1

Volumetric modulated arc therapy planning to reduce ipsilateral submandibular gland and
level 1B nodal radiation for oropharyngeal head and neck cancer
Luke VanLanen, BS; Nick Nguyen, BS, R.T.(R)(T); Travis Kilmer, BS; Nishele Lenards PhD,
CMD, R.T.(R)(T), FAAMD; Ashley Hunzeker, MS, CMD; Karen Lang, MS, R.T.(T), CMD
Medical Dosimetry Program at the University of Wisconsin, La Crosse, WI
Abstract
The radiation therapy treatment of oropharynx cancer has been shown to cause
debilitating side effects from unintentional dose delivered to the submandibular gland (SMG).
Research has demonstrated that the ipsilateral SMG and level 1B nodes are considered low risk
for oropharynx cancer and the disease involvement of the SMG and level 1B nodes is rare. With
minimal literature demonstrating treatment planning outcomes when the SMG and level 1B
nodes were excluded from the low risk clinical target volume (CTV), researchers theorized that
by excluding the ipsilateral SMG and level 1B nodes from the low risk CTV and actively
attempting to reduce dose, these structures can be spared while maintaining similar coverage,
organ at risk (OAR) sparing and maximum dose. Five patients from a single institution were
retrospectively planned utilizing a volumetric modulated arc therapy (VMAT) technique with
active SMG and level 1B node sparing. New planning target volumes (PTVNEW) were recreated
from the original PTV (PTVORIG) by omitting the ipsilateral SMG and level 1B nodes from the
original CTV (CTVORIG) and creating a 3 mm expansion. Prescription dose was maintained from
the original plan and dose to the organs at risk (OAR) was attempted to be planned within 2% of
the original. Wilcoxon signed rank tests were used to compare the new target sizes versus the
original target sizes for the ipsilateral SMG and level 1B nodes rather than paired t-tests or a
doubly multivariate repeated measures analysis due to small sample sizes and outliers. This study
demonstrated no significant difference in population distributions between the dose received by
the ipsilateral SMG for the new target size and the original target size (P = 0.132) at the 5% level
of significance (P < 0.05). However, the responses for level 1B nodes (P = 0.026) were
significantly different.
Keywords: VMAT, submandibular gland, 1B nodes, oropharyngeal cancer
Introduction
The incidence of oropharynx cancer has been on the rise with a predicted 53,000 new
diagnoses in 2019, however, the death rate for these cancers has decreased over the past 30
 2

years.1 The lower death rate can be attributed, in part, to the different modalities of treatment that
are currently available. Specifically, oropharynx cancer can be treated with surgery,
chemotherapy, radiation therapy, or a multimodality approach.
The two main radiotherapy techniques for treating patients with oropharyngeal cancer
have been volumetric modulated arc therapy (VMAT) and static field intensity-modulated
radiotherapy (IMRT). The VMAT technique has shown several advantages over IMRT in
various planning criteria. Dai et al2 described the benefits of improved target homogeneity and a
notable decrease in monitor units (MUs) and treatment times when compared to IMRT. Dai et al2
also found a decrease in dose to several organs at risk (OAR) including a lower dose to the oral
cavity and mandible when using VMAT. Likewise, an article by Zhang et al3 described the
feasibility of lowering the dose to the submandibular gland (SMG) for patients treated with
VMAT even when the planning target volume (PTV) overlaps the SMG. Lower dose to the
OAR, such as the SMG, is especially important when reducing the risk of side effects.
The SMG is a vital gland in the human body that secretes saliva. It has been shown to
produce 90% of unstimulated saliva and, although it is not the target of oropharyngeal cancer
treatment, it is often located within the treatment field. When this salivary organ is spared, the
patient’s quality of life improves.4 The improved quality of life can especially be observed at
night when submandibular secretion is strongly correlated to nighttime xerostomia.5 Patients
with xerostomia have had a hypofunction of salivary output resulting in sore throat, altered taste,
dental decay, changes in voice quality, and impaired chewing and swallowing function.6 Side
effects can result in reduced nutritional intake and weight loss; ultimately affecting general
health and quality of life.6 Due to the aforementioned side effects, it is imperative that every
attempt be made to spare the SMG, though it is not the only normal tissue typically included in
treatment volumes that should be avoided.
Historically, level 1B nodes have also been included in the target volumes despite,
various studies that have demonstrated that level 1B nodal involvement is rare for oropharynx
cancers.7-9 In a meta-analysis study from 2010 to 2016, Lee et al7 showed that of 102 patients
with surgically treated oropharyngeal squamous cell cancer, only 4.3% had level 1B nodal
involvement. Similarly, Ho et al8 reported that only 2.7% of level 1B nodes were affected among
oropharyngeal cancer patients and Sanguineti et al9 stated < 5% of the level 1B nodes were
involved. The seldom occurrence of level 1B nodal involvement has indicated a low risk for
 3

