Ryan Pohl

DOS 531: Clinical Onc. For Med. Dos.

02/16/17

Head and Neck Assignment

After identifying a specific case answer the following questions:

1. How was this patient positioned? What positioning devices/accessories were used, how
and why?

Patient was a 53-year-old, white female presented with stage II (T2, N0, M0) squamous
cell carcinoma on the left side of her nasal cavity. For simulation and treatment, she was
positioned head-first and supine to allow easy access of her treatment site. A slant board
and base plate with a B2 block and 3-point thermoplastic mesh face mask was used to
immobilize the patient. This customizable material is commonly used to create a
reproducible setup; ensuring the patient receives treatment in the area they are supposed
to.1 An oral stent was utilized to prevent unnecessary irradiation in normal adjacent
tissue. In addition, a knee sponge was used to relieve stress put on her lower back and
she held a grip ring to allow her arms to rest in a comfortable position. Overall, the goal
of immobilization is to produce a position for the patient that is both reproducible and
comfortable. Some clinics fill the nasal cavity with wax to reduce dose heterogeneity, but
the physician did not deem it necessary in this case.

Figure 1: Patient position for simulation/treatment

 2. What specific avoidance structures were contoured? What is their tolerance dose?

Head and neck cancers can be very complex and often involve delineation of small but
significant structures. For this patient, intravenous (IV) contrast was used to enhance
blood vessels and improve visualization of these tissues. In addition, to help identify
structures with subtle density differences her computerized tomography (CT) scan was
sent to MIM software to be fused with a magnetic resonance imaging (MRI) scan. The
specific avoidance structures that were contoured include the brain, brainstem, carotid
arteries, cochlea, eyes, lens, parotid glands, and spinal cord. The physician provided the
following objectives for this plan: the brain stem (with 2mm expansion) was to have a
max dose to 60 Gy to 0.03 cc, the spinal cord (with 5 mm expansion) was to have a max
dose of 55 Gy to 0.03 cc, the eyes were to have a max dose of 60 Gy to 0.03 cc, the
carotid arteries were to have a max dose of 40 Gy to 0.03 cc, and the parotids were to
have a mean dose of 26 Gy to both glands. Exact constraints on cochlea and lens were
not provided in this case, but according to RTOG 0615 cochlea should not have 5%
volume receive more than 55 Gy and lens should have a maximum dose of 8-10 Gy.1 The
patient received previous external beam radiation therapy to the same site so these
objectives reflected a combined dose from the previous and current treatment. A second
course of curative radiation can be given to select patients with unresectable local
recurrence.2 However, the time between treatments should be at least 2 years and the
volume should be as small as possible.

Figure 2: Areas of interest taken from radiotherp-e program3 (not patient CT scans)
 Fi
gure 3a: Composite (sum of two treatments) dose-volume histogram (DVH) of critical structures

Figure 3b: Composite DVH of critical structures (continued)

Figure 4a: DVH of second course of radiation therapy (VMAT)

Figure 4b: DVH of second course of radiation therapy (continued)

 3. What are the anatomical boundaries of the tumor volume?

As mentioned previously, this patient was diagnosed with stage II (T2, N0, M0)
cancer of the nasal cavity. According to the Union for International Cancer
Control (UICC), a T2 nasal tumor involves two subsites in a single site (which is
seen in this patient) or extends into adjacent sites within the nasoethmoidal
complex.2 The volume of the tumor with a planning margin was approximately 54
cubic centimeters. It is located on the left side of the patient and spreads from the
septum to the nasal conchae. Nasal cavities start superiorly at the cribriform plate
of the ethmoid bone and extend inferiorly to the horizontal plate of the maxillary
bone. It opens posteriorly to the nasopharynx and is separated into left and right
halves by septal cartilage, the perpendicular plate of ethmoid bone, and the
vomer.4

Figure 5: Border of patient's tumor. Target volumes are contoured in salmon color.

Figure 6: Anatomic borders of the nasal cavity2

 4. Are lymph nodes included in the treatment area? If so can you identify the level
nodes use a diagram and screen shots to help you label the nodal regions treated.

For this particular case, I verified with a dosimetrist at my site that the patient was
node negative and therefore no lymph nodes were included in her area of
treatment. Using literature from Videtic and Woody,1 I was able to confirm that
lymph nodes are not treated electively if confined to the nasal cavity. Lymph node
involvement is seen in less than 20% of nasal cavity tumors.2 When positive
nodes are implicated, they are most often Level I and II nodes (particularly
submandibular and subdigastric).5 To treat bilateral level I and II nodes, a
physician may elect to treat the patient using a mustache field.1

Figure 7: Most commonly involved lymph nodes for nasal cavity cancers (taken from IMAIOS) 6

Figure 8: Example of patient with T1N1M0 neuroendocrine carcinoma of left nasal cavity. Level
I and II lymphatics treated with mustache field. 1
 5. What radiation technique is used to treat this patient? Describe in detail the
technique.

