Clinical Oncology Assignment 1

Head and Neck Treatment Case Study

The evolution of treatment planning for radiation oncology has led to more accurate and

clinically effective treatment plans in the last 20 years. This change has become very impactful

for head and neck treatments, especially with the introduction of VMAT which has improved

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plan quality and treatment delivery time . In this paper, a case study was performed on a patient

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diagnosed with malignant neoplasm of the supraglottis staged from the AJCC 8 edition . This

patient was prescribed a dose of 70Gy in 35 fractions equaling out to 2Gy daily for the primary

treatment of the larynx by the oncologist. A boost treatment of a 56Gy in 35 fractions was also

prescribed for the neck lymph nodes. Many trials have shown that doses as high as 70Gy can be

effective and are common for curative-intent diseases in the head and neck when given between

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1.8 and 2.5Gy per fraction daily . This study will explore the details of how this patient was

treated, along with the outcome of the final plan that the patient is currently being treated with.

The positioning of this patient during simulation was an important aspect of making an

effective treatment plan. The patient was laid supine on the table with a thermoplastic face and

neck mask with a precise bite. Face and neck masks help reduce movement during treatment and

increase the reproducibility of the treatment day to day. This is because the thermoplastic

material allows the mask to conform around the contour of the patient when hot. As the mask

cools, it becomes a rigid surface around the patient and locks them in place. The precise bite,

which attaches directly to the face mask, also makes the treatment more reproducible by

positioning the teeth, maxilla, and mandible of the patient.

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There are many different organs in the head and neck region that should be avoided when

constructing a treatment plan. Image 1 below shows a coronal and sagittal view of the patient

with the OARs and PTVs contoured.

Image 1: A coronal and sagittal view of the patient with the visible OARs contoured. The

contours are as follows: spinal cord (yellow), brainstem (light green), esophagus (light blue),

left/right brachial plexus (dark blue and dark green), mandible (brown), and oral cavity (dark

orange). The PTV for the larynx can be seen in red. The PTVs for the lymph nodes are contoured

in pink or light red running down the lateral neck.

Since so many OARs needed to be considered while constructing the treatment plan, a lot of

effort was put into limiting the dose. For the parotid glands, there were some avoidance

structures used to limit dose delivered as seen in Image 2. This was done because of the overlap

of the parotid glands with the PTV. The parotid glands and other salivary glands are very

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radiosensitive organs, and damage can result in a loss of saliva production . This was confirmed
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after speaking with an experienced physicist at the clinic who expressed that most patients would

return after treatment and would not be producing any saliva due to the damage to their salivary

glands before VMAT/IMRT was introduced.

Image 2: An axial view depicting the left parotid (blue) and right parotid (pink). The avoidance

structures can be seen as blue structures that overlap the prescription 5600cGy isodose line.

A posterior avoidance structure was also used to aid in limiting dose to the spinal cord and

brainstem. This structure appears as a long tube engulfing the spinal cord and brain stem and is

seen in turquoise in Image 3 below. Both the posterior avoidance structure and the parotid

structures helped aid in the optimization process by allowing for more control over the amount of

dose these organs received.

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Image 3: An image depicting the posterior avoidance structure (turquoise tube) used to limit the

dose being delivered to the spinal cord and brainstem.

Table 1: A table depicting the OARs that were contoured and evaluated in the final plan. The

oncologist’s instructions are listed, along with the final calculation and if the goal was met. Each

goal that was not met was verified and noted as acceptable by the doctor.

Structure Instructions Results Instruction Met (Y/N)

PTV Larynx V70Gy > 95% 97.5% Yes

PTV LN Neck V56 > 95% PTV LN LNeck = 95.1% Yes

PTV LN RNeck = 95.1%

Yes
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Brachial Plexus Trunks Max dose < 66Gy to no BrachialPlexL = 56.7Gy Yes

more than 0.03cc BrachialPlexR = 56.9Gy

Yes

Spinal Cord+5mm Max dose < 48Gy to no D0.03cc = 40.5Gy Yes

more than 0.03cc

Brain Stem+3mm Max dose < 50Gy to no D0.03cc = 42.1Gy Yes

more than 0.03cc

Lips Mean dose < 20Gy Mean = 14.3Gy Yes

Oral Cavity Mean dose < 30Gy Mean = 25.7Gy Yes

Parotid Glands Mean dose < 26Gy to ParotidR = 24.0Gy Yes

parotid gland ParotidL = 26.4Gy No

Submandibular Glands Mean dose < 39Gy to SubmandR = 67.5Gy No

submandibular gland SubmandL = 65.8Gy No

Mandible Max dose < 105% Max = 94.99% Yes

V44Gy < 42% V44Gy = 37.7% Yes

V58Gy <25% V58Gy = 2.1% Yes

CochleaR Max dose of 45Gy to Max = 13.2Gy Yes

0.03cc

Mean dose of 30Gy Mean = 10.1Gy Yes

CochleaL Max dose of 45Gy to Max = 8.6Gy Yes

0.03cc
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Mean dose of 30Gy Mean = 7.1Gy Yes

Cervical Esophagus Mean dose < 30Gy Mean = 15.1Gy Yes

Pharyngeal Mean dose < 45Gy Mean = 50.1Gy ALARA

Constrictors ALARA

Thyroid Mean dose < 50Gy Mean = 54.5Gy ALARA

ALARA

In the table above (Table 1), a list of the final OAR dose values are listed as well as the

initial instructions provided by the MD. Most of the goals were met, including 97.5%

prescription dose coverage of the PTV in the larynx and 95.1% coverage of the lymph nodes on

the left and right side of the neck. Adequate PTV coverage was met, however, some of the

constraints for the OARs were not achieved. This was the case for the submandibular glands and

the left parotid. The submandibular glands crossed over with the lymph node PTVs, which

resulted in limited control in lowering the dose for each gland. The left parotid also partially

crossed over with the PTV, but the oncologist let it be slightly hot to maintain coverage of the

