Alex Murray

DOS 531 Clinical Oncology for Med Dos

Head and Neck Assignment; Group 1: Oral Cavity

The patient I will be presenting for this assignment is a 57 year old woman with stage IVA,
T4aN2bM0 squamous cell carcinoma of the left hard palate. She is one and a half months post-
surgical resection of the 2.5x2.0x1.5cm well differentiated lesion and left selective neck
dissection. In addition to radiation therapy she will receive adjuvant cetuximab. 63 Gy was
delivered in 30 fractions to the PTV drawn by the physician.

1. How was this patient positioned? What positioning devices/accessories were used,
how, and why?

The patient was positioned supine and head first into the machine with a one inch black
mattress underneath her. She was on a head and shoulder board indexed at the top of the
table. A clear C head rest was used to tilt her head ever so slightly back so that her chin
was pointed somewhat upwards and reduce skin folding in the treatment area. A head
and shoulder mask was made and the area around her mouth, from above her top lip to
just before the apex of her chin was cut out. She held a Lucite mouth piece in her mouth
to push her tongue out of the treatment fields. A large half cylinder cushion was placed
under her knees to relieve some pressure from her lower back. Red wax was placed in
her mouth to cover her fillings to avoid as much scatter as possible. Her arms were down
at her sides. She had teeth pulled prior to the simulation.

Figure A. Clear C Silverman headrest Figure B. Head and Shoulder board

2. What specific avoidance structures were contoured? What is their tolerance dose?

The following are the avoidance structures that were contoured and their tolerance doses.

Avoidance Structure Objective TD 5/5

Brain Dmax < 54 Gy 1/3: 60 Gy
3/3: 45 Gy
Left Cochlea Dmax < 40 Gy 60 Gy
Dmean < 35 Gy
Right Cochlea Dmax < 30 Gy 60 Gy
Dmean < 22 Gy
 Constrictor Muscles Dmean < 30 Gy Dmean < 60 Gy
Esophagus Dmean < 30 Gy 1/3: 60 Gy
2/3: 58 Gy
3/3: 55 Gy
Larynx Dmean < 30 Gy 45 Gy
Cartilage: 70 Gy
Mandible Dmax <66 Gy 1/3: 60 Gy
2/3: 60 Gy
3/3 65 Gy
Oral Cavity Dmax < 60 Gy 60 Gy
Dmean < 30 Gy
Right Parotid Dmean < 26 Gy 32 Gy
Spinal Cord Dmax < 45 Gy 47 Gy

3. What are the anatomical boundaries of the tumor volume? You should use
Radiotherap-e (http://www.radiotherap-e.com) and other anatomy references to
help you describe this. You can use a diagram and screen shots of your CT data to
point out the boundaries.

The inferior border of the oral cavity is formed by the mylohyoid muscle and the superior
border is the hard palate.1 The anterior border of the oral cavity is the skin-vermillion
junction and it extends posteriorly to the retromolar trigone superiorly and the
circumvallate papillae inferiorly. It is divided into subsites; the lip, floor of the mouth,
oral tongue (anterior 2/3), buccal mucosa, upper and lower gingiva, hard palate, and
retromolar trigone. The hard palate extends from the superior alveolar ridge to the
posterior edge of the palatine bone and is semilunar in shape. 2 In this specific case, the
boundary of the treatment volume was the post-operative bed.

Figure C. Boundaries of the Oral Cavity1

 Figure D. Visualization of anatomical boundaries of the hard palate (From
http://www.radiotherap-e.com)

4. Are lymph nodes included in the treatment area? If so, can you identify the level
nodes use a diagram and screen shots to help you label the nodal regions treated.

Lymph nodes were included in the treatment area. Of the 23 nodes that were biopsied,
six were positive. Levels I, II, III, and IV on her left side were involved and treated and
level I on her right side was included in the treatment. Some level V, VI, and VII nodes
were covered in the treatment volumes. Level I includes the submental and
submandibular nodes. Level II includes the superior spinal accessory nodes, superior
jugular nodes, and jugulodigastric nodes. Level III includes the midjugular nodes. Level
IV includes the juguloomohyoid nodes and inferior jugular nodes. Level V includes the
inferior spinal accessory and transverse nodes. Level VI includes Pretracheal and
paratracheal nodes. Level VII includes the infraclavicular and anterior mediastinal
nodes.
 Figure E. Diagram of lymph node levels (From
http://www.slideshare.net/diptimanbaliarsingh775/cervical-lymph-nodes)

Jugulodigastric Nodes

Lateral Cervical Nodes:

Superior Deep Nodes

Spinal Accessory Nodes

Figure F. Axial view of level II nodes

 Submandibular Nodes

Jugulodigastric Nodes

Lateral Cervical Nodes:

Superior Deep Nodes

Spinal Accessory Nodes

Figure G. Axial view of level I and II nodes

Midjugular Nodes

Lateral Cervical Nodes:

Deep Nodes (Middle)

Spinal Accessory Nodes

Figure H. Axial view of level III nodes

 Paratracheal Nodes

Juguloomohyoid Nodes

Lateral Cervical Nodes:

Inferior Deep Nodes

Figure I. Axial view of level IV and V nodes

Supraclavicular Nodes

Infraclavicular Nodes

Figure J. Axial view of level VII nodes

5. What radiation technique is used to treat this patient? Describe in detail the
technique.

This patient was treated on a Tomotherapy machine, which looks very similar to a typical
CT machine. During treatment, the couch is continually moving through the aperture
while the linear accelerator head and gantry is rotating clockwise around the patient
creating a helical pattern.3 The collimator is a long narrow slit design with MLCs coming
in at right angles that move to create different beam shapes. This allows for more
conformal coverage of the PTV and reduces dose to normal tissues. The technique used
is called Tomo Helical IMRT (THI) and was developed at the University of Wisconsin in
Madison, WI. The patient was aligned using marks on the mask, as well as, megavoltage
CT (MVCT) imaging for every fraction. 6 MV energy was used as this is the only energy
available on Tomo. The field width was 2.512 cm and dynamic, as the MLCs were
continuously moving throughout the delivery of the radiation. The plan was calculated
using the fine (0.195 x 0.195 cm) grid and the planning modulation factor was 2.650.
The pitch was 0.287 and the gantry period was 13.9. The duration of her treatment was
429 seconds (7.15 minutes).

Figure K. Diagram of TomoTherapy unit (From http://www.thelancetnorway.com)

 References

1. Vann AM, Dasher BG, Wiggers NH, Chestnut SK. Portal design in radiation
therapy. 3rd ed. Augusta, GA: Phoenix Printing.; 2013: 8-9.
2. Washington CM, Leaver DT. Principles and practice of radiation therapy. 3rd ed. St.
Louis, MO: Elsevier, Mosby; 2010: 721
3. Khan FM, Gibbons JP. The Physics of Radiation Therapy.5th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2014: 435-437.