Matthew Taylor

Parotid Clinical Lab Assignment

7/30/2015

Plan #1Wedged Pair

Structure and Dose Tolerance
Mandible 1cc<72Gy
Left Parotid Mean dose<
26Gy
Oral Cavity Mean dose< 40
Gy
Cord Max point dose of 45 Gy

Actual Dose to Structure

Max point dose of
Mean dose of 9.84 Gy

Met or Exceeded Constraint?

Met
Met

Mean dose of 12.42 Gy

Met

Max point dose of 27.21 Gy

Met

A) How does the patient position affect your beam arrangement?

Patient postion will affect beam arrangement by making the wedged pair less steep if the
patients chin is angled to the ceiling in comparison to a more neutral head position. This in turn
may open the door to more ORs and create more toxicity to the patient.
B) If you were not able to get adequate coverage on the parotid using the wedged pair
technique, what were your constraints?
I was able to get adequate coverage using this technique.
Normalized to the 96% isodose line with 99.5% of the PTV receiving 95% of the dose
Structure and Dose Tolerance
Mandible 1cc<72Gy
Left Parotid Mean dose< 26
Gy
Oral Cavity Mean dose< 40
Gy
Cord Max point dose of 45 Gy

Actual Dose to Structure

Max point dose of 65.51 Gy
Mean dose of 9.84 Gy

Met or Exceeded Constraint?

Met
Met

Mean dose of 12.42 Gy

Met

Max point dose of 27.21 Gy

Met

Not Noramlized- 100% of PTV receiving 88.52% of prescription dose

Structure and Dose Tolerance

Actual Dose to Structure

Met or Exceeded Constraint?

Mandible 1cc<72Gy
Left Parotid Mean dose< 26
Gy
Oral Cavity Mean dose< 40
Gy
Cord Max point dose of 45 Gy

Max point dose of 62.88 Gy

Mean dose of 9.44 Gy

Met
Met

Mean dose of 11.92 Gy

Met

Max point dose of 26.12 Gy

Met

In order to meet the coverage that the plan was asking for while also reducing dose to the ORs, I
normalized the plan to the 96% isodose line. Along with that I also included .5 cm bolus to the
skin in order to help get the coverage to the superficial portion of the PTV. Using 6MV energy
also helped with getting coverage to the superficial portion of the PTV. Along with that, using
6MV energy helped reducing dose to the ORs due to its penetration ability being smaller in
comparison to higher energies. As for the wedges, I used both 45 degree angled wedges on both
beams. I found after trial and error that this angle would help best in order to obtain the covarage
needed over the PTV. Once the wedge configuration was decided I then played with the
weighting of the beams in order to spread out the hot spot so that it was either inside the PTV or
spread out outside of the PTV.

The beam matching technique was harder to accomplish. I have only ever done this in a breast
planning with matching an IMN field with two photon fields treating the breast and SCLV. In the
screenshot of the plan I have the yellow line showing the 95% isodose line for the node coverage
and how it is spread throughout the composite of the two plans. The blue isodose line is the 95%
line for the right parotid coverage.
For both of these plans I had a half beam block and the dose was being calculated to a calc point
for each plan. The calc point played the same role that an isocenter would, allowing for 100% of
the dose at the calc points. Allowing a half beam block would avoid any sort of hot/cold spot
from the diverging beams. Once the two plans were put together, modifications on the beams
were done in order to avoid hot spots at the match slice.

Plan #2 Mixed Beam

Structure and Dose Tolerance
Actual Dose to Structure
Met or Exceeded Constraint?
Mandible 1cc<72Gy
Max point dose of 69.8 Gy
Met
Left Parotid Mean dose< 26
Mean dose of 13.73 Gy
Met
Gy
Oral Cavity Mean dose< 40
Mean dose of 2.8 Gy
Met
Gy
Cord Max point dose of 45 Gy Max point dose of 48.9 Gy
Not met
In order to get the coverage that this plan was asking for I utilized the electron beam in order to
get coverage superficially while allowing the photon beam to help get coverage to the more
deeper areas of the PTV.

A) How does this plan compare to the wedged pair plan?

This plan obtains very similar coverage for the PTV in comparison to the wedged pair, however
the plan is much more hot and the cord constraint is not being met. As you can see in the
screenshot of the plan, the PTV is being covered by a big hot spot. The wedged pair plan had a
hot spot that wasnt nearly as big and had parts where the hot spots were spread throughout the
plan from slice to slice.
B) Were there any dose constraints not met?
As for constraints for this plan, the cord max point dose constraint was not met. Along with that
the left parotid was receiving more dose in comparison to the wedged pair but the constraint was
still met.

Plan #3 IMRT Technique

Structure and Dose Tolerance
Mandible 1cc<72Gy
Left Parotid Mean dose< 26
Gy
Oral Cavity Mean dose< 40
Gy
Cord Max point dose of 45 Gy

Actual Dose to Structure

Max point dose of 63.7 Gy
Mean dose of 6.6 Gy

Met or Exceeded Constraint?

Met
Met

Mean dose of 14.9 Gy

Met

Max point dose of 22.1 Gy

Met

A) What beam arrangements did you try?

As for beam angles, I brought the beams in coming from the ipsilateral side. Similar to
lung plans, I wanted to avoid irradiating the contralateral side as much as possible to
spare as much function as I could for the patient. All the beams were co-planar. Had some
beams not been coplanar, it would have introduced more ORs that would be receiving
exit dose from the non-coplanar beams.
B) Why did you decide on your final one?
I decided on my final beam arrangement because I was happy with the dose coverage for
the PTV and had significantly reduced the dose to the surrounding ORs in comparison to
the previous plans that have been worked on in this project. As you can see from the
screenshot below, the isodose lines are highly conformal with only the 40% (orange) and
50% (black) bleeding out slightly anteriorly and posteriorly.

Below I have more detailed images showing the details of the plan. When optimizing to create
this plan I created a structure called IMRT avoid in order to help drive dose to the PTV while
also allowing a buildup region in order for the dose to realistically get the coverage I would like
over the PTV. The IMRT avoid structure encompassed everything outside the PTV. I clipped this
structure to the body and allowed for a .7 cm buildup region between this structure and the PTV.
I determined my dose parameters based what was of most importance. The NTO objective is to
reduce dose to normal tissues. I gave my PTV the most priority and then carved my dose to be
more conformal overall. The PTV was given a priority of 300 while the IMRT avoid structure
was given a priority of 100. The NTO objective was at a priority of 150. I only put one limit on
the IMRT avoid. This gave the system the idea that I didnt want the structure to get any dose
greater than what I had set. As for the PTV I had an upper and lower limit. Establishing these two
limits gave the system the sense that I didnt want the PTV to get any dose lower or higher than
what I had set. The gap between the two structure objectives was to help with the dose build up
region.