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Asim Farooki
Clinical Practicum III
Using an Open/Closed Wedge IMRT plan for the treatment of Laryngeal Cancer
Cancers of the larynx represent approximately 2% of all cancer diagnoses and is
considered to be the most common type of head-and-neck cancer. The American Cancer
society estimates that 60% of all laryngeal cancers start in the glottis, the location for the
vocal cords.1 Cancer of the larynx has shown a strong link in people with a history of
cigarette smoking. In a short time, the radiation oncology field has come a long way with
the development of new sophisticated techniques such as IMRT along with gating that
has allowed dosimetrists and physicists to approach the tumor treatments and be able to
plan and deliver highly conformal radiation doses custom-tailored to a patients anatomy
and tumor in three dimensions as compared to yesteryears treatment methods. Even with
the available treatment protocols in place, external beam radiation therapy for laryngeal
cancer can be a difficult to plan as the PTV includes the larynx and bilateral cervical
(neck) lymph nodes, which are wrapped around the spinal cord. This complicates the
treatment because the curative radiation doses required tend to exceed the spinal cords
tolerance dose and without careful treatment planning, the patient can be put at risk for
radiation-induced myelopathy.
The selected patient for this project was a 53-year-old Caucasian female that
presented to her physician with progressive voice hoarseness. An endoscopy revealed a
lesion on the left vocal cord. The biopsy was positive for squamous cell carcinoma. The
oncologist initially recommended surgery with laryngectomy since her past medical
history consisted of external radiation therapy to the neck, including part of the larynx for
squamous cell carcinoma of the left anterior tongue. However, the patient refused the
procedure and agreed to re-radiation to the larynx. Because of the history of prior
irradiation, the patient was sent for further evaluation via a PET/CT, which revealed a 3.5
cm glottic and subglottic extension that was consistent with laryngeal carcinoma. With
the possibility of laryngeal necrosis and myelitis due to past irradiation, the patient
accepted all risks, refused to have the laryngectomy and agreed to the radiation therapy.

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Therefore, an IMRT plan was considered for the treatment. IMRT has shown promising
results for producing highly conformal dose distributions with steep dose gradients to
target areas of concern while sparing nearby critical organs in the neck.2
The patient was simulated for treatment planning using the radiation oncology
departments CT scanner. The patient was placed lying down in the supine position and
a knee wedge was placed under the knees for patient comfort. Patient simulation based on
patient positioning is crucial for optimal treatment and needs to be reproduced on a daily
basis. For that reason, a custom aquaplast mask was created to limit the head movement
during treatment to ensure no movement and correct isocenter setup as seen in Figures 1
and 2. Using the lasers present in the CT room, the intersecting points were marked on
the patients custom-made facemask.
Once the dosimetrist verified the simulation, the images taken were then
contoured and the attending radiation oncologist put the PTV. Using Pinnacles treatment
planning system, the spinal cord was contoured with a 5mm margin. The CTV
encompassing the larynx was contoured and a 5-mm margin was added to it to create the
PTV. A normal tissue was also auto-generated for optimization. The physician prescribed
a total 7000 cGy dose, which was to be delivered in 35 fractions (200 cGy/fraction) to
100% point dose to the target PTV.
The initially created plan was generated using a small 8.5 cm x 7.5 cm opposed lateral
fields without the use of a wedge. Using 6MV photon energy along with MLCs, the field
was created to reduce dose to the normal tissues and surrounding OR. The fields were
centered on the vocal cords and allowed adequate flash over the anterior skin surface to
prevent underdosage of the anterior commissure as the cephalad margin was marked at
the caudal aspect of hyoid bone and caudal margin placed at the inferior border of the
cricoid cartilage. The PTV received a maximum dose of 7539 cGy with a maximum
hotspot of 108% in the center of the PTV as seen in Figure 3. The fields were weighted
favoring the right posterior oblique (RPO) over the left posterior oblique (LPO) 60% to
40% field weight. The spinal cord received a maximum dose of 734 cGy.
Since the patient had a past history of irradiation in the area of the current
treatment plan, it was important to minimize the dose as much as possible to the spinal
cord and surrounding normal tissue, therefore the use of open/closed wedge technique

