.=NA

30% vol.=NA

30% vol. =NA

Lt Submandible

3000 cGy
Max Mean

max dose 151

150 cGy

max dose 2203

1639 cGy

max dose 619

129 cGY

All

Gland
Oral Cavity

2600 cGy
Mean 3500

2015 cGy

1049 cGy

1446 cGy

All

95% getting

96.3% getting

95 % getting

All

cGy
Right Parotid
(GTV)
PTV

95% of

Tumor gets

100% of dose

100% of dose

100% of dose

109.8%

124.5%

104.7%

100% of
Hotspot

dose
<110%

Electron mixed
beam hot spot
of concern

(Table 1)

(Image 1)
The Right Parotid was labeled GTV and 1cm margin was added to the GTV to create the PTV shown in
red. The PTV was subtracted 0.3cm from skin in order to help the treatment planning system from
generating a hot plan due to pushing dose to the surface of the skin. When this technique is used, it is
important to watch the 100% coverage line to ensure it covers the surface of the skin if the physician
wants the entire surface treated.
I contoured more structures than are generally needed to treat the parotid in order for me to see how all
structures where affected, even distal ones.
Plan#1
Ipsilateral wedged pair for right parotid.
a) How would, or how does, the position (chin extended) affect your beam arrangement?
Answer: By extending the chin, it pulls the treatment volume away from the neck.

b) If you not able to get adequate coverage on the parotid using the wedged pari technique, what
were your constraints?
Answer: As shown in table 1, the wedged pair technique was able to cover get prescribed coverage of the
PTV while meeting all constraints.

(Image 2)
Image 2 is a transverse view of wedged pair.

(Image 3)
Half beam technique was utilized to mitigate problems associated with beam divergence between abutting
fields.

(Image 4)
Image 4 shows the beam information for every field used in the wedge pair technique with AP neck node
treatment. The neck node field was calculated to a depth of 3cm. 1cm bolus was utilized to cover the PTV
that was very superficial to the skin. The image is the plan sum view of the wedge pair fields combined
with the AP neck nodal field. Notice the thicker light blue line highlighting the 5040 line. The neck node
prescription is 5040 cGy.

(Image 5)
DVH of wedge pair field with neck nodal AP field. The wedge pair field met all constraints shown in the
constraints table.
Plan #2
Ipsilateral Photon/Electron (Mixed beam)
Achieve the required coverage on the parotid gland and PTV using electrons for the superficial gland and
photons to reach the deeper lobe.

a) How does this plan compare to your wedged pair plan?

Answer: First of all, the electron/photon plan is much hotter and less conformal than the wedge pair plan.
As shown in the transverse view of the electron technique, a substantially large amount of tissue falls
within the 100% isodose line. The lateral photon also pushes some dose to the contra lateral parotid gland
whereas the wedge technique angles the beams so they do not go through the contra lateral parotid gland.
b) Was there any dose constraints not met?
Answer: All dose constraints were met with the exception of the hotspot of 124%. The eclipse planning
system has high hot spots when calculating electron fields so although 124% seems really high it is not as
bad as it seems with the inherent increased hot spots with electron calculation. Although the constraints
are met the following structures are close to the constraint limits: Brainstem max 50Gy, Cord max 42Gy,
Cord Margin 47.5 Gy, and the contra lateral parotid mean of 17.3 Gy is substantially high for not being
near the treatment area.

(Image 6)
The text box above, in image 6, shows the treatment parameters used for the photon and electron field.

(Image 7)
Plan #3
IMRT plan of choice.
a) What beam arrangements did you try?
Answer: I tried two partial arc treatments and a 3 field static IMRT plan.
b) Why did you decide on your final one?
The plans were so close that both of them are viable options. I chose the 3 field IMRT because dose to the
Oral cavity and Mandible were lower and the hot spot for the 3field IMRT was only 104.7% while the
rapid arc was 109.8%. Also, I felt that since the 3 fields of the IMRT are only 50 degrees apart the arc
treatment would not be any faster. Furthermore, it is a greater challenge to get the bolus exactly where it
is needed for the arc treatment as shown in the diagram below. The 3 field IMRT requires a smaller
amount of bolus that is easier to place by the therapist before treatment.

(Image 8)
The bolus placement is not optimal on the arc plan. But I was afraid to make it any larger due to the
difficulty of keeping it in contact with the surface of the patient.

(Image 9)
This is a transverse view of the 3 field IMRT. 1 cm bolus was used in order to push the dose to the
superficial aspect of the PTV. Image 9 shows all the data in relation to the parameters of the beams
planned.

(Image 10)
Image 10 is a comparison between the 3 field and the partial arc plan.

(Image 11)
DVH comparing the 3 field IMRT with the partial arcs plan. Notice the hotspots and difference in dose of
the mandible and oral cavity in Image 11.