Sheil

Pat Sheil
Head and Neck Assignment
DUE on or before Sunday Feb 26th
Group 2: Nasal cavity or Paranasal Sinus

Malignancy: Malignant neoplasm of the nasal cavity

1. How was this patient positioned? What positioning

devices/accessories were used, how and why? (5 points)

The patient was positioned on the CT table head first and in the
supine position with both arms at her side. A neutral headrest
was used to support her head. A knee sponge was placed
underneath her legs to provide comfort and support. A short
aquaplast mask was used to aid in patient immobilization and
treatment reproducibility. This mask would be clamped into the
extended headrest where it restricted the patients ability to
move her head, providing a more accurate treatment daily.

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

tolerance dose? (20 points)

The medical dosimetrist contoured the patients organs at risk,

which included the brainstem, brain, left/right optic chiasm,
left/right optic nerve, and left/right lens. The dosimetrist followed
prescription objectives given by the doctor to make the
treatment plan. The following includes the specific avoidance
structures and their tolerance dose:
Brainstem- Max dose=54 Gy
Brain- Max dose=60Gy
Left/Right Optic Chiasm- Max dose=45 Gy
Left/Right Optic Nerve- Max dose=45 Gy
Left/Right Lens- Max dose=7 Gy
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Figure 1. DVH showing each OR meeting the prescribed constraints.

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. (20 points)

Due to the midline location of disease, the boundaries of the

tumor volume encompassed bilateral portions of the nasal cavity.
The superior border included the floor of the orbit but remained
below the cornea and covered the ethmoid sinuses.1 The inferior
border covered the lateral commissure of the lip. Medially, the
field came across the midline 1.5cm to include the ethmoid sinus
and medial aspect of the contralateral orbit. Laterally, the field
extended to include the entire maxillary sinus. Posterior border
included the nasopharynx and pterygopalatine fossa. Anterior
border included the entire nasal cavity due to the whole area
being treated. A 0.5cm margin was placed around the GTV, which
can be seen in figure 2 below. The GTV encompassing the entire
nasal cavity made for the lens of the eyes to be of the utmost
importance when setting the MLC blockage.
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Figure 2. Frontal/Sagittal/Transversal aspect of anatomical boundaries.

Lime green line representing 100% isodose coverage.

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. (20 points)

Lymph nodes were not included in the treatment area for this
particular case. According to the consultation note by the doctor,
it stated that there was No cervical, supraclavicular,
infraclavicular, axillary, epitrochlear, inguinal or popliteal,
lymphadenopathy involvement. In general, the nasal cavity
drains into the retropharyngeal, submandibular, junctional, and
subdigastric nodes, but less than 10% of patients present with
lymph node metastasis. 2

Figure 3. Treatment Area (Sagittal View)- showing no lymph node involvement

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Figure 4. General Head & Neck Lymph Node Display

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

in detail the technique (35 points)

Treatment for this patient was done on a Varian iX 3418 linear

accelerator using IMRT technique. This technique was used to
allow for maximal target tissue coverage while minimizing
toxicity to normal tissues, especially sparing of the lens. The
volume of interest (VOI) for this particular patient was irregularly
shaped and in close proximity to critical structures. The intensity
modulation allows for that extra degree of freedom to achieve
dose conformity around the irregularly shaped VOI.3

For this treatment, 4 fields using opposed wedges and 6 MeV

energy beams were used. The gantry angles were 330 degrees
(RAO/RAO1) and 30 degrees (LAO/LAO1). All 4 fields had a
collimator angle of 90 degrees to achieve desired dose
distribution and help spare critical structures. Field weighting
among the four fields were the following: A RAO-29%, A1 RAO1-
20%, B LAO-31%, and B1 LAO1-20%.

Blocked 2D fields were used to encompass the region while

limiting dose to adjacent structures and to decrease the risk of
associated side effects. This can be seen in the figure below.
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Figure 5. 2D Blocked Field- Shielding the Right/Left Lens

MLC was shaped around the GTV with an added 0.5cm margin to
ensure proper dose to GTV and to shield all organs at risk in close
proximity. Due to the collimator angle of 90-degrees, the MLCs are
positioned in a vertical manner.

Figure 6. LAO and LAO 1 Field- MLCs Conforming Around GTV

Wedges were added to each field to create a more homogenous dose

distribution throughout the field. The heels of the RAO/LAO wedges
face each other in order to spread the dose evenly. For the RAO field, a
60-degree wedge was added. RAO1 field added a 30-degree wedge to
further improve dose distribution from RAO. For the LAO, a 60-degree
wedge was added. LAO1 field added a 30-degree wedge to further
improve dose distribution as well from LAO. When there are two angles
this close to each other, 60-degree wedges are required to balance
dose accordingly. The reference point was placed deep into the nasal
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septum in order to ensure adequate dose reached the posterior portion

of the field.

Figure 7. Reference Point Location and Wedge Placement

References:
1. Vann, AM. Intro to Oncology and Head and Neck Cancers.
[Softchalk]. La Crosse, WI: UW-L Medical Dosimetry Program;
2017.
2. National Cancer Institute. Paranasal Sinus and Nasal Cavity
Center. https://www.cancer.gov/types/head-and-
neck/patient/paranasal-sinus-treatment-pdq#section/_22.
Accessed February 24th, 2017.
3. Khan, FM. The Physics of Radiation Therapy. 5th Philadelphia, PA:
Lippincott Williams & Wilkins; 2014.