Parotid Lab

Ashley Coffey
One dataset was used for planning all three plans in this lab. The patient has their chin in
a neutral position and is scanned while wearing a head and neck mask with an Accufoam custom
headrest. The right parotid gland was contoured and made the GTV; the PTV is the GTV plus a
one centimeter margin. Each plan was prescribed 60Gy in 30 fractions with the goal of a full
60Gy to the GTV and 95% of the dose (57Gy) to encompass the PTV. The following critical
structures were also contoured and evaluated with each plan: brainstem, cord, cord with 5mm
margin (cordPRV), mandible, oral cavity, left parotid, larynx, and esophagus. I utilized the
standard head and neck constraints that are used at VCU Massey Cancer Center for every plan.
Plan 1A: Wedge
For Plan 1A, I used 45 degree wedges on both RAO and RPO fields. A 5mm bolus was
added to the field due to inadequate coverage of the GTV and PTV on the surface.
Patient
Name:
Plan Name:
Trial Name:

Right Parotid
RtParotid
Parotid_Wedge(1a)

Energ Angle Couc Collimato

Weigh
y
s
h
r
Jaws
Wedge
t
MU
1.1RAO
6X
320
0
90
4x4
45
52.5% 138
1.2RPO
6X
230
0
270
4x4
45
47.5% 125
I did not need to use couch angles and if I were to have an extended chin, I would not
need to use couch angles. Extending the chin would not affect my arrangement with this plan
unless the angles would benefit from a slight adjustment; there are no major changed that would
be needed. With this simple plan, I was not able to receive desired coverage of the GTV or PTV.
With prescribing to the 90% line, I covered 95.5% of the GTV with 60Gy and only 80.7% of the
PTV. The deepest portion of the PTV extended into the mandible and did not receive proper
coverage. However, I was able to reach 95% of the dose to the PTV at 95.9% coverage. The
remaining dose constraints were met with this plan.

Patient Name: Right Parotid

Plan Name:
RtParotid
Trial Name:
Parotid_Wedge(1a)

GTV_60Gy
PTV_60Gy
PTV_57Gy(95%
)
Brainstem
Cord
CordPRV5mm

Dose (Gy)
60
60

%Volume
95.50%
80.70%

Goal %
100
95

Met?
No
No

57
50
40
45

95.95%
0.00%
0.00cc
0.00cc

95
0
<0.03cc
<0.03cc

Yes
Yes
Yes
Yes

Mandible
Oral Cavity
Lt Parotid
Larynx
Esophagus

60
45
30
45
45

19.22%
0.78%
0.00%
0.00%
0.00%

30
50
50
30
30

Yes
Yes
Yes
Yes
Yes

Plan 1B: Wedge plus neck nodes

For Plan 1B, I added an AP neck field that extended down the right neck and just below
the supraclavicular bone. This technique was created with a half beam block of the upper field
and the neck was prescribed to 50.4Gy in 1.8Gy fractions.
Pt Name: Right Parotid
Plan Name: RtParotid
Trial Name: Parotid_Neck(1b)
Energ
y

Angle
s

Couc
h

Collimato
r

X Jaws
(cm)

Y Jaws
(cm)

Wedg
e

Weigh
t

MU

1.1RAO
1.2RPO
1.3 AP

6X
6X
6X

320
230
0

0
0
0

90
270
0

0x8
4x4
8x0
4x4
7x4
0 x 11
*Half beam
blocked

45
45
0

31%
27%
42%

In order to evaluate coverage to the nodes (about 3 centimeter depth), I contoured a nodal
field that was subtracted from 5 millimeters of skin and did not extend beyond 3 centimeter
depth. While prescribing to the 90% line, I received 97.8% coverage to the GTV, 82.1%
coverage to the PTV at 60Gy, and 96.1% coverage to the PTV at 95% of the dose. The neck
nodes I contoured received 96.6% of the 50.4Gy prescribed. Average depth of the 50.4Gy was
about 4 centimeters, which covered the nodes nicely. It could seem that it is too deep but the
neck is not a uniform tissue. All of the remaining constraints on the critical structures were met.

