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Aubrie Rice

Head and Neck Assignment


DUE on or before Sunday Feb 26th

Find a case in your clinic that presents with a primary lesion in the:

Oropharynx (Group 4)

Stage IVa (cT1-T2N2b) Squamous Cell Carcinoma of the right glossopharyngeal sulcus

After identifying a specific case answer the following questions:


1. How was this patient positioned? What positioning devices/accessories were used, how and why?
(5 points)
Patient is supine with arms at sides. Aquaplast head and shoulder mask is used in
combination with a C headrest. A knee sponge is placed under the patients knees. Patient
also has a custom dental stent.
Arms at sides: We want the patients arms to be down at their sides and not over their heads
due to the fact that we want them out of the treatment field. Arms at sides is also more
reproducible than having their arms positioned on their stomach (which may be more
comfortable). Reproducibility is important for the shoulder area for H&N cases because we
are commonly treating the supraclavicular nodes. This is also why the aquaplast head and
shoulder mask is used in this case opposed to a shorter mask.
Knee sponge: placed for patient comfort
Custom dental stent: In this oropharyngeal case, we are targeting the right tonsil and
glossopharyngeal sulcus. The custom dental stent helps to open the jaws and move the hard
palate away from the treatment area, therefore limiting dose to the hard palate. It also
depresses the tongue both of which allow for a more reproducible daily setup.

2. What specific avoidance structures were contoured? What is their tolerance dose? (20 points)
Structure Tolerance dose 5/5 Structure Tolerance dose 5/5
1/3 2/3 3/3 1/3 2/3 3/3
5 cm 10 cm 20 cm Esophagus 60 58 55
Spinal Cord 50 50 47 Larynx 45
Brainstem 60 53 50 Lacrimal Gland 26
Brachial Plexus 62 61 60 Thyroid 45
Optic nerves 50 Inner ear 30
Optic Chiasm 50 Lens 10
Healthy Brain 60 50 45 Mandible 60 60 65
Parotid Gland 32

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)
The treated volume should include (from radiotherap-e):
Superior: the skull base and mastoid
Inferior: the supraclavicular nodes
Beam split above the larynx at the thyroid notch if possible
Anterior: a 2 cm margin on the tumor and include a portion of the buccal mucosa and the oral
tongue.
Lateral: Include IB-V and retropharyngeal
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Superior border: base


of skull/mastoid tip

Anterior: include a
portion of the buccal Inferior border:
supraclavicular nodes Beam split above the
mucosa and the oral larynx at the thyroid
tongue. notch
Superior border: base
of skull/mastoid tip

Lateral: Include IB-V


and retropharyngeal

Inferior border:
supraclavicular nodes
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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)
Yes, lymph nodes are included in the treatment area.
RP nodes
Right: Level IB, II, III, IV, V
Left: Level II, III, IV

Real patient plan: e- anatomy:

Yellow: Just the Right


side treated
Red: Both sides treated

R L
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Radiotherap-e: Real patient CT:
IVb

IVa
VB - elective

III
VA - elective

IB - elective
II
CTV
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IIA
CTV

5. What radiation technique is used to treat this patient? Describe in detail the technique (35 points)
If VMAT How many arcs, which direction? Is there collimator rotation? Is there a couch rotation?
If so, which direction and why? Include all specific setup information.
The technique used to treat this patient is VMAT. VMAT stands for volumetric
modulated arc therapy and is a type of IMRT (intensity modulated radiotherapy). The
principle behind IMRT is to treat from a number of different gantry angles (or in VMATs
case, a continuous arc) with non-uniform fluences in order to deliver high dose to the
target volume and spare normal tissue. In a VMAT treatment, the gantry moves in a
continuous motion with varying MLC leaves and dose rate throughout the course of the
arc. Inverse planning is used and dose is computed by the treatment planning system
by sampling the delivery at a variety of gantry angles. 1 With inverse treatment planning,
desired dose distribution is specified by the planner and intensity maps are then
calculated by the computer (optimization).2
The plan consists of 3 arcs:
G200-160: clockwise C350
G161-201: counter clockwise C80
G200-160: clockwise C70
There are different collimator rotations on each arc. These are listed above. Different
collimator angles allow MLCs to modulate dose from different angles, therefore
optimizing the dose distribution.
There are no couch rotations.
Setup info: Patient is supine with arms at sides. Aquaplast head and shoulder mask is
used in combination with a C headrest. A knee sponge is placed under the patients
knees. Patient also has a custom dental stent.
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References

1. Khan, FM. Intensity Modulated Radiation Therapy. The Physics of Radiation Therapy. 5th
ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014:430-439.
2. McDermott PN, Orton CG. Special Modalities in Radiation Therapy. The Physics &
Technology of Radiation Therapy. Madison, WI: Medical Physics Publishing; 2010:Chapter
20.