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Amanda Lisher

DOS 772: Clinical Practicum II


Clinical Lab Assignment: LEFT Parotid
August 9, 2015
Plan #1
Table 1: OR constraints for LT parotid plan 1, wedged pair.
Structure
Constraint
Actual Dose
LT Parotid

Constraint Met?

GTV: V100= 100


PTV: V95= 100
Max < 54Gy
V60= 1%
Max < 45Gy

GTV: V100=76%
PTV: V95=95%
Max=27.83 Gy
V60=0%
Max=27.27 Gy

No

Max=2.85 Gy
Mean=1.26 Gy
Max=4.07 Gy
Mean=1.42 Gy
Max=1.5 Gy

Yes

Lt Lens

Max < 50Gy


Mean < 35Gy
Max < 50Gy
Mean < 35Gy
Max < 25Gy

Rt Lens

Max < 25Gy

Max=1.89 Gy

Yes

Lt Optic Nerve

Max=1.73 Gy
V60=0%
Max=1.36 Gy
V60=0%
Mean=3.37 Gy

Yes

Larynx

Max < 54Gy


V60= 1%
Max < 54Gy
V60= 1%
Mean < 45Gy

Mandible

Max < 70Gy

Max=64.41 Gy

Yes

Oral Cavity

Mean < 40Gy

Mean=22.91Gy

Yes

Rt Parotid

Mean < 26Gy


V30 < 50%

Mean=1.07 Gy
V30=0%

Yes

Brainstem
Spinal Cord
Lt Orbit
Rt Orbit

Rt Optic Nerve

Yes
Yes

Yes
Yes

Yes
Yes

MCHATTON, JAMES,
Date/Time:
20150807 18:46:23
L2889
Comment:
PPPplan 1
PAROTID PLANNING PROJECTInstitution:
9.6 Lawrence Radiation Oncolog...
Trial_1
Physician/Physicist: AT/RH
R04.P04.D05
Planner:
ML
Not Locked

Patient Name:
Patient ID:
Plan Name:
Trial Name:
Revision:
Lock Status:

Plan Summary Sheet


Beam Setup
Beam
LAO
LPO
AP SCV

Machine
LMH IX
LMH IX
LMH IX

Energy
6XLCCO
6XLCCO
15XLCCO

Modality
Photons
Photons
Photons

Beam
LAO
LPO
AP SCV

Collimators (cm) (Control Pt 1)


X1
X2
Y2
Y1
4.00
4.00
5.00
3.50
4.50
4.00
4.50
3.50
4.00
4.00
6.00
6.00

Prescription
LT PAROTID
LT PAROTID
AP SCV

Gantry
Start / Stop
45 / 45
135 / 135
0 / 0

Couch
0
0
0

SSD (cm)
Isocenter Start / Avg
isoM
98.07 / 98.07
isoM
97.94 / 97.94
scv is... 100.00/ 100.00

Coll Block
0.0 MLC
0.0 MLC
0.0 MLC

MU Per Fraction
217
218
186

Wedge
Bolus
45_MLC... No
45_MLC... No
None
No

Comp
No
No
No

Prescriptions
LT PAROTID
Prescribe 200 cGy per fraction to 97 % of point dose at "calc ptM" for 30 fractions.
Beam weights are proportional to point dose.
Actual point dose at "calc ptM" from all prescriptions/beams is 6211.89 cGy.
2 beams are assigned to this prescription.

AP SCV
Prescribe 180 cGy per fraction to 100 % of point dose at "scv calc ptM" for 28 fractions.
Beam weights are proportional to point dose.
Actual point dose at "scv calc ptM" from all prescriptions/beams is 5063.72 cGy.
1 beam is assigned to this prescription.

Isocenter
isoM
Position patient such that lasers line up with patient marks.
Move the table LEFT 5.00 cm (looking from foot of table.)
Move the table UP 2.02 cm.
Move the table IN (toward the gantry) 0.00 cm.

scv isoM
Position patient such that lasers line up with patient marks.
Move the laser RIGHT 5.00 cm (looking from foot of table.)
Move the table UP 2.28 cm.
Move the table IN (toward the gantry) 9.50 cm.

