Aubrie Rice

Rad Sci 4389

Research Proposal

Research Proposal
Aubrie Rice
rice.528@buckeyemail.osu.edu
The Ohio State University

Aubrie Rice
Rad Sci 4389
Research Proposal
Introduction
Discrepancies in head and neck setups have been of great interest to many people in the
field of radiation therapy. Due to the technological advancements in therapy treatments such as
Intensity Modulated Radiation Therapy (IMRT) and Stereotactic Radiotherapy (SRT), the
reproducibility of head and neck setups has become even more essential. These treatments
involve delivering higher doses to much smaller volumes than with conventional treatments. This
increases the importance of accuracy for these types of treatments in order to treat the full tumor
volume and avoid normal tissue. Due to these factors there has been an increased interest in the
cause and resolution of discrepancies in such setups. Research has been conducted in the past
with the goal finding the specific areas of the head and neck that these discrepancies are
happening in.1, 2 Ahn et al concluded in their research that when it comes to the skull, mandible,
and cervical spine, significant random variation exists in patient positioning.1 These variations
included translational and rotational position, lordosis and scoliosis.1 Further research has been
done in order to test different aspects of head and neck setups: some testing a specific
immobilization device, some comparing two or more, and some testing strategies to manage
these deformations in positioning.2,3,4,5 Van Beek S et al for example concluded that there were no
significant differences between a standard Posifix headrest and a custom made vacuum cushion
when comparing changes in posture.3 These studies have been useful in many ways but their
results also prove that further research will need to be conducted in order to find out what
immobilization device can reduce discrepancies in head and neck setups.
Hypothesis
This research study will examine a headrest that is made of thermoplastic material and is
formed to the curvature of the patients neck. A headrest that is made of this type of material will
be more durable than a custom vacuum cushion headrest or other types of moldable headrests
that can be deformed with a certain pressure. Using thermoplastic material will eliminate
possible changes in the headrest and therefore reduce discrepancies in the curvature and rotation
of the spine.
Literature review
Previous research that has been conducted on the topic of discrepancies in head and neck
setups consist of several trends. These trends are seen in the area of research, methodology and

Aubrie Rice
Rad Sci 4389
Research Proposal
findings. As for areas of research, these studies make up three separate groups. One group of
research focuses on the locating the specific areas of the head and neck that problems with setups
are happening in.1, 2 Another group of research focuses on finding corrections for deformations in
head and neck setups.2, 4 The last group of research on the topic of head and neck setup errors
focuses on comparing different immobilization devices to see which has the best results or is the
most consistant.3, 5
A couple trends in the methodology of these studies are present as well. The first notable
trend is that all six of these research studies have similar sample sizes, all consisting of fewer
than 50 patients. The sample sizes were ten5, fifteen6, nineteen4, twenty-three1, thirty3, and fortyfive2. These sample sizes, especially the studies with less than thirty patients, are limiting to the
validity and reliability of the studies results. Larger sample sizes would allow for the
identification of possible outliers or confounding variables and therefore show more accurate and
reliable results. Another trend worth noting is the imaging that was used and what baseline image
this was compared to. Li et al used Vision RT which was different than all other studies
mentioned.5 Ahn et al compared planned computed tomography (CT) rescans at fraction 11, 22,
and 33 with the treatment planning CT.1 All four of the other studies compared cone beam
computed tomography (CBCT) scans to the treatment planning CT. Van Beek et al compared ten
CBCT scans per patient to the treatment planning CT though the fraction number of these scans
was not noted.3 This could prove to be a limitation of this study considering increasing
deformation over time can not be noted. Van Kranen et al compared daily cone beam scans to
their patients planning CT scan. Yin et al compared three CBCT scans per patient to the
planning CT scan, one cone beam image was taken after daily conventional positioning, one after
online corrections were made (to test correction strategies) and one after one week of treatment.6
This is a notable difference from the study of Van Beek.3 Though Yin et al did use less CBCT
images in their study (3 vs 10), timing of their scans was at least noted.3, 6 When it comes to
findings, several of the previous authors research shows trends. Ahn et al and Giske et al both
conclude that there are several locations in the head and neck that are experiencing deformations
and that these areas are not just changed in one directional plane.1, 2 Ahn et al found in their
research that significant random variation exists in areas such as the skull, mandible, and cervical
spine.1 These variations included translational and rotational position, lordosis and scoliosis.1

