1

Yasmin Ahmed
Clinical Practicum II- Parotid Lab
August 9, 2015
Note: Dose constraints for all plans are according to limits set by my clinical site. Plan 1 and 2
were both planned with a 1cm auto-surround margin around the planning target volume (PTV).
Plan 1: Wedge Pair
Patient Positioning: The patient is lying supine with a headrest and aquaplast mask. A knee
sponge was placed under the patients knees for comfort.
Critical Structures:
Critical Structure
Spinal Cord
Brainstem
Anterior Oral Cavity

Tolerance Dose
Max Dose <4700cGy
Max Dose <4700cGy
D65<3000cGy

Dose Received
2825.2cGy
3219.8cGy
65%= 1840cGy

Constraint Met
Yes
Yes
Yes

Mandible

D35<3500cGy
V6600cGy<0.1cc

35%= 2026cGy
Maximum= 6335.5cGy

Yes

Beam Parameters:
Gantry
Angle
Beam 1 (Parotid)
60
Beam 2 (Parotid)
120
Beam 3 (Neck)
0

Beam
Energy
6x
6x
10x

Wedge Angle
EDW 45 In
EDW 45 Out
None

Collimator
Angle
90
90
0

Couch
Angle
0
0
0

Field Size
8.9cm x 8cm
8.9cm x 8cm
9.5cm x 12cm

This is an axial slice showing the gross tumor volume (GTV) and PTV coverage, and the
maximum point dose for the sum plan.

This is an axial slice showing the neck nodes volume and coverage to that area.

This is a coronal slice showing the GTV, PTV, and neck nodes coverage.
Dose Volume Histogram (DVH) of plan 1 sum:

1a) With the chin extended, it is easier to avoid having the beams enter or exit into the chin. The
lower aspect of the field needs to be at the base of the mandible and extending the chin makes it
a straight line. Also, with the anterior field for the neck nodes, it is easier to have a match line in

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a place that avoids dose to the chin. If the chin is not extended, the anterior field will go thru the
chin.
1b) The GTV was covered by 95%, but the PTV was not adequately covered. This was due to the
fact that the PTV was close to the skin and was not able to receive adequate dose to that area.
This may have been remedied with the addition of a bolus.

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Plan 2: Ipsilateral Photon/Electron (Mixed Beam)
Critical Structures:
Critical Structure
Spinal Cord
Brainstem
Anterior Oral Cavity

Tolerance Dose
Max Dose <4700cGy
Max Dose <4700cGy
D65<3000cGy

Dose Received
4692cGy
4711cGy
65%= 100cGy

Constraint Met
Yes
No
Yes

Mandible

D35<3500cGy
V6600cGy<0.1cc

35%= 140cGy
Maximum= 6345cGy

Yes

Beam Parameters:

Beam 1
(Photon)
Beam 2
(Electron)

Gantry
Angle
72

Beam
Energy
10x

Bolus

Couch
Angle
0

Cone Size

3mm

Collimator
Angle
0

72

12e

3mm

10cm x 10cm

NA

Field
Size
8.7cm
x
9.6cm
NA

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This is an axial slice showing the GTV and PTV coverage with the placement of a 3mm bolus.

This is an axial slice of plan 2 showing the location of the maximum point dose.
DVH of plan 2:

2a) For this plan a 3mm bolus was added to both the photon and electron beams. However, the
DVH for plan 2 shows inadequate coverage to the GTV and PTV as compared to plan 1. This
plan was also not as homogenous as plan 1. For this volume, the better approach may be the
wedge pair with a bolus instead of mixed beams.
2b) The dose constraint for the brainstem was not met.

Plan 3: Static Beam IMRT

Critical Structures:
Critical Structure
Spinal Cord
Brainstem
Anterior Oral Cavity

Tolerance Dose
Max Dose <4700cGy
Max Dose <4700cGy
D65<3000cGy

Dose Received
2307.5cGy
2235cGy
65%= 645cGy

Constraint Met
Yes
Yes
Yes

Mandible

D35<3500cGy
V6600cGy<0.1cc

35%= 888cGy
Maximum= 6331.3cGy

Yes

Beam Parameters:

Beam 1
Beam 2
Beam 3
Beam 4
Beam 5

Gantry
Angle
10
50
90
130
170

Beam
Energy
6x
6x
6x
6x
6x

Wedge Angle
None
None
None
None
None

Collimator
Angle
0
0
0
0
0

Couch
Angle
0
0
0
0
0

Field Size
6.2cm x 9cm
7.0cm x 9.0cm
8.0cm x 9.0cm
7.0cm x 8.5cm
5.8cm x 8.5cm

This is an axial slice showing the GTV and PTV coverage.

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This is a coronal slice showing the maximum point dose for plan 3.
DVH of plan 3:

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3a) I tried two different beam arrangements. I tried a 5 beam and a 6 beam plan. For both plans I
kept the beams more toward the left side, which is where the tumor is located. There is no reason
to have beams entering from the right side. Doing so will give unnecessary dose to normal tissue
and structures on the contralateral side.
3b) I decided to choose the 5 beam arrangement for my final plan. This plan was very similar to
the 6 beam plan as far as the PTV coverage and dose to critical structures. Hence, there was no
reason to keep the additional beam. Of all 3 plans, this was the best plan produced in terms of
GTV/PTV coverage and dose to critical structures.