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Dosimetric Evaluation of Collimator Angles to Reduce Laryngeal Dose in Base of Tongue

Treatment Planning for Volumetric Modulated Arc Therapy.

I. Abstract
II. Introduction
A. PI: Goal of radiation therapy, dose limitation to OAR, and doses used in H&N
plans (Reference: Yeh,1)
B. PII: Toxicities to H&N patients (Reference: Kumar et al,2 Hutchison et al,3
Kaae et al,4 Prameela et al,5)
C. PIII: Introduce the benefit of using collimator angles in VMAT plans.
(Reference: Ahn et al,6 Kim et al,7)
D. PIV: Summarize introduction points
1. Problem: The problem is that current VMAT techniques result in higher
laryngeal doses that cause profound side effects such as dysphagia. 
2. Purpose: The purpose of this study is to determine if VMAT collimator
angles of 90° or 0° can further limit the dose to the larynx while
still providing full dose coverage to the target volume. 
3. Hypotheses: The research hypothesis (H1) is VMAT plans with 3 arcs that
utilize collimator angles of 30°, 330° and 90° will reduce mean laryngeal
dose for BOT patients.  The null hypothesis (H0) is VMAT plans with 3
arcs that utilize collimator angles of 30°, 330° and 90° will not reduce
mean laryngeal dose for BOT patients.
III. Materials and Methods
A. Patient selection and setup
1. P1: Patient population
i. Ten patients from a single institution
ii. Inclusion criteria (SCC, SIB, nodal involvement, stage III-IVc,
PTV-70 Gy (200 cGy/fx, nodes- 63 Gy, 180 cGy/fx), PTV length
of 23cm or less
iii. Exclusion criteria (BID, sequential boost, pre-treatment surgery,
previous RT, bolus plans)
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iv. Prescribed dose of 70 Gy to Primary target and 63 Gy to nodal

volume at 2 Gy and 1.8 Gy respectively
2. PII: Simulation procedures
B. Contours
1. PI- Targets (CTV, PTV)
2. PII- OAR (Spinal cord, spinal cord PRV, brainstem, brainstem PRV,
parotids, lips and oral cavity, pharynx, larynx, mandible, esophagus,
submandibular gland, brachial plexus (Reference: RTOG 1016,8 RTOG
0619,9)
C. Treatment planning
1. PI: Planning details
i. Eclipse TPS
ii. Anisotropic Analytical Algorithm (Version 11.0.31)
iii. 6 MV
2. PII: Planning procedures
i. Arc Geometry (Table 1)
ii. Collimator angles (Figures 1a,b & 2a,b)
iii. Margin for jaws, jaw tracking and total jaw size
3. PII: Optimization
i. Dose constraints for optimization
ii. Larynx dose reduced as much as possible while meeting all other
dose constraints
iii. Normal tissue objective (NTO)
iv. Plan normalization of 95% of PTV70 getting 100% of prescription
dose
D. Plan comparison
1. PI: Evaluated metrics
i. OAR: Mean larynx dose, attempted to keep dose parameters for
other OAR within 3% of each other between Plan 1 and Plan 2
ii. Target: PTV evaluation – 95% of the target volumes received ≥
100% of the prescription dose, max dose < 82 Gy
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E. PI: Statistical analysis

1. Analysis based on UWLAX stats lab
i. One-sided t-test to compare Mean Laryngeal Dose
ii. Shapiro-Wilk normality test
iii. P <0.05 is considered statistically significant
IV. Results
A. PI: Larynx dose for collimator (H1) 90⁰ and (H0) 0⁰
1. Mean larynx dose for Plan 2 was significantly lower than Plan 1 P <
0.0005 = Reject Null Hypothesis (Figure 3)
2. OAR & target dose for Plan 1 and Plan 2
i. Reference table with any OAR that fell outside of 3% between
Plan 1 and Plan 2 (Table 2)
ii. Target objectives were met for all plans
V. Discussion
A. PI: Summarize goal of study and target coverage
B. PII: Summarize mean larynx dose in relation to collimator angle (Reference:
Murtaza G et al,10)
C. PIII: Summarize trends of OAR and target dose in relation to collimator angle
(Reference: MacDonald et al,11 Khan et al,12 Ming-Hsien et al,13)
VI. Conclusion
A. PI: Summarize the study
1. Problem: The problem is that current VMAT techniques result in higher
laryngeal doses that cause profound side effects such as dysphagia. 
2. Purpose: The purpose of this study is to determine if VMAT collimator
angles of 90° or 0° can further limit the dose to the larynx while
still providing full dose coverage to the target volume. 
B. PII: Other metrics not measured in this study
1. Volumetric or maximum dose to the larynx
2. Effect of collimator rotation based on OAR location
C. PIII: Limitations/future research
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1. Limitations: all patients were collected from 1 institution with same TPS
and algorithm
2. Future research: Tumors in other sites of the H&N region, reducing dose
to another OAR of the H&N region, different TPS/Linear Accelerator, test
90⁰ collimator vs other angles to find ideal collimator angle, review 90⁰
collimator on other dosimetric constraints
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References 