Figure 1: Plan parameters for left parotid plan 1, wedged pair.


Plan Authorization:

Pinnacle v9.6
Pg 1 of 1 PLN

Patient Name:
Patient ID:
Plan Name:
Lock Status:

MCHATTON, JAMES,
L2889
PAROTID PLANNING PROJECT
Not Locked

Date/Time:
20150807 18:15:53
Comment:
PPPplan 1
Physician/Physicist:
AT/RH

Figure 2: Plan 1 isodose distribution (Green=100%, Purple=95%, Blue=100% prescribed SCV


dose, Red=75%, Aqua=40%).

Revision:
Planner:
Institution:

R03
ML
9.6 L

Patient Name:
Patient ID:
Plan Name:
Lock Status:

MCHATTON, JAMES,
L2889
PAROTID PLANNING PROJECT
Not Locked

Date/Time:
20150807 18:18:18
Comment:
PPPplan 1
Physician/Physicist:
AT/RH

Figure 3: Location of the maximum dose for plan 1.

Revision:
Planner:
Institution:

R03.P04.D05
ML
9.6 Lawrence

RTP System 9.6

Patient Name:
Patient ID:
Plan Name:
Lock Status:

MCHATTON, JAMES,
L2889
PAROTID PLANNING PROJECT
Not Locked

Date/Time:
20150807 18:34:29
Comment:
PPPplan 1
Physician/Physicist:
AT/RH

Revision:
Planner:
Institution:

R04.P04.D05
Page:
ML
Scaling:
9.6 Lawrence Radiation Oncology

1 of 1
Fill Page

Patient Name:
Patient ID:
Plan Name:
Lock Status:

MCHATTON, JAMES,
L2889
PAROTID PLANNING PROJECT
Not Locked

Date/Time:
20150807 18:34:47
Comment:
PPPplan 1
Physician/Physicist:
AT/RH

Revision:
Planner:
Institution:

R04.P04.D05
ML
9.6 Lawrence

RTP System 9.6

Patient Name:
Patient ID:
Plan Name:
Lock Status:

MCHATTON, JAMES,
L2889
PAROTID PLANNING PROJECT
Not Locked

Date/Time:
20150807 18:36:28
Comment:
PPPplan 1
Physician/Physicist:
AT/RH

Revision:
Planner:
Institution:

R04.P04.D05
Page:
ML
Scaling:
9.6 Lawrence Radiation Oncology

1 of 1
Fill Page

RTP System 9.6

Patient Name:
Patient ID:
Plan Name:
Lock Status:

MCHATTON, JAMES,
L2889
PAROTID PLANNING PROJECT
Not Locked

Date/Time:
20150807 18:36:07
Comment:
PPPplan 1
Physician/Physicist:
AT/RH

Revision:
Planner:
Institution:

Figure 4: Plan 1 DVH


A. With the chin extended, the patients orbits would be lifted superiorly away from the
oblique fields. My patient did not have his chin extended, and I had to be extra cautious
that my fields did not exit through the contralateral orbit.
B. I was not able to achieve the prescribed isodose coverage. This was primarily due to dose
lost in the superficial parotid tissue, near the build-up region. Coverage was also
suboptimal in the superior parotid, due to the field size being shortened to avoid dose
exiting through the contralateral orbit, as mentioned above.

R04.P04.D05
Page:
ML
Scaling:
9.6 Lawrence Radiation Oncology

1 of 1
Fill Page

Plan #2
Table 2: OR constraints for LT parotid plan 2, mixed beam.
Structure
Constraint
Actual Dose
LT Parotid

Constraint Met?

