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Nick Hopkins, Savannah Coleman, Julie Puzzonia, Jackie Palermino

DOS 711: Research Methodology

Research Pitch
Photon beam attenuation occurs any time a material with density enters the path of the
beam. When delivering radiation therapy treatments to target volumes, objects that impede the
effects of the radiation could alter dose distributions and decrease target coverage. There is no
standard practice currently established in regards to accounting for these devices in contouring or
in dose calculations.1 Many institutions have implemented couch models to incorporate
obstruction to the beam path when treating with posterior beam angles; however, often times
immobilization devices remain unaccounted for in dose calculations.
Immobilization devices are a staple in radiation therapy aiding in setup reproducibility
and limiting intrafractional movement of the patient. One particular area that is highly dependent
on the use of immobilization is the treatment of head and neck cancers. Common devices used
for treatment include head holders, thermoplastics, and table top extensions/overlays. Previous
studies have shown that immobilization devices attenuate a portion of the beam2-4 and various
studies have reported that immobilization devices decrease skin sparing.4-6
While most current literature regarding immobilization devices involves intensity
modulated radiation therapy (IMRT) and 3D-based planning, one study reported by Olsen et al7
shows a statistically significant impact on planning target volume (PTV) coverage due to head
and neck immobilization devices using volumetric modulated arc therapy (VMAT). However,
limitations to this study exist in that it was carried out using a single calculation algorithm in the
treatment planning system (TPS) Eclipse, and organ at risk (OAR) structures were not
considered. Thus, a retrospective study will be conducted to determine the dosimetric impact of
of head and neck immobilization devices on the PTV, in addition to OAR’s using the Eclipse
TPS with Anisotropic Analytical Algorithm (AAA) and Acuros XB, along with Pinnacle TPS
using Collapsed Cone Convolution (CCC).
Research Outline
➢ Clinical Sites Involved:
○ Georgia Radiation Oncology Augusta University-Augusta, GA
○ Beaumont Health Systems - Royal Oak, MI and Troy, MI
○ Lahey Hospital and Medical Center - Burlington, MA
➢ Proposed Methodology:
○ Approximately 15-20 Head and Neck Cases
■ Try and choose patients with similar disease sites and locations of tumors.
○ TPS Systems
■ Eclipse - AAA
■ Eclipse - Acuros XB
■ Pinnacle - CCC
○ Machines
■ Varian Edge
■ Varian Novalis
■ Elekta Agility
○ Protocol for Each Patient
■ One plan calculated with just patient body contour
■ One plan calculated with immobilization devices and accompanying air
gap included in the body contour
■ Gather data for PTV and each OAR
○ Statististical Points for Comparison (Dose Volume Histogram Based)
● Percentage of the PTV that received 95% of the prescription dose
● The dose covering 100% of the PTV (D100)
■ Skin
● Maximum dose received
● Mean dose received
■ Parotids
● Maximum dose received
● Mean dose received
■ Spinal Cord
● Maximum dose received
● Mean dose received
■ Brainstem
● Maximum dose received
● Mean dose received
■ Mandible
● Maximum dose received
● Mean dose received
➢ Proposed Work Division:
○ Writer:
○ Leader:
○ Role for Others:
■ 5-7 patients each to re-plan and gather data points
■ Conduct data analysis and comparison
■ Help writer with research/editing (likely split the paper into areas to
specifically help with)
1. Olch AJ, Gerig L, Li H, Mihaylov I, Morgan A. Dosimetric effects caused by couch tops
and immobilization devices: Report of AAPM Task Group 176. Med Phys. 2014;41:61501–
2. Munjal RK, Negi PS, Babu AG, et al. Impact of 6MV beam attenuation by carbon fiber
couch and immobilization devices in IMRT planning and dose delivery. J Med Phys.
3. Seppälä JKH, Kulmala JAJ. Increased beam attenuation and surface dose by different
couch inserts of treatment tables used in megavoltage radiotherapy. J Appl Clin Med Phys.
4. Dieterich S, Ford E, Pavord D, Zeng J. Immobilization techniques in radiotherapy. In:
Dieterich S, Ford E, Pavord D, Zeng J, ed. Practical Radiation Oncology Physics.
Philadelphia, PA: Elsevier, Inc; 2016:87-94.
5. Lee N, Chuang C, Quivey JM, et al. Skin toxicity due to intensity-modulated radiotherapy
for head-and-neck carcinoma. Int J Radiat Oncol Biol Phys. 2002;53(3)630-637.
6. Pashkovskaya OA, Bedny IV, Anikeeva OY, Polovnikov ES. The evaluation of skin
toxicity during brain tumor irradiation dose calculation. Int J Biomed. 2013;3(4):283-286. Accessed April 24, 2018.
7. Olson A, Phillips K, Eng T, et al. Assessing dose variance from immobilization devices in
VMAT head and neck treatment planning: A retrospective case study analysis. Med Dos.