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Jeanette Keil
April Case Study
April 8th, 2018
SIB Split X-Jaw VMAT Planning for Head and Neck
History of Present Illness: The patient that I used for this case study is a 74 year-old man who
underwent a left carotid endarterectomy on January 15, 2018. During the surgery, he was noted
to have a concerning cervical lymph node. This lymph node was removed and sent to pathology
where it was identified as squamous cell carcinoma. The patient did not complain of dysphagia
or odynophagia but did note that he had some intermittent left-sided ear pain. He also denied
having any lump on his neck prior to his carotid endarterectomy. At this point, the patient was
referred to an otolaryngology specialist where they performed a fiberoptic laryngoscopy and was
found to have a 1.5 cm fungating lesion at the base of tongue at midline.
After the lesion was identified, the patient was then sent for diagnostic imaging to help
determine staging. He had a PET scan on February 8, 2018 which showed hypermetabolism
along the base of tongue consistent with malignancy. There were also no metastases seen at this
time. In January 2018 the patient met with Medical and Radiation Oncology where he was
recommended for concurrent Cetuximab and radiotherapy.
Past Medical History: The patient presented with some significant medical history including:
cerebrovascular accident (CVA), carotid artery disease, dyspnea, hypertension, hyperlipidemia,
leg edema, and sciatica. His past surgical history consists of: angiogram, left endarterectomy,
and left rotator cuff surgery. The squamous cell carcinoma at base of tongue was discovered
during the left endarterectomy procedure.
Social History: The patient is married and has three children. He is retired from working at
General Motors in a factory. He reported hazardous material exposure to industrial chemicals
during his career. He has never smoked and has never used illicit drugs. The patient reported
that he is a former alcohol user having an average of 15 drinks per day but stopped in 2003. The
patient’s family history of cancer is non-contributory.
Medications: At the time of consultation with radiation oncology, the patient stated that he was
using the following medications: Atorvastatin, Metoprolol, Senna, Plavix, Lisinopril,
Oxycodone, and Aspirin.
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Diagnostic Imaging: After the suspicious lymph node was removed during his left carotid
endarterectomy on January 15, 2018, the patient was sent for a PET scan on February 8, 2018.
This PET scan showed hypermetabolism along the base of tongue consistent with malignancy.
There were no signs of metastases and he was staged as cT1N1Mx.
Radiation Oncologist Recommendations: Since there was no evidence of metastatic disease
on his PET scan, the radiation oncologist recommended a course of definitive external beam
radiotherapy utilizing intensity modulated arc radiotherapy (IMRT) with a daily cone-beam CT
localization as per NCCN guidelines. This treatment will be treated concurrently with systemic
therapy under the supervision of the medical oncologist.
The Plan (Prescription): The physician prescribed a simultaneous integrated boost (SIB) plan
to go to 7000cGy in 35 fractions. There are 3 planning target volumes (PTV) that will be treated
simultaneously. The PTV High will receive 7000cGy in 200cGy per fraction, the PTV
Intermediate will receive 6125cGy in 175cGy per fraction, and the PTV Low will receive
5775cGy in 165cGy per fraction. This plan will be delivered through Volumetric Arc Therapy
(VMAT) as per the physician.
Patient Setup/ Immobilization: After the patient was consulted by both medical and radiation
oncology we proceeded to schedule him for CT simulation on February 6, 2018. The patient was
positioned head first and supine on the IMRT board with his arms down at his sides in shoulder
retractors. The positions of the retractors were recorded by the therapists to ensure consistent
setup daily. His head and neck were immobilized with a short Aquaplast mask and an Accuform
head rest. A knee sponge was placed under his legs for comfort. Three-point marks were made
on the mask for triangulation and the shifts will be made on the first day of treatment (Figure 1).
IV contrast was used during simulation to further assist the physician with tumor localization.
Anatomical Contouring: The CT scan from simulation was imported into the Eclipse treatment
planning system (TPS) for contouring and planning. The PET scan from February 8, 2018 was
also imported into the TPS for image registration. The medical dosimetrist first created a
registration of the PET scan and the planning CT scan to assist the physician in contouring the
gross tumor volume (GTV) and the clinical target volume (CTV). The physician reviewed the
scan and determined that a deformable registration was not needed and proceeded to contour the
GTV, CTV, and PTV. The medical dosimetrist then contoured all the organs at risk (OAR) in
the head and neck region including: brain, brainstem, spinal cord, esophagus, eyes, lens, lips,
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mandible, optic nerve, oral cavity, parotid glands, all PRV structures needed, and optimization
(OPTI) structures for the PTVs. The PTV 5775 OPTI was created by subtracting the PTV 5775
from the PTV 6125 and the PTV 6125 OPTI was created by subtracting the PTV 6125 from the
PTV 7000. This will help in the optimization stage of planning. At this point the physician
reviewed all contouring done by the medical dosimetrist and gave the approval to proceed with
planning.
Beam Isocenter/ Arrangement: One of the main focal points of this case study is to discuss the
beam arrangements that were created to treat this very large PTV in the head and neck region.
The medical dosimetrist first placed a beam in the area of the PTVs. The Eclipse arc geometry
tool was used to assist in isocenter placement by selecting the 2 full arc option with a 15º
collimator rotation and to cover the whole PTV 5775 with a 0.5cm margin and then allowing the
tool to move the isocenter to an ideal location. The isocenter was evaluated to ensure that
treatment delivery would not cause a collision with the couch or patient (Figure 2). Once the two
arcs were created with the X and Y-jaws at the optimal positions to allow for full coverage, both
arcs were duplicated so that there was a total of 4 arcs. The next step is to split each arc into two
treatable arcs that will delivery optimal fluence. Some studies have addressed the need to
minimize the X-jaw of each field to 15cm because of the maximum movement of a leave in a
MLC Bank. By creating a plan where all the leaves can move into any possible position needed,
during the optimization process, will allow the PTV to be irradiated and OARs to be spared to
the full ability of the algorithm at each gantry position.1 Each arc was closed on either the X1 or
X2 jaw to give a maximum width of 15cm. Arc 1 and 1A will travel clockwise from 181º to
179º with a 345º collimator angle. Arc 2 and 2A will travel counter clockwise 179º-181º with a
15º collimator angle (Figures 3&4).
Treatment Planning: The treatment plan for this patient was created using the Eclipse
treatment planning system version 13.5. The planning was based off the prescription and plan
orders given by the physician. For this head and neck plan the critical structure constraints were
based off of the Radiation Therapy Oncology Group (RTOG) protocol 0225 and is documented
with a plan order (Figure 5).2 A VMAT plan was suggested at the time of simulation by the
physician to increase the conformality in the area of the PTVs while significantly reducing the
dose to the OARs in the head and neck region. Since this was an SIB treatment, all OARs were
evaluated in the optimization stage of planning to keep them within the limits defined by RTOG
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0225 and there was no plan summation needed. All PTVs were covered appropriately and all
OARs were kept within the constraints except for the oral cavity – PTV maximum dose. The
maximum dose limit was defined at 6000cGy but the maximum dose to the oral cavity – PTV
was 6256cGy (Figures 6 &7). This was evaluated by the physician and approved because of the
proximity of the oral cavity to the base of tongue GTV.
Quality Assurance/ Physics Check: Our department uses the Mobius3D dose verification
system to evaluate all IMRT and VMAT plans. This system uses collapsed-cone, convolution-
superposition dose calculation to evaluate the data and is done by our physicists on site. The
Mobius3D program evaluates target coverage, dose volume histogram (DVH) limits, 3D gamma,
and deliverability of each treatment plan. Our physicists also check all information entered into
the Mosaiq record and verify system and must be approved by the physician and therapists prior
to any treatments.
Conclusion: Our dosimetry team has only recently started using this split X-jaw VMAT
technique for head and neck planning. This technique proves to be very successful at creating a
more optimal fluence for large or wide PTVs when compared to delivering the same two arcs
with a max X-jaw setting at -7.5cm and 7.5cm (Figures 8-15). This technique also creates a plan
with a lower maximum dose which is critical in reducing toxicity in normal structures. Although
there are great advantages regarding maximum dose and conformality, the one disadvantage of
using this technique is that there is a longer daily treatment time. It is important to evaluate each
patient to ensure that they will be able to withstand the time it will take to deliver 4 full arcs
compared to a standard of 2 arcs for this type of treatment.
I actually picked up on this technique quite easily and saw a huge improvement in my
head and neck planning almost immediately. While researching the topic of using a 15cm X-jaw
for VMAT optimization I noticed that there was a gap in the literature and a need for more
research to be done to determine the effectiveness of this technique for treating large PTVs in all
areas of the body. I did struggle to explain the effectiveness of this technique to other
dosimetrists and physicians, but they soon understood the rational and have accepted this as a
regular treatment in our clinic. I have been able to reach out to other dosimetrists in our practice
during peer review and there has been a lot of positive feedback regarding their treatment plans
when this technique is applied. Overall, I have had a huge interest in researching this further and
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will continue to utilize this technique to gain some more perspective into the advantages of split
X-jaw VMAT planning.
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References

