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Ontida Apinorasethkul
DOS792 Fieldwork II
July 13, 2015
Parotid Clinical Lab Assignment
This assignment was the comparison of 3 different planning techniques treating a parotid.
The CT data set used in this project was for mock plans from a head and neck patient. A parotid
gland was contoured as Gross Tumor Volume (GTV). Planning Target Volume (PTV) was 1 cm
margin from the GTV (Figure 1). The goal for each planning technique was to cover the GTV
with 60 Gy and 95% of prescription dose to cover the PTV. The planning techniques compared
were wedge pair, wedge pair with anterior neck field, mix electron and photon, and Intensity
Modulated Radiation Therapy (IMRT) plans. All the plans were treating to 60 Gy in 30
fractions, unless specified otherwise. Critical structures contoured were listed in Table 1.
Plan 1 was the wedge pair photon beams. Both fields used 6 MV energy for superficial
coverage since there was less building up region of 1.5 cm when comparing to 15 MV energy
with 3 cm build up region. Gantry of 125 and 35 were used with 90 collimator angles on both
beams. The collimator rotation was necessary to enable the use of dynamic wedges. If the
collimator angle was left at 0, physical wedge would be needed, however, it was not available at
our facility. With the collimator angle being rotated to 90, the multileaf collimators (MLCs)
move superior to inferior and vice versa, instead of left to right (Figure 2). Margin of the MLCs
was set to 0.8 cm from PTV to account for the beams penumbra. Thirty degree dynamic wedges
were used with the wedge heels facing toward each other (Figure 3). A calculation point was
used to normalize the plan and ensure that the treatment volumes received adequate coverage.
There were equal weighting from both fields. The plans maximum dose of 6664 cGy was
within the parotid (Figure 4). The GTV and PTV met the constraints. All organs at risk (OR)
listed in Table 1 met the constraints, except the mandible. The dose volume histogram (DVH) of
GTV, PTV, and critical structures was shown in Figure 5.
Plan 1.1 had a lower anterior neck field in addition to the wedge pair fields in plan 1. The
lower anterior neck field was treating to 50.4 Gy in 28 fractions. It was a 6 MV field of 0
gantry. The field was half beam block abutting the bottom of the wedge pair fields to reduce
divergence. This patients head position was not turned to the contralateral side or
hyperextended, therefore, axial slice in Figure 6 showed thin strip of the neck getting treated due

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to the cord block. The field size of this field was 11 cm x 10 cm blocking the cricoid and
covering the lower neck nodes (Figure 7). A calculation point was normalized at the depth of 3
cm (Figure 8). By adding a lower neck field, the dose to constrictor, cord, ears, larynx, and left
submandibular increased (Table 1). The GTV and PTV met the planning goals as well as other
OR in Table 1, except the mandible (Figure 9). The dose max of this plan was 6795 cGy in
which the hot spot fell in the PTV volume of the wedge pair plan due to some divergence from
the anterior lower field.
Plans 2 and 2.1 were the mix of electron and photon plans. Electron plan provided better
skin dose when comparing to a photon plan, however, photon plan provided better coverage at
depth. Electron plan was a single 20 MeV field enface using 85 gantry rotation. Isocenter was
placed at the center of the volume. Block margin was set to 0.8 cm from PTV with a cone size of
10 cm by 10 cm (Figure 10). There was no plan normalization, however, the plan was prescribed
to 89% isodose line. As for the photon plan, the same 85 gantry rotation was used with MLC
margin of 0.8 cm from PTV (Figure 11). A calculation point was placed at 4.5 cm from the skin
to increase the coverage to the deepest part of the PTV. Plan sum had 40% of electron plan and
60% of the photon plan to meet the GTV and PTV constraints. Majority of the OR were meeting
the constraints in Table 1, except left middle ear, mandible and left submandibular. All treatment
volumes and OR doses were shown in Figure 12. Dose max of this plan was 6720 cGy in the
PTV volume.
The final plan for comparison was plan 3, a Rapid Arc (RA) plan. RA is a type of IMRT
plan using arc technique. It was preferred over the multiple beam IMRT technique by our
facility due to faster treatment time, more accurate treatment since the patient would be less
likely to move during a short period of time. Two 6-MV partial arcs were set from 180 to 10
counterclockwise and 10 to 180 clockwise (Figure 13). This arc angle was chosen because it
was unnecessary to irradiate through the patients mouth and oral cavity. The complimentary
collimator angles of 20 and 340 were set based on PTV volume to reduce tongue and groove
effects (Figure 14). Isocenter was placed in the center of the volume to avoid the field size open
more than it needed, which could increase MLC leakage. The field size of arc 1 was 7.3 cm by
8.7 cm and arc 2 was 8.0 cm by 8.5 cm. Treatment volume was adequately covered and met the