oropharynx cancer and could potentially be spared from side effects. The increase in patient
quality of life and decrease in potential for late occurrences of xerostomia when the level 1B
nodes are spared can be attributed to the additional sparing of the SMG.10
Though research has shown that the disease involvement of the SMG and level 1B nodes
is rare, there has been a paucity of literature demonstrating treatment planning outcomes when
the ipsilateral SMG and level 1B nodes are excluded from low risk clinical target volume
(CTV).7 The purpose of this study was to lower the dose to the ipsilateral SMG and level 1B
nodes by omitting both from the low risk CTV and actively reducing dose to these structures
through optimization while still maintaining target coverage and similar OAR sparing. The first
null hypothesis (H10) was that excluding the ipsilateral SMG from the low risk CTV has no
effect on the dose delivered to the SMG. The second null hypothesis (H20) was that excluding the
ipsilateral level 1B nodes from the low risk CTV has no effect on the dose delivered to the level
1B nodes. Wilcoxon signed rank tests were used to test level of significance (P < 0.05) of change
between the original and revised plan.

Methods and Materials

Patient Selection and Setup
The selection criteria for this retrospective study included patients with a history
of oropharyngeal squamous cell carcinoma, base of tongue (BOT), or tonsil cancer and had
received oropharynx radiotherapy treatment. A total of 5 patients were collected from a single
clinical institution. Out of all 5 patients, 4 had unilateral disease and 1 of the patients was treated
bilaterally. The patient with bilateral disease was divided into 2 distinct sites, totaling 6. The
exclusion criteria for this study included patients requiring surgical removal of the SMG, patients
considered high risk due to metastatic disease to the lymph nodes, and/or patients with gross
disease extending into the SMG.
All patients underwent a CT simulation for radiation treatment planning. The patient was
positioned headfirst supine with a custom 5-point thermoplastic mask and neck support on an
indexed s-frame. The 5 CT scans were performed using contrast, for improved nodal
delineation, with a slice thickness of 3 mm.
Target Delineation
 4

Target volumes included the gross tumor volume (GTV), CTV, and PTV that were
delineated by the radiation oncologist. The original PTV (PTVORIG) was created with a 3 mm
expansion of the original CTV (CTVORIG) which included the ipsilateral SMG and level 1B
nodes (Figure 1). Contoured by an experienced radiation oncologist, the new CTV (CTVNEW)
excluded, but abutted, the ipsilateral SMG and level 1B nodes. The new PTV (PTVNEW)
was recontoured by a radiation oncologist for retrospective planning by placing a 3 mm
expansion on the CTVNEW. The PTVNEW included a 3 mm overlap with the SMG and level 1B
nodes and was cropped 5 mm from the skin’s surface to maintain consistent with the PTVORIG.
The only change to the treatment volume in the revised plans was the absence of the SMG and
level 1B nodes from the CTVNEW (Figure 2). Normal structures contoured in each plan included;
skin, mandible, parotid gland, spinal cord, spinal cord planning organ at risk volume (PRV),
brain, brainstem, brainstem PRV, optic nerve, optic chiasm, orbit, and lens. The PRV expansion
for the spinal cord and brainstem was 5 mm and 3 mm, respectively.
Treatment Planning
Patients in this study were treated with doses ranging from 54-70 Gy. Four of the patients
were treated with 3 PTV structures treated to 54, 63 and 70 Gy and 1 patient had 2 PTV
structures treated to 54 and 66 Gy. All treatment regimens were given prescriptions that matched
the standard of care and the original prescriptions. Each plan was normalized using a volume-
based normalization technique. Plans were normalized so that 95% of the PTV volume received
the prescription dose.
The treatment planning system (TPS) used for the planning of all 5 patients was Monaco
(Elekta). Treatment plans were generated using a VMAT technique consisting of 2-3 non-
coplanar arcs and 360° of rotation. The plans were all recreated using 6 MV energy. The
retrospective replans aimed to maintain target coverage and OAR sparing but also spare the
ipsilateral SMG and level IB lymph nodes.
To evaluate the different methods of planning, a dose volume histogram (DVH) for each
technique was generated to collect data for dosimetric analysis. The first priority
was normalization to the PTV as instructed by the radiation oncologist. Each plan was
normalized such that 100% of the prescription dose covered 95% of the PTV while OAR sparing
was attempted to not differ > 2% from the original plan. This included maintaining the maximum
dose of the revised plan within 2% of the original plan. The researchers also compared the
 5

