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Doris Chen
Final Planning Project
October 31, 2015
History and Extend of Gross Disease
Patient RV is a 66-year-old retired historian of Hispanic descent. He expressed feeling
perpetual pain and experienced swelling of his left upper neck. After being admitted to the
hospital in September 2015, the physician noticed 6 cm mass in the left upper neck with
significant trismus. A CT scan of the neck revealed a 4 cm x 5.5 cm heterogeneous mass in the
left parotid gland with regularity and narrowing of the proximal portion of the internal carotid
vessel, near its bifurcation. There was also suspicion of left laryngeal thickening. The head and
neck examination revealed a large multilobulated mass on the left upper neck from the posterior
to the left pre-mastoid region. There were no other palpable neck nodes. There was a fungating
and ulcerating mass in the left in the left retromolar tigone. Fine needle aspiration was positive
for squamous cell carcinoma (SCC) although patient RV's previous PET/CT did not show
evidence of uptake in the area of interest. Patient RV lost over 30 pounds within the last three
months as a result of pain, difficulty swallowing, and difficulty in opening his mouth. He had a
strong 50-year history of heavy smoking and drinking. The radiation oncologist diagnosed
patient RV with oral cavity cancer, SCC of the retromolar tigone, clinical stage T4N2bM0.
Treatment Prescription
Patient RV was offered a combined external radiation therapy and chemotherapy - weekly
cisplatin of 40-50 mg/mL surface areas. The external radiation therapy will be using IMRT with
image guidance. The IMRT allows the delivery of 6996 cGy (212cGy/fx) to the gross tumor
volume, while delivering 5940 (180cGy/fx) to the high risk region while the contralateral (right)
side will receive 5400 cGy (180cGy/fx). Additionally, bilateral supraclav of 5040 cGy
(180cGy/fx) will be give to treat the neck nodes using a 3D technique. The physician wanted
95% of the PTV covered by 95% of the dose for each dose levels. For the supraclav nodes, the
physician requested point dose of 3 cm depth.
Simulation Process & Setup
Patient RV was simulated in the supine position with the head facing in the superior
direction and feet in the inferior direction. A wedge was placed at where the femur articulated
with the tibia/fibula or patient comfort, and to allow the spine to rest in a more neutral position.

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Patient RV was immobilized with an Aquaplast mask that followed the curvatures of his head.
Arms straps were used to pull the shoulders out of the treatment field. Additionally, a bite block
was used to get the tongue out of the treatment field. The radiation therapist placed 3 BB markers
(two laterals and one anterior) for initial setup, prior to shifting to the isocenter.

Figure 1: Patient RVs supine, head and neck set. Head is immobilized with an Aquaplast mask,
a bite block in place, arm straps, and knee wedge.
Treatment Planning Process
After the CT scans were transferred into Pinnacle 9.10 TPS, the physician delineated
three PTVs 6996 an isocenter was chose to allow a 1 cm gap between the AP supraclavicular
(SCLV) field and the head and neck beams. The purpose of the 1 cm gap is to prevent the match
line from being under or overdosed. The goal was to have the 5000cGy isodose line (IDL)
continuous throughout the head and neck region of interest. The AP SCLV field was rotated 90degrees so that the multi-leaf collimators (MLCs) were oriented in the sup-inf position. A
midline block was used to reduce dose to the spinal cord. Also, blocks were placed to shield the
uninvolved lungs without blocking the supraclavicular nodes. cGy, 5940 cGy, and 5400 cGy.
Since the physician did not specify adding a bolus, I created three planning PTVs that cropped
the original PTVs 5mm from the body to account for dose build-ups. Also, by cropping the PTVs
5mm from the body would help ease the optimization process because it would be difficulty to

