Karen Krueger

Parotid Lab
August 5, 2015
Plan 2 Mixed Beam- The patient was supine, with a large mask (that covered the patients
shoulders), on head rest A. A knee sponge was placed under the knees and the patients arms
were by her side.

GTV 100% > 6000cGy

GTV 100% = 4932.34cGy

Not Met

PTV > 95% = 6000cGy

68.67% = 6000cGy

Not Met

Max= 4635.6cGy
V48= 0

Met

Max= 4939.2cGy
V50= 0

Met

Mean= 3138.1cGy

Not Met

Max= 6924.8cGy
V70= 0
V60= 15.86

Not Met

Max= 517.4
Mean= 227.8
V50= 0

Met

Max= 4899.3cGy
Mean= 2288.2 cGy

Met

Max= 4440.7cGy
Mean= 2458.1cGy
V52= 0

Met

R Lens= 126.6cGy
L Lens= 151.6cGy

Met

Spinal Cord
Max < 4700cGy
V48<0.03cc
Spinal Cord +5mm
Max < 5000cGy
V50 <0.01cc
Contralateral Parotid
Mean < 2000cGy
Mandible
Max < 7500cGy
V70 <1%
V60<15%
Larynx
Max < 6600cGy
Mean 4400cGy
V50 <27%
Oral Cavity
Max < 6000cGy
Mean <3000cGy
Brainstem
Max < 5400cGy
Mean <3600cGy
V52 <0.03cc
Lens 0%= 300cGy

Cochlea
Mean<4500cGy

Mean= 3958.7

Met

Plan 2 Mixed beam

a) My wedged pair plan was much better. Mixed beam plans may be more suitable for small
superficial PTVs. When you have a treatment volume that extends deep into the patient, it is
more difficult to get the required coverage with mixed beam than it is with a wedged pair
technique. It was much easier to keep the dose out of the spinal cord with the wedged pair
because the wedge in the posterior oblique field pulled the dose distribution away from the spinal
cord.
b) Yes. The GTV and PTV coverage was not achieved. The contralateral parotid constraint was not
met and the mandible V60 constraint was not met.
I attempted this plan many ways. I have a large volume so I started with 6MV photons
and 20 MeV electrons. I created a separate plan for each. I adjusted my weighting by changing
the fractionation number between the two (i.e. prescribing 18 fractions to photons and 12
fractions to the electrons). I tried multiple variations and was not able to achieve coverage of the
PTV. A classmate then informed me that I can create one plan with a photon and electron field
and adjust the weighting. I did that. I still used 6MV and 20Mev. I normalized the plan so that
the 95% isodose level covered the PTV. I got a great looking plan with beautiful coverage, and
then realized that my spinal cord dose was way too high. It was close to 5900cGy. I tried
multiple things to reduce the cord dose. I placed a 15wedge in the beam. I then increased the
wedge to 30, 45, and finally 60. Although the dose to the cord was reduced, the plan got much
hotter. I added bolus to the photon field, then the electron field. I deleted the bolus from the
photon field. I tried decreasing the electron energy and the coverage decreased. I tried changing
the margin around the PTV. I used 1.5cm, 1.0cm, and 0.5cm. The plan was still hot and the cord
dose was still high to get any decent coverage. I tried using field-in-field with the collimator

turned to 90 for the photon field in order to block out only the spinal cord outside of the PTV.
The cord dose was reduced slightly. I tried using the field-in-field technique to block the spine
including the spinal cord in the PTV. Again the coverage was reduced, but the cord looked better.
I tried adjusting the weighting to bring the coverage back up, but the cord just got hot again. I
noticed in Bentel that a 15 wedge and electron compensator were used for mixed beam. We
dont have an electron compensator so I drew the block to cover the cord and act as a
compensator and placed a 15 wedge in the beam. The cord dose looked great, but the coverage
was horrible. I fit the electron block around the PTV with no margin, and the plan was still no
good. By this time, I had tried every electron energy, every wedge, and every form of blocking
that I could think of and still the plan was not acceptable.
At this point, my physicist, Angelika Impeduglia-Gielow (who is also a CMD) said that
she would like to see my plans. She confirmed that it was not possible to get adequate coverage
to my PTV with a mixed beam plan. She looked at my plans and determined that she liked the
dose distribution of the 9Mev and 6MV plan the best. She said normalize it down and use that, so
I did. I normalized to reduce the dose to the cord to 4700cGy or less.
The plan does not look great, but I tried. The mandible V60 constraint was not met
because part of the mandible is in the PTV. This could have been prevented if the chin was
extended. The contralateral parotid did not meet the constraint because the 40% isodose level
covered it. I had a deep PTV volume and when I normalized to get deep coverage, the
contralateral parotid received more dose.
I learned a lot from working on this plan. I would never attempt a mixed beam plan with
a deep seated tumor, especially if the spinal cord is directly in the treatment field, unless I were
prescribing to a dose suitable for the spinal cord. In Bentel, a 15 wedge and electron
compensator were used. In addition, in Bentel, the mixed beam plan was prescribed for 5000cGy.
I may have been more successful with a smaller field. The PTV extended posterior and medial,
which made it more difficult to acquire coverage and spare the spinal cord. I understand that the
deeper coverage should come from the photons and the superficial coverage from the electrons. I
also understand that a wedge and electron compensator may be used to manipulate the dose and
spare the spinal cord in some cases. However, when I applied these techniques my coverage was

greatly reduced. If presented with a situation like this in the future, I will save time and opt for
other planning techniques if possible.
If I had continued to work on this plan, I would have reduced the margin around the PTV.
However, I followed the advice of my physicist and feel that I invested enough time in this
activity to learn what was expected. In the end, I was not able to get a good plan with this
technique. This was a valuable lesson for me to learn. Sometimes you have to know when to call
it quits.

Figure 1. Isodose distribution of mixed beam plan with maximum dose location shown.
Planning target volume (PTV) shown in red.

Figure 2. Isodose distribution of mixed beam. PTV shown in red. Gross tumor volume shown in
orange.

Figure 3. Dose volume histogram (DVH) of the mixed beam plan.

Figure 4. Plan for mixed beam technique.

Figure 5. Comparison of parotid and parotid bed size.