Aaron Wright

DOS 773 Clinical Practicum III

11/29/15
An elderly man found a mass in his right neck in February of this year. He attributed it to a
recent respiratory tract infection and thought the swollen right neck node was related. After the
respiratory infection cleared the neck mass continued and enlarged. The patient contacted his
primary care physician who treated a 3 cm mass in the jugulodigastic area with antibiotic
showing slight decrease in size, but the mass did not disappear. The patient underwent an
excisional biopsy of the cervical node and the path report returned showed positive for
moderately differentiated squamous cell carcinoma. A subsequent PET scan showed asymmetric
enlargement of the right pharyngeal tonsil 17 mm in size compared to the left, with a
standardized uptake value (SUV) of 8 suspicious for primary lesion. The right tonsil was staged
as a T1N2aM0. The ideal treatment option according to the NCCN guidelines for a T1, N2
cancer is concurrent systemic chemotherapy with radiation. With there only being one solitary
node in the right neck, the optimal radiotherapy treatment goal would be to treat only the right
oropharynx and the right cervical neck, as well as supraclavicular lymph nodes. The anticipated
goal dose was 66.5 Gy total to the right oropharynx with lesser dose of 63 Gy to the lymph nodes
in the right neck at 1.8 Gy per fraction. The supraclavicular goal was a standard 54 Gy at 1.8 Gy
per fraction with an added mid-line block to protect the cord.
The simulation process performed involved the patient in the supine position with the use of a
Civco Aquaplast large mask extending down to the shoulders. Due to the kyphotic nature of the
patients back a prone pillow was used under the patients pelvis, which allowed the patients
torso to lay flatter on the treatment couch. An autotraction system was used to pull the patients
arms and shoulders down and out of the neck fields. A knee sponge was placed under the
patients knees for comfort. The isocenter and filed boarders were selected by the radiation
oncologist and marked by the simulator therapist. The treatment setup is shown below with
images of mask with designated treatment fields marked on the mask.

A CT was performed with 145 CT 2.5 mm slice thicknesses. The CT slices were imported into
the CMS XiO treatment planning system and fused with the PET scan for delineation of target
structures. The radiation oncologist contoured the GTV1, an 8 mm margin around the GTV1 to
create the CTV1. Adding a 10 mm margin around the GTV1 created the PTV1. The PTV2 was
created encompassing the cervical neck nodes. All critical organs at risk (OR) structures were
contoured the closest critical structures included the spinal cord, mandible, larynx, oral cavity,
and left parotid. The other OR structures contoured nearby were the brain stem, bilateral inner
ears, and the patients skin. There was a margin of 3 mm created around the inner ear volumes.
There was also a 1 cm margin placed around the cord for MLC block formation.

The goals were to cover the 1ST priority PTV1 with a minimum of 95% of the 7020 cGy dose, as
well as, the PTV2 at a lower 6300 cGy dose while sparing the left parotid and neck if possible.
All plans were to meet the RTOG 1016 dose limits for critical structures. The radiation
oncologist drew the MLC blocking for the supraclavicualar field with the added mid-line block
field for sparring of the spinal cord. The weight point was set to a 3.5 cm depth for both fields.
These fields remained constant throughout all plans developed.

All plans created used the same isocenter and abutted the supraclavicular fields. All plans
utilized the same 6 MV beam energies. The first plan performed consisted of a 3D conformal
technique with an AP, PA, LAO, and RPO beam configuration. All beams were parallel
opposing the plan consisted of the AP/PA beams 180 cGy for 22 fx to a total of 3960 cGy and
then obliques for off-cord. For all beams in the plan the PTVC was used with a 1 cm margin to
form the MLC pattern. The weighting was adjusted for both beams and required a 30 wedge on
both beams reducing the hot spot and improving dose distribution. The first off-cord set of
oblique fields were constructed with an LAO beam at 30 and an RPO beam at an opposed 208.
For these beams the cord + 1 cm margin was used to alter the MLC block around the PTVC and
block the cord + 1 cm volume. By using the cord + 1 cm the cord is better protected from patient
movement, set up errors, as well as, any scatter or MLC leakage. The weighting was again
adjusted for LAO/RPO beams and required less wedge with a 15 wedge on both beams. The
off-cord 1 oblique fields allowed the PTV2 to reach the lesser-required minimum 95% of 6300
cGy. The final off-cord oblique beams reduced the field covering the PTVC to include only
PTV1 as the requirement for a higher dose of 7020 cGy. The angles were adjusted LAO/RPO
10 at 40 and 218 respectively to promote better dose distribution for PTV1. The beams were
weighted equally and utilized the same 15 wedges with a prescribed dose of 7.2 Gy. The plan
met the goal of differential dosing to both PTVs however it however the PTV1 could not be
covered by 95% although the CTV1 was covered. The plan gave a plan that allowed the cord to
receive a max dose of 47.38 Gy and a global hot spot of 118% within the mandible. This plan did
a wonderful job of protecting the contralateral left parotid at 46 cGy with the draw back of
delivering an unacceptable amount of dose at 78.24 Gy to the mandible, which had a limit of
max 66 Gy. The oral cavity was also on the upper limit with a mean dose of 35.43 Gy with
requirement being mean dose 30-35 Gy.

The second plan consisted of the same off-cord oblique angles and altering the AP/PA fields to
match the same angles as the 1st off-cord field angles at 30 and 208. This was done to reduce
the dose given to the cord. The dose stepping was similar to that of the first plan with the first
oblique fields receiving 45 Gy this time because we are beginning with less cord involvement.
The first off-cord angles were the same with this course receiving 18 Gy and the final off-cord
again receiving 7.2 Gy. This plan decreased the cord dose by 400 cGy with a max of 43.97 Gy
and reduced the hotspot to 111% again in the mandible. The plan still produced more than
desired max dose to the mandible. Again the PTV1 was not covered by the minimum
requirement of 95%.