volume receiving 100% of the prescription dose (V100%). The second priority was to spare the
ipsilateral SMG while maintaining coverage to the PTV. The SMG was considered spared with a
mean dose < 39 Gy. The third priority was to spare the level 1B nodes and compare the dose to
the original plan. The level 1B nodes were considered successfully spared if they received a
mean dose of < 39 Gy.11 Lastly, the OAR structures were compared via the 2 treatment plans for
each patient that included the following: mandible, parotid gland, spinal cord, spinal cord PRV,
brain, brainstem, brainstem PRV, optic nerve, optic chiasm, orbit, and lens. Maximum and mean
doses were recorded for the contoured OAR.
Statistical Methodology, Collection, & Analyses
Wilcoxon signed rank tests were used to compare the new target volumes versus the
original target volumes for the ipsilateral SMG and level 1B nodes rather than paired t-tests or a
doubly multivariate repeated measures analysis due to very small sample sizes and outliers. The
sample size contained two measurements for patient 2 because there was bilateral disease.
Statistical analysis was conducted using R (R Core Team, 2019).12 A level of significance of P <
0.05 was used for each individual hypothesis test and no correction was applied to control the
Type 1 error rate for multiple testing.
Results
Patient 1 had 3 target volumes, 70 Gy, 63 Gy, and 56 Gy. The normalization for the
PTVs was kept the same such that V100% was at 95%. The mean dose to the ipsilateral SMG and
level 1B nodes was 65.87 Gy and 66.48 Gy for the original plan, respectively. The revised plan
produced a mean dose of 61.62 Gy and 58.83 Gy to the ipsilateral SMG and level 1B nodes,
respectively. This resulted in a 6.45% decrease for the ipsilateral SMG and a 11.51% decrease in
dose for the ipsilateral level 1B nodes. Furthermore, attempting to maintain OAR dose within 2%
from the original plan was unsuccessful for the brainstem, contralateral parotid gland, larynx and
esophagus. The variance of dose for the OAR that exceeded a 2% difference in mean dose
between the original plan and the revised plan ranged from a 2.48% difference for the
contralateral parotid gland to an 8.66% difference for the brainstem. However, the variance of
maximum dose for the revised plan was maintained within 2% of the original plan with a
difference of 0.79%.
Patient 2 had bilateral disease, therefore, the SMG and level 1B nodes on both sides were
evaluated independently. The patient had 3 target volumes treated to 3 different
 6

