1

A Retrospective Analysis to Determine the Dosimetric Impact of Head and Neck

Immobilization Devices on Target Volumes and Organs at Risk with Various Treatment
Planning Algorithms
Nick Hopkins, BS, RT(T); Savannah Coleman, BS, RT(T); Jacquelyn Palermino, BS, RT(T);
Julie Puzzonia, BS, RT(T); Ashley Hunzeker, MS, CMD; Nishele Lenards PhD, CMD,
RT(R)(T), FAAMD; Alyssa Olson, MS, RT(T), CMD
Medical Dosimetry Program at the University of Wisconsin, La Crosse, WI

ABSTRACT
Immobilization devices are essential in radiation therapy by aiding in setup reproducibility.
There is a dearth of literature on the effects of immobilization in dose calculations for volumetric
modulated arc therapy (VMAT) planning. A retrospective study was performed to determine the
dosimetric impact of head and neck (HN) immobilization devices on the planning target volume
(PTV) and organs at risk (OAR) using the Eclipse treatment planning system (TPS) with
Anisotropic Analytical Algorithm (AAA) and Acuros XB (AXB), along with Pinnacle TPS using
Collapsed Cone Convolution (CCC). Data was collected from the treatment plans of 21 HN
patients and comparison plans were created to account for the immobilization devices in dose
calculations. Evaluations of the treatment plans showed that PTV coverage decreased when
considering immobilization in dose calculations. When assessing the percentage of the PTV that
received 100% of the prescription dose (V100), there was a mean change in coverage from 91.4%
to 74%. In addition, a reduction of dose to OAR tested significant (p<0.05) for the spinal canal,
brainstem, mandible, and left parotid. The skin dose to a volume of 1 cc (D1.0 cc) and 0.03 cc (D0.03
cc ) showed a mean percent increase of 5.62% and 3.15% respectively. The plans for all 3
treatment planning algorithms displayed consistent trends of decreased dose to PTV and OAR,
and increased dose to the skin with the inclusion of immobilization devices in dose calculations.
The results of this study suggest additional care should be taken to consider immobilization
devices during treatment planning.

Keywords: Immobilization Devices, Radiotherapy, Attenuation, Head and Neck, VMAT,