This patient has received external beam radiation on two separate

occasions for the same site. First course of radiation employed a 9-field
coplanar IMRT technique. IMRT has proven ability to improve target
coverage and spare more normal tissue when treating a head and neck
site. In a study by Cheng et al,5 when treating nasopharyngeal
carcinoma, the fractional volume of the parotid gland receiving more than 30
Gy was 66.6% for tomotherapy, 48.3% for fixed- field IMRT, and 93% for
conventional therapy. According to J. Wochos, a physicist at my clinical site,
more beam angles generally allow for more modulation. The planned target
volume for this treatment had an irregular shape, so increasing modulation
allowed for a more conformal dose. Each beam was separated by a gantry
angle of 40 and had no rotation in the collimator. The treatment area had a
relatively shallow depth so an energy of 6 MV provided sufficient penetrating
power for every field. The prescription dose was 6000 cGy delivered in 30
fractions. A challenge when planning nasal cavity treatments is avoiding dose
to eyes, lens, and optic nerves. Non-coplanar beam arrangements with three to
five sagittal midline beams could help to avoid entrance or exit dose to
these structures, but was not selected for this case.2 I was not able to talk to the
dosimetrist who designed this particular plan, but another dosimetrist
speculated that the non-coplanar arrangement could have possibly taken too
long; risking patient movement and decreasing dose accuracy.

Field Beam Gantry Collimator Couch Monitor Fraction

Name Energy Angle Rotation Rotation Units Dose
(MU) (cGy)
Field 1 RPO1 6 MV 220 0 0 114 29.4
Field 2 RPO2 6 MV 260 0 0 106 15.4
Field 3 RAO1 6 MV 300 0 0 102 9.8
Field 4 RAO2 6 MV 340 0 0 69 36.2
Field 5 LAO1 6 MV 20 0 0 90 30.6
Field 6 LAO2 6 MV 60 0 0 80 15.8
Field 7 LPO1 6 MV 100 0 0 156 10.6
Field 8 LPO2 6 MV 140 0 0 102 27.5
Field 9 POST 6 MV 180 0 0 211 30.3

Table 1 Beam properties for patient's first course of radiotherapy (IMRT)

The most recent course of radiotherapy for this patient implemented volumetric
modulated arc therapy (VMAT). VMAT is a type of intensity-modulated radiation
therapy where the gantry and multi-leaf collimators (MLC) are in continuous
motion while treating the patient. An advantage of a continuous radiation
delivery method like VMAT is that the treatment time is significantly shorter than
fixed-field IMRT plans. Subsequently, the number of MU used for treatment is
decreased and integral dose is reduced. The dose is spread out across the patient,
 which prevents hot spots at a patients surface. In this nasal cavity case, the
planner was able to reach dosimetric goals by incorporating two full arcs. The
first arc started at a gantry of 181 and rotated clockwise to 179. The second arc
moved counter-clockwise from 179 to 181. The first arc had a collimator
rotation of 15 and the second arc was 345. The collimator is rotated to prevent
overdosing an area with interleaf leakage.7 If the collimator is left at 0, there is a
gap parallel with the rotation of the axis which would form a high dose shell at the
point of rotation. Turning the collimator essentially allows the leakage dose to
spread out to a bigger area. Both arcs had an energy of 6 MV and no couch
rotations were necessary. For the second course of radiotherapy, the dosimetrist
was able to keep the dose to eyes and lens quite low while delivering 6600 cGy in
33 fractions.

Figure 9: Isodose lines showing composite dose in axial view.

 References

1. Videtic GMM, Woody NM. Handbook of Treatment Planning in Radiation

Oncology. 2nd ed. New York: demosMedical; 2015.

2. Barrett A, Dobbs J, Morris S, Roques T. Practical Radiotherapy Planning. 4th ed.

Italy: Hodder Arnold; 2009.

3. Systems AI. Nasal Cavity. Radiotherap-e. https://www.radiotherap-

e.com/default.aspx. Accessed February 24, 2017.

4. Lenards, N. Cross-sectional Anatomy: Head. [SoftChalk]. La Crosse, WI: UW-L

Medical Dosimetry Program; 2016.

5. Chao KSC, Perez C, Brady L. Radiation Oncology Management Decisions. 3rd

ed. Marinetti T, ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2011.

6. Micheau A, Hoa D. Lymph nodes of the face, neck, thorax, abdomen and pelvis -
hepatic segmentation - entire body scan (CT) in oncology. IMAIOS.
https://www.imaios.com/en/e-Anatomy/Thorax-Abdomen-Pelvis/Lymph-nodes-
CT?structureID=5364&frame=65. Accessed February 23, 2017.

7. Teoh M, Clark CH, Wood K, Whitaker S, Nisbet A. Volumetric modulated arc

therapy: a review of current literature and clinical use in practice. The British
Journal of Radiology. 2011;84(1007):967-996. doi:10.1259/bjr/22373346.