1. Yeh SA. Radiotherapy for head and neck cancer. Semin Plast Surg. 2010;24(2):127–136.
https://doi.org/10.1055/s-0030-1255330
2. Kumar R, Gupta H, Konwar K, Sharma R, Anand AK, Sachdeva S. Impact of early
dysphagia intervention on swallowing function and quality of life in head and neck
cancer patients treated with intensity-modulated radiation therapy or image guided
radiation therapy with or without surgery/chemotherapy. Asian J Oncol. 2015;1(1):37-43.
https://doi.org/10.4103/2454-6798.165109
3. Hutchison AR, Cartmill B, Wall LR, Ward EC. Dysphagia optimized radiotherapy to
reduce swallowing dysfunction severity in patients undergoing treatment for head and
neck cancer: A systematized scoping review. Head Neck. 2019;41(6):2024-2033.
https://doi.org/10.1002/hed.25688
4. Kaae JK, Spejlborg ML, Spork U, Bjorndal K, Eriksen JG. Reducing late dysphagia for
head and neck cancer survivors with oral gel: A feasibility study. Dysphagia.
2019;35(2):231-241. https://doi.org/10.1007/s00455-019-10018-9
5. Prameela C, Ravind R, Renil Mon R, Sheejamol VS, Dinesh M. Radiation dose to
dysphagia aspiration-related structures and its effect on swallowing: Comparison of
three-dimensional conformal radiotherapy and intensity modulated radiation therapy
plans. J Cancer Res Ther. 2016;12(2):845-851. https://doi.org/10.4103/0973-
1482.163676
6. Ahn BS, Park SY, Park JM, Choi CH, Chun M, Kim J. Dosimetric effects of sectional
adjustments of collimator angles on volumetric modulated arc therapy for irregularly-
shaped targets. PLoS One. 2017;12(4):1-14.
https://doi.org/10.1371/journal.pone.0174924
7. Kim YH, Park HR, Kim WT, et al. Effect of the collimator angle on Dosimetric
verification of volumetric modulated arc therapy. J Korean Phys Soc. 2015;67(1):243-
247. https://doi.org/10.3938/jkps.67.243
8. U.S. National Library of Medicine. RTOG 1016: Phase III trial of radiotherapy plus
cetuzimab versus chemoradiotherapy in HPV-associated oropharynx cancer.
https://clinicaltrials.gov/ProvidedDocs/34/NCT01302834/Prot_SAP_001.pdf. Updated
February 23, 2016. Accessed April 1, 2020.
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9. RTOG 0619: A Randomized phase II trial of chemoradiotherapy versus

chemoradiotherapy and vandetanib for high-risk postoperative advance squamous cell
carcinoma of the head and neck.
https://pdfs.semanticscholar.org/9ce6/b604748034855dc6797891020c7b76039f5b.pdf?
_ga=2.120078216.1894391104.1592792325-1376015872.1592792325. March 25, 2010.
Accessed May 26, 2020
10. Murtaza G, Mehmood S, Rasul S, Murtaza I, Khan E. Dosimetric effect of limited
aperture multileaf collimator on VMAT plan quality: A study of prostate and head-and-
neck cancers. Rep Pract Oncol Radiother. 2018;23(3):189-198.
https://doi.org/10.1016/j.rpor.2018.02.006
11. MacDonald RL, Thomas CG, Syme A. Dynamic collimator trajectory algorithm for
multiple metastases dynamic conformal arc treatment planning. Med Phys. 2018;45(1):5-
17. https://doi.org/10.1002/mp.12648
12. Khan M, Rehman J, Chow J. SU-E-T-604: Dosimetric Dependence On the Collimator
Angle in Prostate Volumetric Modulated Arc Therapy. Med Phys. 2014;44(6):366-367.
https://doi.org/10.1118/1.4888940
13. Ming-Hsien L, Sheng-Fang J, Chih-Chieh C, Jang-Chun L, Jo-Ting T. Variations in
dosimetric distribution and plan complexity with collimator angles in hypofractionated
volumetric arc radiotherapy for treating prostate cancer. Med Phys. 2018;19(2):93-102.
https://doi.org/10.1002/acm2.12249
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Figures

Figure 1. The collimator configuration utilized for Arc 1 and Arc 2. Figure (A) demonstrates the
collimator angle of 30⁰ and Figure (B) displays the collimator angle of 330⁰.

Figure 2. The collimator configuration utilized for Arc 3. Figure (A) demonstrates the collimator
angle of 0⁰ and Figure (B) displays the collimator angle of 90⁰.
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Figure 3. The 4.7 Gy reduction in mean laryngeal dose between Plan 1 (0⁰) and Plan 2 (90⁰).
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Tables
Table 1. Arc geometry for Plan 1 and 2.
Arc Plana,b Gantry Start Gantry Stop Gantry Rotation Collimator
Angle (⁰) Angle (⁰) Direction Angle (⁰)
1 1,2 181.0 179.0 Clockwise 30
2 1,2 179.0 181.0 Counterclockwise 330
3 1 181.0 179.0 Clockwise 0
3 2 181.0 179.0 Clockwise 90
a
Plan 1 utilized the 0⁰ collimator.
b
Plan 2 utilized the 90⁰ collimator.

Table 2. Patient optimization outcomes of the OAR that fell within and outside of the 3%
tolerance between Plan 1 and Plan 2.
OAR Dose Within 3% Increase in Dose Decrease in Dose Percentage of
Parameters (Gy) by >3% from by >3% from Deviation
Plan 1 to Plan 2 Plan 1 to Plan 2 Between Plan
1 and Plan 2
(%)
Lips Dmean 9 1 0 3.3
Mandible Dmax 9 1 0 4.9
Oral Cavity, 9 0 1 3.1
Uninvolved Dmean
Parotid Gland, Left 9 1 0 10.1
Dmean
Parotid Gland, Right 9 1 0 10.3
Dmean
Abbreviations: OAR, Organs at Risk; Dmean, the average dose the OAR received; Dmax, the maximum dose the
OAR received.