1. Vieillot S, Azria D, Lemanski C, et al. Plan comparison of volumetric-modulated arc

therapy (RapidArc) and conventional intensity-modulated radiation therapy (IMRT) in
anal canal cancer. Radiation Oncology. 2010;5(1):92. https://doi.org/10.1186/1748-
717X-5-92.
2. Lee N, Garden A, Kramer A, et al. A phase II study of intensity modulated radiation
therapy (IMRT) +/- chemotherapy for nasopharyngeal cancer. Radiation Therapy
Oncology Group (RTOG).
https://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=0225.
Published 2005. Accessed April 7, 2018.
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Figures

Figure 1. Full body image showing patient positioning on IMRT board with Aquaplast mask
and shoulder retractors.
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AP DRR Right Lateral DRR

Figure 2. Digitally reconstructed radiographs (DRRs) showing isocenter placement.

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Figure 3. Fields 1 and 1A. Both CCW 181°-179°. Beams split to 15cm wide x-jaw fields.

Figure 4. Fields 2 and 2A. Both CW 179°-181°. Beams split to 15cm wide x-jaw fields.
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Figure 5. Plan Order created from RTOG 0225.

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Figure 6. Dose Volume Histogram (DVH) of the SIB head and neck plan showing prescription
doses to the PTVs and doses to the OARs.
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Figure 7. Chart showing the goal and plan doses to the OARs per the plan order. Oral cavity –
PTV maximum dose was not achieved.
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Figure 8. SIB plan dose distribution in axial plane.

Figure 9. SIB plan dose distribution in axial plane.

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Figure 10. SIB plan dose distribution in axial plane.

Figure 11. SIB plan dose distribution in axial plane.

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Figure 12. SIB plan dose distribution in axial plane.

Figure 13. SIB plan dose distribution in coronal plane.

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Figure 14. SIB plan dose distribution in coronal plane. Focused on GTV highlighted in red.

Figure 15. SIB plan dose distribution in sagittal plane.