1

Kevin Kocos
Case Study
April 5th, 2017
IMRT for Supraglottic Cancer of the Neck
History of Present Illness: The patient is a 69 year-old male who seen in early November 2016
for non-painful hoarseness of his voice that had been ongoing for 3 months. He was found to
have a supraglottic mass that was fixating the right vocal cord and was concerning for invasive
squamous cell carcinoma (SCC) through indirect laryngoscopy. In the middle of November
2016 the patient underwent positron emission tomography (PET) that revealed the supraglottic
mass was extending inferior into the neck. He was given a diagnosis of T4aN2C cancer that
gave suspicion for metastatic disease that was later confirmed during surgery.
The gentleman presented to ear nose and throat (ENT) where it was recommended that he
undergo a total laryngectomy. The patient was strongly opposed to the procedure so in late
November 2016 they proceeded with a tracheostomy, direct laryngoscopy (DL) with biopsies
and upper esophageal endoscopy. The operative exams revealed T4aN2cM1 (Stage IVc)
laryngeal cancer within the supraglottic region. In addition, a biopsy of the right piriform sinus
revealed invasive non-keratinizing squamous cell carcinoma (SCC), p16: negative. p16 is a
protein that is well implicated as a tumor suppressor marker. This protein is most often involved
with human papillomavirus (HPV) associated cancers of the cervix and head and neck.1 The 2nd
tracheal ring, tracheostomy revealed focal acute inflammation with no evidence of malignancy.
In the endoscopic, ultra sound guided, (EUS) fine needle aspiration, (FNA) it was found that
lymph node 2R was also positive for SCC.
The patient was seen for a consultation with the radiation oncology department in early
December 2016. It was presented to the patient and his family that the best course of treatment
for T4aN2cM1 in his position would be combined chemotherapy and radiation treatment (RT).
The side effects and benefits of the combined treatment were discussed in detail and all questions
and concerns were answered to the patient and his familys satisfaction. It was then decided to
proceed with RT and concurrent chemotherapy.
Past Medical History: The patient has a past medical history of severe depression,
hypertension, glaucoma, seborrheic dermatitis, glaucoma, myopia, astigmatism, presbyopia,
 2

pharyngitis, chronic low back pain. The patient has a surgical history of eye enucleation and
total knee replacement. The patient also reports no known allergies.
Social History: The patient is married with two children. He was a 3 year veteran of the United
States Marine Corps in the 1960s. For the next 30 plus years he worked manual labor jobs on
and off to make a living. The patient is a recovering heavy alcoholic and was a former 1 to 2
pack per day smoker for 20 plus years. The patients father died of cancer and notably had a 4
year old son who passed away from a medulloblastoma at the age of 4. He credits the passing of
his son greatly contributing to his severe depression.
Medications: The patient uses the following medications: Oxycodone, fentanyl patch, lorazepam
injection, atorvastatin, enoxaparin, allopurinol, citalopram, ketotifen, meloxicam, saline flush,
acetaminophen, artificial saliva, bisacodyl, sennosides 8.6 mg, amlodipine besylate 5mg,
Lisinopril, magnesium hydroxide, polyethylene glycol 3350, sodium fluoride 1.1%, Fluticasone
prop 50 mcg 120 nasal, allopurinol 100 mg, atenolol 25 mg, hydrochlorothiazide 25 mg,
clonidine.
Diagnostic Imaging: Indirect laryngoscopy in early November 2016 was performed in clinic
which revealed the supraglottic mass over the right vocal cord. A PET scan shortly after showed
that the mass was extending lateral to the right thyroid cartilage for approximately 11 mm and
was adjacent to the right common carotid artery. Also on the PET Scan, the mass was measured
to be approximately 3.7 x 2.9 x 2.3 cm and was also associated with narrowing of the airway.
After the PET scan, a diagnosis of T4aN2C was determined with a suspicion of M1 disease.
Direct laryngoscopy under anesthesia was performed in late November 2016. In this
procedure a biopsy of the right piriform sinus also confirmed invasive non-keratinizing SCC,
p16: negative. During the procedure, a 2nd tracheal rings tracheostomy also showed no evidence
of malignancy. Also during the DL, suspicions for metastases were confirmed when lymph node
2R was found to have SCC which was done by EUS guided FNA.
Full mouth radiographs were also obtained during the patients dental workup that
revealed a periapical lesion in tooth number 30. This tooth was extracted for the patient so that
he could be cleared for RT. The patient was also recommended to have a fractured filling of his
maxillary premolar fixed before RT.
 3