Algorithms
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Introduction
Photon beam attenuation occurs any time a material with sufficient density intersects the
path of a radiation beam. There is no industry standard currently established accounting for
immobilization devices in contouring or in dose calculations.1 When designing radiation therapy
treatment plans, immobilization devices in the path of the radiation beam could alter dose
distributions and decrease target coverage. Many institutions, for example, have implemented
couch models to incorporate photon beam attenuation when treating with posterior beam angles;
however, immobilization devices often remain unaccounted for in dose calculations.
Immobilization devices are essential in radiation therapy by aiding in setup
reproducibility and limiting intrafractional patient movement. One treatment site that is highly
dependent on the use of immobilization for radiotherapy includes HN cancers. Common devices
used for treatment in this anatomic region include head holders, thermoplastic masks, and table
top extensions/overlays. Previous studies have shown that immobilization devices attenuate a
portion of the beam and increase skin dose.2-6
While most current literature compares the effect of immobilization devices on intensity
modulated radiation therapy (IMRT) and three-dimensional (3D) based planning, Olson et al7
showed a statistically significant impact on PTV coverage due to HN immobilization devices
using VMAT alone. However, limitations of the study included using a single calculation
algorithm in the TPS without evaluation of dose to OAR. Thus, the purpose of this retrospective
study was to determine the dosimetric impact of HN immobilization devices on PTV and OAR
coverage using the Eclipse TPS with AAA and AXB, along with the Pinnacle TPS using CCC.
Methods and Materials
Patient Selection & Setup
All patients selected for this study were diagnosed with cancer of the HN region. The
patients were prescribed definitive radiation doses between 60-70 Gy to the primary tumor. The
patients were selected from 3 different clinical institutions consisting of 8 patients with tonsillar
cancer, 5 patients with base of tongue (BOT) cancer, 3 patients with oropharyngeal cancer, 1
patient with laryngeal cancer, 1 patient with cutaneous squamous cell metastasis, 1 patient with
floor of mouth cancer, 1 patient with right parotid cancer, and 1 patient with an unknown
primary of squamous cell cancer. Each clinical site contributed 7 patients to this study, allowing
for an equal distribution of patients planned with each treatment planning algorithm. All
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retrospective cases chosen were planned using a VMAT technique; plans generated using a non-
VMAT treatment technique were excluded from this study. In addition, patients with primary
gross tumor volume (GTV) involvement of the skin surface were excluded.
All patients in this study underwent a simulation procedure in which a CT scan was
obtained for treatment planning. The patients were simulated in the supine head-first treatment
position with the scanning field of view (FOV) to include the entirety of the immobilization
devices in the target area. The patients simulated at clinical site 1 included the use of the
following immobilization devices during simulation: CIVCO Type-S standard perforated
thermoplastic mask, CIVCO Type-S tabletop overlay board, QFix head holder, and CIVCO
AccuForm cushion. The patients simulated at clinical site 2 utilized the QFix Curve Board, S-
Frame perforated thermoplastic mask, and for some patients a CIVCO AccuForm cushion
(Figure 1). Finally, patients simulated at clinical site 3 were immobilized using CIVCO Type-S
head-only perforated thermoplastic mask, CIVCO Type-S tabletop overlay board, QFix
Silverman head holder, and for some patient's a CIVCO AccuForm cushion.
Contouring
The CT scan obtained from simulation was used for the contouring of normal structures
and target volume delineation. Treatment volumes such as the GTV, clinical target volume
(CTV), and PTV were delineated in the TPS by the physician. For the purpose of this study, the
PTV was specific to the volume encompassing the primary tumor bed.
The OAR evaluated in this study included the spinal canal, brainstem, mandible, skin,
and right and left parotid glands. The skin was defined as a 3 mm interior ring that was created
from the external surface contour. All normal tissue contours were delineated by the medical
dosimetrist and approved by the radiation oncologist. Any OAR that were missing from the
original data set were contoured for the completeness of data analysis. An exception to this was
when the primary tumor invaded the OAR, in which case, the dose to that structure was
excluded.
To assess the effect of immobilization devices in the planning process, specific contours
were created depending on the TPS utilized. The Eclipse TPS ignores any CT data that is outside
of the body contour with the exception of contours assigned as a “support” structure. For all
retrospective Eclipse plans, the body contour was extended to include the immobilization devices
which allowed the TPS to calculate dose to all CT densities within the body contour (Figure 2).
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In the Pinnacle TPS, all CT densities beyond a specified tissue-air threshold are
automatically assessed and used in dose calculation. Clinically, this threshold is often set too
high (0.6 g/cm3) to recognize the lesser densities of immobilization devices. For this study,
assessments were performed with the threshold set to 0.0 g/cm3 to incorporate all densities
within the treatment scan. A contour separate from the patient was created to encompass all
immobilization devices within the treatment area (Figure 3). This contour was overridden to the
density equivalence of air to be comparable to the Eclipse TPS plans without the extended body
contour.
