Jessica Ezelle

Head and Neck Assignment

1. The patient was positioned on a BoS frame board (typically used in proton
therapy but our clinic also uses it in conventional therapy too). The patients
head was positioned neutral and a patient specific head mold was created.
Jump ropes were used to pull the patients shoulders down and out of the
field. Then a custom head and neck mask was made covering the patients
face and shoulder area. This to ensure the patients head and shoulders are in
the exact same position every day and so that the patient marking can be
made on the mask instead of the patients face. Also, a small knee sponge
was placed under the patients knees to help with their back comfort.
2. Specific avoidance structures:
In the DVH there were several critical structures highlighted

organ 1/3 2/3 1 end point

brain stem 60Gy 53Gy 50Gy necrosis/infarction
chiasm 50Gy 50Gy 50Gy blindness
ear 30Gy 30Gy 30Gy acute serous otitis
ear 55Gy 55Gy 55Gy chronic serous otitis
clinically manifested nerve
left plexus 60Gy 60Gy 60Gy damage
right and left
lens 10Gy 10Gy 10Gy cataract
right and left
parotid 32Gy 32Gy 32Gy xerostomia
50(5c 50(10c 47(20c
spinal cord m) Gy m) Gy m) Gy myelitis/necrosis
45
temporal lobe 60Gy 50Gy Gy necrosis/infarction
larynx (cartilage) 79Gy 70Gy 70Gy cartilage necrosis
larynx (vocal
cords) 45Gy 45Gy 45Gy edema

3. Anatomical boundaries:
Posterior: Depending on the level of the tumor the posterior border can be
encompassed by the clivus (which can often be involved in nasopharynx
cancers but not this one), the temporal bones, and the occipital bones and
C1.
Laterally: the pterygoid muscles, buccal fat pads and sphenoid bones
encompass the nasopharynx
Anteriorly: the base of tongue and intrinsic tongue muscles, maxilla(hard
palate) and nasal cavity/maxillary sinuses depending on the level of the
tumor.
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The olive green is the nasal cavity, the yellow is the maxillary sinuses, the red
the pterygoid muscles, the purple the temporal bone and the blue is the
clivus. The shaded in green is the nasopharynx CTV as defined my
radiotherap-e.com. The picture on the right is the same view without all the
drawings.

The olive green is the nasal cavity, the yellow the maxillary sinuses, the blue
is the clivus and the red is the sphenoid bones and the shaded in green is the
nasopharynx as determined my radiotherap-e.com. The picture on the right is
the same image without the drawings.
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The blue is the clivus, the red is the occipital bone, the purple is the pterygoid
muscles, green is the buccal fat pads, yellow, maxilla (alveolar ridge) and the
fuchsia is the maxilla(hard palate). The shaded in green is the nasopharynx
CTV as determined my radiotherap-e.com. the right sided picture is the same
image without all the drawings.

The blue is C1, the purple is the pterygoid muscles, the green is the
buccinator muscles, the yellow is the maxilla(alveolar ridge), and the fuchsia
is the tongue, intrinsic muscles. The shaded in green is the nasopharynx CTV
as determined my radiotherap-e.com. the right sided picture is the same
image without all the drawings.
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4. Lymph nodes included in the treatment were in the left neck Levels VA, Level
II, and Level III. And 1 lymph node in the right neck at Level II.
The Level V nodes are found posterior and lateral from approximately C4-T1
The level II nodes are lateralling in the midsection of the neck from C2-C4
The level III nodes pick up where the Level 2 nodes leave off laterally at the
midsection of the neck and move more anteriorly from C4-C6

The green shaded in is the Level II nodes at C3- the red is Level IB and the
blue is Level VIII

The shaded in blue is the Level III nodes at C5 the purple is level VIA and the
tan is Level V.
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5. The technique used for this treatment was Tomotherapy. First the patient is
aligned externally and then an MVCT is taken of the patient to align the
patient internally. Once the patient is in treatment position and their CT from
todays treatment is properly aligned with the CT taken at the time of
simulation, an intensity-modulated therapy begins in a fan-beam fashion.
Tomotherapy used multi-leaf collimation attached to a conventional C-arm
gantry to modulate the intensity of the beam. 1 The patient is constantly
moving through the gantry as the treatment is being delivered and the beam
is delivered in a helical fashion like a CT-scanner with the use of slip-rings to
transmit and power data.1 With Tomotherapy your able to put dose
constraints on certain organs and volumes just like IMRT or VMAT so that you
can avoid critical structures and deliver a higher dose to the tumor volume at
risk. Also, it is able to treat long fields so that if a tumor is up high in the head
area but has low neck nodes it is not a problem.

References:
1. Mackie T, Balog J, Ruchala K, et al. Tomotherapy. Seminars in Radiation
Oncology. 1999;9(1):108-177. doi:http://dx.doi.org/10.1016/S1053-
4296(99)80058-7.