GTV: V100= 100


PTV: V95= 100
Max < 54Gy
V60= 1%
Max < 45Gy

GTV: V100=90.4%
PTV: V95=98%
Max=32.6 Gy
V60=0%
Max=29.8 Gy

No

Max=2.29 Gy
Mean=0.85 Gy
Max=1.33 Gy
Mean=0.76 Gy
Max=0.84 Gy

Yes

Lt Lens

Max < 50Gy


Mean < 35Gy
Max < 50Gy
Mean < 35Gy
Max < 25Gy

Rt Lens

Max < 25Gy

Max=0.94 Gy

Yes

Lt Optic Nerve

Max=4.63 Gy
V60=0%
Max=1.88 Gy
V60=0%
Mean=1.35 Gy

Yes

Larynx

Max < 54Gy


V60= 1%
Max < 54Gy
V60= 1%
Mean < 45Gy

Mandible

Max < 70Gy

Max=70.7 Gy

No

Oral Cavity

Mean < 40Gy

Mean=11.8 Gy

Yes

Rt Parotid

Mean < 26Gy


V30 < 50%

Mean=16.4 Gy
V30=0%

Yes

Brainstem
Spinal Cord
Lt Orbit
Rt Orbit

Rt Optic Nerve

Yes
Yes

Yes
Yes

Yes
Yes

MCHATTON, JAMES,
Date/Time:
20150807 19:44:06
L2889
Comment:
PPPplan 2
PAROTID PLANNING PROJECTInstitution:
9.6 Lawrence Radiation Oncolog...
Trial_2
Physician/Physicist: AT/RH
R04.P05.D06
Planner:
ML
Not Locked

Patient Name:
Patient ID:
Plan Name:
Trial Name:
Revision:
Lock Status:

Plan Summary Sheet


Beam Setup
Beam
LT LAT
LT LAT e

Beam
LT LAT
LT LAT e

Machine
LMH IX
LMH IX e

Energy
6XLCCO
15 MeV

SSD (cm)
Modality Prescription
Isocenter Start / Avg
Photons LT PAROTID
calc p...
96.30 / 96.30
Electrons LT PAROTID e 12e is... 100.50/ 100.50

Collimators (cm) (Control Pt 1)


X1
X2
Y2
Y1
4.00
4.00
4.50
4.50
5.00
5.00
5.00
5.00

Gantry
Start / Stop
90 / 90
90 / 90

Couch
0
0

Coll Block
0.0 MLC
0.0 Yes

MU Per Fraction
177
133

Wedge
Bolus
45_MLC... No
None
Yes

Comp
No
No

Prescriptions
LT PAROTID
Prescribe 80 cGy per fraction to 97 % of point dose at "calc ptM" for 30 fractions.
Beam weights are proportional to point dose.
Actual point dose at "calc ptM" from all prescriptions/beams is 6319.35 cGy.
1 beam is assigned to this prescription.

LT PAROTID e
Prescribe 120 cGy per fraction to 90 % of point dose at "12e calc pt" for 30 fractions.
Beam weights are proportional to point dose.
Actual point dose at "12e calc pt" from all prescriptions/beams is 6609.11 cGy.
1 beam is assigned to this prescription.

Isocenter
calc ptM
Position patient such that lasers line up with patient marks.
Move the table LEFT 3.05 cm (looking from foot of table.)
Move the table UP 2.02 cm.
Move the table OUT (away from the gantry) 0.75 cm.

12e iso
Position patient such that lasers line up with patient marks.
Move the table LEFT 7.25 cm (looking from foot of table.)
Move the table UP 2.01 cm.
Move the table OUT (away from the gantry) 0.75 cm.

Figure 5: Plan parameters for LT parotid plan 2, mixed beam.


Plan Authorization:

Pinnacle v9.6
Pg 1 of 1 PLN

Patient Name:
Patient ID:
Plan Name:
Lock Status:

MCHATTON, JAMES,
L2889
PAROTID PLANNING PROJECT
Not Locked

Date/Time:
20150807 19:43:48
Comment:
PPPplan 2
Physician/Physicist:
AT/RH

Figure 6: Isodose distribution and maximum dose point for plan 2, wedged pair (Green=100%,
Purple=95%, Red=75%, Aqua=40%).