Aubrie Rice
Rad Sci 4389
Research Proposal
Giske et al found in their research that systematic deformations of one to four millimeters existed
with greatest variation of C6 compared to C1-2 vertebrae.2 Giske et al also tested correction
strategies for the deformations they found in their study and found that while rotational error
correction helped, it still did not fix the problem.2 Van Kranen et al tested two types of correction
strategies.4 One was referred to as mean correction while the other was referred to as MiniMax
correction.4 Mean correction minimized the sum of squared errors while MiniMax correction
minimized the maximum setup error and thereby reduced the largest errors as much as
possible.4 Researchers concluded that MiniMax corrections reduced errors the most but 16% of
fractions with residual errors were still greater than five millimeters after use of this correction. 4
Study results from both Giske and Van Kranen prove that there is an obvious need in the
improvement of immobilization devices in these head and neck setups. If technological/online
corrections are not fixing the problem, this is a sign that the source of the problem needs to be
located and improved. Even Van Kranen et al note in their discussion that proactive efforts
should be taken to avoid these deformations in the first place.4 The researchers note,
Improvements in patient support and immobilization could reduce local residual setup errors.4
Another finding from previous research3 compares two different headrests and was conducted by
Van Beek et al. These researchers found that there was no clinically significant difference
between a standard Posifix headrest and a custom made vacuum cushion headrest.4 These results
also show that further research will need to be done in order to improve immobilization in head
and neck setups. This research study will do just that, by not only taking into account the need
for a larger sample size but also noting the previous headrests that did not prove to correct
existing problems in head and neck deformations.
Methods
This research study will address the gaps and limitations that presented in
previous research. The sample size will be larger so that confounding variables and outliers can
be more easily identified. A larger sample size will also make the results more reliable. Two
groups of thirty head and neck patient will be evaluated. Patients will be randomly assigned to
one of the two groups. One group will be positioned using a MOLDCARE cushion headrest and
the second group will be positioned using a posterior thermoplastic headrest that can be further
formed to the patients neck and shoulders. All sixty patients will undergo regular computed

Aubrie Rice
Rad Sci 4389
Research Proposal
tomography (CT) scans used for treatment planning using an approved method of
immobilization. A total of six cone-beam computed tomography (CBCT) scans will be
preformed on each patient throughout the course of treatment at 4, 8, 12, 16, 20, and 24 fractions
using a standard imaging protocol for head and neck procedures. Rotational and translational
error will be evaluated for 12 bony landmarks (C1-7, mandible, hyoid bone, jugular notch,
larynx, and skull) in three directions (anterior/posterior, superior/inferior and left/right). These
errors will be measured by finding the difference in position when compared to the treatment
planning CT.
The experiment is designed this way in order to be able to distinguish any clinically
significant improvements in management of deformations over time with the posterior
thermoplastic compared to the more commonly used MOLDCARE cushion headrests. Sample
size is sufficient enough to give reliable results and by taking CBCT scans over the course of
treatment, it will be possible to compare the two headrests at the same points in time as well.
Possible results
If hypothesis is true: The local misalignments of all 12 bony landmarks for translational
and rotational error for the MOLDCARE cushion headrest were all greater than 0.5 mm and 0.5
degrees in all three directions. The local misalignments for all 12 bony landmarks for the
posterior thermoplastic headrest were all less than 0.5 mm and 0.5 degrees in all three directions
for translations and rotations. Table 1 (pg. 6) lists exact readings of each of the 15 bony
structures.
If hypothesis is false: No clinically significant difference was found in the translational
and rotational error when comparing the MOLDCARE cushion headrest to the posterior
thermoplastic headrest.