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find a solution that would deliver adequate dose to the skin without increasing the global
maximum dose.
The organs at risk (OR) contoured were: right parotid, larynx, oral cavity, spinal cord,
brainstem, and temporomandibular joint (TMJ). The left parotid was not listed as an OR because
the entire PTV6996 encompassed the left parotid. Additionally, the spinal cord had a 5mm
expansion to help save the spinal cord since all three PTVs wrapped around the spinal cord. It
would be difficult to come up with a plan that would meet the spinal cord and brainstem
constraint without underdosing each the PTV.
An isocenter was chosen strategically to allow a 1 cm gap between the AP
supraclavicular (SCLV) field and the head and neck beams. The purpose of the 1 cm gap is to
prevent the match line from being under or overdosed. The goal was to have the 5000cGy
isodose line (IDL) continuous throughout the head and neck region of interest. The AP SCLV
field was rotated 90 so that the multi-leaf collimators (MLCs) were oriented in the sup-inf
position. A midline block was used to reduce dose to the spinal cord. Also, blocks were placed to
shield the uninvolved lungs without blocking the supraclavicular nodes.

Figure 2: AP SCLV field with midline and lung blocks. The 3cm depth normalization point
(yellow) was placed at least 1cm away from the field edge. The isocenter (pink) was placed 1cm
inferior to the head and neck PTVs 6996 cGy (blue), 5940 cGy (red), 5400 cGy (green).
For the approved IMRT (IMRT 1) plan, 9 beams were evenly spaced 40 apart starting at
180 with no collimation. In the comparison IMRT plan (IMRT 2); the same beam angles were
used except three of the fields (G20, G180, and G340) were collimated 90 to better block the
spinal cord and the brainstem. The reason why G20, G180, and G340 were collimated 90
was because in those fields, the spinal cord and brainstem were oriented vertically, rather than on
an angle. Since this patient was treated with a single isocenter, only 90 collimations would
preserve a perfect matchline with the AP SCLV field without any beams overlapping. If the
collimator were rotated obliquely such as 45 or 315, these fields would overlap with the AP
SCLV field, which would increase the dose to the matchline area. Although couch rotations
would address the beam divergence issue if the collimator were rotated obliquely or noncardinally, the patients poor health condition could not tolerate an extensive treatment time.
The first iteration of the IMRT 1 plan did not yield fruitful results. The spinal cord

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exceeded the 45 Gy limit and the brainstem was receiving a little more than 54 Gy. Also, it was
impossible the get the mean dose of the right parotid less than 20Gy because the PTV 5940 and
5400 were located within close proximity of the parotid. If the right parotid were to be saved,
both PTVs had broad shoulders and 95% IDL failed to cover 95% of the target. Therefore, the
physician prioritized adequate coverage to all three PTV levels, serial organ (spinal cord and
brainstem) preservations, and oral cavity criteria. He was willing to accept higher mean dose to
right parotid under the condition that all of his objectives were met.
Based on the physicians request, I re-optimized the plan and increased the number of
segments from 50 to 70 to give the treatment planning system (TPS) more options on generating
beamlets. The second iteration successfully saved the spinal cord and brainstem; however, the
high dose levels spilled outside of the PTVs and went into the normal tissue. Normally, I would
create ring structures for the PTVs to make the plan more conformal, but since the PTVs were
fairly close to each other, the ring structures would be counterproductive and confuse the
optimizer. Instead, I created an avoidance structure that contoured out the regions where the high
dose spillage occurred and gave this structure a fairly high priority. Figure 3 is the coronal view
of the IMRT 1 (approved plan) showing the spinal cord (magenta) and brainstem (cyan) being
enveloped by the three PTV levels. The different dose levels nicely conformed to the each
individual PTVs. Figure 4 is the dose volume histogram (DVH) of IMRT 1, which included the
three different PTV levels and OR. In this plan, only the right parotid exceeded its mean dose of
20Gy where the mean dose was 53.4Gy. The maximum high dose was 110.7%, which met the
criteria of global hotspot not exceeding 110%.

Figure 3: PTVs 6996 cGy (blue), 5940 cGy (red), 5400 cGy (green). Serial Organs spinal
cord (magenta) and brainstem (cyan). IDLs 6996 (yellow), 6646 (green, which is 95% of
6996), 5940 (blue), 5400 (orange) and 5000 (white).

Figure 4: Transverse view of PTVs 6996 cGy (blue) and 5940 cGy (red) wrapping around the
spinal cord (magenta). IDLs 6996 (yellow), 6646 (green, which is 95% of 6996), 5940 (blue),
5400 (orange) and 5000 (white).

