I.

ABSTRACT
II. Introduction
A. Head and neck cancer treatment results in the submandibular gland (SMG) and
level 1B nodes receiving high levels of radiation. The SMG/1B nodes are
considered low risk for oropharynx cancer. Irradiating the gland and node leads to
an increase in patients experiencing xerostomia and possibly a decrease in the
patients’ quality of life.1 Commented [AH1]: There are some flow issues in the
intro that need to be addressed. Here you talk about
2
1. Lee et al demonstrated that the percentage of 1B nodal xerostomia but you don't mention it again until you go into
detail in C1 and C2. When you bring up the problem with
involvement is rare since oropharynx cancer doesn't drain into the level 1B irradiating the gland, the paragraph should naturally flow
into discussing these side effects.
nodes. The SMG is also included in the PTV because of its location to the
Commented [AH2]: referring to cancer as "draining" is
1B node and does not have any nodal drainage function. not scholarly. Reword.

2. Jackson et al1 demonstrated for the at-risk contralateral SMG and

1B nodes that it was possible to spare them by maintaining a mean dose of
≤39 Gy. A possible way to improve treatments would be by adhering to
the dose constraints of ≤39 Gy because it would decrease the risk of
xerostomia and improve patients’ quality of life.1
B. There have been many studies documenting the possibility of sparing the Commented [KL3]: Too wordy... Many studies have
documented..
submandibular gland and level 1B nodes. A noteworthy example of such study is
one by Jackson et al.1
1. Historically, level 1B nodes have been included in the treatment
volumes. This is contrary to many studies demonstrating that the
percentage of 1B node involvement is rare.
I. Lee et al2 showed for 102 patients observed from 2010 to 2016,
only 4.3% had 1B nodal involvement.2
II. An article by Francis Ho et al4 states that for level 1B nodes there
is only a 2.7% chance of the nodes being affected.
III. Giuseppe Sanguineti et al6 stated that there is less than a 5% of the
level 1B nodes being impacted.

2. Using VMAT to treat the patients could also prove to be an advantage Commented [KL4]: volumetric modulated arc therapy
3
(VMAT)
to maintain lower doses. Therefore, this study will aim at testing the
possibility of sparing irradiation to the ipsilateral SMG and 1B nodes.
 C. The reason we want to spare the SMG is because about 53,000 people will get
7
oropharyngeal cancer in 2019 according to the American Cancer Society. The
SMG is a vital gland in the human body that secretes saliva. It has been shown to
produce 90% of unstimulated saliva and, when spared, improve the quality of life
of patients.8
1. This benefit can be especially seen during nighttime when
9
submandibular flow is strongly correlated to nighttime xerostomia.
2. Patients with xerostomia have a hypofunction of salivary output
resulting in sore throat, altered taste, dental decay, changes in voice
quality, and impaired chewing and swallowing function.10
3. Side effects can result in reduced nutritional intake and weight
loss. This can significantly affect general health and quality of life of the
subjects involved.10
III. Methods and Materials
Patients
A. Patients diagnosed with oropharyngeal history of squamous cell carcinoma, base of
tongue (BOT), and tonsil head and neck cancer were considered for this study.
1. Five patients were collected from a single clinical location, Advanced Oncology
Center. These patients have been treated using radiation therapy for
oropharyngeal head and neck cancer. The patients selected for this study have not
had surgery removing the submandibular glands.
2. Patients not eligible for this study included those that were considered high risk,
had metastatic disease to the nodes, and/or gross tumor extending into the SMG.
B. Computed Tomography (CT) scans were obtained during the simulation. For the
simulation and treatment, patients were positioned head-first, supine including the
immobilization face mask in the treatment area.
Commented [AH5]: Not scholarly writing. You need to
reword this entire sentence. Something to the effect of "The
incidence of oropharynx cancer is on the rise with a
predicted 53,000 new diagnoses in 2019."
Commented [AH6]: observed
Commented [KL7]: Add a better transition sentence to
open this paragraph...Ex. According to the American Cancer
Society, approximately 53,000 people will get
oropharyngeal cancer in 2019, most requiring radiotherapy
as a standard treatment option. Then go into the benefits
of excluding the SMG from the treatment volume.
Commented [AH8]: The last paragraph of the intro
should summarize the points of the intro (lightly) with the
last sentence of the paragraph stating "The purpose of this
study was to..."
Commented [KL9]: This is a case study, so you should use
Patient Selection & Target Delineation.
Commented [AH10R9]: Yes, this might be a deviation
from your initial thoughts but with only 5 patients, you need
to consider a case study format.
Commented [AH11]: This is a patient identifier. Remove.
Commented [KL12]: to remove
Commented [KL13]: lymph nodes or node positive
disease
Commented [KL14R13]: You could also mention the the
stage of disease of your patient population.
Commented [AH15]: Remove. Recognized by AMA.
Commented [KL16]: There is a lot of important details in
this paragraph about the aquistion of the treatment
planning CT and immobilization. Work on the flow of the
paragraph.
Commented [KL17R16]: thermoplastic mask? does the
mask extend through the shoulders? Was there custom
headrest or mouthpiece for chin and tongue positioning?
What type of CT scanner? All important details to paint the
picture for your readers.
 1. The simulation was the same for all the selected patients. The five scans utilized
contrast and had a slice thickness of 3mm. Immobilization devices used are the
head and neck mask, and s-frame. Commented [KL18]: Indicate single institution but you
can't specifically mention the name of the facility because of
HIPPA and the paper is a product of UW-L.
Contouring

A. Volumes of interest including gross tumor volume (GTV), clinical target volume (CTV), Commented [AH19]: ? Volumes of interest? Volumes of
interest are not like OAR so your wording here is not
and planning target volume (PTV) were delineated by the radiation oncologist. appropriate.