doses which included 70 Gy, 63 Gy, and 59.4 Gy. The normalization for the PTVs was kept the
same such that V100% was at 95%. For the left side of the patient, the mean dose to the SMG and
level 1B nodes was 63.30 Gy and 62.28 Gy for the original plan, respectively. On the same side,
the revised plan produced a mean dose of 62.39 Gy and 58.31 Gy to the ipsilateral SMG and
level 1B nodes, respectively. This resulted in a 1.44% decrease in dose to the SMG and a 6.37%
decrease in dose to the level 1B nodes. For the patient’s right side, the mean dose to the SMG
and level 1B nodes was 63.61 Gy and 63.15 Gy for the original plan, respectively. On the same
side, the revised plan produced a mean dose of 58.31 Gy and 53.66 Gy to the ipsilateral SMG
and level 1B nodes, respectively. This resulted in an 8.33% decrease in dose to the SMG and a
15.03% decrease in dose to the level 1B nodes. Furthermore, attempting to maintain OAR doses
within 2% from the original plan was successful for both sides of the patient’s body except for
the patient’s left parotid gland. The left parotid gland had a maximum dose variance of 2.42% in
the revised plan when compared to the original plan. In addition, the objective of maintaining the
maximum dose for the revised plan within 2% of the original plan was successful with a
difference of 0.66%.
Patient 3 had 2 target volumes treated to 2 different doses. The doses to the volumes
included 66 Gy and 54 Gy. The normalization for the PTVs was kept the same such that V100%
was set to 95%. The mean dose to the ipsilateral SMG and level 1B nodes was 54.78 Gy and
43.51 Gy for the original plan, respectively. The revised plan produced a mean dose of 37.50 Gy
and 27.71 Gy to the ipsilateral SMG and level 1B nodes, respectively. This resulted in a 31.54%
decrease in dose to the ipsilateral SMG and a 36.31% decrease in dose for the ipsilateral level 1B
nodes. Furthermore, attempting to maintain OAR dose within 2% from the original plan was
unsuccessful for the brainstem, contralateral parotid gland, larynx, spinal cord, ipsilateral parotid
gland and mandible. The variance of mean dose for the OAR that exceeded 2% between the
original plan and the revised plan ranged from 2.35% (ipsilateral parotid) to 14.34%
(contralateral parotid). However, the variance of maximum dose for the revised plan was
maintained within 2% of the original plan with a difference of 0.83%.
Patient 4 had 3 target volumes treated to 3 different doses. The doses to the volumes
included 70 Gy, 63 Gy, and 56 Gy. The normalization for the PTVs was kept the same such that
V100% was at 95%. The mean dose to the ipsilateral SMG and level 1B nodes was 67.87 Gy and
66.64 Gy for the original plan, respectively. The revised plan produced a mean dose of 41.88 Gy
 7

and 42.03 Gy to the ipsilateral SMG and level 1B nodes, respectively. This resulted in a 38.30%
decrease in dose to the ipsilateral SMG and a 36.93% decrease in dose to the ipsilateral level 1B
nodes. Furthermore, attempting to maintain OAR dose within 2% from the original plan was
unsuccessful for the spinal cord, ipsilateral parotid gland, larynx and contralateral parotid gland.
The variance of maximum dose for the OAR that exceeded 2% between the original plan and the
revised plan ranged from 2.38% (larynx) to 10.03% (ipsilateral parotid gland). However, the
variance of maximum dose for the revised plan was maintained within 2% of the original plan
with a difference of 1.71%.
Patient 5 had 3 target volumes treated to 3 different dose levels. The doses to the volumes
included 70 Gy, 63 Gy, and 56 Gy. The normalization for the PTVs was kept the same such that
V100% was at 95%. The mean dose to the ipsilateral SMG and level 1B nodes was 71.73 Gy and
68.18 Gy for the original plan, respectively. The revised plan produced a mean dose of 70.15 Gy
and 61.80 Gy to the ipsilateral SMG and level 1B nodes, respectively. This resulted in a 2.20%
decrease in dose to the ipsilateral SMG and a 9.36% decrease in dose to the ipsilateral level 1B
nodes. Furthermore, attempting to maintain maximum OAR dose within 2% from the original
plan was unsuccessful for the brainstem and the spinal cord with an increase of 11.93% and
3.44%, respectively. However, the variance of maximum dose for the revised plan was
maintained within 2% of the original plan with a difference of 1.28%.
The results from the revised plans created in this study demonstrated no significant
difference in population distributions between the dose received by the ipsilateral SMG for the
new target volume and the original target volume (P = 0.132) at the 5% level of significance (P <
0.05). However, the responses for level 1B nodes (P = 0.026) were significantly different, with
the distribution of the new target volume, represented by the boxplots in Figure 4, shifted to the
left of the distribution for the old target volume. That is, generally lower values were observed
for the level 1B nodes with the new target volume. Therefore, when considering mean dose to
the ipsilateral SMG, the findings of this study failed to reject the null hypothesis (H10) that
excluding and limiting dose to the ipsilateral SMG from the low risk CTV and actively reducing
dose to this structure had no effect on dose delivered to the ipsilateral SMG. Conversely, when
considering mean dose to the level 1B nodes, the findings of this study rejected the null
hypothesis (H20) that excluding and limiting dose to the level 1B nodes from the low risk CTV
actively reduced dose to this structure and had the effect of lowering the dose delivered to the
 8

