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.
Not Met
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
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.