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Heather Maurer
April Case Study
April 25, 2014
Radiation Therapy for the True Vocal Cords
History of Present Illness: Patient RH is a 59 year old male who received multiple biopsies for
abnormal development of his bilateral vocal cords. Biopsies in this area are often done under
anesthesia using an endoscope.
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In February 2012 his left posterior vocal cord was discovered
through biopsy to be positive for carcinoma in situ. In April 2012 he had surgery, left partial
laser cordectomy, for treatment of this finding. Post-surgery he had no evidence of recurrence
until 2014. In February 2014 he had an in clinic laryngoscopy which showed a small defect on
the left vocal cord. Though he had no other concerning lesions or hyperkeratotic areas and his
vocal cords were fully mobile bilaterally his physician elected to send him for a diagnostic
laryngoscopy with biopsy. This procedure was performed in March 2014. Pathology for the
right true vocal cord revealed well-differentiated squamous cell carcinoma with superficial
invasion. The left true vocal cord was positive for carcinoma in situ and was found to have
detached fragments of squamous cell carcinoma without stromal invasion. Also the right false
vocal cord was shown to have low-grade dysplasia. With the knowledge of these results his
physician requested a positron emission tomography (PET) scan which was performed in April
2014. The PET scan identified focal uptake in the left true vocal cord and anterior commissure
with no evidence of nodal metastatic disease.
In April 2014 RHs case was discussed in head and neck tumor boards. It was recommended to
have definitive radiation in order to preserve his voice function. RH states his voice is currently
raspy but stable and hasnt noticed changes over the past two years. He denies any other
symptoms and has agreed to proceed with radiation treatments after a full discussion with the
radiation oncologist regarding the complications, benefits, and side effects of the treatment.
Past Medical History: Prior to the complications with his vocal cords in 2012 RH had a very
unremarkable medical history. He has since received a left partial laser cordectomy and states he
has hypertension.
Social History: RH is married and works in construction. He states that he has smoked
cigarettes, approximately 2 packs per day for 35-40 years and he quit smoking 5 years ago. He
has been reported by others to be an excessive drinker and he admits to drinking a 6 pack of beer
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per day. RH has stated he will try to decrease his alcohol intake while under treatment. He also
reports that he has never used smokeless tobacco or illicit drugs and has no allergies. Glottic
cancer is highly associated with smoking and though alcohol has not been directly related to
glottis cancer it has corresponded with supraglottic cancer.
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He also mentioned his father had
prostate cancer.
Medications: RH has been prescribed the following medications atenolol (Tenormin) 50 mg
daily, diltiazem (Tiazac) 180 mg daily, hydrocodone-acetaminophen (Norco) 5-325 mg every 4-
6 hours as needed for pain, naproxen sodium (Aleve) 220 mg daily, nystatin 100,000 unit/mL
suspension 5mL twice a day, and omeprazole (Prilosec) 40 mg delayed release daily.
Diagnostic Imaging: RH received a laryngoscopy in February 2012 along with a biopsy which
indicated carcinoma in situ. In February 2014 he received another laryngoscopy and left partial
laser cordectomy and in March 2014 another laryngoscopy and biopsy was performed showing
well-differentiated squamous cell carcinoma with superficial invasion of the right true vocal
cord. The left true vocal cord was also positive for carcinoma in situ with detached fragment of
squamous cell carcinoma without stromal invasion and the right false vocal cord had low grade
dysplasia. He also received a PET scan in April 2014 showing focal uptake in the left true vocal
cord and anterior commissure with no evidence of nodal metastatic disease.
Radiation Oncologist Recommendations: RHs case was presented and discussed during head
and neck tumor board and definitive radiation was recommended in order to preserve his vocal
function. After review of RHs past medical documentation and imaging the radiation oncologist
discussed several topics with RH and his wife. They discussed the natural history and prognosis
of his disease, that the patients early stage glottis cancer can be treated with excellent results
with radiation alone, as well as alternatives to radiation. Early glottis cancers such as RHs
T2N0 show a cure rate of 90-95% with radiation treatment.
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The radiation treatment was
discussed in detail including risks, benefits, short term side effects and long term complications,
as well as the logistics. The simulation procedure was described along with the 5 point mask that
would need to be worn for the daily treatments, which would be Mondays through Fridays for 5
weeks.
The Plan: The recommendations for radiation consisted of two opposed lateral beams with
isocenter centered in the clinical target volume (CTV) drawn by the physician. The fields
included the hyoid bone at the superior aspect and extended 2 cm inferior to the larynx. The
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posterior edge of the field clips the anterior surface of vertebrae C5 & C6 while the anterior field
edge gives at least a 2 cm margin on the larynx allowing adequate room for motion while
breathing or swallowing during treatment. The physician prescribed a total of 66.25 Gy in 2.25
Gy fractions. A 3D plan was designed resulting in a 108.8%, or 70.97 Gy, max hot spot.
Patient Setup/Immobilization: RH underwent his computed tomography (CT) simulation in
April 2014. He was placed on his back on the table of a Phillips Big Bore CT scanner. His head
and shoulders were on a Civco head and neck board designed to allow the Civco 5-point masks
to attach directly to the board. His head was also placed on a Civco headrest that fit the contour
of his neck and back of head. The headrest was affixed into the head and neck board. There was
an egg crate cushion under his body that extended from the head and neck board to his hips
(Figure 1). His arms were placed at his sides holding arm pulls while his legs were straightened
against the plate his arm pulls were attached to, allowing them to pull his arms and shoulders
inferiorly (Figures 1-2). An aquaplast mask was then made covering from the top of his head to
just inferior to his shoulders(Figures 1 & 3). Special attention was paid to keep his chin elevated
and shoulders inferior allowing adequate room for lateral treatment angles without unwanted
structures in the fields.
Anatomical Contouring: Once the CT scan was completed the data set was loaded into
Varians Eclipse Treatment Planning System (TPS). The resident assigned to RHs physician
contoured the larynx and had the contour checked by the physician. For this particular case there
were not any organs at risk contoured.
Beam Isocenter/Arrangement: Once the CTV was approved by the physician and a planning
directive was filled out describing what requirements the physician has for the plan the
dosimetrist could get started. The dosimetrist started by adding a plan for a Varian EX linear
accelerator and a 6 MV beam in Eclipse TPS, then placed the isocenter of that beam in the center
of the drawn CTV (Figures 4-6). The first treatment angle was set at 90 degrees with a field size
set giving approximately a 2 cm margin around the larynx using the jaws. With the collimator set
at 0 degrees the field size set was treating a small portion of the mandible. To avoid the
mandible, the collimator was rotated slightly and fields adjusted. The fields included the hyoid
bone at the superior aspect and extended 2 cm inferior to the larynx. The posterior edge of the
field clips the anterior surface of vertebrae C5 & C6 while the anterior field edge gives at least a
2 cm margin on the larynx allowing adequate room for motion while breathing or swallowing.
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This margin will also prevent underdosage of the anterior commissure.
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Once the filed was set it
was parallel opposed to 270 degrees (Figures 5 & 6).
Treatment Planning: According to the planning directive the physician was requesting 95% of
the CTV drawn to be covered by the 95% isodose line (IDL). Meaning 95% of the volume of the
CTV would receive about 62 Gy. The planning directive also requested minimal use of wedges
and to keep the hotspot anterior. Due to the thickness of the treatment area a beam energy of 6
MV was chosen for treatment on a Varian EX linear accelerator. Using the previously stated
fields, roughly a 2 cm margin on the larynx, the 6 MV beams equally weighted without a wedge
and normalized to the isocenter did not allow the proper coverage. The plan was then
normalized to a thicker portion of the treatment area and re-calculated. The new calculation gave
adequate coverage with an anterior hotspot of 112.7%. The physician was shown this plan and
also the same plan with two 15 degree wedges added, one on each field with heels anterior. The
wedges kept the anterior hotspot yet brought the dose down to 108.8%. The 95% IDL covered
100% CTV in both plans shown to the physician. In the end, he chose the plan with the wedges
and the lower max dose (Figures 7-9).
Quality Assurance/Physics Check: The dosimetrist sent the final plan approved by the
physician to the Mobius 2
nd
check software. This software checks the monitor units (MU) and
also checks the planning objectives and dose volume histograms (DVHs) of the plan (Figures 10
& 11). The plan must be within 3-5% depending on the type of treatment in order to pass the
Mobius check. Once the plan has passed the physics staff will do a visual check against the
requests of the physician on the directive and make sure the plan is ready for treatment. The
final QA check is just prior to treatment when the therapists will image all fields and cross check
plan parameters to the treatment parameters.
Conclusion: The challenges of this case started with patient positioning. This shows how
important patient positioning is in the simulator. If the simulator staff were able to get the
patients chin elevated slightly more, then the collimator wouldnt have needed a rotation.
Fortunately they were able to get the shoulders low enough that they didnt come close to the
field even with the collimator rotation. Another complication came with dose distribution. In
order to achieve proper dose distribution normalization may need to be off set to a thicker area in
the treatment field. Also, even though the directive requested to stay away from wedges,
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copying the plan and seeing what they do could help. Showing the physician both plans and how
the wedges could help in this case turned out to be beneficial.