137
119
184

GTV_60Gy
PTV_60Gy
PTV_57Gy(95%
)
NeckNodes
Brainstem
Cord
CordPRV5mm
Mandible
Oral Cavity
Lt Parotid
Larynx
Esophagus

Patient Name:
Plan Name:
Trial Name:

Right Parotid
RtParotid
Parotid_Neck(1b)

Dose (Gy)
60
60

%Volume
97.88%
82.14%

Goal %
100
95

Met?
No
No

57
50.4
50
40
45
60
45
30
45
45

96.15%
96.61%
0.00%
0.00cc
0.00cc
19.26%
1.42%
0.00%
0.00%
0.00%

95
95
0
<0.03cc
<0.03cc
30
50
50
30
30

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Plan 2: Mixed Energy

For Plan 2, I combined the wedge pair with an electron field and bolus. Typically, these
would be done with the wedge pair initially and boosted with the electron field; this essentially is
the same as a composite plan that would be treated clinically. After adjusting the plan multiple
times, I decided to give the photon beams 150cGy and the electron field 50cGy. This provided
the best coverage of the GTV and PTV. Due to picking 16MeV, a 5mm bolus was also used in
order to pull some more dose to the surface will still reaching a decent depth with the 16MeV.
For the photon beam, I prescribed to the 90% line and for the electron beam, I prescribed DMax
to 90%. This plan was the only plan to completely cover the actual GTV with 100% coverage at
60Gy. The PTV coverage at 95% was also better than the two previous plans (93.9%). Even with
it being better, it didnt reach the goal of 95%. All of the other constraints met without an issue as
well.

Patient Name:
Plan Name:
Trial Name:
1.1RAO
1.2RPO
1.3 RLat16MeV

Right Parotid
RtParotid
Parotid_Mixed(2
)
Energy
6X
6X
16MeV

Angles Couch Collimator

320
0
90
230
0
270
270
0
0

Jaws
4x4
4x4
10x10

Wedge
45
45
0

Weight
52.5%
47.5%
100%

MU
171
168
58

Patient Name:
Plan Name:
Trial Name:
GTV_60Gy
PTV_60Gy
PTV_57Gy(95%)
Brainstem
Cord
CordPRV5mm
Mandible
Oral Cavity
Lt Parotid
Larynx
Esophagus

Dose (Gy)
60
60
57
50
40
45
60
45
30
45
45

Right Parotid
RtParotid
Parotid_Mixed(2)
%Volume
100.00%
93.89%
99.48%
0.00%
0.00cc
0.00cc
18.45%
0.41%
0.00%
0.00%
0.00%

Goal %
100
95
95
0
<0.03cc
<0.03cc
30
50
50
30
30

Met?
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Plan 3: IMRT/VMAT
For Plan 3, I used two dynamic ARC beams from 200 degrees to 0 degrees clockwise and
2 degrees to 198 degrees counterclockwise. One of the ARCs being offset by 2 degrees is a
practice used at my site due to the program calculations being done every four degrees; with
offsetting it by two degrees, it will calculate from more points. The jaws were allowed to be
moving during treatment and the energy still at 6MV.
Patient Name:
Plan Name:
Trial Name:

Right Parotid
RtParotid
IMRT(3)

1.1 CW Arc
1.2 CCW Arc

Energy
6X
6X

Angle
s
200-0
2-198

Couch Collimator
0
45
0
315

Jaws
Moving
Moving

Wedge
None
None

Weight
47.7%
52.3%

Using these beam arrangements were successful in delivering decent coverage to the
GTV and good coverage to the PTV as well as keeping doses to the surrounding structures very
low. VMAT has become an extremely useful tool on shaping producing conformal isodose lines
and avoiding critical structures well. They are becoming a dominant form of treatment in my site
and with good reason. The dose to the mandible and oral cavity were actually lowest and
coverage the highest on this plan compared to the conformal plans. Coverage to the GTV was
96.8% and the PTV was 98.6%. The PTV at 57Gy was 99.8% coverage. This is better than the

MU
145
159

previous three plans. The isodose lines also shape tightly to the contour with only low doses
spilling around the volumes.

Patient Name: Right Parotid

Plan Name:
RtParotid
Trial Name:
IMRT(3)

GTV_60Gy
PTV_60Gy
PTV_57Gy(95%
)
Brainstem
Cord
CordPRV5mm
Mandible
Oral Cavity
Lt Parotid
Larynx
Esophagus

Dose (Gy)
60
60

%Volume
96.89%
98.61%

Goal %
100
95

Met?

57
50
40
45
60
45
30
45
45

99.83%
0.00%
0.00cc
0.00cc
8.46%
0.71%
0.00%
0.00%
0.00%

95
0
<0.03cc
<0.03cc
30
50
50
30
30

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
Yes*