Kristine Phillips
Clinical Practicum II - Clinical Lab Assignment
Right Parotid
7/21/2016
Plan 1: Ipsilateral wedged pair for the right parotid
For the first plan, I designed a 3D treatment technique utilizing wedged pair beam
arrangement. I contoured the right parotid and labeled it GTV and I put a 1cm margin
around it and labeled it PTV. I designed the field shape by fitting my MLCs to the PTV
with a 1cm margin in order to achieve the desired PTV dose coverage. You can see in the
transverse view below the wedge pair arrangement with 30 degree wedges utilized with
heels positioned together. Gantry angles for this plan included 320 and 245 degrees;
collimator for both fields was set at 90 degrees in order to achieve the desired wedge
position with heels together. The signature isodose arrangement with wedged pair
technique is the pie shape and the wedges (positioned with heels together) is required to
push the hot spot/dose away from where the two fields intersect the most with full dose;
dose is pushed laterally and posterior to increase coverage to the PTV. You can also see in
the image below that the original PTV surrounding the GTV fell outside the body with
how superficial the parotid is drawn; because of this, I cropped the PTV to remove parts
extending outside the body but I took it in from the skin surface as I know we would
never achieve coverage of the PTV without cropping it from the skin surface (taking into
account Dmax location for 6MV!). I cropped the PTV .4cm from the body and removed
any of the GTV extending outside the PTV after doing that (as it was seen in some of the
slices).
2 Gy per fraction to a total of 60 Gy was prescribed to treat the right parotid in
this plan. The patients chin position was set in a neutral position. Chin position can be a
catch 22; we want the patient to be in a position that is comfortable for them so they can
hold still throughout the entire treatment but extended chin is sometimes necessary to
spare surrounding structures regardless of how uncomfortable this may make the patient.
A chin that is in the neutral position is more in line/plane with the parotid so the desired
position of the chin would be an extended position; you can see in the image below that
an extended chin position would help to move the mandible/jaw out of the PTV and
decrease dose to this structure. The image below shows a neutral position of the chin but
if the patient was able to hold an extended chin position, we could possibly decrease dose
to the mandible (in orange contour).
With the wedged pair technique, 6MV energy was used for the superficial parotid
gland and one can see below that the 95% isodose line appears to cover almost all of the
PTV. I prescribed to the 95% in order to get PTV/GTV coverage of 60Gy to 95% of the
volume. Max dose of 108.5% (but would actually be 113.5% after scaling/prescribing to
95% isodose line).
With use of a DVH, it is easy to assess dose distribution to the target volumes as
well as surrounding critical structures. 3D plans can create challenges when it less then
optimal dose is being delivered to surrounding structures. Below is the DVH achieved
with this wedged pair plan and one can see that 60 Gy (prescription dose) is achieving
96% coverage of the PTV after prescribing to the 95% isodose line. All of my desired
dose constraints to surrounding critical structures have been proven to meet their
respective tolerance doses and this is also displayed below.
Critical
Structure
TD 5/5 (cGy)
Maximum
Dose (Gy)
Mean Dose
(Gy)
Cord
2/3
volume=5000
2/3
volume=6000
Mean dose
<4000
2/3
volume=3200
24.859
Mandible
Oral Cavity
Left Parotid
Tolerance
Met?
9.351
Dose to
2/3
volume
(Gy)
.744
66.82
20.528
14.69
yes
24.852
21.371
20.8
yes
16.858
1.766
1.389
yes
yes
I felt that my coverage to the PTV using the wedged pair technique and 6MV
energy was just meeting the desired coverage. I was missing dose to the superficial
portion of the parotid gland as Dmax of 6MV is 1.5cm from the skin surface. Because of
this, I added .5cm bolus to cover the two fields I placed for my wedged pair technique.