1. Previously treated head and neck tumors will be re-planned with attempts to spare
SMG and level 1B nodes. The PTV from the previous treatment will be
recontoured by Radiation Oncologist Ashwin Shinde for retrospective planning.
B. Normal structures contoured in all plans include; skin, mandible, parotid gland, spinal
cord, spinal cord PRV, brain, brain stem, brain stem PRV, optic nerve, optic chiasm,
orbit, and lens.
1. PRV expansion for the spinal cord will be 5mm. PRV expansion for the brain
stem will be 3mm.
C. The only other structure that will be contoured will be a table contour. Commented [KL20]: treatment table. remove the second
"contour"
1. The contour for the table will have a manual density over-ride that accurately in the sentence.

represents the treatment table. This contour will be included in the treatment Commented [AH21R20]: C should be removed all
together as it's not relevant for planning.
plans.
 References
1. Jackson WC, Hawkins PG, Arnould GS, Yao J, Mayo C, Mierzwa M. Submandibular
gland sparing when irradiating neck level 1B in the treatment of oral squamous cell
carcinoma. Med Dosim. 2018. In press. doi:10.1016/j.meddos.2018.04.003 Commented [KL22]: Doi references are not formatted
correctly.
2. Lee NC, Kelly JR, Park HS, Yarbrough WG, Burtness BA, Husain, ZA. (2017). The risk
Commented [AH23R22]: I will continue to count each
of level IB nodal involvement in oropharynx cancer: Guidance for submandibular gland incorrect doi reference as an AMA error so they need to be
fixed, not ignored.
sparing irradiation. Pract Radiat Oncol. 2017;7(5): e317-e321.
doi:10.1016/j.prro.2017.02.004
3. Dai X, Zhao Y, Liang Z, et al. Volumetric-modulated arc therapy for oropharyngeal
carcinoma: A dosimetric and delivery efficiency comparison with static-field IMRT.
Physica Medica. 2015;31(1):54-59. doi:10.1016/j.ejmp.2014.09.003.
4. Ho FCH, Tham IWK, Earnest A, Lee KM, Lu JJ. Patterns of regional lymph node
metastasis of nasopharyngeal carcinoma: A meta-analysis of clinical evidence. BMC
Cancer. 2012;12(1). doi:10.1186/1471-2407-12-98
5. Chen J, Ou D, Hu C. Sparing level Ib lymph nodes by intensity-modulated radiotherapy
in the treatment of nasopharyngeal carcinoma. Int J Clin Oncol. 2013;19(6):998-1004.
doi:10.1007/s10147-013-0650-6
6. Sanguineti G, Califano J, Zhou J, et al. Defining the Risk of Involvement for each Neck
Nodal Level in Patients with Early T-stage/Node-positive Oropharyngeal Carcinoma. Int
J Radiat Oncol Biol Phys. 2008;72(1). doi:10.1016/j.ijrobp.2008.06.506
7. Key Statistics for Oral Cavity and Oropharyngeal Cancers. American Cancer Society.
https://www.cancer.org/cancer/oral-cavity-and-oropharyngeal-cancer/about/key-
statistics.html. Accessed June 24, 2019.
8. Gensheimer M, Liao J, Laramore G, Parvathaneni U. Safety of Submandibular Gland-
Sparing Intensity Modulated Radiation Therapy for Head-and-Neck Cancer. Int J Radiat
Oncol Biol Phys. 2013;87(2). doi:10.1016/j.ijrobp.2013.06.153.
9. Terhaard C, Dijkema T, Braam P, Raaijmakers C, Roesink J. Importance of Sparing
Submandibular Gland Function to Improve Patient-reported Xerostomia. Int J Radiat
Oncol Biol Phys. 2010;78(3). doi:10.1016/j.ijrobp.2010.07.218.
10. Pinna, R., Campus, G., Cumbo, E., Mura, I., & Milia, E. (2015). Xerostomia induced by
radiotherapy: An overview of the physiopathology, clinical evidence, and management of
the oral damage. Ther Clin Risk Manag. 171-188. doi:10.2147/tcrm.s70652 Commented [KL24]: Great job with your extra research
this week. The content of your outline is much more in-
depth and will help you when you actually start writing the
paper. The take away for improvements is to clean up some
of the wordy and awkward sentences. I am really excited to
see the results of your research!
-Karen