Radiation Oncology Recommendations: After a thorough physical exam and review of the
diagnostic imaging, the radiation oncologist recommended a 7 week course of daily RT with
chemotherapy. The physician also counseled the patient and family that it is somewhat unlikely
that this course would be curative but it would offer the best long term control. Due to the fact
that his M1 disease is regional, the RT would include very large treatment fields and we would
be aggressive as the patient is comfortable with in order to give the most relief and possibly
provide a cure. The patient was heavily favoring doing nothing. The patient and family were
then counseled on the nature of the disease with respect to the right common carotid artery and
narrowing of the airway. They were made aware that with no intervention, hospice care should
be administered with a life expectancy of no more than 6 months.
The Plan (prescription): The radiation oncologists treatment recommendation for the patient
was a 9 field intensity modulated radiation therapy (IMRT) using a simultaneous integrated boost
(IMRT-SIB) also known as dose painting technique. IMRT-SIB has been developed as a method
to alter the delivery of a dose to a patient to achieve higher doses and better conformities to the
PTV.2 This can be achieved by while still limiting organs at risk (OR) to safe dose constraints
and minimizing acute and long term toxicities. Although there have been recent concerns for
recurrence within the PTV due to elevated doses using IMRT-SIB, this method does have the
ability to reduce risk to the low and intermediate risk areas of disease. The plan would consist
of a total of 6996 cGy delivered to the planning treatment volume (PTV) for 33 fractions of 212
cGy per fraction. This IMRT-SIB plan would be done concurrently with cisplatin chemotherapy.
Administration of concurrent cisplatin with radiotherapy demonstrated an 84% rate of larynx
preservation in a randomized intergroup trial as well as a 54% 5 year survival rate.3
Patient Setup/Immobilization: In the middle of December 2016, the patient underwent a
computed tomography (CT) simulation in the Toshiba Aquilion CT Machine. The patient placed
given a S-Frame with a B-Headrest using Accuform to mold the headrest to the patients
contours so they will be put in a reproducible position for every treatment (Figure 1). Also, the
patient was placed supine on the CT simulation couch with both of their arms down at their side,
hanging onto pulleys (Figure 2). They were also given a sponge under their knees for comfort
and support. The patient was also then fit for an aquaplast mask that is molded specifically to
their head and neck to hold them in place. The patient was then lined up with their specific
 4

coordinates each day before treatment where marks were placed on the mask. The patient was
also given a 5mm bolus to be worn around his stoma for each of the treatments (Figure 3).
Anatomical Contouring: After completing the CT scan, the radiation oncologist contoured the
tumor and the scan was then exported to the Pinnacle3 Treatment System Version 9.10 treatment
planning system (TPS). The dosimetrist fused the PET scan with the CT simulation in order for
the oncologist to be able to fully account for the areas of disease while contouring the PTVs.
Once the scan was imported and fused, the radiation oncologist then contoured a PTV 6996, PTV
6300 and a PTV 5600. The medical dosimetrist was then in charge of contouring the ORs which
included the spinal cord/spinal cord planning organ at risk volume (PRV), brainstem/brainstem
PRV, mandible, oral cavity, left and right submandibular salivary glands, left and right parotid
salivary glands, brachial plexus, esophagus and mandible. Using a dose constraint sheet, the
medical dosimetrist then began planning the IMRT plan.
Beam Isocenter Arrangement: Isocenter of the treatment field was placed by the radiation
oncologist during the CT simulation. It was placed anterior to the body of the 4th cervical
vertebrae (Figure 4). The isocenter was also posterior to the aryepiglottic folds and on the
posterior aspect of the PTV 6996 halfway between the inferior and superior borders (Figures 5-
7).
All 9 fields of the IMRT plan were prescribed to the previously mentioned isocenter and
all beams were set to 6 megavoltage (MV) energy for our clinics Varian Clinac iX Linear
Accelerator. Due to the large field sizes that were used to effectively treat the metastatic disease
along with the primary tumor, 5 of the 9 fields were split into two separate beams and 2 of the 9
fields were split into 3 separate beams. There were 2 left posterior oblique (LPO) fields placed
at 160 and 120, both of them being 2 field splits. There was left anterior oblique (LAO) field
at 80 that remained a single field and there was also LAO field at 40 that was a 2-field split
(Figure 8). An anterior field at 0 was split into 3 different beams. There was also a right anterior
oblique (RAO) field that was set at 320 and was split into 2 beams (Figure 9) as well as a RAO
beam set 280 that was not split. Finally, there was a right posterior oblique (RPO) field at 240
that was split into 2 beams as well as a RPO field set at 200 that was split into 3 fields (Figure
10).
All of the previously mentioned fields did not have any collimator or couch rotations.
Within the treatment planning process, the dosimetrist input the head and neck IMRT objectives
 5

