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DOS 772 Clinical Practicum II

Parotid clinical lab
Joanne Li
July 31, 2016

Planning Assignment (Parotid)

Target organ(s) or tissue being treated: left parotid and neck nodes.
Prescription: PTV 60 Gy Parotid (2.0 Gy x30 Fx) for parotid; PTV 50.4 Gy Neck nodes (1.8 Gy
x 28 Fx).
Organs at risk (OAR) in the treatment area (list organs and desired objectives in the table below):
(Reference RTOG 0225)

Organs at
risk

Desired
objective
(s)

Achieve
d
objectiv
e(s) in
plan 1

Achieved
objective(s
) in plan 2
(Mixed
beams)

Achieved
objective(
s) in
plan3
(IMRT)

(wedge
pair)

PTV 60Gy

PTV 60Gy

Mandible

Brainstem

Lt External
ears
LtSubmandib
ular
Rt_Parotid

L_Cochlea
Spinal Cord

Lt_Eye
Lt_Lens
Tongue
(Oral
cavity)

PTV
60Gy95
%
<20%
PTV60Gy
110%
60 Gy or
1cc of
PTV65Gy

54 Gy or
V 60 Gy
1cc
Mean
50Gy
As low as
possible

Mean
26Gy
Or
20cc20G
y
or V50% <
30Gy
Max < 50
Gy
45 Gy or
V 50 Gy
1 cc
Mean 50
Gy
As low as
possible
55Gy or
1% of
PTV65Gy

99%

97%

99%

108%

107%

100%

Max
66.7Gy
1cc of
PTV=66
Gy
3.6Gy

1cc 65 Gy

60.1Gy

37Gy

19Gy

57 Gy

Mean=60.1
Gy
Max = 65
Gy

59 Gy

Mean:
1.2Gy

Mean 20 Gy
Or 20
cc=0Gy.

Mean =7.7
Gy

Max 28.6
Gy
Max
17.6Gy

Max 51Gy

Max 28 Gy

Max=47Gy
1 cc.

Max=31.5
Gy

Mean
0.67 Gy
Max 0.81
Gy
Max 34
Gy

Mean=0.63
Gy
Max 0.59
Gy
Max 59Gy

Mean=8
Gy
Max 0.8Gy

Max
65.7Gy

61Gy

Max 31Gy

Plan #1
Ipsilateral
Wedged
Pair
Design an
ipsilateral
wedged pair
plan for the
parotid (use
references
or
mentors if
needed).

a) How would, or how does, the patient position (chin extended) affect your beam
arrangement?
If the chin was extended, I would have more room to arrange the beams to avoid the lens, spinal
cord, and shoulders especially left shoulder.
b) If you were not able to get adequate coverage on the parotid using the wedged pair
technique, what were your constraints?
With the ipsilateral 45-degree wedges in place, 95% of PTV parotid was covered by 99% of the
prescribed dose. The deeper portion of the left parotid was not covered well and the surface part
was also shy due to the capacity of penetration of photon beams and the superficial location of
the target. To achieve the best dose coverage, dose was prescribed to 98% isodose line, and the
overall plan was 12% hotter. Dose to OARs such as mandible and left external ear exceeded dose
constrains.

Figure 1: Plan 1 with wedged pair plan, transversal view of isodose lines with ipsilateral a pair of
45-degree wedges

Figure2: Plan 1 with wedged pair plan, transversal, coronal, and sagittal views of isodose lines at
maximum dose location.

PTV
LParotid

Figure 3: Plan 1 with wedged plan, DVH with GTV, PTV, and critical OARs.

GTV
LParotid

After contouring the GTV, PTV, and the OARs, I started planning with 6 MV external
photon beams. I first created a plan for left parotid with two beams from anterior and posterior
oblique directions. The dose per fraction was 200 cGy for 30 fractions with total dose 6000 cGy.
I turned the spinal cord and right and left eyes structures on, and adjusted the beam angles to
avoid those OARs, which resulted in two beams with 20 degrees and 110 degrees. The collimator
and couch were all at zero degree. To be able to push the dose more centrally to cover the target,
a pair of ipsilateral 45-degree wedges was added with heels towards central axis seen in Figure1.
To be able to get expected wedge direction, I had to change collimator to 90 degree and refit the
MLC to target with blocking certain leaves to avoid spinal cord and lens. I ever tried wedges
with 30, and 60-degree and was finally satisfied with the 45-degree wedge for more conformal
dose coverage and dose distribution. The field size for left anterior oblique beam was 9.9 cm
x6.0cm; the posterior oblique beam field size was 11.5cmx7.9cm. Field weightings were also
carefully adjusted with 53.3 % in anterior oblique beam and 46.7% in posterior oblique beam to
cool down the plan for more conformal distribution, and to shift the hot spot near to the PTV.
The prescription dose was prescribed to 98% isodose line. The 100% (6000cGy), 95%
(5700cGy), 75% (4500cGy), and 40% (2400cGy) of isodose lines based on the absolute dose
were listed and reflected in figure 2. The DVH with a list of OARs were shown in figure 3. The
algorithm for calculation was AAA in all three plans.
The dose for neck nodes was 5040 cGy with 180 cGy for 28 fractions. Based on the
parotid plan, I created an anterior field to the left neck nodes just abutting below the LPO field of
the parotid plan with half beam technique. To do so, I copied and pasted the original parotid plan
to a new plan. I moved the matching line just to the edge of MLC blocking of the inferior edge of
LPO field. I manually moved the isocenter vertically to the matching line. By moving the
isocenter, it created a half beam for parotid field shown in figure 4 below.
Based on this plan, I added an anterior field to the left neck nodes at the same isocenter
with zero collimator. MLC were fitted to the left neck nodes with blocking a few leaves to avoid
the spinal cord. A lower anterior ipsilateral neck field that abuts the bottom of the wedged fields
with half beam technique was created. To be able to prescribe the dose to 3.0 cm depth, I
measured 3.0 cm from skin surface along with the geometric central axis of PTV neck nodes. I
then created a calculation point and move the point to the 3.0 cm depth. See figure 5. I also made
sure there was no MLC blocking at matching line between upper and lower fields.

