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Evaluation of Dosimetric Target Volume Changes in Head and Neck Cancer Patients Due
to Weight Loss
Authors: Ryan Clark, B.S., Glenda Longoria, B.S.
Medical Dosimetry Program at the University of Wisconsin - La Crosse, WI
Abstract:
Introduction: The purpose of this case study is to determine if weight loss during the course of
radiation therapy for head and neck patients affects the dosimetric target volumes if adaptive
planning is not considered.
Case Description: The patient presented in this case study was an ideal candidate due to his
drastic weight loss during the course of his treatment. This patient lost a total of 19.5% total
body weight during his radiation therapy and was evaluated for an adaptive plan 14 days prior to
the completion of his prescription by receiving a repeat computed tomography (CT) simulation
for comparison. The new CT data allowed for further evaluation for this study.
Conclusion: The results from this case study concluded that the patients weight loss did affect
the dosimetric changes in the treatment plan. In this case in particular, doses to the PTVs were
exceeded beyond prescription dose.
Key Words: Head and Neck Cancer, Weight Loss, Adaptive Planning, Target Volume
Introduction
Head and neck cancer represents approximately 6% of all cancer cases, and includes
malignancies that develop in the nasal cavity, paranasal sinuses, pharynx, larynx, and oral
cavity.1 The most common type of head and neck cancer is squamous cell carcinoma, which
arises after long, repeated exposures to carcinogens such as alcohol and tobacco, as well as
exposure to human papillomavirus.
Surgery, radiation therapy, and chemotherapy are each significant components of the
treatment approach recommended for patients with cancer of the head and neck.2 During the
course of radiation therapy for head and neck cancer patients, a side effect frequently seen is
weight loss. This can occur as a result of the radiation toxicity making it difficult or painful
swallow, and causing a loss of physical ability to process the food due to physical changes from
radiation.3

Intensity modulated radiation therapy (IMRT) and more specifically, volume modulated
arc therapy (VMAT) plans, are increasingly being used in radiation therapy for cancer of the
head and neck due to the sharp dose fall-off that spares normal surrounding tissue while
delivering high doses to the treatment volume.3 They are also known to decrease the side effects
that occur with radiation therapy than with 3D conformal radiation therapy. While IMRT and
VMAT planning have many benefits, the problem of weight loss and tumor shrinkage during
radiation therapy still arises in many cases of head and neck cancer treatments, thus affecting
dose coverage of the targets and surrounding structures.2
The purpose of this case study is to determine how the effect of weight loss can cause
dosimetric changes in regards to the dose coverage of targets and surrounding healthy tissues
when using IMRT planning for head and neck cancer patients.
Case Description
Patient Selection
Potential patients that were evaluated for the study were those who lost anywhere from
5%-20% of their body weight during the course of their 6-8 week radiation treatment course.
Unfortunately, many did not have an adaptive plan evaluation during the course of their
treatment, so those cases were omitted. Since this case study consisted of only one patients
data, the information was limited and poses a drawback for this research.
The subject used for this case study was selected based on several factors. Patient, J.D.,
was diagnosed with cancer of the head and neck of an unknown primary, his weight loss during
radiation therapy was significant, and a CT was performed prior to the end of his treatment that
allowed for testing of our hypothesis for this study.
J.D. was diagnosed with squamous cell carcinoma of the head and neck region in 2013.
It was determined to be stage IVA (T0N2bM0) at the time of diagnosis as 3 lymph nodes were
positive for metastatic disease, with the largest lymph node measuring 2.7 cm. He underwent a
left neck dissection with bilateral tonsillectomies and received concurrent chemotherapy during
the course of his radiation therapy.
The CT that was performed before completion of treatment was ordered by the radiation
oncologist to see if there were significant tumor volume changes, and also to evaluate the need
for an adaptive plan. Once the CT was performed it was concluded that an adaptive plan was not

needed for this patient, and all sequential boost fields were created using the original CT
simulation, which reflected images prior to the J.D.s weight loss.
For the purpose of this study, the new CT that was performed for possible adaptive
planning provided our research with the images necessary for plan comparison while
incorporating the factor of J.D.s weight loss. The images were fused into the treatment plans
that were utilized for this patient and the targets and OARs were adjusted accordingly, allowing
for a visual representation of the possible variations in tumor dose coverage for the plan if no
adaptive plan was used.
Once the radiation oncologist consulted with the patient, a CT simulation was ordered to
begin treatment planning. During simulation, J.D. was set up in a supine position, head first on
the CT table. An aquaplast mask was fitted to his face for immobilization, and his arms were
pulled downward using shoulder straps. For additional comfort, a table pad was placed under his
torso, and a knee wedge was placed under his knees. Additionally, three reference set-up points
were added to the aquaplast mask for positioning purposes.
Target Delineation
This plan consisted of 1 GTV volume and 3 PTVs. The radiation oncologist manually
contoured GTV 66 and allowed a 1 cm margin to give us PTV 66, both of which encompass the
area of tumor resection. PTV 50 was also added and represents the region of bilateral neck
lymph nodes, and PTV 60 represents the ipsilateral lymph node region.

