1

Jenny Kouri
Clinical Lab: Parotid
Clinical Practicum II
Aug. 7, 2015
For each plan:
1.) Make a chart listing all of the surrounding critical structures and their tolerance doses.
After completing each plan, record the dose that each structure actually received in a
column next to the maximum tolerance dose. Indicate in a 3rd column whether the
structure tolerance was met or exceeded.
OAR
Constraint
Plan #1: Plan Sum Plan #2: Mixed
Plan #3: IMRT
(Gy)
beam (Gy)
Contralateral Mean < 25 Gy
14.3, 15.8
10.3, 11.7
5.2, 6.2
Parotid (Left)
Mandible
Max < 70 Gy
59.7
64.9
65
Cervical
1cc of volume < 45 Gy,
23.4, 3.1
16.5, 3.2
15.4, 2.51
Spinal Cord
Mean <35 Gy
Brain
Max < 72 Gy to partial
49.6
38.7
13.7
brain
Oral Cavity
1cc of volume < 55 Gy,
.72, 2.3
3.9, 14.2
13.7, 24.8
Max < 65 Gy
Larynx
Mean < 44 Gy, Max < 63
.39, .57
4.0, 5.8
4.1, 6.1
Gy
All constraints were met for all plans. Plan #3, IMRT, resulted in the lowest amount of dose
delivered to the OARs with the exception of the larynx, oral cavity, and mandible. After
analyzing the results of all the plans, I think if I omitted the LAO beam of the IMRT plan, I
would be successful in lowering the dose to the oral cavity and larynx. It is important to note,
since the right parotid is receiving all 60 Gy (since it is the PTV), that the number one goal after
target coverage is limiting the dose to the contralateral (left) parotid gland. The lowest dose
delivered to the left parotid was achieved by the IMRT plan when compared to the other plans.
2.) Print or capture an image of at least one transverse slice of the plan showing the isodose
coverage of the parotid and the PTV, the maximum dose location, and the 100%, 95%,
75%, and 40% isodose lines. (Label the isodose levels)
Images will be shown for each plan. The colors of the isodose lines for all the plans are of the
following:
6000 cGy
5700 cGy
4500 cGy
2400 cGy

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3.) Provide a DVH with the GTV, PTV, and all surrounding critical structures.
The following colors are designated to represent the GTV, PTV, and surrounding critical
structures:
GTV
PTV
Mandible (extends almost to 6000 cGy)
Spinal Cord
Oral Cavity
Left Parotid (1000-1500 cGy)
Brain
Larynx
4.) Provide a detailed description of each plan (beam angles, energy, cone or field size,
wedges used, and any other parameters that you may have changed: couch angle,
collimator angle, etc.). This can be a print out or it can be typed in a separate document
but all information required to treat this patient must be provided for each of the 3 final
plans.
Plan #1
1.) Using references and preceptor assistance, design an ipsilateral wedged pair plan for the
parotid.

Field

MLC

Field
Weightin
g

Gantry
Angle
(deg)

Collimato
r Angle
(deg)

Couch
Rotatio
n (deg)

Wedge

SS
D

1a ant

Static

0.421

0.0

90.0

0.0

97.1 76.0

1b rt
Static
lat
1c post Static

0.678

270.0

90.0

0.0

EDW30OU
T
EDW30IN

0.328

180.0

90.0

0.0

None

96.9 57.0

Field

Field X
(cm)

X1
(cm)

X2
(cm)

Field
Y1
Y (cm) (cm)

Y2
(cm)

X
(cm)

MU

99.2 107.0

Y
(cm)

Z
(cm)

1a ant

8.3

-1.2

9.5

5.3

2.5

2.8

-5.5

1b rt lat

8.3

-1.2

9.5

7.4

3.6

3.8

-5.5

1c post

8.3

-1.2

9.5

5.3

2.8

2.5

-5.5

For Plan #1, adequate coverage of the target was not achieved. The most coverage was achieved
with a 30-degree wedge pair with the following beam angles and weighting listed above. The
maximum dose was found at 6504 cGy, which is an 8% increase of the prescription dose, 6000
cGy. The minimum dose and mean dose was 4595 cGy and 5968 cGy, respectively. To get full
coverage, I rotated the collimators to rotate the wedges, which pushed dose to cover the entire
target. Unfortunately, I did not receive the email with the images of this plan. However, all
constraints were met. The left parotid received a mean and max dose of 17.1 Gy and 19.1 Gy;