Revision:
Planner:
Institution:

R04.P
ML
9.6 L

RTP System 9.6

Patient Name:
Patient ID:
Plan Name:
Lock Status:

MCHATTON, JAMES,
L2889
PAROTID PLANNING PROJECT
Not Locked

Date/Time:
20150807 19:45:27
Comment:
PPPplan 2
Physician/Physicist:
AT/RH

Revision:
Planner:
Institution:

R04.P05.D06
Page:
ML
Scaling:
9.6 Lawrence Radiation Oncology

1 of 1
Fill Page

RTP System

Patient Name:
Patient ID:
Plan Name:
Lock Status:

MCHATTON, JAMES,
L2889
PAROTID PLANNING PROJECT
Not Locked

Date/Time:
20150807 19:45:44
Comment:
PPPplan 2
Physician/Physicist:
AT/RH

Revision:
Planner:
Institution:

R04.P05.D06
Page:
ML
Scaling:
9.6 Lawrence Radiation Oncology

1 of 1
Fill Page

RTP System 9.6

Patient Name:
Patient ID:
Plan Name:
Lock Status:

MCHATTON, JAMES,
L2889
PAROTID PLANNING PROJECT
Not Locked

Date/Time:
20150807 19:46:45
Comment:
PPPplan 2
Physician/Physicist:
AT/RH

Revision:
Planner:
Institution:

R04.P05.D06
Page:
ML
Scaling:
9.6 Lawrence Radiation Oncology

1 of 1
Fill Page

Patient Name:
Patient ID:
Plan Name:
Lock Status:

MCHATTON, JAMES,
L2889
PAROTID PLANNING PROJECT
Not Locked

Date/Time:
20150807 19:47:09
Comment:
PPPplan 2
Physician/Physicist:
AT/RH

Figure 7: Plan 2 DVH


A. The GTV coverage for the mixed beam plan is significantly better. Most of the OR doses
were comparable between the two plans. However, the dose to the right parotid increased
with the mixed beam plan. This is due to increased exit dose from the lateral beams. With
the wedged pair plan, both beams were angled in a way that the exit dose almost
completely missed the right parotid. The oral cavity dose was twice as much in the
wedged pair plan, for the same reasonthe PO field was angled toward the oral cavity,
contributing exit dose. The lateral beams in the mixed plan contribute lower dose to the
oral cavity. The left optic nerve dose increased slightly with the mixed beam plan, most
likely due to the inferior 45-degree wedge that I placed on the photon beam, which
pushed the dose more superior than in the wedged pair plan.

Revision:
Planner:
Institution:

R04.P05.D06
ML
9.6 Lawrence Radiation O

B. The mandible max dose increased slightly in the mixed beam plan, enough that it
exceeded the dose constraint. The mandible volume directly abuts the parotid gland,
making it a difficult OR to avoid. Also, while the isodose coverage was better with the
mixed beam plan, the prescribed dose was still not achieved. Dose was lost in the PTV
inferiorly due to the 45-degree wedge placed to push dose superior. There was also some
of the deeper PTV tissue that was not adequately covered. The GTV dose was suboptimal
superficially, again, despite the electron beam and a 0.5cm bolus placed on the skin
surface. Incidentally, I should have done a better job cleaning up the bolus. I built it using
the tools in Pinnacle, but I did not look closely enough to notice that the bolus overlapped
itself around the ear, making the effective bolus 1.0cm or more. This most likely
contributed to the placement of the maximum dose point, in addition to the wedge.
Plan 3
Table 3: OR constraints for LT parotid plan 3, IMRT.
Structure
Constraint
Actual Dose
LT Parotid

Constraint Met?

