Adaptive Planning in Intensity-Modulated Radiation Therapy for Head and Neck Cancers:

PURPOSE: Radiotherapy has been used in the treatment of patients with head-and-neck cancer for several decades. However, whether RT is used definitively in an organ-preserving strategy or postoperatively to enhance locoregional control, an adequate radiation dose must be accurately delivered to the desired target volume throughout the treatment course. The clinical consequences for inaccuracy include both potential underdosage of the target volumes (with a resultant increased risk of tumor recurrence) and potential overdosage of normal tissues (with a resultant increased risk of complications). Recent advances in image-based treatment planning have improved the clinician s ability to design conformal treatment plans that maximize both tumor coverage and normal tissue sparing. It has long been recognized that some patients receiving RT to the head-and-neck will have significant anatomic changes during their treatment course, including shrinking primary tumours or nodal masses, resolving postoperative changes/edema, and changes in overall body habitus/weight loss. Although at times these are clinically relevant even with conventional RT techniques, concern is heightened that geometric changes have even greater significance when using the more modern, highly conformal RT delivery methods. Currently, RT is planned on the basis of the acquisition of a single set of CT scans before the start of treatment. This treatment plan includes a margin for potential microscopic spread (i.e., clinical target volume), along with the anticipated uncertainties related to daily setup variation and intrafractional organ motion (i.e., planning target volume).This margin does not specifically address ongoing alterations in anatomy during the next 6 7 weeks of therapy. These anatomic changes throughout fractionated RT could have significant dosimetric effects in the setting of highly conformal treatment approaches, such as intensity-modulated RT (IMRT).

Volumetric and positional changes in GTV: The GTVs decreases throughout fractionated RT. The absolute volume loss is larger for large tumours/ nodes. The rate of volume loss correlates with the initial volume of gross disease as determined on the initial CT scan indicating that the initial volume is a good determinant for the rate of volume loss during the course of RT. When tracking the geometric shift of a structure relative to an internal reference point (C2 bony structure), GTV loss is frequently found to be asymmetric.

Volumetric and positional changes in normal tissue structures: The parotid glands were noted to decrease in volume during the course of RT.The parotid gland on both sides shifts medially over time.Recently, interest has increased in using highly conformal RT technology (such as IMRT) to reduce late toxicity by sparing normal tissues while maintaining the local control rate.The achievement of this objective, however, requires the construction of tight dose gradients between the tumor and normal tissues.The anatomic changes observed over time may have potential dosimetric implications when conformal treatment approaches are used. This is particularly important, because the parotid glands move medially toward the high-dose region.In these situations, the medial shifts of the parotid glands may result in a higher actual radiation dose to the parotid than previously calculated in the original treatment plan. The irradiated submandibular glands shrink and shifts upward, medially, and posteriorly. For the spinal cord, significant dosimetric changes might be noted. That is to say the anatomic changes that may occur during the period of treatment may be summarised as: (1) a mean relative shrinkage of the primary tumor GTVT and nodal GTVN. (2) a mean relative shrinkage of the homolateral and heterolateral parotids. (3) a mean relative shrinkage of the prophylactic homolateral and heterolateral nodal CTV (CTVN).

METHOD: The patients will undergo serial CT scans during their radiation course after undergoing the planning CT scan.Between the planning CT scan and subsequent scans,positional variability and anatomic changes during treatment are to be correlated with changes in dosimetric parameters to target and avoidance structures.

The subsequent scans will be used to generate new IMRT plans, if deemed necessary, for the remaining fractions of treatment.Attempts will be made to maintain the original CTVs with modifications that adapt to the changes in the anatomic structure displayed in the scans.However GTVs will be reconstructed according to shrinkage and/or distortion of primary tumor or lymph node shown in the new scans. Normal structure and critical organs will be contoured as planned. For positional analyses, a central bony reference (C2 vertebral body) will be contoured on every CT scan. The calculated center of mass (COM) for this structure will be determined for each CT set, and this single point will be used as a common reference for all evaluations of positional change among the GTVs and normal tissues. The difference in position between the C2 vertebral COM and any other unique structure will be a simple positional vector that could be followed over time. Because this reproducible landmark is going to be used for the positional analyses rather than an externally defined point such as a skin tattoo or the treatment isocenter, daily setup variation will be excluded from this analysis. To quantify the positional shifts for parotid glands, we can calculate the change in COM relative to the reference bony structure (C2) in the medial-lateral directions only (most dominant and important directions). This change in parotid COM position can also be compared with the change in external volume (one slice) at the level of C2 vertebral body and at the base of the skull.