into the TPS. The TPS was then adjusted until acceptable coverage for the PTVs were reached
that also achieved the appropriate dose constraints for the surrounding ORs. The TPS was also
instructed to split any fields that were too large. Fields treated in the Varian Clinac iX that are
greater than 13 cm have a limitation with the multi-leaf collimators (MLCs). According to the
lead dosimetrist (J.M. Schmitz, CMD, oral communication, March 2017) each individual leaf in
the collimator has a maximum range of 13 cm. Therefore, when a field becomes larger than this,
a leaf from the opposite side of the collimator would have to close the gap, opening up the
possibility for extra scatter dose from the collimator. In order to alleviate this issue, larger fields
can be split into multiple fields.
Treatment Planning: Once the imaging was prepared and the PTVs were contoured in the
Pinnacle3 Treatament System Version 9.10, the radiation oncologist provided treatment
objectives as well as a dose constraint table to the medical dosimetrists. The dose constraint
table was developed from RTOG 1016 recommendations. IMRT-SIB technique was used that
incorporated 3 different PTVs. Each one of these PTVs would be treated in each fraction but
each to a different prescribed dose. All three of the PTVs were given a hard constraint of 95%
of their volume required to be equal or greater than their prescription (D95 greater than or equal
to 6996, 6300 and 5600). Designating a structure to have a hard constraint means that achieving
the objective is a top priority and treatment will not proceed without achieving it. Designating a
structure to have soft constraints meant that great effort would be taken to meet the constraint but
that exceptions could be made depending on the patients circumstances. The OR dose
constraints were: spinal cord PRV D0.03cc less than 50 Gy, spinal cord D0.03cc less than 45 Gy,
brainstem PRV D0.03cc less than 52 Gy, brainstem D0.03 cc less than 50 Gy, contralateral
parotid mean dose less than 26 Gy, esophagus mean dose less than 30 Gy, oral cavity mean dose
less than 30 Gy, oral cavity D1cc less 60 Gy, ipsilateral parotid mean dose less than 26 Gy,
mandible D1cc less than 66 Gy, mandible mean dose less than 35 Gy, contralateral
submandibular salivary gland mean dose less than 39 Gy. Normal tissues outside the treatment
were also given a constraint of D1cc is less than or equal to 74 Gy. All OR dose constraints were
designated as soft constraints except for brainstem, brainstem PRV, spinal cord, spinal cord PRV
which were hard constraints.
The TPS was instructed to use direct machine parameter optimization with a maximum
number of 160 segments used. The treatment plans prescriptions were each normalized to 96%
 6