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References
1. Shaha AR, Strong EW, eds. Cancer of the head and neck. In: Murphy GP, Lawrence W,
Lenhard RE American Cancer Society Textbook of Clinical Oncology. 2
nd
ed. Atlanta,
GA: The American Cancer Society; 1995: 355-377.
2. Lozano R. Head and neck cancers. In: Washington CM, Leaver D, eds. Principles and
Practice of Radiation Therapy. 3
rd
ed. St. Louis, MO: Mosby; 2004:683-721
3. Bentel GC. Radiation Therapy Planning 2
nd
ed. New York, NY: McGraw-Hill; 1996.

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Figure 1. Patient setup on Civo head and neck board with Civco mask and arm pulls.


Figure 2. Foot plate and arm pull attachment.
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Figure 3. Civco 5-point aquaplast mask attached to Civco head and neck board.

Figure 4. Four panel screen shot of isocenter placement. (Purple structure is CTV)
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Figure 5. Field shape and isocenter placement for left lateral beam. Also showing wedge
orientation. (Purple structure is CTV)

Figure 6. Field shape and isocenter placement for right lateral beam. Also showing wedge
orientation. (Purple structure is CTV)
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Figure 7. Single panel axial view of dose distribution. (Purple structure is CTV)
Figure 8. Single panel coronal view of dose distribution. (Purple structure is CTV)
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Figure 9. Single panel sagittal view of dose distribution. (Purple structure is CTV)

Figure 10. Dose Volume Histogram (DVH). (Purple line is for CTV)
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Figure 11. A section of the plans second check through Mobius software.