Incorporating parotid gland inhomogeneity into head-and-neck treatment optimization through the use of artificial base plans.

Despite a great improvement in target volume dose conformality made possible in recent years by modulated therapies, xerostomia remains a common and severe side effect for head-and-neck radiotherapy patients. It is known that parotid glands exhibit a spatially varying dose response; however, the relative importance of subregions throughout the entire gland has yet to be incorporated into treatment plan optimization, with the current standard being to minimize the mean dose to whole parotid glands. The relative importance of regions within contralateral parotid glands has been recently quantified, creating an opportunity for the development of a method for including this data in plan optimization. We present a universal and straightforward approach for imposing varying sub-parotid gland dose constraints during inverse treatment planning by using patient-specific artificial base plans to penalize dose deposited in sensitive regions. In this work, the proposed method of optimization is demonstrated to reduce dose to regions of high relative importance throughout contralateral parotids and improve predictions for stimulated saliva output at 1-year post-radiotherapy. This method may also be applied to impose varying dose constraints to other organs-at-risk for which regional importance data exists.