I added a plan sum with the neck nodes plan in half beam and the original parotid plan
with a full beam. I found a hotter area between these two fields due to the divergence of upper
parotid field in a full beam. The plan sum with the half beam neck nodes plan and the half beam
parotid plan did not have dramatic dose divergence in between. The dose color washing of
comparison of both plan sums was seen in figure 6. My preceptor also agreed with the sum of
both plan with half beam fields for treatment purpose to avoid hot spot from beam divergence
between upper parotid and lower neck fields.
The final plan 1 with left parotid and lower neck nodes fields with half beam technique at
maximum dose location was shown in figure 7. The 100% (6000cGy), 95% (5700cGy), 75%
(4500cGy), and 40% (2400cGy) isodose lines of left parotid and 100% (5040cGy), 95%
(4788cGy), 75% (3780cGy), and 40% (2016cGy) isodose lines of left neck nodes were labeled
with absolute doses. The DVH with detailed OAR was shown in figure 8. To achieve the best
dose coverage, dose was prescribed to 98% isodose line. The maximum dose of final plan was
114% of 6000cGy. The hot spot was located in PTV parotid.

Figure 4: Plan 1, new isocenter of left parotid field with half beam technique .

Figure 5: Plan1, dose was prescribed to 3 cm depth for left neck nodes field.

Figure 6: Plan 1, beam divergence between parotid and neck node fields with (left) and without (right)
half beam technique.

Figure 7: Plan1, the final plan with parotid and neck nodes fields, the dose distribution and DVH at
maximum dose point in parotid PTV.

Figure 8: Plan 1 with parotid and neck nodes fields, DVH with OAR.

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?
Under plan evaluation, I compared both plans by looking at the isodose lines, hot spot,
the maximum dose, color wash view of dose distribution and DVH. The dose coverage in
the plan with mixed beams of photon and electron and the plan with 6 MV photon and a
pair of wedges were comparable. However, the dose distribution in mixed plan was more
conformal but hotter than the wedged pair plan. The isodose lines were more uniform in
mixed plan but deeper with the 75% and 40% isodose lines crossing the middle line of
the brain which increased dose to brainstem and opposite OARs such as right parotid.
b) Were there any dose constraints not met?
The deeper portion of the parotid was still not covered well. I thought the plan with
mixed photon and electron energies would be better than wedged plan in terms of dose
coverage especially at superficial portion. Probably the parotid or PTV parotid was not
accurately contoured at superficial portion which does not give dramatic difference
between photon and mixed electron plans. The dose to OAR such as brainstem, right
parotid, left external ear, and spinal cord was much higher. To achieve better coverage,
the plan was 10% hotter.
In plan 2, I started with photon beam with 6 MV energy to the left parotid. I divided the
dose to half which was 3000 cGy, and would prescribe the other half to the electron plan. I
aligned the beam to be en face perpendicular to the skin surface of left parotid. Correspondingly,
the gantry was at 100 degree, the collimator was at 45 degree, and the couch was at 342 degree.
However, after calculation, I found the left shoulder was in the path of the beam which created
an unnecessary hot spot in shoulder. So I rearranged the couch to 350-degree. The beam to
surface was not exact en face then but was acceptable.
I measured the treatment depth of parotid to decide the beam energy of electron plan
which should be 12 MeV with 96.40% isodose line at 3.5 cm depth. I also tried 6 Mev and 9
Mev in separate plans, which showed the poor coverage of deeper portion of the parotid. The
uneven surface of parotid around left ear created either too hot or too cold area in skin surface.
So I added two 0.5 cm boluses anterior and posterior of the ear. I linked the boluses to the
electron and photon plans to make dose distribution more conformal. The isodose lines of plans
with and without bolus were shown in figure 9. To achieve better dose coverage of target, the