PTV. According to Table 1, the left parotid gland received 26.4Gy. Any dose more than 20Gy

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can increase the risk of loss of saliva production by greater than 20% . These final values were

verified by the doctor as acceptable for treatment. The toxicity endpoints for the OARs along

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with the associated symptom can be found below in Image 4 . Additionally, the location of the

lymph nodes caused the submandibular glands to not meet the dose constraints provided.
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Image 4: Images displaying the toxicity endpoints for OARs in the body.

The lymph nodes that were treated in this patient were levels I-V. Image 5 below

provides axial images labeled with each lymph node region that was treated.
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Image 5: Axial images labeling the nodal regions being treated in the head and neck. The images

start superiorly and move inferior in the patient with the first image being the most superior and

the last image being the most inferior.

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The addition of the lymph nodes for this plan resulted in larger treatment fields. The borders for

this plan span inferiorly to T4 to encompass all the lymph nodes, and superiorly to the level of

the midbrain which can be seen in Image 6. Laterally, the fields extend to the coracoid of the

scapula on the left and right side of the patient. Medially, the treatment field splits the vertebral

body on the inferior end. As you move more superiorly in the patient the lateral and medial fields

are angled to include the whole neck.

Image 6: Two images depicting the treatment borders of the fields. On the left, a coronal CT

image depicts the superior and inferior borders. On the right, an axial CT displays how far the

field extended laterally into the patient.

A VMAT plan was requested for this patient because the oncologist wanted to cover the

tumor volume with narrow margins and spare the OARs present. To achieve coverage of the
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tumor volume, four rotational arcs were used. Each arc rotated completely around the patient

either clockwise or counterclockwise. No beam off angles were used to protect any organs as

seen in Image 8. After each rotation, the direction of the field was flipped to achieve a faster

treatment time. Additionally, each field had a different gantry angle to allow the MLCs to fit

different anatomical areas. There was no methodology for choosing the gantry angles, but the

MLCs were visually analyzed by the dosimetrist, and they decided that the angles chosen would

achieve adequate coverage. The angles of rotation and the gantry angles can be seen in Image 7

below.

Image 7: An image depicting the rotational angles for each field around the patient, along with

the gantry angles for each field.

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Image 8: An image depicting the rotational directions around the patient. Each arrow on the

posterior side of the patient displays whether each field is going clockwise or counterclockwise.

Graph 1: A final DVH depicting the amount of dose each OAR received, along with the PTV

coverage. Each OAR is appropriately labeled with the corresponding line.

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Analyzing the information from Table 1 and Graph 1, it was found that the OAR dose

constraints were met. As mentioned before, some of the constraints for the submandibular glands

and the parotid glands were not met. This was due to the crossing over of the organs with the

PTV and was verified by the oncologist. However, 20/23 of the constraints were met for this

difficult head and neck plan. The ability to meet these constraints was a product of the number of

arcs used, the gantry angles chosen, and the manipulation of the VMAT optimization process.

VMAT/IMRT has shown to be a valuable tool in the treatment of head and neck patients

allowing for better tumor coverage and dose sparing for OARs. With the use of four arc fields,

the dosimetrist was able to achieve above 95% coverage of the prescription dose, and able to

meet 20/23 of the dose constraints. The borders of this plan extended from the midbrain

superiorly to T4 inferiorly. These borders were used to adequately cover regions I-V of the

lymph nodes within the neck, along with the larynx. Currently, this patient is a few fractions into

their treatment and the oncologist is satisfied with the outcome of the plan.
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References
1.) Alvarez-Moret J, Pohl F, Koelbl O, Dobler B. Evaluation of Volumetric Arc Therapy
(VMAT) with Oncentra MasterPlan for the Treatment of Head and Neck Cancer. Journal of
Neuro-Oncology. 2010; 110.
https://ro-journal.biomedcentral.com/articles/10.1186/1748-717X-5-110#:~:text=Dual%20a
rc%20VMAT%20is%20a,the%20PTV%20and%20OAR%20sparing.

2.) American Cancer Society. Laryngeal Cancer Stages.

https://www.cancer.org/cancer/types/laryngeal-and-hypopharyngeal-cancer/detection-diagnosis-s
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taging/staging.html. 2021. Accessed April 24 , 2024

3.)Grewal A, Jones J, Lin A. Palliative Radiation Therapy for Head and Neck Cancers.
International Journal of Radiation Onocology, Biology, Physics. 2019. 105(2), 254-266.
https://www.sciencedirect.com/science/article/abs/pii/S0360301619307461

4.) Brodin, N. P, & Tomé, A. Revisiting the dose constraints for head and neck oars in the

current era of IMRT. Oral oncology. 2018. 86, 8-18.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6481934/

5.) Grundmann, O, Mitchell, C, & Limesand, K. Sensitivity of salivary glands to radiation: From
animal models to therapies. Journal of dental research. 2009. 88(10), 894-903.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2882712/

6.) QUANTEC Summary: Approximate Dose/Volume/Outcome Data for Several Organs.

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http://individual.utoronto.ca/dtsang/misc/quantec.pdf. Accessed April 26 , 2024