ipsilateral level 1B nodes. Side-by-side boxplots for the mean dose to the ipsilateral SMG and
level 1B nodes for each target volume are shown by Figure 3 and Figure 4. Additionally,
maximum and mean dose comparisons between the SMG and level 1B nodes for the original and
revised plans are shown by Table 1 and Table 2.
Discussion
The incidence of oropharynx cancer has been on the rise and while treating the disease is
often the highest priority, it’s important to spare normal tissues without disease involvement to
reduce side effects. Treating the SMG with radiation therapy has shown to cause debilitating side
effects.1,6 By sparing this salivary organ, the patient’s quality of life can improve.4 Additionally,
the level 1B nodes have typically been included in the treatment of oropharynx cancer which
may be unnecessary as there have been several studies stating the rarity of level 1B nodal
involvement for oropharyngeal cancers.7-9 Though research has shown that the disease
involvement of the SMG and level 1B nodes is rare, there has been minimal literature
demonstrating treatment planning outcomes when the ipsilateral SMG and level 1B nodes are
excluded from low risk CTV.7 The main purpose of this study was to examine the dose to the
ipsilateral SMG and level 1B nodes when omitted from the low risk CTV while actively
reducing dose to these structures and maintaining the overall integrity of the treatment plan.
Wilcoxon signed rank tests were used to test level of significance (P < 0.05) of change between
the original and revised plan.
The first priority was to control target coverage through the use of normalization. With
PTV coverage normalized to V100% at 95%, the results demonstrated that equivalent
normalization to PTVNEW can maintain a plan maximum dose within 2% of the original plan. By
utilizing mean dose to measure the dose to the target volume, researchers identified only 1
outlier. The outlier was related to the PTV receiving 54 Gy (PTV 54) from patient 3 which had a
mean dose that changed by 7.10%. However, despite the 1 deviation, the remaining target
volume mean doses never varied by more than 2%, demonstrating that the revised
plans were created similarly to the original plan. This outcome differed from results of a previous
study by Jackson et al13 where the PTV was grossly underdosed by 10% to 20% in the region
overlapping the SMG. It was noted that comparing PTV coverage from the original plan to the
revised plan for this study was not equivalent because the volumes differed. Nevertheless, the
 9

gross disease treated in both the original and revised plans were equal despite different target
volumes.
Doses to the ipsilateral SMG exceeded 60 Gy for 4 out of 5 plans, and the mean dose of <
39 Gy was met for only 1 plan. With P = 0.132, successful sparing of the SMG was deemed
statistically insignificant (P < 0.05). The prescribed dose for the patient where SMG sparing was
successful was lower than the prescription doses for the rest of the patients, which could
correlate to the successful sparing of ipsilateral SMG. As noted earlier, the study by Jackson et
al13 demonstrated a mean dose of < 39 Gy was possible with the sacrifice of PTV coverage. After
further research, Zhang et al3 concluded that SMG sparing is feasible when there is < 20%
overlap with the PTV.
When the dose to the level 1B nodes was compared between the original and revised
plans, the decrease was considered statistically significant (P = 0.026). However, the nodes were
not successfully spared according the study criteria of a mean dose < 39 Gy. Only 1 plan
successfully spared the level 1B nodes with a mean dose of 27.71 Gy, a 36.31% decrease from
the original plan. A possible explanation for successfully sparing the level 1B nodes in this 1
patient is that a lower prescription dose was used compared to the other patients. In any event,
with coverage maintained through normalization, complete sparing of the level 1B nodes was not
possible for a majority of the patients.
When evaluating the results for the maximum dose for each plan and OAR, the criteria
was to be within 2% of the original plan. This research showed that it was possible for the
maximum dose 2% threshold to be maintained for all 5 plans. Patient 4 had the largest maximum
dose variation at 1.72% and patient 2 had the smallest difference at 0.66%. As for the OAR
comparison, not all OAR dose met the 2% criteria. The researchers hypothesized that OAR
objectives may not have been possible to achieve with the added effort of SMG and level 1B
node sparing. Other contributing factors such as tumor size, location and extension within the
body could have contributed to not achieving other dose constraints as well.
The results of this study demonstrated it was not feasible to spare the SMG and level 1B
nodes, even when excluded from the CTV, and meet the same dosimetric coverage goals of the
original treatment plan. Underdosing the PTV in this area in an attempt to spare these structures
may not always be appropriate. When PTV expansions are modified, such as removing an OAR
from the treatment volume, there is a greater risk of underdosing the subclinical disease. The
 10

