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Evgenia Nigay

DOS 531: Head and Neck Assignment

Group 3: Nasopharynx

1. How was this patient positioned? What positioning devices/ accessories

were used, how and why?

Patient was positioned supine on a shoulder board and C-

headrest to extend the neck. Aquaplast mask was used over
head and shoulders to immobilize the patient. Bite block was
used to move the tongue out of the treatment field.

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

tolerance dose?

Avoidance Tolerance Dose

Orbit Max < 50 Gy, mean < 35 Gy
Lens Max < 25 Gy
Optic nerve Max < 54 Gy
Optic chiasm Max < 54 Gy
Cochlea V55 < 5%
TMJ Max < 70 Gy
Parotid Mean < 26 Gy, V30 < 50% (for
one), V20 < 20cc (for both)

Submandibular Mean < 39 Gy

Brainstem Max < 54 Gy
Oral cavity Mean < 40 Gy
Mandible Max < 70 Gy
Spinal cord Max < 45 Gy
Larynx Mean < 45 Gy
Lungs V20 < 37%, mean < 20 Gy
3. What are the anatomical boundaries of the tumor volume?

Anatomical Boundaries

Sup: sphenoid bone

Inf: roof of soft palate
Ant: posterior openings of nasal cavity and posterior bony
nasal septum
Post: clivus and C1-C2 vertebral bodies

Treatment Field Boundaries

Sup: sphenoid sinus, cavernous sinus, base of skull

Inf: treat LAN supraclavicular and lower cervical nodes
Ant: posterior 2 cm of nasal cavity, posterior 1/3 of
maxillary sinus, posterior of orbit
Post: behind spinous processes, posterior pharyngeal
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 included in the treatment area were:
Supraclavicular and lower cervical nodes (Level Vb)
Retropharyngeal nodes, posterior cervical nodes (Level Va)
Deep cervical nodes (Level IV)

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

detail the technique.
VMATtechnique was used to treat the nasopharyngeal portion of
the tumor volume and AP/PA technique was used for the LAN.
Mono-isocentric technique was used to avoid shifting the patient
between treatment of the two regions.
VMAT: 2 full arcs (energy of 6x) were used for the
treatment 1 counter-clockwise and 1 clockwise; there
were no couch kicks; collimator rotation of 35 and 320
was used to minimize the interleaf MLC leakage.
Simultaneous integrated boost (SIB) technique was used to
deliver the dose of 5,940 cGy to the initial PTV, while
delivering 7,020 cGy to the smaller (boost) PTV volume.
AP/PA technique (6x photons) was used to deliver the
5,940 cGydose to the supraclavicular nodes. Because
mono-isocentric set up was used and isocenter for the LAN
was the same as for the cervical irradiation, half-beam
block technique was implemented to avoid divergence into
the cervical fields. Collimator rotation of 90 was used to
achieve better conformity of the MLCs to the tumor
volume. There were no couch kicks.