GTV: V100= 100


PTV: V95= 100
Max < 54Gy
V60= 1%
Max < 45Gy

GTV: V100= 99.9%


PTV: V95= 99.9%
Max= 29.54 Gy
V60= 0%
Max= 23.52 Gy

Yes

Max= 4.29 Gy
Mean= 1.35 Gy
Max= 4.04 Gy
Mean= 0.89 Gy
Max= 1.74 Gy

Yes

Lt Lens

Max < 50Gy


Mean < 35Gy
Max < 50Gy
Mean < 35Gy
Max < 25Gy

Rt Lens

Max < 25Gy

Max= 1.43 Gy

Yes

Lt Optic Nerve

Max= 1.66 Gy
V60= 0%
Max= 1.12 Gy
V60= 0%
Mean= 0.53 Gy

Yes

Larynx

Max < 54Gy


V60= 1%
Max < 54Gy
V60= 1%
Mean < 45Gy

Mandible

Max < 70Gy

Max= 63.27 Gy

Yes

Oral Cavity

Mean < 40Gy

Mean= 13.77 Gy

Yes

Rt Parotid

Mean < 26Gy


V30 < 50%

Mean= 6.8 Gy
V30= 0%

Yes

Brainstem
Spinal Cord
Lt Orbit
Rt Orbit

Rt Optic Nerve

Yes
Yes

Yes
Yes

Yes
Yes

MCHATTON, JAMES,
Date/Time:
20150809 14:05:22
L2889
Comment:
PPPplan 3
PAROTID PLANNING PROJECTInstitution:
9.6 Lawrence Radiation Oncolog...
Trial_3
Physician/Physicist: AT/RH
R05.P06.D07
Planner:
ML
Not Locked

Patient Name:
Patient ID:
Plan Name:
Trial Name:
Revision:
Lock Status:

Plan Summary Sheet


Beam Setup
Beam
180PA
220RPO
340RAO
20LAO
60LAO
100LPO
140LPO

Beam
180PA
220RPO
340RAO
20LAO
60LAO
100LPO
140LPO

Machine
LMH IX
LMH IX
LMH IX
LMH IX
LMH IX
LMH IX
LMH IX

Energy
6XLCCO
6XLCCO
6XLCCO
6XLCCO
6XLCCO
6XLCCO
6XLCCO

Modality
Photons
Photons
Photons
Photons
Photons
Photons
Photons

Collimators (cm) (Control Pt 1)


X1
X2
Y2
Y1
4.00
4.00
4.50
4.50
4.00
4.00
4.50
4.50
4.00
4.00
4.50
4.50
4.00
4.00
4.50
4.50
4.00
4.00
4.50
4.50
4.00
4.00
4.50
4.50
4.00
4.00
4.50
4.50

Prescription
parotid IMRT
parotid IMRT
parotid IMRT
parotid IMRT
parotid IMRT
parotid IMRT
parotid IMRT

Gantry
Start / Stop
180 / 180
220 / 220
340 / 340
20 / 20
60 / 60
100 / 100
140 / 140

Isocenter
imrtM
imrtM
imrtM
imrtM
imrtM
imrtM
imrtM

Couch
0
0
0
0
0
0
0

SSD (cm)
Start / Avg
93.65 / 93.65
90.58 / 90.58
90.55 / 90.55
95.99 / 95.99
98.09 / 98.09
98.12 / 98.12
97.72 / 97.72

Coll Block
0.0 MLC
0.0 MLC
0.0 MLC
0.0 MLC
0.0 MLC
0.0 MLC
0.0 MLC

Wedge
None
None
None
None
None
None
None

MU Per Fraction
61
39
82
42
57
50
45

Bolus
No
No
No
No
No
No
No

Comp
No
No
No
No
No
No
No

Prescriptions
parotid IMRT
Prescribe 200 cGy per fraction to 97 % of "PTVmGAP" mean dose for 30 fractions.
Actual "PTVmGAP" mean dose from all prescriptions/beams is 6170.13 cGy.
7 beams are assigned to this prescription.

Isocenter
imrtM
Position patient such that lasers line up with patient marks.
Move the table LEFT 5.00 cm (looking from foot of table.)
Move the table UP 2.02 cm.
Move the table OUT (away from the gantry) 1.00 cm.