Treatment Planning
All patients in this study were treated with a curative intent, using treatment doses
ranging from 60-70 Gy. There were 12 patients treated to a definitive dose of 70 Gy, 3 treated to
a dose of 69.96 Gy, 2 treated to a dose of 68 Gy, 2 treated to a dose of 66 Gy, and 3 treated to a
dose of 60 Gy. The patients were treated using a standard fractionation schedule with daily
treatments of 5 days per week.
The TPS used for dosimetric calculations included Varian Eclipse and Philips Pinnacle.
The treatment plans were generated using a VMAT technique consisting of 2-3 arcs with the
smallest arc spanning 197° and the largest arc spanning 358°. All plans created used a photon
energy of 6 MV, with delivery on the Elekta Agility at clinical site 1, Varian Novalis or Varian
TrueBeam at clinical site 2, and Varian Edge at clinical site 3.
Throughout the initial planning process, plans were optimized to achieve target coverage
goals while considering normal tissue constraint recommendations as proposed by published
sources such as Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC) and
Radiation Therapy Oncology Group (RTOG) protocols.8 The immobilization devices were
introduced into the dosimetric calculation process to reflect either the addition or subtraction of
immobilization devices for the corresponding TPS. Throughout this process, plan normalizations
were kept consistent and beams were re-computed to assess any changes in target coverage and
dose to OAR.
Plan Comparisons
The process of plan evaluation was dependent on the TPS used for each patient. With the
Eclipse TPS, the PTV coverage and dose to OAR were evaluated first from the initial treatment
plan without the inclusion of immobilization devices. The plan was then copied, and the body
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contour was extended to include all HN treatment devices. The beams were then re-computed
using fixed monitor units (MUs) to ensure consistent normalization and dose to targets and OAR
were analyzed in the comparison plan.
In the Pinnacle TPS, the initial plan represented the inclusion of the immobilization
devices because the planning system detects all densities within the scan above the tissue-air
threshold. The treatment devices were then contoured, and the CT density of this contour was
assigned to 0 g/cm3, air equivalence, to simulate the exclusion of the devices. The beams were
then re-computed maintaining the same normalization and MUs to achieve the comparison plan.
During plan evaluation, the spinal canal, brainstem, mandible, and right and left parotid
glands were assessed using the mean dose (Dmean) and the D0.03 cc with and without the inclusion
of immobilization devices. For the skin, D1 cc and the D0.03 cc were reported with and without
inclusion of immobilization devices. With regard to target coverage, the percent volume of the
PTV that received 95% of the prescription dose (V95), and the percent volume that received
100% of the prescription dose (V100) were analyzed with and without the inclusion of
immobilization devices. To further evaluate the changes between plans, the percent difference of
each OAR and PTV metric was computed. This information was used to derive mean values and
mean percent differences from the data collected. These additional calculations allowed for data
classification based on the metric or TPS used.
Results
Target Coverage
The data obtained from this study showed a decrease in PTV coverage when
immobilization devices were accounted for in dose calculations. When evaluating the PTV V95,
the mean value of all cases decreased from 99.3% to 98.2% after the plans were recomputed to
account for the attenuation of the immobilization devices. When analyzing the mean value of the
PTV V100, the effects of immobilization were even more apparent with a change in coverage
from 91.4% to 74.0% (Figure 4). Furthermore, the mean of the percent difference was calculated
for the PTV V100, which showed a significant change of 45.0% between plans.
Organs at Risk
When evaluating the OAR in both plans, the data collected showed a decrease in dose
when immobilization devices were included in planning. The mean of the percent difference
ranged from 0.28% to 2.50% between plans (Figure 5). To ensure that the results were not due to
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random error, a repeated measures T-Test was performed. This test found that all OAR presented
a significant change between plans (p <.05) except for the mean dose of the right parotid gland
(p=.09).
Unlike the other OAR, the skin showed an increase in dose when including
immobilization devices in the dose calculation (Figure 6). The mean of the percent difference for
the D1.0 cc was a 5.62% increase in dose and the D0.03 cc showed a 3.15% increase in dose between
plans. A repeated measures T-Test also confirmed that these findings were significant (p<.05)
between plans.
Planning Algorithms
In the current study, researchers gathered data using 3 different treatment planning
algorithms including Pinnacle’s CCC, and Eclipse’s AAA and AXB. The results showed a
consistent trend across all planning algorithms with an increase in skin dose when including
immobilization devices in the dose calculations. For example, the percent difference of D1.0 cc of
the skin showed increases in plans ranging from 0.88%-8.28% using CCC, 7.97%-12.71% using
AAA, and 2.72%-7.56% using AXB. In addition, all planning algorithms showed a trend of
decreased PTV coverage and dose to OAR when evaluating the mean of the percent difference
between plans with and without immobilization (Table 1).
Discussion
The results of this study were consistent with the findings of Olson et al7 suggesting that
the attenuating effects of immobilization have an impact on PTV target coverage. In addition,
these findings were confirmed using a larger sample size and were consistent when tested across
3 different treatment planning algorithms. This suggests that there is a deficit in treatment