You can see in the screen shot below that the gantry and heel position stayed the same as
the wedged pair alone technique and the images display the placement of the bolus. After
adding the bolus and linking them to my fields, I increased my wedge and used 45 degree
wedges with heels position together, as opposed to the 30 degree wedges utilized in the
first plan; this functioned to push the hot spot medially. By adding bolus, you can see in
image 1 that now my 100% isodose line almost completely encompasses my PTV with a
max dose of 108.8% (which is the same max dose I achieved with the wedged pair
technique but remember, I had to scale to the 95% meaning the maximum dose in the first
plan was 5% hotter then the same plan with bolus!). You can also see in the DVH below
(image 2) that the PTV is receiving 60 Gy, the prescribed dose, to 99.5% of its volume
without prescribing/scaling dose to a different line.
1.
2.
We then were asked to add a single lower AP field on the ipsilateral neck that
abutted the wedged pair fields. I created a point that was at a depth of 3cm from the
surface and labeled it cptNeckNodes. I prescribed 50.4Gy to this volume at 1.8Gy per
fx/day (for a total of 28 fractions). Image 1 below displays my field shape design for this
field with the PTV, mandible, left parotid, and cord also displayed; this design was
created to include/treat the nodal region in the neck. This additional field was set with the
superior border at 0 in order to create a half beam block with the wedged pair fields. I
would have wanted to create a mono-isocenter from the start and set the inferior border of
the wedged pair beams to 0 in order to better match a lower field and be certain that there
was no beam divergence of one field going into the other fields. Image 2 below displays a
transverse slice of the dose distribution from calculating this single AP field and the third
image displays the dose distribution in all three planes. The AP field had field parameters
with gantry at 0 degrees, collimator at 90 degrees, and couch rotation of 0 degrees.
1.
2.
3.
A plan sum was created so that I could sum the dose together from the wedged
pair beam arrangement that targeted the right parotid and the single AP field that targeted
the nodal neck area. Below is an image that displays such dose distribution from the two
plans in all three planes.
The first image below displays the maximum dose location (global max dose) for
the plan sum and it is indicated by the black cross on the three planes; you can see that
the global max dose is at the border of the PTV in the inferior/posterior/medial direction.
The location of this hotspot is in a different spot than what was witnessed in my wedged
pair technique only. This location could maybe be attributed to the addition of the AP
nodal neck field and the fact that my abutting fields are not a true half beam block (I have
jaw X2 jaw at 0 for AP field that abuts the wedged pair fields but X1 was not set to 0; I
just instead have z equaling the X1 value). You can also see the DVH displayed for the
plan sum below that shows dose to the PTV, GTV, and surrounding critical structures.
1.
2.
Plan 2: Ipsilateral photon/electron (mixed beam)
I created a plan that utilized a mix of photons and electrons to target the right
parotid. Because the parotid gland is so superficial, the electrons would help target the
superficial portion of the gland while the photons would target the posterior/medial
portion of the gland. The first plan I created (wedged pair technique) was missing dose to
the superficial portion of the gland so thats when I resorted to the placement of .5cm
bolus over the fields; this mixed beam plan has the potential to do what bolus did for the
initial plan. The first image below shows a single lateral photon field targeting the PTV in
blue. You can see that the 100% isodose line crosses almost exactly halfway and the 95%
covers a little more. I have the gantry at 270 with 10MV energy with hopes to cover just
the medial portion of the gland and electrons will cover the superficial portion that I am
lacking with this single field. I decided to run the same field with 6MV energy to see how
well it does with the medial portion of the gland (in case electrons couldnt cover that
entire area that is lacking in dose superficially); this is display in the second image below.
The third image displays the dose distribution of the single lateral electron field. I kept
gantry at 270 degrees, used a 10x10cm cone, and 6MEV energy. I also darkened the 80%
isodose line in this plan as that appears to cover the superficial portion of the gland that I
missed in the single photon field and I would prescribe dose to that line.
1.
2.
3.