Figure 8: Plan parameters for LT parotid plan 3, IMRT.

Plan Authorization:

Pinnacle v9.6
Pg 1 of 1 PLN

Patient Name:
Patient ID:
Plan Name:
Lock Status:

MCHATTON, JAMES,
L2889
PAROTID PLANNING PROJECT
Not Locked

Date/Time:
20150809 14:01:35
Comment:
PPPplan 3
Physician/Physicist:
AT/RH

Figure 9: Isodose distribution and maximum dose point for plan 3, IMRT (Green=100%,
Purple=95%, Red=75%, Aqua=40%).

Revision:
Planner:
Institution:

R05.P06.D0
ML
9.6 Lawrenc

RTP System 9.6

Patient Name:
Patient ID:
Plan Name:
Lock Status:

MCHATTON, JAMES,
L2889
PAROTID PLANNING PROJECT
Not Locked

Date/Time:
20150809 14:03:16
Comment:
PPPplan 3
Physician/Physicist:
AT/RH

Revision:
Planner:
Institution:

R05.P06.D07
Page:
ML
Scaling:
9.6 Lawrence Radiation Oncology

1 of 1
Fill Page

Patient Name:
Patient ID:
Plan Name:
Lock Status:

MCHATTON, JAMES,
L2889
PAROTID PLANNING PROJECT
Not Locked

Date/Time:
20150809 14:03:36
Comment:
PPPplan 3
Physician/Physicist:
AT/RH

Revisio
Planne
Institut

RTP System 9.6

Patient Name:
Patient ID:
Plan Name:
Lock Status:

MCHATTON, JAMES,
L2889
PAROTID PLANNING PROJECT
Not Locked

Date/Time:
20150809 14:05:02
Comment:
PPPplan 3
Physician/Physicist:
AT/RH

Revision:
Planner:
Institution:

R05.P06.D07
Page:
ML
Scaling:
9.6 Lawrence Radiation Oncology

1 of 1
Fill Page

Patient Name:
Patient ID:
Plan Name:
Lock Status:

MCHATTON, JAMES,
L2889
PAROTID PLANNING PROJECT
Not Locked

Date/Time:
20150809 14:04:44
Comment:
PPPplan 3
Physician/Physicist:
AT/RH

Figure 10: Plan 3 DVH


A & B. At our clinic, the script for IMRT is for a 9-field plan, with beams entering every 40
degrees around the isocenter (180, 220, 260, 300, 20, 60, 100, 140 degrees). For this plan, I did
not want beams entering through the right side of the patient if possible. There is no reason to
have a beam entering near the right parotid, for instance, when it would be best to spare the right
parotid as much as possible. It would be best to avoid this area in order to maintain salivary
gland function, given that we are treating the left parotid. So for this plan, I eliminated the beams
at 260 and 300 degrees from the start. Typically, when we are treating a small volume that sits
relatively lateral in the patient, we will use beams spaced closer together, maybe 25-30 degrees
in between rather than 40 degrees. For this patient, however, the point of maximum dose

Revision:
Planner:
Institution:

R05.
ML
9.6 L

typically resides near the skin surface, where there are tissue irregularities and varying target
depths. I felt that scooting the beams closer together would increase the area where beams
overlap, which would contribute dose to already hot tissue. So I decided to keep the beams
spaced 40 degrees apart. My final plan consisted of 7 beams, at 180, 220, 340, 20, 60, 100 and
140 degrees. This arrangement allowed me to achieve the isodose distribution I was hoping for,
without making the plan too hot. Fewer beams might have achieved the same coverage, with
less time on the table for the patient. However, I feel this plan was a good balance between target
coverage and hot spots. With 7 beams the dose to normal tissue, namely the shallow area near
the parotid gland, was spared excess entry dose. The exit dose from all beams was also nicely
spread among the adjacent OR, making it so no one area took a larger amount of exit dose.

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