planning practices across multiple systems in accounting for immobilization devices in dose
calculations.
The data from this study also showed a reduction in dose to OAR when accounting for
immobilization devices in dose calculations. The inaccuracies of dose reporting to OAR could
impact treatment planning in numerous ways. For example, in HN planning, trade-offs often take
place as the medical dosimetrist tries to maximize PTV coverage and minimize dose to OAR.
The reduced dose to OAR from the inclusion of immobilization devices could indicate that there
was more room to optimize coverage to the PTV and enhance treatment outcomes.
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All OAR metrics tested significant except for the mean dose reported to the right parotid.
Although the percent difference of the right parotid mean dose did display a reduction, the
change was not great enough to test significantly. This lack of significance may be ascribed to
the sample size, where further testing with a larger sample might show significance.
Furthermore, the researchers in this study also considered skin dose which is a topic of
interest with regards to VMAT treatment techniques. Bredfeldt et al9 suggested up to an 8%
higher skin dose with a marginally higher significance of Grade ≥ 2 acute skin toxicities when
using a VMAT treatment technique vs. IMRT in HN patients. Lee et al5 reported a bolus effect
from thermoplastic masks in HN cancer with an increase in the average skin dose by 18%.
Although these previous studies differ by reporting measurements of skin dose using
thermoluminescent dosimeters, the results are aligned with the findings of the current study
indicating an increase in skin dose due to HN immobilization in VMAT planning. Therefore, it is
suggested that care be taken in VMAT planning with considerations of limiting skin toxicity.
Conclusion
The presence of immobilization devices in dose calculations influences PTV coverage,
OAR, and skin dose. The decrease in PTV coverage and dose to OAR can be attributed to the
increased attenuation of the photon beam when considering immobilization. For PTV coverage,
the greatest effects were seen when assessing the V100, which may be attributed to differences in
dose homogeneity within the PTV. For OAR, although the mean of the percent difference did not
suggest a large change, all changes tested statistically significant with the exception of the mean
dose to the right parotid.
The current literature is supported by the findings of this study showing an increase in
skin dose due to the inclusion of immobilization devices in dose calculations. Multiple
researchers have shown the potential for a bolus effect with the use of immobilization devices
related to 3D conformal and IMRT planning.3,5-6 The results of this study validate the literature
and, in addition, suggest the need for considerations of skin toxicity in VMAT planning.
Finally, the effects of immobilization across 3 different treatment planning algorithms
were observed, which has not been addressed in current literature. All planning algorithms used
in this study produced findings consistent with previous conclusions recommending the
standardization of immobilization device inclusion in treatment planning. The conclusions made
in this study were not without limitations. Further research, including a larger sample size for
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each individual treatment algorithm, may aid in determining the dosimetric impact of HN
immobilization devices on OAR. Additional research may also be completed using one data set
across multiple planning algorithms with and without immobilization devices to further evaluate
the specific differences in dose calculation algorithms.
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References
1. Olch AJ, Gerig L, Li H, Mihaylov I, Morgan A. Dosimetric effects caused by couch tops and
immobilization devices: Report of AAPM Task Group 176. Med Phys. 2014;41(6):61501–
61530. http://dx.doi.org/10.1118/1.4876299
2. Munjal RK, Negi PS, Babu AG, et al. Impact of 6MV beam attenuation by carbon fiber
couch and immobilization devices in IMRT planning and dose delivery. J Med Phys.
2006;31(2):67–71. http://dx.doi.org/10.4103/0971-6203.26690
3. Seppälä JKH, Kulmala JAJ. Increased beam attenuation and surface dose by different couch
inserts of treatment tables used in megavoltage radiotherapy. J Appl Clin Med Phys.
2011;12(4):15-23. http://dx.doi.org/10.1120/jacmp.v12i4.3554
4. Dieterich S, Ford E, Pavord D, Zeng J. Immobilization techniques in radiotherapy. In:
Dieterich S, Ford E, Pavord D, Zeng J, ed. Practical Radiation Oncology Physics.
Philadelphia, PA: Elsevier, Inc; 2016:87-94.
5. Lee N, Chuang C, Quivey JM, et al. Skin toxicity due to intensity-modulated radiotherapy for
head-and-neck carcinoma. Int J Radiat Oncol Biol Phys. 2002;53(3):630-637.
http://dx.doi.org/10.1016/S0360-3016(02)02756-6
6. Pashkovskaya OA, Bedny IV, Anikeeva OY, Polovnikov ES. The evaluation of skin toxicity
during brain tumor irradiation dose calculation. Int J Biomed. 2013;3(4):283-286.
https://elibrary.ru/item.asp?id=20922807. Accessed April 24, 2018.
7. Olson A, Phillips K, Eng T, et al. Assessing dose variance from immobilization devices in
VMAT head and neck treatment planning: A retrospective case study analysis. Med Dosim.
2018;43(1):39-45. http://dx.doi.org/10.1016/j.meddos.2017.08.001
8. Marks LB, Yorke ED, Jackson A, et al. Use of Normal Tissue Complication Probability
Models in the Clinic. Int J Radiat Oncol Biol Phys. 2010;76(3):S10-S19.
http://dx.doi.org/10.1016/j.ijrobp.2009.07.1754
9. Bredfeldt J, Sapir E, Masi K, Schipper M, Eisbruch A, Matuszak M. TH-EF-BRD-11:
Clinical Skin Toxicity Comparison and Phantom Dose Measurements for Head and Neck
Patients Treated with IMRT vs. VMAT. Med Phys. 2015;42(6):3742-3742.
http://dx.doi.org/10.1118/1.4926298
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Figures

