Group 5 Research Proposal Timothy Zehnder

Sara Kempton
Lauren Geisking

Working Title:

Utilizing skin rind contours as a method for assessing tissue loss along the beam path, leading to dose
deviations, in patients undergoing head and neck proton therapy

Literature Review:

Malnutrition is an ongoing issue for patients diagnosed with head and neck cancers. Decreased
caloric and water intake, difficulties regarding recovery of invasive procedures, side effects from treatment
and the increased caloric usage from the body's natural healing process are all factors that attribute to
malnutrition.1 Although malnutrition in the management of head and neck cancers is well known and
regulated, approximately 88% of patients still experience some level of taxing side effects. 2 Research has
been conducted on the best ways to prevent malnutrition in head and neck cancer patients but, as of recent,
there is not a definitive answer to this problem. Along with increasing recovery times and causing long
term harm or death to a patient, malnutrition affects the delivery of radiation therapy as well.
Intensity Modulated Radiation Therapy (IMRT) has become the gold standard of radiation
treatment for patients with head and neck treatment. IMRT deals with very sharp dose gradients which
rely on a reproducible tissue volume for the beam to pass through. It has been shown that changes in those
tissue volumes could shift the steep dose gradients away from the target volumes leading to a mistreatment
of a patient.3 With treatments volumes getting more conformal and total dosing of radiation therapy
treatment increasing, it is paramount importance that the dose is accurately delivered.
Studies have attempted to address these issues with tissue changes during a patient’s course of
IMRT by introducing adaptive therapy. Adaptive therapy address the changing tissue from malnutrition
and treatment side effects.4 Research in adaptive planning has shown that is very effective at sparing dose
limiting organs at risk (OAR) and preventing overdosing of target volumes but it is not as effective at
limiting typical side effects like decreased salivary output. 4 Adaptive planning offers physicians the ability
to continuously deliver accurate doses of radiation to their patients throughout an entire course of
treatment. The question now is when is adaptive planning necessary in the treatment process?
Studies have attempted to determine the best method of determination of adaptive planning, but
more research is needed. Methods such as set amount of weight loss, set periods for replanning, in depth
analysis of daily Image Guided Radiation Therapy (IGRT) scans and image registrations have been used
in the determination of adaptive radiotherapy.5 These methods range from inaccurate at the worse to time
and labor intensive at the best. It is for these reasons that we wanted to discover if we could create a
method of determining when adaptive planning was necessary using a method that is accurate, fast and
non-labor intensive.
We believe that the creation of skin rind contours will give the therapists, physicians and
physicists the ability to determine, on a daily basis, if the patient needs adaptive planning. Researching the
relevant clinical data for skin rind analysis is paramount importance if they are to be useful in the clinical
setting. This study will be focused on finding what amount of tissue loss inside of the 20% isodose lines
leads to a deviation in treatment delivery. Utilizing that data, we can then start to build recommended skin
rind analysis settings for daily use on the treatment machine. This method could have the ability to save
the patient from superfluous appointments and unnecessary extra doses from CT planning scans. Utilizing
this method on the daily IGRT scans allows for a continuous monitoring of the treatment volume
throughout treatment and thus an accurate portrayal of when adaptive planning is necessary.

Problem Statement:

There is a lack of guiding indicators to alert the need of adaptive planning due to external tissue loss in
patients treated for head and neck cancer with proton therapy.
Group 5 Research Proposal Timothy Zehnder
Sara Kempton
Lauren Geisking

Purpose Statement:

The purpose of this study is to determine if a skin contour can be an effective determinant of external
tissue loss leading to clinically significant plan deviations and replanning for head and neck cancer
patients.

Hypothesis Statements:

H1a: Tissue loss inside of the beam path (inside of the 20% isodose line) will create clinically significant
deviations from a treatment plan in proton therapy to the head and neck. Clinical significance would be a
loss of PTV coverage below 95% isodose coverage at 95% of the PTV. The PTV target loss constraint
assumes that the plan was initially created with 95% isodose coverage at 100% of the initial PTV leading
to a total loss of 5% coverage from the initial plan.

H1b: Tissue loss inside of the beam path (inside of the 20% isodose line) will create clinically significant
deviations of hot spot. Clinically significant hot spot increase would be an increase of at least 5% from
the initial plan.