Figure 1: Target volumes

Contouring
Contouring in this critical area of the neck was extremely important as there are many
organs at risk in this region. Once GTV and PTV volumes were drawn, the medical dosimetrist
proceeded to contour all necessary structures for this plan, which included: the body, right and
left brachial plexus, brain, brain stem, optic chiasm, cochleae, eyes, lenses, optic nerves,
esophagus, larynx, mandible, oral cavity, parotid glands, submandibular glands, spinal cord, and
upper left and right lungs.
Treatment Planning (dose constraints)
Varian Eclipse was the treatment planning software used for the treatment planning and
was created for treatment delivery on a Varian iX linear accelerator using VMAT technology.
Each PTV had a separate plan created that utilized an energy of 6 megavoltage and had the jaw
sizes to encompass the entirety of each target volume. Each plan for this patient utilized two to
three arcs with different collimator angles for additional MLC modulation and better dose
conformity. The dose constraints were used as guidelines during the optimization phase of the
treatment planning to stay within tolerance of the surrounding critical structures. The structures
at risk in the area are demonstrated in Table 1 and all structures remained under tolerance doses.
The main plan that contributed the most dose was designated to treat PTV 50 to a total
dose of 5000 cGy in 25 fractions. The additional sequential boost fields were added to the patient
prescription to deliver 1000 cGy in 5 fractions to PTV 60 which included the ipsilateral lymph
nodes and tumor site PTVs, then a final boost to deliver an additional 600 cGy to PTV 66, the
area of tumor resection, in 3 fractions. These plans were summed together for the purpose of this
study to analyze the total intended dose for entirety of the patients treatment course.

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Table 1: TD 5/5 Normal tissue tolerances of the head and neck
1.8 - 2.0 Gy per fraction4
Organ

1/3

2/3

3/3

End Point

Brachial Plexus

60-62

60-61

55-60

Nerve damage

Brain

58

51

47

Necrosis/Infarction

Brain Stem

60

53

50

Necrosis/Infection

Optic Chiasm

50

50

50

Blindness

Lens

10

10

10

Cataract

Ear

55

55

55

Chronic serous otitis

Optic Nerve

50

50

50

Blindness

Esophagus

60

58

55

Clinical stricture/perforation

Larynx Cartilage

79

70

70

Cartilage Necrosis/edema

Mandible

61

61

60

Limited joint function

32

32

32

Xerostomia

Spinal Cord

50 (5 cm)

50 (10 cm)

47 (20 cm)

Myelitis/Necrosis

Lung

45

30

17

Pneumonitis

Parotid Gland

Results:
When comparing both plans side by side, the changes seem minimal, however once a
plan evaluation was performed, the differences were certain. Figure 1 demonstrates the tumor
volume dose coverage on the original CT scan before patient had any weight changes. Figure 2
demonstrates the tumor volume dose coverage after weight loss on the new CT image using the
original treatment plan.

Figure 1: Axial view of target volumes before weight loss

Figure 2: Axial view of target volumes after weight loss

Figure 3 below demonstrates the dose volume histograms as a plan comparison between
the two plans. The DVH lines with triangles illustrate the plan that was calculated using the CT
after weight loss, whereas the DVH values that have squares represents the plan using the
original CT scan. The recorded difference in the dose coverage for each PTV when comparing
the two plans, show the dose to be greater when incorporating the patient CT scan that was taken
after weight loss. The mean amount of dose is in excess for each of the PTVs and contralateral
glands as shown below:

PTV 66 Mean: 1% more than the original planned dose

PTV 60 Mean: 1.5% more than the original planned dose
PTV 50 Mean: 2.4% more than the original planned dose
Right Submandibular Gland Mean: 3.7% more than the original planned dose
Right Parotid Gland Mean: 5.3% more than the original planned dose

Figure 3: Plan comparison DVH

Discussion:
Tumor shrinkage and weight loss in the radiation therapy treatment area did, in fact,
change the dosimetric calculated doses for the patient. After analyzing the results to determine
the calculated differences between the two plans, it was determined that once the patient lost
weight and body mass, the target areas were in fact receiving more dose when using the updated
scan for planning. The areas most affected were the contralateral glands located in the patients
neck, receiving up to 5.7% more than the prescribed dose.
Conclusion:
The knowledge gained during this study confirmed the theory that weight loss can lead to
dosimetric changes in the target volumes for patients with cancer of the head and neck.
Depending on the area of treatment, the changes that occur during radiation therapy as a result of
weight loss may have a more significant impact on surrounding structures. Adaptive planning

and weight monitoring for head and neck patients should be considered before they begin
radiation therapy to ensure that all possible measures are being taken for optimal treatment.

References
1. Argiris A, Karamouzis M V, Raben D, et al. Head and neck cancer. The Lancet. 2008;371:
1695-1709.
2. Chen C, Fei Z, Chen L, et al. Will weight loss cause significant dosimetric changes of target
volumes and organs at risk in nasopharyngeal carcinoma treated with intensity-modulated
radiation therapy. Medical Dosimetry. 2014; 39(1): 34-37.doi:10.1016/j.meddos.2013.09.002
3. Ghadjar P, Hayoz S, Zimmermann F, et al. Impact of weight loss on survival after
chemoradiation for locally advanced head and neck Cancer: secondary results of a
randomized phase III trial (SAKK 10/94). Radiation Oncology (London, England).
2015;10:21. doi:10.1186/s13014-014-0319-y.
4. Vann AM, Dasher B, Chestnut SK, et al. Portal Design in Radiation Therapy. 2nd ed. R.L.
Bryan Company. Columbia, S.C., 2006.