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planning goals (Figure 15). The OR met the constraints, except for the mandible (Table 1).
Dose max of this plan was 6609 cGy in the PTV volume.
Head and neck patients were often asked to lift chin up and keep the head extended to
have the orbits be out of the fields as much as possible. However, for this parotid case, the
volumes were much lower from the eyes, therefore, the exit dose to the eyes was not an issue.
When comparing the wedge pair plan with the mix electron-photon plan, more low dose were
spread out in the wedge pair plan than the electron-photon plan, however, higher dose volume
encompassed the PTV better in the wedge pair plan (Figure 16). The wedge pair plan gave less
of the higher dose to the normal tissue. It also met more of the normal tissue constraints than the
mix electron-photon plan. The mix plan exceeded the dose on left middle ear and left
submandibular since they were adjacent to the treatment volume (Figures 17-18). The most
conformal plan would be RA plan in which it contained more spread of low dose, but the 95% or
5700 cGy isodose line was tighter around the PTV volume than the other 2 planning techniques
(Figure 19). Since all the techniques exceeded the mandible max dose, RA plan gave the lowest
dose to the mandible and met all other OR and treatment volume constraints, while it was the
most conformal plan.

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Figures

PTV
GTV

Figure 1. This image demonstrated the GTV of parotid in red and PTV volumes in blue.

Figure 2. Beams eye view of a field in the wedge pair plan displayed 90 collimator angle with
MLC leaves traveling superior to inferior. This collimator rotation enabled the use of dynamic
wedge.

Figure 3. The wedge pair plan had 2 wedge heels toward each other in the axial view.

Figure 4. The wedge pair plan labeled with 100%, 95%, 75% and 40% isodose lines.

Figure 5. DVH of relevant critical structures, GTV and PTV of the wedge pair plan.

Figure 6. Axial slice of the anterior neck field showed a small strip of skin irradiated due to the
patients neck was not rotated to the contralateral side.

Figure 7. Beams eye view of the anterior neck field with the cord as the green contour.

Figure 8. The anterior neck plan displayed with 100%, 95%, 75% and 40% isodose lines and
the calculation point at 3 cm depth.

Figure 9. DVH of relevant critical structures, GTV and PTV of the wedge pair plan with
anterior neck plan.

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Figure 10. Beams eye of the view electron plan with a 10 cm by 10 cm cone and 0.8 cm block
margin.

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Figure 11. Beams eye view of the photon plan with 0.8 cm MLC margin from PTV.

Figure 12. DVH of relevant critical structures, GTV and PTV of the mix electron-photon plans.

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Figure 13. An axial view of the RA plan showing 2 partial arcs clockwise and counterclockwise
from 180 to 10.

(a)

(b)

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Figure 14. Complimentary collimator angles of (a) 20 and (b) 340 of the 2 partial arcs of the
RA plan.

Figure 15. DVH of relevant critical structures, GTV and PTV of the RA plan.

(a)

(b)

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Figure 16. Dose comparison of all 3 planes between (a) the wedge pair plan and (b) the mix
electron-photon plans.

(a)

(b)

Figure 17. Left middle ear dose comparison between (a) the wedge pair plan and (b) the mix
electron-photon plans.

(a)

(b)

Figure 18. Left submandibular dose comparison between (a) the wedge pair plan and (b) the
mix electron-photon plans.

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Figure 19. RA plan demonstrated a conformal dose wrapping the PTV volume.

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Tables
Table 1. OR goal constraints and doses on all the plans used for comparison.
Dose
(cGy)
Brainstem
Constrictor
Cord
Middle Ear_L
Middle Ear_R
Larynx
Mandible
Oral Cavity
Parotid_R
Submandibu
lar_L
Submandibu
lar_R

max
mean
max
mean
mean
mean
max
mean
mean
mean

5400
5000
4500
3000
3000
2000
6000
2000
2600
3000

Plan1
Wedge
Pair
2401
432
2291
2127
88
285
6586
1634
87
2293

mean

3000

138

Plan1.1
WP +
Neck
2419
911
2449
2140
95
633
6673
1650
98
2690

Plan2
mix E+X

Plan3
RA

4096
2189
4368
3316
2320
1027
6552
463
2261
3498

1307
382
832
582
299
146
6433
792
369
1356

164

1711

211

Note: Bold red text represents OR dose exceeding constraints.