study by Lee et al7 stated the disease involvement of these structures is low, so the risk could be
worth making if sparing the function of the SMG and level 1B nodes were possible. However,
the results of this study failed to spare the SMG according to the mean dose of < 39 Gy. The
dose to the ipsilateral SMG and level 1B nodes was lowered, but it was not significant enough to
warrant a smaller PTV volume and increased risk of underdosing the disease. Although sparing
the SMG and level 1B nodes may be an option that a radiation oncologist could further explore,
it may not be possible to achieve adequate target coverage and spare the SMG and level 1B
nodes.
Conclusion
There was a limited amount of research available regarding the exclusion of the SMG and
level 1B nodes from the low risk CTV in oropharyngeal cancer despite research stating that the
disease involvement of these areas is rare.7 Sparing the SMG and level 1B would help improve
the patient's quality of life and multiple studies have shown the potential benefit of sparing the
salivary function of a patient.1,2,4,5,7 The purpose of this study was to examine the dose to the
ipsilateral SMG and level 1B nodes when omitted from the low risk CTV while also attempting
to minimize dose to these structures and maintaining the overall integrity of the treatment plan.
Ultimately, the goal was to adequately cover the tumor volume while sparing the SMG and level
1B nodal function.
Researchers in this study revealed that the overall mean dose to the SMG and level 1B
nodes were 55.30 Gy and 50.39 Gy, respectively. Therefore, the researchers were unable to
cover the PTV and spare the SMG and level 1B nodes simultaneously. An attempt to spare the
ipsilateral SMG and level 1B nodes should be made even if a plan sparing those structures is
likely impossible due to the amount of target overlap with these structures.
A limitation of this study was the small sample size of patients evaluated for re-planning.
With only 5 patients investigated, it may be possible that expanding the number of patients
involved in this study would improve the validity of this study. Another limitation to this study
was the diversity of clinical sites. All the patients used in this study came from the same site and
were contoured by the same radiation oncologist. Additional sites, a variety of radiation
oncologists, and a greater diversity of patients could produce more statistically valid results if
this study were replicated.
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Acknowledgments

We would like to express our gratitude to Dr. David Reineke of the UWL Statistical Consulting
Center for his contributions to the statistical analysis and interpretation of statistical results.
However, any errors of fact or interpretation remain the sole responsibility of the authors.
 12

