Research Proposal Document

Working Title
A retrospective study investigating the ability to plan on iterative CBCT scans to determine if
planning during the patient’s course of treatment can lead to a more robust plan
A retrospective study investigating the impact of modifying air cavity material densities in
oropharyngeal squamous cell carcinoma intensity modulated radiation therapy

Problem Statement
The problem is that patients who may require adaptive planning during treatment require an
additional CT simulation where they are exposed to additional radiation from planning CTs as
well as increased wait times due to scheduling restrictions where these barriers may prevent
patients without extreme differences from being candidates for adaptive treatment.
Purpose Statement
The purpose of this study will be to collect data for calibration curves using HyperSight iCBCT
imaging protocols to determine if dose calculation using Acuros is a feasible alternative to
resimulation with CT
Hypotheses Statements or Research Questions
H1A : The first research hypothesis (H1) is that there will be a greater than 1.5% difference in
surrounding OAR’s in plans that are re-planned on iCBCT scans compared to the original plan.
H10 : The first null hypothesis (H1) is that there will be a less than 1.5% difference in
surrounding OAR’s in plans that are re-planned on iCBCT scans compared to the original plan.
H1A : The first research hypothesis (H1) is that there will be a maximum dose difference greater
than 1.5% in the plans that have a change in material densities for air cavities compared to
uncorrected volumes.
H10 : The first null hypothesis (H1) is that there will be a maximum dose difference less than
1.5% in the plans that have a change in material densities for air cavities compared to
uncorrected volumes.
H2A : The second research hypothesis (H2) is that there will be mean dose increase that is greater
than 1.5% in plans that have a change in material densities for air cavities compared to
uncorrected volumes.
H20 : The second null hypothesis (H2) is that there will be mean dose increase that is less than
1.5% in plans that have a change in material densities for air cavities compared to uncorrected
volumes.
Summary
The oropharynx lies posterior to the circumvallate papillae of the oral cavity and extends
posteriorly to the pharyngeal walls. The superior border is the soft palate and the inferior border
is the hyoid/vallecula.1 Major structures of the oropharynx include the base of tongue, tonsils,
soft palate, vallecula, and posterior pharyngeal wall.1

Historically, tobacco and alcohol consumption has been the primary cause of cancer of
the oropharynx. Recently, the primary etiological factor has been more associated with human
papilloma virus (HPV).1 Squamous cell carcinoma (SCC) represents about 90% of oropharyngeal
cancer cases.

The American Joint Committee of Cancer (AJCC) tumor, node, and metastasis (TNM)
staging system is used for prognosis and treatment decisions for oropharyngeal SCC. There are
various treatment modalities for oropharyngeal tumors including surgery, radiation therapy, and
systemic therapies. The treatment approach is individualized to the patient and the treatment
goals.1 Radiation therapy to the oropharyngeal region is associated with side effects including
mucositis, pharyngitis, xerostomia, dysphagia, subclinical hypothyroidism and more.1

Planning Target Volumes (PTVs) are expansions of the soft tissue mass that account for
tumor movement and patient setup inconsistencies. Lung studies have shown that removal of air
cavities from a PTV can produce a more homogeneous dose distribution.2 However, when air
cavities are included in the PTV and calculated to a lower material density, dose distribution
challenges arise because the inverse treatment planning software has a difficult time pushing
dose to these areas when creating an IMRT treatment plan.3

Each patient that receives radiation treatment to the head and neck has a planning scan on
a computed tomography scanner so that each voxel in the patient's scan has the correct material
density.4 Having the correct material density for each tissue in the body is essential so that when
a treatment plan is made, the fluence of the dose is accurately modeled to what will be delivered
on the treatment machine. The study by Cheung and others proves that the change in material
density greatly impacts the dose distribution through certain areas. Their study shows that the
mean dose to the nasopharynx was impacted by 8.6% when the material density to the area was
changed from lung density (0.011-0.624 g/cm3) to air density (0.000- 0.020 g/cm3).4 Our study
will focus on areas of the oropharynx where there is an air cavity in the PTV region. This volume
will be overridden to a material density that more closely resembles the surrounding tissue. We
will change the material density to a value of 0.525 g/cm3 so that when the air cavity is shifted or
not present, the tissue that takes place of the air is already accounted for in a less drastic way.
The chosen value will allow both the air cavity and the tissue around the area to be accounted for
in an average material density.

This retrospective study aims to investigate whether modifying the material density of air
cavities enhances the accuracy of material representation in the oropharyngeal region during
IMRT for SCC. By addressing setup inconsistencies encountered throughout treatment courses,
this study aims to mitigate hotspots occurring at the original air cavity locations, in turn
improving treatment outcomes for those with oropharyngeal SCC.
 References
1. Grégoire V, Giraud P, Vieillevigne L, Maingon P. Managment of oropharyngeal
squamous cell carcinoma. Cancer/Radiothérapie. 2022; 26(1-2):174-188.
https://doi.org/10.1016/j.canrad.2021.10.002
2. Gan W, Duan Y, Wang H, et al. Dosimetric effect of intensity-modulated radiation
therapy for postoperative non-small cell lung cancer with and without air cavity in the
planning target volume. Medical Dosimetry: Official Journal of the American
Association of Medical Dosimetrists. 2022;47(1):32-37.
doi:https://doi.org/10.1016/j.meddos.2021.07.005
3. Asher D, Amestoy W, Studenski MT, et al. Dosimetric comparison of intensity-
modulated radiation therapy for early-stage glottic cancers with and without the air cavity
in the planning target volume. Medical Dosimetry. 2019;44(4):405-408.
doi:https://doi.org/10.1016/j.meddos.2019.02.007
4. Cheung MLM, Chow VUY, Kan MWK, Chan ATC. The effect of material assignment in
nasal cavity on dose calculation for nasopharyngeal carcinoma (NPC) using Acuros XB.
J Appl Clin Med Phys. 2022;23(8):e13698. doi:10.1002/acm2.13698