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was implemented in the plan to improve the treatment plan. Because of the patients
sloped surface a combination of 15 and a 30 wedges were inserted to better compensate
for the sloping skin surface and to help deliver a more uniform dose. 4 beams (2 RPO
and 2 LPO) were utilized as each oblique pair had a 15 and a 30 wedge. The RPO and
LPO 30 wedge beams were weighted more heavily at 35% each beam and the 15
wedged beam pairs were weighted 15% each for a total of 100%. Using this technique,
the total dose delivered was 7251 cGy and the hot spot was lowered to 103%. The spinal
cord too received a lower dose using this technique. A lower spinal cord dose was more
beneficial for this particular patient because of her past irradiation history. There was no
need for a couch or collimator rotation as the only OR was the spinal cord in the field and
the hot spot was kept anterior of that in the final treatment plan. The IMRT objectives set
forth were met with this plan as the final PTV max dose was 7251 cGy and was under the
7300 cGy constraint. The spinal cord constraint was a dose below 750 cGy. The spinal
cord dose received a dose of 583 cGy in this plan. After the radiation oncologist
reviewed the plan and the previous irradiated history, the physician believed the plan met
his requirements as the IMRT wedged plan reduced the dose inhomogeneity and allowed
an acceptable dose distributions to the PTV surrounding the OR, the larynx and lymph
nodes surrounding the spinal cord.
During my clinical experience, countless times I used a wedged pair technique,
but because of the patients past radiation history and the complexity of the case, I was
able to better understand and learn about combining different wedges angles and for
using open-closed wedge technique to improve the dose distribution and the importance
of keeping the hot spot not only in the PTV but away from the previously irradiated
spinal cord. The dosimetrist at the facility has been incredibly helpful in not only this
case but in many instances to help me incorporate more of what I have learned and how
to improve what I already know. In this case, the use of IMRT with the wedge technique
helped minimize the dose within the PTV for both the larynx and the spinal cord. This led
the dose to be more homogenous, which overall helped reduce the normal tissue
complications and along with improved target coverage, as it spared the spinal cord more
than the conventional lateral opposed non-wedged beam pair. An important key point
here I picked up was to be able to pick the right wedge angles. That is important for this

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treatment because the anterior commissure can be compromised due to
overcompensation. Finally, with head and neck cancers being tricky to contour and plan,
I got more thorough practice in recognizing, recalling, and contouring the structures
located here along with adding rings to try to contain the hotspot within the PTV and
away from the spinal cord.

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References
1. American cancer society. Laryngeal Cancer
http://www.cancer.org/cancer/laryngealandhypopharyngealcancer/detailedguide/laryngea
l-and-hypopharyngeal-cancer-key-statistics.
2. Gomez D, Cahlon O, Mechalakos J, Lee N. An investigation of IMRT vs.
Conventional 2D and 3DCRT for early stage larynx cancer. Rad Onc. 2010;5:74-83.
http://dx.doi.org/10.1186/1748-717x-5-74
3. Discussion with Larry Farina, CMD at Wyckoff Hospital. October 21, 2014.

Figures

Figure 1. Patient positioned during CT simulation prior to planning

Figure 2. The patient is seen immobilized in a customized thermoplastic mask, which is


secured to the couch with the neck in an extended position.

Figure 3. DRR illustrating the Treatment Field.

Figure 4. Isodose coverage of treatment field with a 108% hot spot seen in red on the
superior end in the non-wedged plan.

Figure 5. DVH illustrating the dose received by the PTV and the spinal cord in the nonwedge plan.

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Figure 6. Isodose coverage of treatment field with a 106% hot spot seen in red on the
superior end in the open/closed wedge plan.

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Figure 7. DVH illustrating the dose received by the PTV and the spinal cord in the
wedge plan.

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Tables
ROI

Type

Target

Actual

Constraint

(cGy)

(cGy)

(cGy)

Met?

PTV

Max Dose

7300

7519

Yes

Spinal Cord

Max Dose

750

734

Yes

Cord + 5 mm

Max Dose

900

1717

No

Table 1. IMRT Target Goals for the non-wedged plan in priority order.
ROI

Type

Target

Actual

Constraint

(cGy)

(cGy)

(cGy)

Met?

PTV

Max Dose

7300

7252

Yes

Spinal Cord

Max Dose

750

583

Yes

Cord + 5 mm

Max Dose

900

1608

No

Table 2. IMRT Target Goals for the final wedged plan in priority order.