Paula Paez
Clinical Oncology Assignment
The plan I will be discussing in this paper is a dose-painted, head and neck treatment that
my preceptor planned and discussed with me. The patient is a 77-year-old Caucasian male with
Stage IVA (cT3, cN2c, cM0, p16-) right oropharyngeal cancer. He has bilateral level IB and IIB
lymph node involvement. The initial presentation for the patient was feeling something on the
roof of his mouth; it rapidly increased in size to the point where he had a difficult time
swallowing. He also noted some increased coughing and the feeling of dry mouth. Biopsy
pathology reported superficial papillomata's fragments of squamous mucosa demonstrating high-
grade dysplasia with associated hyperparakeratosis, P16 was negative. The patient has extensive
disease in the head and neck area. He presented to radiation oncology with the following
symptoms: decreased hearing, sensation of fullness in the ear, fatigue, and voice change. He
denies shortness of breath.
It is essential that the patient is in the same position for daily treatment as they were
during the Computed Tomography (CT) simulation; reproducibility is especially important in
allowing for the reduction of target margins and reducing organ at risk dose. For this CT
simulation, the patient was placed in the supine position and immobilized using a Q-3 head rest
with a moldcare pillow, aquaplast mask, and shoulder pulls, positioned at D+E. The moldcare
pillow and aquaplast mask were used to immobilize the patient’s head and neck in a slightly,
hyper-extended position. The head and chin are tilted back/up to move the mandible away from
the treatment field. Using proper shoulder positioning is also important when performing head
and neck radiation. The shoulder pulls help to depress the shoulders away from the treatment
area so that the beam does not enter through them. Shoulder pulls also provide stability
and support which is essential to ensure that the shoulders do not “shrug up” into the treatment
field and attenuate the beam. At my institution, shoulder pulls are used both in SIM and during
treatment.
This patient did have a few deviations from my institution's standard sim protocol for
oropharyngeal cancer. Typically, a patient with disease in the oral cavity is evaluated prior to CT
simulation by a dentist. The patient may need extractions or be given a fluoride tray to help
protect their teeth. However, due to the extent of this patient’s disease, the medical and radiation
oncologists decided to expedite the start of treatment without obtaining dental clearance. Bite
blocks are used at my clinical site to help provide separation between the tongue and hard palate;
this separation can help reduce the dose to the unaffected regions of the oral cavity which will
minimize side effects. Unfortunately, the patient was unable to tolerate the use of a bite block.
For this patient, the physician wanted to treat definitively with concurrent systemic
therapy and RT using an IMRT plan. The prescription was 70 Gy/ 35 fx for high-risk disease, 63
Gy/35 fx for intermediate disease, and 56 Gy/35 fx to low-risk disease. A dose-painting, IMRT
planning technique was used to deliver all three dose levels simultaneously during each fraction.
The physician’s rationale behind the total dose and fractions was based on the NCCN guidelines
for high-risk head and neck cancer with concurrent systemic treatment. 1 The patient will be
receiving concurrent Cisplatin weekly 40mg/m2.
The critical organs at risk that were contoured included the brainstem, larynx, esophagus,
spinal cord, lens, mandible, parotid glands, oral cavity, submandibular glands, and the
pharyngeal constrictors. I have attached screenshots of the target and organs at risk.
Axial view
Sagittal View
Coronal View
Axial View
Sagittal View
Coronal View
Axial View
Sagittal View
Coronal View
Organ Constraints Montefiore Goals Toxicity to organs
(QUANTEC DATA)
H & N (1.8-2Gy/fx)
Esophagus V45 <45 V45 <25 % Pharyngoesophageal stenosis
Brainstem Entire brainstem <54 Gy Dose to .03cc 54Gy Radiation-induced brainstem
necrosis
Larynx Mean 44 Gy Mean 40 Gy Voice changes, trouble
swallowing, Xerostomia (Dry
mouth)
Oral Cavity Mean < 50 Gy Mean 30 Gy Damage to salivary glands
V50 30%
Pharyngeal Mean < 50 Gy Mean 60 Gy Dysphagia
Constrictors V65 50 %
Lens Max Dose <25 Gy Dmax <2 Gy (each) Cataract, retinopathy
Mandible Max 70 Gy V65 <10% Osteoradionecrosis (pain,
swelling, sores)
Parotid Glands Mean < 25 Gy (each) DMean £ 26 Gy (each) Xerostomia (Dry mouth)
Submandibular Mean <35 Gy Mean £ 26 Gy (each) Xerostomia (Dry mouth)
Glands
Spinal Cord Max 50 Gy DMax <45 Gy Neurological Damage
Some of the various lymph nodes that can be involved with right oropharyngeal cancer
would be the right retropharyngeal, right level II, III, and IV cervical lymph nodes. This patient
had specifically had bilateral level IB submandibular and IIB upper jugular pathologic node
involvement. Below I have attached some screenshots displaying these areas.
