Impact of patient positioning on radiotherapy dose distribution: An assessment in parotid tumor

Purpose: We intended to study the impact of patient positioning on the dose distribution within target volume and organs at risk in patients with parotid malignancies treated with 3D conformal radiotherapy (3D-CRT) with photon wedge pair (WP) or intensity modulated radiotherapy (IMRT).Methods: Three patients with a non-Hodgkin’s lymphoma of the right parotid gland were consecutively immobilized using thermoplastic cast in 2 positions: supine with head in neutral position (HN) and with head turned 90° to the left side (HT). Images for treatment planning purpose were acquired in both positions. For both positions, photon WP plans and 5 field IMRT plans were generated, after contouring clinical target volume (CTV), planning target volume (PTV= CTV + 5 mm margin) and organs at risk (OAR). All plans were evaluated for target coverage and dose to OARs.Results: Both CTV and PTV were apparently larger in HN compared with HT (31.76±8.89 cc, 30.31±7.83 cc and 62.49±19.01 cc, 58.89±15.33 cc) respectively. The CI value for PTV was slightly better for HT compared to HN position in both the WP and IMRT plans. The homogeneity was comparable in both the head positions in case of WP plan. The mean HI of PTV was increased in case of IMRT plan at HT versus HN position (1.108 vs. 1.097). A change in head position from HN to HT with wedge pair plan resulted in a reduction of brainstem Dmax and Dmean. Lesser dose was observed in HN position for contralateral parotid. A difference of 0.9 Gy in the average Dmax to spinal cord was seen. The values of Dmean to mandible, oral cavity, ipsilateral and contralateral cochlea were higher in the HT position. A change in head position from HN to HT with IMRT plan resulted in a dose reduction in average Dmax to brainstem. The spinal cord Dmax increased at the HT position by 1.2 Gy. The dose to contralateral parotid and cochlea was comparable in both the positions. However, the Dmean to oral cavity was reduced at HT position. Whereas for IMRT versus wedge pair plan at head neutral position average Dmean to the contralateral parotid was reduced with the IMRT plan. A considerable reduction in Dmax to spinal cord and Dmean to ipsilateral cochlea was observed. A slight increase in average Dmax to brainstem and was observed with the IMRT plan. The doses to the remaining OARs were lesser in case of IMRT plan. For IMRT versus wedge pair plan at head tilt position slight increase in average Dmax to brainstem was observed in case of IMRT plan. A considerable reduction in Dmax to spinal cord and Dmean to ipsilateral cochlea was observed. The doses to the remaining OARs were reduced with IMRT plan.Conclusion: Change in head position from neutral to 90° contralateral tilt for wedge pair plan in parotid tumor may considerably reduce dose to the brainstem and spinal cord with a modest increase in dose to mandible, oral cavity, contralateral parotid, and bilateral cochlea. The alteration in head position has minimal impact on IMRT planning.