1

Fieldwork II Clinical Lab

Parotid Planning Comparison
Karol Wynn, CMD
1) Ipsilateral Wedge Pair:
A CT data set with a neutral chin position and an extended chin position were used to
complete plans with a wedge pair for the primary target and a split beam low neck field. Both
plans were normalized such that 95% covered 100% of the PTV_6000 and 100% to the Parotid
Bed with a prescription of 60Gy/30 fractions (fx). The low neck fields were normalized to an off
axis calculation point at a depth of 3cm to deliver 50.4Gy/28fx. Beam energy for all fields were
6MV. The plan utilizes 0.5cm bolus. Tables 1and 2 list all field parameters.

Axial on the left is a chin neutral position and the right axial is the chin extended position.
The isodose lines (idl) displayed are 6000cGy in red, 5700cGy in yellow, 4500cGy in orange and
the 2400cGy in cyan.
As seen in the above images the head position is critical when treating parotid cancer.
The head neutral or chin down position has more of the base of skull and orbits in the treatment
region. In positioning a patient for parotid treatment, the chin extension allows for separation of
the orbits and lens from the superior aspect of the target volume. This extension is needed to
allow for divergence of the posterior oblique field.

A split beam Low Neck Field was placed on both plans by placing the field at the 50% isodose
volume of the wedge pair plans.

Coronal on the left is a chin neutral position and the right axial is the chin extended position.
The isodose lines displayed are 6000cGy in red, 5700cGy in yellow, 5040cGy in blue, 4500cGy
in orange and the 2400cGy in cyan.
Table 1: Right Parotid Chin Neutral Plan Parameters

Table 2: Left Parotid Chin Extended Plan Parameters

DVH: Chin Neutral, RT Parotid Plan:

PTV- red
Fushia_GTV

Oral
Cavity

Esophagus
Mandible
Brainste
m
Left_Parotid

Cord

Larynx

DVH : Chin Extended, Left Parotid Plan

PTV_Parotid

Oral Cavity

Parotid Bed

Brainstem

Cord
Esophagus

R_Parotid

2) Mixed Photon and Electron:

Larynx
Mandible

The CT data set for the Left Parotid Bed was utilized for this comparison.

The isodose lines displayed are 6000cGy in red, 5700cGy in yellow, 4500cGy in orange and the
2400cGy in cyan. The plan is a sum of a 6MV photon plan and a 16MeV electron using a left
lateral field for both plans. The plan utilizes 0.5cm bolus. The photon field is normalized to
isocenter at the 95% idl and delivers 24Gy/30fx. The field is shaped with MLC to the PTV6000
plus 1.5cm. The electron plan is normalized to the 90% idl and delivers 36Gy/30fx. The block
cutout is fielded to the PTV6000 plus 1.5cm. The field is at an extended SSD due to the cones
proximity to the patiens shoulder. Multiple electron energies and field weightings were tried.
Table 3 lists the beam parameters for both fields. This plan did not meet the objectives for
coverage or critical structure dose. The contralateral parotid was not spared as well as with the
wedge pair plan or the IMRT plan. The wedge pair was a better plan. This data set had the
parotid bed outlined by the physician; perhaps if this was an intact parotid with 1cm PTV margin
the mixed energy plan would be better. The maximum depth for the PTV is 5.2cm.

Table 3: Plan parameters mixed energy

DVH: Mixed Energies Plan.

Larynx

PTV600
0
L_Parotid
Bed

R_Parotid

Brainstem

Spinal Cord
Mandible
Esophagu
Oral Cavity

3) IMRT Plan
The CT data set for the Left Parotid Bed was utilized for this comparison. A five field
IMRT plan (Angles- 330, 35, 90, 120 and 160) was compared to a VMAT plan. The
plans used 0.5cm bolus over the parotid bed.
The VMAT plan was selected due to better dose homogeneity and sparing of critical
structures.
This is an axial view of VMAT plan. The plan is normalized to deliver 95% to 100% of
PTV6000 and 100% to the Parotid Bed GTV. The isodose lines displayed are 6000cGy in
red, 5700cGy in yellow, 4500cGy in orange and the 2400cGy in cyan. This plan used two
6MV partial arcs CW: 325 to 179 and CCW: 179 to 325. Collimator Angles are 30 for

the CW arc and 330 for the CCW arc.

DVH: VMAT plan.

Esophagus

PTV6000
Oral Cavity

Parotid_Bed

R_Parotid
Larynx
Brainstem
Spinal
Cord

Mandible

Critical Structures Dose Comparison

R Parotid
Spinal Cord
Mandible
Oral Cavity
Larynx
Brainstem
Esophagus

Dose Goal

Wedge

Met

Mixed Energies

Met

VMAT

Met

10Gy mean
45Gy max
66Gy max
30Gy mean
20Gy mean
50Gy max
30Gy mean

Pair
1.6Gy
31.7Gy
64Gy
17.7Gy
7.8Gy
27Gy
0.54Gy

Y/N
Y
Y
Y
Y
Y
Y
Y

15.5Gy
47.8Gy
64.5Gy
36.6Gy
15Gy
32.7Gy
0.59

Y/N
N
N
Y
N
Y
Y
Y

6.2Gy
34Gy
63Gy
10Gy
2.0Gy
15.5Gy
0.30Gy

Y/N
Y
Y
Y
Y
Y
Y
Y