Figure 1. Patient positioning using a QFix Curve Board, thermoplastic mask and AccuForm
headrest.
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Figure 2. Contour representation of body (green) including HN immobilization devices in

Eclipse TPS.
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Figure 3. Contour (purple) used for immobilization devices separate from body contour in
Pinnacle TPS.
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Mean PTV Coverage

120.0%

99.3% 98.9%
100.0%
91.4%
Percent of PTV volume (%)

80.0% 74.0%

60.0%
Mean value Pre
Mean value Post
40.0%

20.0%

0.0%
PTV V95 PTV V100
Dose Volume Objective

Figure 4. The mean PTV coverage for plans without immobilization devices (pre) vs. plans with
immobilization devices (post).
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Organs at Risk
3.00% 0.00E+00
1.00E-02
Mean Percent Difference (%)

2.50%
2.00E-02
3.00E-02
2.00%
4.00E-02

P-value
1.50% 5.00E-02
6.00E-02
1.00%
7.00E-02
8.00E-02
0.50%
9.00E-02
0.00% 1.00E-01

Organ at Risk

Mean Percent Difference Significance Value (p)

Figure 5. The mean percent difference and significance value between plans with and without
immobilization devices for OAR.
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Average
-3.15%
-5.62%

Calculation Algorightm
-2.03%

AxB
-4.03%

AAA
-6.24%
-9.65%

-1.17%

CCC
-3.17%

-12.00% -10.00% -8.00% -6.00% -4.00% -2.00% 0.00%

Mean Percent Difference

Skin D0.03 cc Skin D1.0 cc

Figure 6. Increase in skin dose for patients using the treatment planning algorithms CCC, AAA,
and AXB.
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Tables

Table 1. Mean percent difference reported for PTV and OAR based on TPS algorithm used.
CCC Mean % AAA Mean % AxB Mean %
difference difference difference
Parotid L
D0.03 cc 2.84% 1.44% 1.95%
Dmean 1.88% 1.12% 0.15%
Parotid R
D0.03 cc 1.55% 1.36% 1.91%
Dmean 0.40% 0.11% 0.33%
Spinal Canal
D0.03 cc 1.94% 1.48% 1.97%
Dmean 1.59% 1.37% 2.00%
Brainstem
D0.03 cc 2.05% 1.79% 1.40%
Dmean 1.20% 0.90% 0.37%
Mandible
D0.03 cc 2.06% 1.31% 2.90%
Dmean 2.47% 2.25% 2.78%
PTV
V95 0.57% 0.00% 0.52%
V100 14.69% 16.32% 104.10%