Head and Neck Assignment

Beverly Meyer
Group 4: Oropharynx (Left Base of tongue and tonsil)

How was this patient positioned? What positioning devices/accessories were used, how and
why? (5 points)
This patient was positioned head first supine on an Accufix board extension to the table and a
clear B headrest for maintaining neutral head position. A fibreplast hemi mask was created for
the patient in order to hold shoulders in a depressed position. The patients shirt was off and a
mark was placed on his sternum to ensure his shoulders and thorax were centered properly to the
table. His arms were by his sides, a knee cushion was placed under his knees for comfort, and
his feet were held in place with a foot ring.
What specific avoidance structures were contoured? What is their tolerance dose? (20
points)
Specific avoidance structures that were contoured include the following, along with tolerance
dose:
1. Spinal Cord <45Gy
2. Brainstem <54Gy
3. Mandible <70Gy
4. Parotid Glands mean dose <26 Gy and/or attempt to keep 50% volume to each parotid at or
less than 20Gy
5. Larynx mean dose 43.5Gy or less
6. Mean (max) cochlea 37(45)Gy or less
7. Thyroid 25-35Gy or less depending on adjacent adenopathy
8. Optic nerves (max) <54Gy (limit)
9. Optic chiasm (max) <54Gy (guidelines), <60Gy (limit)
10. Oral cavity (mean) <40Gy
11. Esophagus (mean) <45Gy
12. Lens (max) <25Gy
13. Eyes (mean) <35Gy, (max) <50Gy
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)

The borders for oropharyngeal cancer include the primary tumor and locoregional extensions. It
extends superiorly to the base of skull and the floor of the sphenoid sinus to include
retropharyngeal lymphatics. Inferiorly the supraglottic larynx should be included and posteriorly
to the cervical triangle. Both sides of the lower neck are included.
This patient was diagnosed as Stage IVA, T2, N2b squamous cell carcinoma of the left base of
tongue and tonsil. According to Dr. Joseph Kelley, the patient had two hard nodules by the uvula
in the glossopalatine muscles, so he treated part of the patients soft palate as well.
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)
What radiation technique is used to treat this patient? Describe in detail the technique (35
points)
Lymph nodes are included in the treatment area. They include Levels 1A, 1B, II, and III, which
include the upper and mid-jugulars, submental and submandibular nodes. The patient had a
palpable node in the left level II region measuring 2 cm prior to treatment that had not
completely resolved by the end of treatment.
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.
The initial portion of the treatment (the first 25 fractions) the VMAT plan contained 4 arcs. The
collimator was turned for each arc 30 degrees, or 330 degrees, for better target coverage and cord
sparing. The couch was not turned as I believe the hemi mask depressed the shoulders
adequately to not need the couch rotation to avoid them.

The boost portion (the remaining 10 fractions) was identical to the initial with collimator rotation
as well as the couch. However the boost plan contained only 2 arcs with the gantry rotating from
179 degrees to 320 degrees, since the tumor was left-sided.