The image below displays now the isodose distribution after creating a plan sum
of the photon and electron field. I darkened the 60Gy isodose line to display where my
prescription dose went. I used the lateral photon field that utilized 6MV energy. I adjusted
the dose scheme between the plans in hopes to provide better coverage to the PTV; 10Gy
from electrons and 50 Gy from photons, delivering both fields daily for 20 fractions. My
thought process around giving more dose from the photon fields was to increase dose to
the medial portion of the gland as the superficial portion appears to be covered fairly
well. Regardless, this mixed beam technique does not provide good coverage to the PTV
(in blue) at all. However, by looking at the DVH, 95% of the GTV (in red) is receiving
the prescription dose of 60 Gy (we just would be missing subclinical disease outside of
the parotid). My PTV appears to be covered to a total dose of 42 Gy. When comparing
this to my initial wedged pair beam arrangement plan, it is easy to see that this plan is
inferior to the initial plan. I would add bolus to my wedged pair technique before trying
to abut an electron and photon field to cover the superficial portion of the parotid gland.
This plan meets the dose constraints listed below to the surrounding structures but some
of them are close. The maximum dose to surrounding structures is much higher then what
was witnessed in the other plans, especially dose to the left parotid; by use of two straight
lateral beams coming from the right side, exit dose to the left parotid is much higher and
this would not be a good plan to use for treatment to the right parotid.
Critical
TD 5/5 (cGy)
Maximum
Mean Dose
Dose to
Tolerance
Structure
Cord
Mandible
Oral Cavity
Left Parotid
2/3
volume=5000
2/3
volume=6000
Mean dose
<4000
2/3
volume=3200
Dose (Gy)
(Gy)
Met?
14.218
2/3
volume
(Gy)
.525
41.737
59.926
16.834
1.2
yes
40.847
8.87
1.649
yes
31.291
27.850
27.28
Yes
(barely!)
yes
Plan 3: IMRT technique to treat right parotid
I created an IMRT plan with 5 gantry angles to cover the right side of the
head/neck. The first set of gantry angles I used was: 180 degrees, 204 degrees, 255
degrees, 307 degrees, and 51 degrees. I used the same initial prescription of 2 Gy per
fraction to a total dose of 60 Gy to the PTV with 6MV energy on all fields. Review of the
isodose lines after optimization appeared less than optimal. The 100% isodose line was
dipping in so much and it appeared to be ignoring dose to the GTV/right parotid. The
95% isodose line on this plan did not come close to covering the PTV either and I tried
multiple optimizations with minor adjustments in the priorities of structures. I then tried
a different set of gantry angles. The first 5 gantry angles were more spread out and it
crossed midline of the patient with one gantry angle at 51 degrees. In the second set of
gantry angles, I used 180 degrees, 204 degrees, 240 degrees, 270 degrees, and 325
degrees. The angles I adjusted from the original IMRT plan was gantry angles 255, 307,
and 51 to now 240, 270, and 325. One can see that the second set of gantry angles are
closer together and positioned even more on the right side of the head and neck, avoiding
coming in from the left side at all. I used the same prescription but when I went to the
optimization window, I ended up putting a dose constraint and priority on my right
parotid structure that reflected the same constraints and priority set for my GTV; I
thought that by also putting a constraint on this structure (even though it is the same exact
structure as the GTV), the 100% isodose line might not dip in like it was trying to
spare/avoid the right parotid structure. This trick seemed to work perfectly and you will a
transverse image and a screen shot of the plan in all three planes below. Coverage to the
PTV increased and I was able to prescribe to the 98% so the PTV received the desired
dose. By changing the gantry angles and using the second set, I increased dose to the left
parotid compared with the first set of gantry angles due to the addition of gantry 270 but
you can see in the DVH and table below that the left parotid still meets tolerance/dose
constraints. All structures met their constraints. The hot spot that was achieved with this
plan was 104.2% and one can see how much more conformal the dose is to the PTV that
avoids excessive dose to the surrounding structures.
Critical
Structure
TD 5/5 (cGy)
Maximum
Dose (Gy)
Mean Dose
(Gy)
Cord
2/3
volume=5000
2/3
volume=6000
Mean dose
<4000
2/3
volume=3200
18.738
Mandible
Oral Cavity
Left Parotid
Tolerance
Met?
3.189
Dose to
2/3
volume
(Gy)
.276
62.823
14.907
7.77
yes
16.838
10.310
9.44
yes
7.646
6.747
6.654
yes
yes