Figure 5: PTVs 6996 cGy (blue), 5940 cGy (red), 5400 cGy (green). Serial Organs spinal
cord (magenta) and brainstem (cyan). OR oral cavity (aquamarine), larynx (brown), right
parotid (sapphire), and TMJ (orange).

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The comparison IMRT plan (IMRT 2) was created by copying the IMRT 1 plan then
changing the collimation of G20, G180, and G340 to 90. Collimation was limited to 90
because the plan was intended to be mono-isocentric. Plan IMRT 2 was optimized with the same
objectives and priorities as the IMRT 1 plan. Figure 5 shows that the IMRT 2 plan has a slightly
lower maximum dose of 7728 cGy instead of 7750 cGy in IMRT 1. Fortunately, in both plans,
the hotspot was inside PTV 6996 cGy. Figure 6 is the DVH comparison of IMRT 1 versus
IMRT2. Overall, IMRT 1 with the collimator was kept at 0 did a better job at lowering dose to
the spinal cord and brainstem. However, IMRT 2 (with collimation) was able to improve the
mean larynx dose by 2Gy. Table 1 scored both plans based on tolerances outlined by the
physician.

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Figure 5: Transverse slice of IMRT 2. PTVs 6996 cGy (blue) and 5940 cGy (red) and the spinal
cord (magenta). IDLs 6996 (yellow), 6646 (green, which is 95% of 6996), 5940 (blue), 5400
(orange) and 5000 (white).

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Figure 6: DVH comparison of IMRT 1 (dash) and IMRT 2 (solid). PTVs 6996 cGy (blue),
5940 cGy (red), 5400 cGy (green). Serial Organs spinal cord (magenta) and brainstem (cyan).
OR oral cavity (aquamarine), larynx (brown), right parotid (sapphire), and TMJ (orange).

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Organs at Risk
Right Parotid
Larynx

Oral Cavity*
Spinal Cord
Brainstem
TMJ**

Tolerance
Mean < 20Gy
Mean 44Gy
V50Gy 27%
Max < 66Gy
Mean < 50Gy
Max < 65Gy
Max < 45Gy
Max < 54Gy
Max < 70Gy
V75Gy < 1cc

IMRT 1
Mean = 53.4 Gy
Mean = 33.2 Gy
V50Gy = 5.5%
Max = 56.7 Gy

IMRT 2
Mean = 55.2 Gy
Mean = 31.3 Gy
V50Gy = 6.5%
Max = 57 Gy

Mean = 31 Gy
Max = 59.7 Gy
Max = 45 Gy
Max = 52.1 Gy
Max = 58.4 Gy
V75Gy = 0 cc

Mean = 31.7 Gy
Max = 59.1 Gy
Max = 47 Gy
Max = 54.1 Gy
Max = 65.2 Gy
V75Gy = 0 cc

OR tolerance obtained from QUANTEC

*OR tolerance per RTOG 0920 (oral cavity cancer)
**OR tolerance per RTOG 0615
Table 1: Plan comparison of IMRT 1 (no collimation) versus IMRT 2 (with collimation). Red
indicates the objective is not met.
Education Process
In this project, I have learned how to optimize head and neck cases with three dose levels
plus supraclavicular nodes, the importance of increasing the number of segments (beamlets), and
the significance of collimation. Setting up the supraclavicular field was an invaluable learning
experience, because many variables had to be taken into consideration such as correct placement
of isocenter. I also learned that mono-isocentric plans have many limitations due to obtaining a
perfect matchline free of overlapping fields and divergence. This means, I had to be cautious of
how I collimate the fields. The difficulty of this particular case was preserving the serial organs
since the three PTVs surrounded the spinal cord and brainstem. By increasing the total number of
segments from 50 to 70, it eased up the optimizers ability to find a solution to save the serial
organs. I initially predicated 90 collimations would benefit the spinal cord and brainstem
because those are midline structures and vertical in appearance. However, 90 collimations
actually increased the dose to the serial organs because it was challenging to provide adequate
coverage while saving those structures.