UNIVERSITY OF WISCONSIN-LA CROSSE

Graduate Studies

Parotid Clinical Lab Assignment


Titus Kyenzeh


College of Science & Health
Medical Dosimetry Program


August 2014

1

Introduction
Salivary gland cancer most commonly occurs in the parotid gland, which is just in front of the
ear. Treatment for salivary gland cancer often involves surgery. The standard of care treatment of
parotid gland malignancies is surgery followed by postoperative radiotherapy (RT) when
indicated.
1
According the American Cancer Society, salivary gland cancers are not very
common, making up less than 1% of cancers in the United States. Malignant tumors of the
parotid gland are rare and account for 3% of head and neck cancers.
2

For the purposes of this clinical lab assignment, a computed tomography (CT) scan for a 65-year
old patient who was previously treated for squamous carcinoma of the right tonsil was used. The
patient was ideal for this lab activity because he was scanned in supine position with his chin
extended up with his head immobilized into a neutral position with an Orfit mask and MoldCare.
The medical dosimetrist outlined the left parotid and renamed it gross tumor volume (GTV) for
the purposes of this assignment. The planning target volume (PTV) was created by expanding
the GTV by a 10 mm margin. The surrounding critical structures contoured included the
mandible, right parotid, esophagus, left and right cochlea, spinal cord, brainstem and oral cavity.
Three plans were created: Ipsilateral Wedged Pair (Plan #1); Ipsilateral Photo/Electron (Plan #2);
and VMAT (volumetric modulated arc therapy) as Plan #3. All 3 plans were designed to deliver
a total of 60 Gy to the PTV in 30 fractions of 1.8 Gy daily. The goal of all the three plans was to
obtain 60 Gy to the GTV with the 95% isodose surrounding the PTV.
Plan#1: Ipsilateral Wedged Pair and Lower Neck Single Photon Field
Two angled beams with gantry angles 156 and 58 respectively were used to treat the planning
target volume. On both plans the couch and collimator were kept at the default institutional 180
angle. The field sizes for the left anterior oblique (LAO) and left posterior oblique (LPO) were
7.7 x 9.7 cm and 8.7 x 9.7 cm respectively. Both beams were closed appropriately on the x-jaw
to avoid treating through the spinal cord. Care was taken not to direct exit dose to the
contralateral parotid. A suitable isocenter was created at a past-pointed location medially to
allow for short angles of the beams to avoid treating through uninvolved normal tissue (Figure1).
The calculation point was also placed at a location that was medial to give better coverage of the
2

target. Two 45 hard wedges provided the most conformal plan. In addition to the two wedged-
pair fields, an additional anterior-posterior (AP) half-beam was used on the lower neck to treat
the neck nodes to a dose of 50.4 Gy in 28 fractions. The field size measured 9.2 x 11.4 cm. The
medial edge of the field was retracted laterally to stay off the cord. A small cheater block was
introduced to protect irradiating the cord around C1-C2 (Figure 2). The couch was angled 8
away from 180 while the collimator was rotated 10 to match the field to the inferior edges of
the wedged pair fields. The dose for lower neck beam was calculated at 4.5 cm, which is the
clinical standard depth for anterior neck nodes fields. A 15 sagittal dynamic wedge was used to
homogenize the dose superiorly. The 2 trials were planned with 6X for a 21EX linear
accelerator.
The two plans were computed to the respective calculation points. The wedged pair was
weighted AP to PA 51:49 respectively. An isodose distribution of the composite plan in sagittal
and coronal views is shown in Figure 3. An isodose distribution for the lower neck field on one
transverse slice is presented in Figure 4.
Table 1 shows a record of the dose that each critical structure received against the allowed
maximum tolerance dose. A dose volume histogram (DVH) of the GTV, PTV and all the
surrounding organs at risk (OR) for the composite plan are shown in Figure 5.
Plan#2: Ipsilateral Photon/Electron (Mixed Beam)
Plan 2 consisted of a 6X photon beam and a 16Mev electron field weighted 30% and 70%
respectively. The electron field was an en face electron beam with a custom 10 x 10 cm cutout.
A 105 cm source to skin distance (SSD) was used. One prescription of 60 Gy in 30 fractions was
applied to both beams. The calculation was done at a depth of 4.5 cm. This was necessary in
order to deliver adequate superficial dose as well as to provide appropriate depth for tumor
coverage. In order to account for penumbra, the electron beam was given an 8 mm uniform
blocking margin around the PTV. The photon beam was given 5-6 mm flash (Figure 6). The
weighting of the two beams was manipulated until a uniform dose of 60 Gy was attained with the
95% isodose line adequately surrounding the PTV (Figure 7). The resulting DVH was used to
analyze the dose to the OR (Figure 8). A summary of the critical structure doses is given in Table
2.
3