Sumner Radiation

27 2015
Versionstarting
XiO - Release
4.60.00
I thenOct
turned
to 08:11:48
a static IMRT technique. A five-field plan was created
at 180
with a
Planner ID: frank
Doc: 01020150812.131757.200
distance of 36 between each field with the final field angle of 324. A margin of 3 mm was
IMRT
placed around both PTV1 and PTV2 to
form aPrescription
dose ring and drive the differential doses to their
target volumes. The cord + 1 cm was removed from the 180, 216, and 252 beams to promote
Patient ID:The
M070449
cord sparring.
radiation oncologist also changed the goal of PTV1 to 66.50 Gy and kept the
Name: ROBNETT,ALLEN V
original
63
Gy
requirements
for an IMRT technique being utilized. The prescription used can be
Plan ID: 1B
Description: RT TONSIL HN SEG
foundPlan
below:
Structure

Type

Rank

Objective

-----------------PTV1

-----Target

---1

PTV2

Target

LARYNX
BRAINSTEM ORV

OAR
OAR

2
2

PTV2+0.3

Target

PTV1+0.3

Target

CORD+ 1.

OAR

LT PAROTID

OAR

ORAL CAVITY

OAR

BRAIN STEM
RT INNER EAR
LT INNER EAR
RT IN EAR ORV
LT IN EAR ORV
MANDIBLE

OAR
OAR
OAR
OAR
OAR
OAR

4
5
5
5
5
6

----------Maximum
Minimum
Maximum
Minimum
Maximum
Maximum
Dose Volume
Dose Volume
Maximum
Minimum
Maximum
Minimum
Maximum
Dose Volume
Dose Volume
Maximum
Dose Volume
Dose Volume
Maximum
Dose Volume
Dose Volume

HN CORD
GTV1
CTV1
PET 1
CORD+.6
SAVE
patient
PTVC

OAR
Target
Target
OAR
OAR
OAR
OAR
OAR

15
20
20
21
21
21
21
21

Dose(cGy) Volume(%)

Weight Power Status

--------6800
6800
6500
6450
3500
3000
3000
1500
6500
6450
6800
6800
3000
3000
1500
1600
1400
750
3000
3000
1900

---------0
100
0
100
0
0
50
100
0
100
0
100
0
50
100
0
30
70
0
50
100

-----250
250
250
250
275
100
100
100
125
125
225
225
300
300
300
300
300
300
150
150
150

----2.5
2.5
2.5
2.5
3.2
2.0
2.0
2.0
2.1
2.1
2.3
2.3
3.0
3.0
3.0
3.0
3.0
3.0
2.3
2.3
2.3

-----On
On
On
On
On
On
On
On
On
On
On
On
On
On
On
On
On
On
On
On
On

Maximum
Maximum

2000
2000

0
0

100
100

2.0
2.0

On
On

Maximum
Dose Volume
Dose Volume

3000
3000
1500

0
50
100

150
150
150

2.3
2.3
2.3

On
On
On

After optimization and segmentation of the plan the result was positive for achieving the
minimum 95% coverage of PTV1 at 66.50 Gy. The plan was much more conformal as expected
in comparison to the 3D plans. Being able to rap the dose around the cord allowed me to cover
the both PTVs much more effectively. The downfall to the plan resulted in a much higher hot
spot of 124% however no longer located in the mandible. The dose to the cord was beyond
acceptable limits as well at 49.7 Gy. The dose being given to the left parotid increased but stayed
within the oncologists acceptable amount at 14.25 Gy.

Feeling that I am heading down the correct path to covering the PTV volumes I decided to add
more beams. I had previously had great success with an 11-field plan I decided to try it. The 11field IMRT beam arrangement started again at 180 each field was offset every 20 with the last
field at 30. This plan used the same prescription as before with the 5-field plan and reduced my
global hot spot to 119% within the PTV1. The dose distribution was much more conformal and
evenly spread. Both PTV1 and PTV2 were covered by the minimum 95% of total 66.5 Gy. The
cord was a little higher than the oncologists desired limit with the cord receiving a max of 45.5
Gy. The left parotid dose was lowered to 11.3 Gy as well. I believed that I could lower the dose
to the cord if I were to remove one beam from the posterior of the patient. Also by reducing the
number of beams would allow the patient less treatment time under the uncomfortable mask.

For the last plan I thought of removing the 180 beam first however this reduced my dose to the
very posterior tip of the PTV2 and I decided to put it back on. I then decided to remove the next
posterior beam at 200 and in comparison reduced the cord dose and with out sacrificing too
much PTV2 coverage. Although marginal in comparison there was still a compelling difference
to remove the 200 beam and keep the 180 beam.

The final 10-field beam arrangement met all RTOG 1016 dose limits for critical structures. With
a global hot spot of 78.43 Gy an approximate reduction of 500 cGy and only contributing 117%
of 66.5 Gy contained within PTV1. There was a reduction of dose to the left parotid and
significant reduction of mean dose to the oral cavity at 30.5 Gy in comparison to all plans created
including 3D.

This project served as a wonderful chance to see not only the differences in 3D and IMRT for
conformity but also the strengths that IMRT presents in being able to allow me to cover both
PTVs with differential dosing and spare the cord. I feel that VMAT would have been possibly
more effective if we had the capability but the 10-field IMRT was able to meet the plan criterion
set by the oncologist in this case.

References
1. Head and Neck Cancers. NCCN Clinical Practice Guidelines in Oncology (NCCN
Guidelines). National Comprehensive Cancer Network website.
http://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf. Accessed October
25, 2015.