This patient has extensive head and neck disease. Below are some images displaying the extent
of the disease and the anatomical areas affected.
PTV extending into the posterior aspect of the mandible, level IB lymph nodes in the PTV:
PTV lateral to esophagus on right and left side. Level IB left lymph nodes within PTV:
PTV encompassing the entire level IIB lymph nodes in this slice:
PTV extending into the parotid glands laterally:
PTV lateral to spinal cord:
According to the NCCN guidelines IMRT is the preferred and recommended method to
treat cancers of the oropharynx to be able to reduce dose to critical structures.1 The patient was
planned on a tomotherapy linac using a Helical IMRT with a 6MV rotational beam arrangement,
and a binary, multileaf collimator. A dynamic jaw mode and a field width/jaw of 2.5cm with a
pitch of .289 were selected for treatment. The modulation factor was 1.7. These parameters help
shape the treatment field to the PTVs and influence the modulation and final dose distribution.
The planned beam on time was 369.6 seconds. The estimated gantry period in seconds was 11.9.
There are 31 active rotations. The beam on time divided by the gantry period gives the total # of
rotations. This is important in tomotherapy because the couch and gantry must move at precisely
the right speed to deliver the treatment through the small field width/jaw size.
A few optimization structures were used to create this plan. Some of the structures
created were :“zMand Opt” (mandible overlap with PTVs) to help keep hot spots out of the
mandible, “zDLS shoulders” (a 5mm expansion of the shoulders and upper arms) used as an
“exit only” block to avoid any dose entering through the shoulder region, “zDLS” (a narrow dose
limiting structure, extending from the front of the patients neck to the front vertebral body) used
to help reduce the spillage of dose medially into the larynx, trachea, and esophagus, and “zPost”
(a posterior extension of the brainstem and spinal cord that stops at the external contour) used as
a dose limiting structure to prevent circumferential radiation of the neck so that lymph drainage
is not hindered.
This screenshot shows the “zPost” and “zDLS”
This screenshot shows the “zDLS shoulders”
This is the final DVH with some organs at risk.
The goals used for this plan were the constraint goals from Montefiore. The esophagus
passed the constraint goals; goal is V45 <25%, the outcome for this plan was 21.5 % of the
volume received 45 Gy. The lens also passed the constraint goals; goal is dose to .03 cc £ 2 Gy.
The outcome of the lenses was, R lens received 1.48 Gy and the L lens received 1.43 Gy.
The mandible in this plan did not meet the goals as there is PTV that is infiltrating into the
mandible and therefore the dose to that area was higher than what it would have been if there
was no disease there. The goal for the mandible is V65 £ 10%, the outcome for this plan was the
volume receiving 65 Gy was 14.15%. The submandibular glands did not meet the constraints as
there is also disease in that area that needed to be treated. The goal for the submandibular glands
is mean does £ 26 Gy for each, the outcome for this plan was the R submandibular gland
received 68.28 Gy and the L submandibular gland received 66.71 Gy. The parotid glands passed
the constraint goals; goal is Dmean £ 26 Gy each. The L Parotid received 25.83 Gy and the R
received 25.85 Gy. The spinal cord passed the constraint goals; goal is dose to 0.03cc £ 45 Gy.
The spinal cord received 43.91 Gy. The oral cavity in this plan did not meet the constraint goals
of mean dose £ 30 Gy and V50 £ 30 % as there is extensive disease in this area and part of the
PTV is within this region. The outcome for the oral cavity was the mean dose was 58.0 and the
volume receiving 50 Gy was 66.89%. The pharyngeal constrictor did not pass the constraint
goals as there is a part of the PTV going laterally into the constrictor. The goal is mean dose £ 60
Gy, the outcome in this plan was 61.91 Gy and Volume receiving 65 Gy £ 50 %, the outcome
was 60.75 %. The larynx in this plan passed, the goal is mean dose 40 Gy, outcome was 37. 76
Gy. Lastly, the brainstem also passed the goal of dose .03 54 Gy, the outome was 47.48 Gy.
The plan was normalized to 100% of the PTV receiving 95% of the dose. PTV 7000
received 94.9%, PTV 6300 received 96.32% and PTV 5600 received 99.92%. I have attached the
full MiM DVH report we obtain after the plan has been approved with goals.
This screenshot is displaying the PTV covering part of the constrictor:
This screenshot is displaying the PTV extending to the posterior part of the oral cavity:
References:
1. [Link]. Published 2019.
[Link]
2. Brook I. Late side effects of radiation treatment for head and neck cancer. Radiation
Oncology Journal. 2020;38(2):84-92. doi:[Link]
3. G
repl J, Sirak I, Vosmik M, Tichy A. The Changes in Pharyngeal Constrictor Muscles
Related to Head and Neck Radiotherapy: A Systematic Review. Technology in
Cancer Research & Treatment. 2020;19:153303382094580.
doi:[Link]