Aubrie Rice
Rad Sci 4389
Research Proposal

Table 1:
ROI
C1
C2
C3
C4
C5
C6
C7
Mandible
Hyoid bone
Jugular notch
Larynx
Skull

H&N support
MOLDCARE
Post. Thermoplastic
MOLDCARE
Post. Thermoplastic
MOLDCARE
Post. Thermoplastic
MOLDCARE
Post. Thermoplastic
MOLDCARE
Post. Thermoplastic
MOLDCARE
Post. Thermoplastic
MOLDCARE
Post. Thermoplastic
MOLDCARE
Post. Thermoplastic
MOLDCARE
Post. Thermoplastic
MOLDCARE
Post. Thermoplastic
MOLDCARE
Post. Thermoplastic
MOLDCARE
Post. Thermoplastic

Translations (mm)
AP
SI
LR
1.50
1.12
0.53
0.20
0.10
0.14
1.51
0.53
0.65
0.34
0.10
0.16
1.52
0.89
0.51
0.33
0.10
0.15
1.52
1.87
0.80
0.33
0.10
0.15
1.54
1.48
0.53
0.33
0.10
0.15
1.59
1.24
1.05
0.32
0.10
0.15
1.55
0.74
0.70
0.35
0.10
0.15
0.52
0.65
0.64
0.40
0.12
0.24
0.64
0.69
1.22
0.21
0.21
0.32
0.72
0.70
1.48
0.46
0.24
0.21
0.51
0.80
0.63
0.34
0.25
0.34
0.53
2.0
1.52
0.45
0.23
0.24

Rotations (degrees)
AP
SI
LR
0.70
0.51
0.87
0.09
0.12
0.20
0.55
0.53
0.83
0.10
0.12
0.19
0.65
0.55
0.85
0.09
0.12
0.19
0.55
0.52
0.82
0.09
0.12
0.19
0.51
0.50
0.80
0.09
0.12
0.19
0.53
0.53
0.83
0.09
0.12
0.19
0.60
0.50
0.80
0.09
0.12
0.19
0.63
0.54
1.01
0.16
0.27
0.21
0.52
0.53
0.53
0.24
0.43
0.19
0.74
0.57
0.97
0.38
0.31
0.26
0.51
0.56
1.06
0.26
0.34
0.30
0.80
2.03
2.03
0.38
0.32
0.24

Aubrie Rice
Rad Sci 4389
Research Proposal
References
1. Ahn PH, Ahn AI, Lee CJ, et al. Random positional variation among the skull, mandible, and
cervical spine with treatment progression during head-and-neck radiotherapy. Int J Radiat Oncol
Biol Phys. 2009;73(2):626-33.
2. Giske K, Stoiber EM, Schwarz M, et al. Local setup errors in image-guided radiotherapy for
head and neck cancer patients immobilized with a custom-made device. Int J Radiat Oncol Biol
Phys. 2011;80(2):582-9.
3. Van Beek S, Mencarelli A, Remeijer P, Sonke JJ, Rasch CR. Local interfractional setup
reproducibility for 2 individual head and neck supports in head and neck cancer patients. Pract
Radiat Oncol. 2014;4(6):448-54.
4. Van Kranen S, Van Beek S, Mencarelli A, Rasch C, Van Herk M, Sonke JJ. Correction
strategies to manage deformations in head-and-neck radiotherapy. Radiother Oncol.
2010;94(2):199-205.
5. Li G, Lovelock DM, Mechalakos J, et al. Migration from full-head mask to "open-face" mask
for immobilization of patients with head and neck cancer. J Appl Clin Med Phys.
2013;14(5):243-54.
6. Yin WJ, Sun Y, Chi F, et al. Evaluation of inter-fraction and intra-fraction errors during
volumetric modulated arc therapy in nasopharyngeal carcinoma patients. Radiat Oncol.
2013;8:78.