References
1. 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.
2. Dai X, Zhao Y, Liang Z, Dassarath M, Wang L, Jin L, Chen L, Dong J, Price RA, Ma CM.
Volumetric-modulated arc therapy for oropharyngeal carcinoma: A dosimetric and delivery
efficiency comparison with static-field IMRT. Physica Medica. 2015;31(1):54-59.
http://dx.doi.org/10.1016/j.ejmp.2014.09.003
3. Zhang H, Cao Y, Antone J, et al. A model-based method for assessment of salivary gland and
planning target volume dosimetry in volumetric-modulated arc therapy planning on head-
and-neck cancer. J Med Phys. 2019;44(3):201–206.
http://dx.doi.org/10.4103/jmp.JMP_19_19
4. 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):S59. http://dx.doi.org/10.1016/j.ijrobp.2013.06.153
5. 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):S80. http://dx.doi.org/10.1016/j.ijrobp.2010.07.218
6. Pinna R, Campus G, Cumbo E, Mura I, Milia E. Xerostomia induced by radiotherapy: An
overview of the physiopathology, clinical evidence, and management of the oral
damage. Ther Clin Risk Manag. 2015(1):171-188. http://dx.doi.org/10.2147/tcrm.s70652
7. Lee NC, Kelly JR, Park HS, Yarbrough WG, Burtness BA, Husain, ZA. (2017). The risk of
level IB nodal involvement in oropharynx cancer: Guidance for submandibular gland sparing
irradiation. Pract Radiat Oncol. 2017;7(5):e317-e321.
http://dx.doi.org/10.1016/j.prro.2017.02.004
8. 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):98. http://dx.doi.org/10.1186/1471-2407-12-98
9. Sanguineti G, Califano J, Zhou J, Stafford E, Koch W, Tufano R, Gourin C, Sormani M,
Marur S, Forastiere A. Defining the risk of involvement for each neck nodal level in patients
 13

with early T-stage/node-positive oropharyngeal carcinoma. Int J Radiat Oncol Biol Phys.
2008;72(1):1356-1364. http://dx.doi.org/10.1016/j.ijrobp.2008.06.506
10. Tam M, Riaz N, Kannarunimit D, et al. Sparing bilateral neck level IB in oropharyngeal
carcinoma and xerostomia outcomes. Am J Clin Oncol. 2015;38(4):343–347.
http://dx.doi.org/10.1097/COC.0000000000000064
11. 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.
http://dx.doi.org/10.1007/s10147-013-0650-6
12. The R Project for Statistical Computing. R. https://www.r-project.org/. Accessed September
30, 2019.
13. 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. 2019;44(2):144-149. http://dx.doi.org/10.1016/j.meddos.2018.04.003
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Figures

Figure 1. A sagittal view of the CTVORIG (green) and PTVORIG (magenta) contours in relation to
the ipsilateral SMG (blue) and level 1B nodes (pink) contours for patient 1.
 15

Figure 2. Sagittal view of CTVNEW (orange) and PTVNEW (blue) contours in relation to the
ipsilateral SMG (turquoise) and level 1B nodes (tan) contours for patient 1.
 16

Figure 3. Boxplots of the mean dose in centigray (cGy) to the ipsilateral (Ips) SMG from each
target volume in the original and revised plans for all patients.
 17

Figure 4. Boxplots of the mean dose (cGy) to level 1B nodes from each target volume in the
original and revised plans for all patients.
 18

Tables
Table 1. This table is a display of the ipsilateral SMG dose summary.
Ipsilateral Ipsilateral Ipsilateral Ipsilateral
Patient SMG Mean SMG Mean SMG SMG
Dose (Gy)a Dose (Gy)b Maximum Maximum
Dose (Gy)a Dose (Gy)b
1 65.87 61.62 72.86 73.48
2c 63.30 62.39 71.13 71.82
d
2 63.61 58.31 74.52 76.31
3 54.78 37.5 69.24 69.95
4 67.87 41.88 72.56 69.86
5 71.73 70.15 76.51 77.34
a Original plan
b Revised plan
c Patient's left side of body
d Patient's right side of body
 19

Table 2. This table is a display of the ipsilateral level 1B nodes dose summary.
Ipsilateral Level Ipsilateral Level Ipsilateral Level Ipsilateral Level
Patient 1B Node Mean 1B Node Mean 1B Node 1B Node
Dose (Gy) a Dose (Gy) b Maximum Dose Maximum Dose
(Gy)a (Gy)b
1 66.48 58.83 73.96 74.71
2c 62.28 58.31 73.54 72.43
d
2 63.15 53.66 77.03 76.37
3 43.51 27.71 69.24 69.95
4 66.64 42.03 72.56 71.16
5 68.18 61.8 76.61 77.34
a Original plan
b Revised plan
c Patient's left side of body
d Patient's right side of body