Plan comparison between plan #1 & 2.
Due to the ipsilateral beam configuration, the wedged pair plan did not meet the constraint for
the left cochlea. Similarly, the mean dose to the oral cavity was higher at 22 Gy for the wedged
pair compared to 6.4 Gy for the mixed beam plan. However, the wedged pair plan mean dose to
the contralateral parotid was lower at1.8 Gy compared to 11.1 Gy for the mixed beam plan. This
is can be attributed to the high exit dose in the mixed beam plan configuration. In terms of
conformity and target coverage, the mixed beam plan was a better plan. A summary of the mean
doses for the right and left cochlea, right parotid and oral cavity are presented in Table 4.
Plan#3: Volumetric-Modulated Arc Therapy
The VMAT plan consisted of 2 arcs (clockwise and counterclockwise) both spanning an arc
length of 198 (Figure 9). The alternative to this technique was 4-6 beam step and shoot
intensity-modulated radiation therapy (IMRT). However, due to the location of the tumor, the
technique was dismissed because it would result in high exit dose to the oral cavity and the
spinal cord. An 8 mm ring with a 10 mm margin around the PTV was used to improve dose
conformity around the PTV and avoidance of OR. A few ghost structures were introduced to aid
in lowering the normal tissue doses. Dose constraints were iteratively applied to the PTV and
the critical structures. The isodose distribution for the axial, sagittal and coronal views are shown
in Figure 10. When the OR constraints were met, the medical dosimetrist strived to achieve
ALARA values. Dose volume data for the OR are presented in Figure 11. Table 3 contains the
plan doses to the critical structures.
Results and Discussion
In table 4, results of mean doses for the 4 critical structures are demonstrated for the 3 plans.
The results demonstrate the oral cavity at 29.2 Gy for the VMAT plan, which is higher than the
wedged pair (22.0 Gy) and mixed beam (6.4 Gy). This is due to exit dose from the arcs.
However, in general the VMAT plan produced the best critical structure sparing (Table 3). The
VMAT plan also provided an excellent GTV and PTV coverage, especially in the medial aspect
of the parotid, while still providing maximal contralateral parotid sparing.

4


Conclusions
From this lab assignment, it would be recommended to use VMAT for the treatment of parotid
gland cancers. The technique is known to deliver very conformal plans, with very high degree of
normal structure sparing compared to the 3 dimensional conformal radiation therapy (3DCRT).
The delivery time is short and it does not involve the use of ancillary treatment devices such as
wedges and cutouts. If the lower neck nodes are involved, the neck plan requires the use of table
kicks to match the inferior field edge of the wedged pair field. This is tedious and challenging.
The VMAT plan eliminates all these challenges.


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References
1. Yirmibesoglu E, Fried D, Kostich M, et al. Dosimetric evaluation of an ipsilateral intensity
modulated radiotherapy beam arrangement for parotid malignancies. Radiol Oncol. 2013;
47(4): 411-418.
2. Seifert G, Brocheriou C, Cardesa A, Eveson J. WHO international classication of tumours.
Tentative histological classication of salivary gland tumours. Pathol Res Pract. 1990;186(5):
555-581.