in order to obtain acceptable coverage for the PTVs. All of the 18 total beams were calculated to
the isocenter of the PTV.
Once adequate coverage for all 3 of the PTVs was obtained in the TPS using the IMRT
parameters, the dose volume histogram (DVH) was evaluated in order to obtain acceptable limits
for the ORs (Figure 11). IMRT parameters would then be altered until all the dose constraints
were met and the maximum dose or hot spot fell within the PTV 6996. The DVH revealed that
the PTV 6996 D95 equaled 7013 cGy, PTV 6300 D95 equaled 6574 cGy and PTV 5600 D95
equaled 5638 cGy. The spinal cord PRV D0.03cc equaled 4816 cGy, spinal cord D0.03cc 3872
cGy, the brainstem PRV D0.03cc equaled 4736 cGy, the brainstem D0.03cc equaled 4149 cGy,
contralateral parotid mean dose equaled 2505 cGy, the esophagus mean dose equaled 4230 cGy,
the oral cavity mean dose equaled 2946 cGy, ipsilateral parotid mean dose equaled 3620 cGy,
mandible D1cc equaled 7167 cGy, mandible mean dose equaled 3674 cGy, the contralateral
submandibular salivary gland equaled 5518 cGy and the normal tissue D1cc was equal to 7563
cGy.
Quality Assurance/Physics Check: The monitor units (MUs) were checked using the
MUCheck software in our department. Six calculation points were added in the TPS in order to
properly calculate the MUs from each of the 18 separate fields. Each field was compared
against all of the calculation points to determine which point provided the greatest amount of
MUs in order to give a proper calculation. The acceptable tolerance of difference between the
TPS and MUCheck is 5% and all fields passed this requirement.
A quality assurance (QA) check was done by the physicists in our department using
ArcCheck. ArcCheck is used for all of our IMRT plans and requires a 5% or less difference
when tested. This IMRT plan passed within the required tolerance of -1.9% difference.
Conclusion: IMRT-SIB technique can offer some very attractive treatment options, especially
for advanced stage head and neck cancers of the larynx. Using this technique, also known as
dose painting, has the potential to deliver higher doses of radiation to the high-risk regions with
greater conformity while minimizing the dose to ORs and normal structures. Reviewing this
gentlemans case undoubtedly helped me to broaden my horizons in regards to complicated head
and neck cancers.
While learning about this treatment technique, I admittedly struggled with the concept of
how each of the prescriptions to the 3 separate PTVs were managed during the planning process.
 7

I believe that balancing all of these parameters is one of the biggest challenges during planning a
case of this magnitude. Also due to the large field sizes making it necessary to split many of the
fields, there was an extra layer of complexity to this case that must be accounted for. In
consulting with the dosimetrist I realized that another challenge in this plan was the 6 different
calculation points that were needed in order to check the MUs being delivered to the patient. I
learned that is ideal to place your calculation points in a location where dose can be measured by
as many fields as possible in order to be able to minimize the number of calculation points.
 8

References
1. Chernock R, El-Mofty, Thorstad W, Parvin C, Lewis J. HPV-related nonkeratinizing
Squamous cell carcinoma of the oropharynx: utility of microscopic features in predicting
Patient outcome. Head Neck Pathol. 2009; 3(3): 186-194.
https://doi.org/10.1007/s12105-009-0126-1.
2. Rastogi M, Sapru S, Gupta P, et al. Prospective evaluation of intensity modulated radiation
therapy with simultaneous integrated boost technique (IMRT-SIB) in head and neck
squamous cell carcinoma in patients not suitable for chemo-radiotherapy. Oral Oncol. 2017;
67: 10-16. https://doi.org/10.1016/j.oraloncology.2017.01.005.
3. Chao K, Perez C, Brady L. Radiation Oncology Management Decisions. 3rd ed. Philadelphia,
PA: Lipincott Williams & Wilkins; 2011.
 9

Figures

Figure 1. Patient position on CT Simulation couch.

Figure 2. Anterior view of patient hand position on Civco pulleys.

 10

Figure 3. Bolus setup around patients stoma.

Figure 4. Isocenter Placement: Left Lateral and AP View

 11

Figure 5. Isocenter placement transverse view. PTV 6996 is solid blue color and PTV 5600 is in
solid light purple.

Figure 6. Isocenter placement in coronal view. PTV 6996 is solid blue color and PTV 5600 is in
solid light purple.
 12

Figure 7. Isocenter placement in sagittal view. PTV 6996 is solid blue color and PTV 5600 is in
solid light purple.

Figure 8. IMRT field sizes for Automatically set by TPS.

 13

Figure 9. IMRT field sizes automatically set by TPS.

Figure 10. IMRT field sizes automatically set by TPS.

 14

Figure 11. DVH for the IMRT plan demonstrating all of the critical structures as well as an
acceptable PTV 6996 with a steep shoulder at the top and a small toe at the bottom.
15