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the mandible, max dose of 63.1 Gy; the spinal cord, mean dose of 6.0 Gy and 1cc of volume at
31.4 Gy; the brain, max dose of 46 Gy; the oral cavity, mean dose of .63 Gy and 1cc of volume
at 1.7 Gy; and the larynx, mean dose of .43 Gy and maximum dose of .67 Gy. With the addition
of the anterior neck nodes, the plan with the rotated collimators would not work unless the couch
was kicked to match the half beam block. Therefore, I did not rotate the collimators for the
anterior neck nodes so I could use the original plan for this assignment. I contoured the anterior
neck nodes (level I), cropped this 0.5 cm away from the body, and designated this as the PTV.
The match line was at -5.50. Each field incorporated a little bit of the other PTV. In the plan
sum, I blocked hot spots between the bordered fields. I do not have a image for this as well! So
sorry!
Plan ID

Field ID

MLC

1abc
parotid
1abc
parotid
1abc
parotid
2ab ant
neck
2ab ant
neck

1a ant

Field ID
1a ant
1b rt lat
1c post
2a lao
2b rpo

Gantry
Rtn (deg)
0

Coll Rtn
(deg)
90

Couch
Rtn (deg)
0

Wedge

static

Field
Weight
0.421

1b rt lat

static

0.678

270

90

EDW30IN

1c post

static

0.328

180

90

none

2a lao

static

0.573

30

90

none

2b rpo

static

0.427

230

90

EDW25IN

Field X
(cm)
8.3
8.3
8.3
5.3
4.3

X1
(cm)
-1.2
-1.2
-1.2
2.3
1.5

X2
(cm)
9.5
9.5
9.5
3
2.8

Field Y
(cm)
5.3
7.4
5.3
4.6
5.1

Y1
(cm)
2.5
3.6
2.8
1.5
4.2

Y2
(cm)
2.8
3.8
2.5
3.1
0.9

X
(cm)
0
0
0
0
0

Y
(cm)
0
0
0
0
0

EDW30OUT

Z (cm)

SSD

-5.5
-5.5
-5.5
-5.5
-5.5

97.1
99.2
96.9
91.4
99

Patient positioning affects the beam arrangement. Chin extension aids in decreasing the amount
of exit dose going through the oral cavity.
Plan #2: Ipsilateral Photon/Electron (Mixed Beam)
Achieve the required coverage on the parotid gland and PTV using electrons for the
superficial gland and photons to reach the deeper lobe.

Plan
ID

Field
ID

MLC

Field
Weight

Gantry
Rtn (deg)

Coll
Rtn
(deg)

Couch
Rtn
(deg)

Wedge

Mixed
Beam
p+

1a ant

Static

0.334

345

90

EDW60OUT

Mixed
Beam
p+

1b rt
lat

Static

0.438

270

90

none

Mixed
Beam
p+

1c
post

Static

0.484

195

90

ED60IN

Mixed
Beam
e-

1a ant

Static

0.241

270

None

For this plan, I first created the photon beams with energy of 6 MV. I made sure coverage was
adequate deep and did not focus on the skin surface. Then, I created the electron. The applicator
cone size was 10 x 10 and the cutout had a 1 cm blocked margin. A single lateral 9 MeV beam
was used to cover the skin surface. This plan had a maximum dose, minimum and mean spot of
6639.1 cGy, 5155.7 cGy, and 6209.0 cGy, respectively.

How does this plan compare to your wedged pair plan? Were there any dose constraints not
met?
The coverage was much better with this plan than the wedge pair plan. The plan I created with
rotated collimators/rotated wedges was the best optimal plan in terms of coverage. (I apologize
that I do not have images for that!). What is important to consider during this plan is to keep in
mind the therapists have to go back into the room to set up for the electron treatment in addition
to the photon treatment. This will take additional time and can cause set-up errors and/or put the
patient in more pain while lying on the treatment table. Therefore, I think the best plan, besides
the rotated collimator wedge pair plan, would be the IMRT plan. All constraints were met.
Plan #3
Using an IMRT technique of your choice find the beam arrangement needed to achieve the
required coverage on the parotid gland while sparing the critical structures.
What beam arrangements did you try? Why did you decide on your final one?
For the IMRT plan, I only tried out one arrangement which involved 7 beams at 0, 30, 330,
300, 270, 240, and 205. The MUs varied between 109 and 75. 109 MUs were delivered from
the LAO: 30. This increased the dose to the oral cavity and larynx in comparison to the other
plans. After analyzing the data, I would be interested in omitting that particular field to see if the
target coverage was still adequate. My main concern with omitting this beam is that more dose
would be pushed to the contralateral parotid gland or to the posterior which would include the
brain and brain stem. Since the priority after target coverage would be to spare as much of the
contralateral parotid as possible, this plan may be better off with the LAO included. Preoptimization structures were contoured for the IMRT plan. A 1cm ring was constructed around
the PTV with a 2 cm gap. The ring was cropped away from the mandible by 0.5 cm. A PRV

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structure was created for both the spinal cord and the brain stem with an expansion of 0.3 cm. A
posterior neck structure was used to help carve dose away from the posterior.

The maximum dose was 108.4% over the prescription dose and was found in the PTV. The
minimum dose and mean dose was 89.5% and 104.8%, respectively.