H2a: We can determine what volume of external tissue outside of set tolerances would produce a
deviation from the treatment plan that is clinically significant.

Summary:

Current research has shown that malnutrition and tissue changes can have large impacts on the
delivery of therapeutic radiation to patients with head and neck cancer. Adaptive planning is very
prevalent in modern therapy to help ensure physicians are delivering accurate dose to patients. The
problem is that there is a lack of guiding indicators to alert for the need of adaptive planning because of
anatomy changes. We believe that the addition of skin rind contours to the daily imaging scans will give
the treatment team the ability to accurately determine if adaptive planning is necessary without delivering
extra, unnecessary, dose to a patient. Our research will study previously treated patient data sets and,
using our development method, analyze what amount of tissue loss inside of the 3mm and 5mm rind led
to a clinically significant change in dose delivery. Utilization of the 20% isodose line will create a stable
metric between patients, no matter the beam design and weighting. We will be investigating the
percentage of target loss coverage at the prescription isodose line as well as the increase to the hot spot of
the treatment plan. Our intention is to determine a relevant amount of tissue that falls below the 3mm and
5mm lines of external tissue change so that this can start to be used clinically during image analysis. This
method will be more effective at determining the need to adaptive planning compared to other methods
such as monitoring weight loss. Many patients may experience weight loss, but if their external tissue
does not change inside of the beam path, there may be no deviation to the plan and no need for adaptive
planning. Our study will give concrete, statistical, data on external tissue changes leading to dose
deviation that cannot be determined without a total re-scan and re-plan. That data can then be adapted to
skin rind contours that would then be used daily by the treatment staff to actively monitor external tissue
loss leading to a more accurate adaptive planning schedule in a proton department. Our intention with this
method is for it to serve as a guiding indicator of adaptive planning that has the ability save the patient
time, money and extra, superfluous, dose from unnecessary CT scans.
Group 5 Research Proposal Timothy Zehnder
Sara Kempton
Lauren Geisking

References

1. Martinovic D, Tokic D, Puizina Mladinic E, et al. Nutritional management of patients with head and
neck cancer—a comprehensive review. Nutrients. 2023;15(8):1864. doi:10.3390/nu15081864
2. Vangelov B, Venchiarutti RL, Smee RI. Critical weight loss in patients with oropharynx cancer
during radiotherapy (± chemotherapy). Nutrition and Cancer. 2017;69(8):1211-1218.
doi:10.1080/01635581.2017.1367943
3. Ahn PH, Chen C-C, Ahn AI, et al. Adaptive planning in intensity-modulated radiation therapy for
head and neck cancers: Single-institution experience and clinical implications. International Journal
of Radiation Oncology*Biology*Physics. 2011;80(3):677-685. doi:10.1016/j.ijrobp.2010.03.014
4. Stauch Z, Zoller W, Tedrick K, et al. An evaluation of adaptive planning by assessing the dosimetric
impact of weight loss throughout the course of radiotherapy in bilateral treatment of head and neck
cancer patients. Medical Dosimetry. 2020;45(1):52-59. doi:10.1016/j.meddos.2019.05.003
5. Chen AM, Yoshizaki T, Hsu S, Mikaeilian A, Cao M. Image-guided adaptive radiotherapy improves
acute toxicity during intensity-modulated radiation therapy for head and neck cancer. Journal of
Radiation Oncology. 2017;7(2):139-145. doi:10.1007/s13566-017-0336-1
Group 5 Research Proposal Timothy Zehnder
Sara Kempton
Lauren Geisking

6. Nishimura Y, Ishikura S, Shibata T, et al. A phase II study of adaptive two-step intensity-modulated

radiation therapy (IMRT) with chemotherapy for loco-regionally advanced nasopharyngeal cancer
(JCOG1015). International Journal of Clinical Oncology. 2020;25(7):1250-1259.
doi:10.1007/s10147-020-01665-2
7. Mallick I, Gupta SK, Ray R, et al. Predictors of weight loss during conformal radiotherapy for head
and neck cancers – how important are planning target volumes? Clinical Oncology. 2013;25(9):557-
563. doi:10.1016/j.clon.2013.04.003