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Figures

Figure 1. Isocenter past-pointed to allow shorter beam angles in the wedged pair setup.

Figure 2. A cheater block was introduced to protect irradiating the cord.

Figure 3. Isodose distribution for the composite plan (wedged pair, and lower neck single photon
field plans) in (a) sagittal and (b) coronal views.
7


Figure 4. Isodose distribution for the lower neck field on one transverse slice.

Figure 5. Dose volume histogram of the GTV, PTV, and the involved critical structures for
wedged pair, and lower neck single photon field plans.
8


Figure 6. Both electron and photon beams were given appropriate margins to account for
penumbra.

Figure 7. Conformed isodose distribution for axial, sagittal and coronal views respectively for
the mixed beam plan.
9


Figure 8. Dose volume histogram of the GTV, PTV, and the involved critical structures for
mixed beam plan.

Figure 9. Rooms eye view of the clockwise arc of the VMAT plan.
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Figure 10. Isodose distribution for axial, sagittal and coronal views respectively for the VMAT
plan.

Figure 11. Dose volume histogram of the GTV, PTV, and the involved critical structures for the
VMAT plan.


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Tables
Table 1. Composite doses to the critical structures for the ipsilateral wedged pair and lower neck
single photon field plans.
Structure Dose limit (Gy) Plan dose (Gy) Deviation
Brainstem Max 54 25.8 Pass
Vol. (1%) <60 24.3 Pass
Spinal Canal Max <45 27.9 Pass
R Cochlea Mean 36 2.1 Pass
Vol. (5%) <55 2.4 Pass
L Cochlea Mean 36 52.0 Fail
Vol. (5%) <55 54.7 Pass
Mandible Max 70 63.4 Pass
Right Parotid Mean 26 1.8 Pass
Vol. (50%) <50 1.7 Pass
Esophagus Mean <35 1.4 Pass
Vol. (15%) <54 3.7 Pass
Vol. (33%) <45 2.9 Pass
Oral Cavity Mean <40 22.0 Pass

Table 2. Dose to critical structures for the ipsilateral photon/electron (mixed beam) plan.
Structure Dose limit (Gy) Plan dose (Gy) Deviation
Brainstem Max 54 23.6 Pass
Vol. (1%) <60 19.7 Pass
Spinal Canal Max <45 30.9 Pass
R Cochlea Mean 36 12.0 Pass
Vol. (5%) <55 12.6 Pass
L Cochlea Mean 36 34.4 Pass
Vol. (5%) <55 40.8 Pass
Mandible Max 70 64.9 Pass
Right Parotid Mean 26 11.1 Pass
Vol. (50%) <50 11.3 Pass
Esophagus Mean <35 0.08 Pass
Vol. (15%) <54 0.24 Pass
Vol. (33%) <45 0.16 Pass
Oral Cavity Mean <40 6.4 Pass


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Table 3. Dose to critical structures for the VMAT Plan
Structure Dose limit (Gy) Plan dose (Gy) Deviation
Brainstem Max 54 16.2 Pass
Vol. (1%) <60 13.7 Pass
Spinal Canal Max <45 18.5 Pass
R Cochlea Mean 36 7.7 Pass
Vol. (5%) <55 8.3 Pass
L Cochlea Mean 36 8.3 Pass
Vol. (5%) <55 11 Pass
Mandible Max 70 62.7 Pass
Right Parotid Mean 26 8.1 Pass
Vol. (50%) <50 8.0 Pass
Esophagus Mean <35 0.1 Pass
Vol. (15%) <54 0.2 Pass
Vol. (33%) <45 0.2 Pass
Oral Cavity Mean <40 29.2 Pass

Table 4. Plan comparison: Mean doses for the right and left cochlea, right parotid and oral
cavity.
Organs at risk Mean doses (Gy)
Wedge pair Mixed beam 2 Arc-VMAT
Right Cochlea 2.1 12.0 7.7
Left Cochlea 52.0 34.4 8.3
Right parotid 1.8 11.1 8.1
Oral cavity 22.0 6.4 29.2