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dose in electron plan was prescribed to 90% isodose line and the dose in photon plan was
prescribed to 96%. After calculation, I inserted a plan sum with the electron and photon plans. In
the plan sum, I increased the photon beam up to 150 cGy/fraction with 56.9 % weighting while
decreasing electron beam to 50 cGy/fraction with 43.1% weighting to achieve expected dose
coverage. So the dose per fraction and total dose were not changed. The 100% (6000cGy), 95%
(5700cGy), 75% (4500cGy), and 40% (2400cGy) isodose lines distribution of left parotid with
electron and photon beams at maximum dose location were shown in figure 10. The DVH with
surrounding OAR was shown in figure 11.

Figure 9: Plan 2, isodose lines distribution with and without bolus in place.

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Figure 10: Plan 2 mixed phoon and electron beams, three views of 100% (6000cGy), 95%
(5700cGy), 75% (4500cGy), and 40% (2400cGy) isodose lines distribution at maximum dose
location.

Figure11: Plan 2 mixed phoon and electron beams, DVH and OARs.

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PLAN #3
a. Using an IMRT technique of your choice find the beam arrangement needed to
achieve the required coverage on the parotid gland while sparing the critical
structures.
For each plan in assignment #3 answer the following:
a) What beam arrangements did you try?
I tried IMRT with 4 beams in the left side of brain at 35-degree, 70-degree, 105-degree, and
180-degree, and with 5 beams at 35-degree, 70-degree, 105-degree, 145-degree, and 180degree.
b) Why did you decide on your final one?
The plan with 5 beams was better than 4 beams in terms of better dose coverage and
fewer doses to left cochlea, spinal cord, oral cavity, right parotid, brain stem, and right
and left eyes. The maximum dose in 5 beams was cooler (2.2 %) than 4 beams with 5%
hotter.
In this plan, IMRT technique with 6 MV-energy was used. I started with 5 beams
evenly divided with 35-degree apart in the left side of brain. There was no reason to have
beam crossing through the right side normal tissues. The 5 beams with 35 degrees apart
started at 35-degree, 70-degree, 105-degree, 140-degree, and 175-degree with collimator
and couch at zero. Under BEV, I turned on the right and left eyes and lens structures and
arranged the 140-degree to 145-degree to maximally avoid right eye, and 175-degree to
180-degree to avoid the left eye in the path of the beam. I also closed the superior edge of
jaw to block eyes as much as I could. The dose was prescribed to 100% isodose line
without normalization point for IMRT technique.
After I had the entire settings ready including dose, reference point, and AAA 13
algorithm, I started optimization process. I added 6240 cGy which was 4% greater than
prescription dose as upper level constrains and the prescribed dose 6000cGy as lower
level to the PTV with 100% priorities. A normal structure ring surrounding PTV with 0.3
cm margin to PTV was created to allow dose fall off and increase the dose conformity. I
also added the prescription dose as a lower dose constrain to GTV with 100% priority to
make sure the maximum full coverage of GTV. The OARs were all added upper level

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dose constrains based on dose intent given my physician and the dose tolerance in the
structures. Priority was signed to each OAR at lower level with higher levels in lens and
spinal cord. I carefully adjusted the dose constrains and priorities to the structures while I
watched the according lines in DVH, isodose lines in transversal view of the body, and
the efforts of the optimization process. The highest priority was given to PTV. I
sometimes paused the optimization for more changes. When I saw the PTV coverage was
good and the other OARs reached the goals, I continued the process and let it calculate
automatically. I repeated the process one more time for a better coverage and more
conformal dose distribution.
I even tried 4 beams at 35, 70, 105, and 180-degree with the deletion of the beam
with 145-degree to avoid eyes. However, the dose to left cochlea, spinal cord, oral cavity,
right parotid, brain stem, and right and left eyes were slightly greater, and the plan was
hotter than the one with 5 beams too. So the plan with 5 beams at 35-degree, 70-degree,
105-degree, 145-degree, and 180-degree was the final plan with better overall dose
coverage and dose constrains in OARs. The maximum dose was located in PTV parotid.
The 100% (6000cGy), 95% (5700cGy), 75% (4500cGy), and 40% (2400cGy) isodose
lines distribution of left parotid with IMRT technique at maximum dose location were
shown in figure 12. The DVH with surrounding OARs was shown in figure 13.
Among all three plans, the last plan with IMRT technique was the best one in
terms of the dose coverage, dose constrains to OAR, low dose spread, and dose
conformity.

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Figure 12: Plan 3 IMRT, three views of 100% (6000cGy), 95% (5700cGy), 75% (4500cGy), and
40% (2400cGy) isodose lines distribution at maximum dose location in PTV parotid.

Figure 13: Plan 3 IMRT, DVH with OARs in relative dose.