Ian Zoller

Head and Neck Assignment - Excellent job!

DUE on or before Sunday Feb 26th

Use your Discussion Group placement in the Clinical Oncology course to determine
the Head and Neck region below to research.
Find a case in your clinic that presents with a primary lesion in the:

Group 4: Oropharynx
Patient presented with cT2N2c p16+ squamous cell carcinoma of the right base of
tongue. The patient is receiving 70 Gy to the GTV, 63 Gy to CTV1, and 56 Gy to CTV2
using a simultaneous integrated boost technique in 35 fractions.

After identifying a specific case answer the following questions:

1. How was this patient positioned? What positioning devices/accessories were
used, how and why? (5 points)

The patient was positioned supine on the conformal board using a C headrest
in order to hyperextend the head along with a knee sponge for comfort. An
aquaplast mask was made for immobilization and a custom dental stent was
used in order to separate the tongue and the hard palate. Hand pegs were
placed at position 9 so that the shoulders could be pulled as far out of the
treatment area as possible.

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

dose? (20 points)

Structure Radiotherap-e TDs

Spinal Cord Max < 45 Gy
Brainstem Max < 54 Gy
Brachial Plexus Max < 65 Gy
 Ian Zoller

Globes Mean <35 Gy; Max < 50 Gy

Optic Nerves Max < 54 Gy
Optic Chiasm Max < 54 Gy
Brain Max < 60 Gy (QUANTEC data)
Parotids Mean dose <26 Gy; V20 < 50%
Pharynx Mean < 50 Gy (QUANTEC data)
Larynx Mean < 45.3 Gy
Esophagus Mean < 45 Gy
Oral Cavity Mean < 40 Gy
Mandible Max < 70 Gy
Cochlea Mean < 37 Gy; Max 45 Gy
Thyroid 25-35 Gy or less
Lenses Max < 25 Gy

3. What are the anatomical boundaries of the tumor volume? You should use
Radiotherap-e (http://www.radiotherap-e.com) and other anatomy
references to help you describe this. You can use a diagram and screen shots
of your CT data to point out the boundaries. (20 points)

Tumor Volume:
Superior boundary: Level of the Right tonsillar pillar or the middle of the
dens.
Inferior boundary: Just superior to the hyoid bone at the level of C4
Bounded posteriorly by the cavity of the oropharynx and the right
pharyngeal constrictor muscle
Extends anteriorly 1.5-2.0 cm towards the right submandibular gland.

Dens

Beginning of Hyoid
Tonsillar Pharyngeal
Pillar constrictor

Superior extension Inferior extension

 Ian Zoller

Coronal View Sagittal View

Typical treatment borders:

Superior: Coverage of the skull base and mastoid
Inferior: Include the supraclavicular nodes
Beam split above the larynx at the thyroid notch if possible
Anterior: 2 cm margin on the tumor including the faucial arch, and some of
the oral tongue
Posterior: Include posterior cervical triangle

Saggital view with dose to show 2 cm margin anteriorly into the oral tongue. Also
shows superior inclusion of the skull base and mastoid.
 Ian Zoller

Coronal view demonstrating bilateral treatment and inclusion of the

supraclavicular nodes.

Axial view with coverage of the spinal accessory nodes.

Great explanations and images Ian!

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. (20 points)
 Ian Zoller

Yes, lymph nodes are included. Regions receiving different doses are broken
down below:
70 Gy - Rt base of tongue, Rt level II, and Lt level II LNs.
63 Gy - Bilateral retropharyngeal nodes, Rt levels, I, II, III, IV, V and Lt
levels II, III, V
56 Gy - Rt level IV (lower) and Lt level II (upper), IV

Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 9618

In the screen shots below; Red=PTV 70 Gy, Blue=PTV 63 Gy, Green= PTV 56 Gy

Level I: Submental,
Level II: Submandibular
Jugulodigastric

Level III: Internal

jugular chain
 Ian Zoller

Level IV: Deep cervical

Retropharyngeal
nodes

Level V: Spinal
accessory
 Ian Zoller

5. What radiation technique is used to treat this patient? Describe in detail the
technique (35 points)

If VMAT How many arcs, which direction? Is there collimator rotation? Is

there a couch rotation? If so, which direction and why? Include all specific
setup information.

If IMRT How many beams? What are the beam angles? Is there collimator
rotation? Is there a couch rotation? If so, which direction and why? Include
all specific setup information.

If 3D conformal How many beams? Are half beam (split field) beams used?
Is there collimator rotation? Is there a couch rotation? If so, which direction
and why? Include all specific setup information.

VMAT or volumetric modulated arc therapy is a more complex form of

intensity modulated radiation therapy or IMRT. In standard IMRT, multiple
field sizes or beamlets are shaped at different gantry angles so that a beam
fluence is created that conforms to the tumor while better sparing adjacent
normal structures. Using IMRT, the gantry does not move in between set
angles. VMAT on the other hand uses multiple control points throughout an
arc that shape to the tumor volume. In this way, the gantry and MLCs are
moving while the beam is on. This allows for shorter treatment times and
better dose conformity. During optimization the simultaneous integrated
boost technique was used to ask for uniform dose distributions within
different dose levels in the same 35 fraction plan.

Arc 1; Gantry 200-160; Collimator 350

Arc 2; Gantry 161-201; Collimator 70
Arc 3; Gantry 200-160; Collimator 80

This treatment uses a total of three arcs with no table kicks. Arc 1 is
oriented with the MLCs running horizontally to treat the entire PTV. Arc 2
has the collimator turned so that the MLCs run vertically. This beam uses a
smaller field size and treats the superior extent of the PTV. The reason for
the smaller field size is that with Varian linacs, the MLCs are only allowed 15
cm of overtravel. The field size is limited so that no part of the PTV is left
open during treatment delivery. Arc 3 is similar to Arc 2, however the lower
half of the field is treated in this rotation. In addition to the smaller field size,
having the collimator turned so that the MLCs run vertically helps to better
shield midline structures such as cord. A total of three arcs also helps
improve the conformity of the plan.
 Ian Zoller

Arc 1 MLCs Arc 2 MLCs

Arc 3 MLCs