ORAL CAVITY CANCER

PRESENTATION
Marina Cousins, Sherikah Paskaran and Jay Varma

CONTENT
 Introduction to the oral cavity and its anatomy
 The associated OARs and Target Volumes
 The dose prescription for the oral cavity
 The rationale and justification behind the standard and advanced
radiotherapy technique for treating the oral cavity

 The advantages and disadvantages of each technique

 The beam arrangements and beam modifications used in the
radiotherapy treatment

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 INTRODUCTION
 The medical term for the mouth is the oral cavity

 Oral cancer is the 16th most common cancer worldwide, and makes up
between 60-85% of all head & neck cancers (cancerresearchuk.org
2015)

 More than 90% of all oral cancers are squamous cell carcinoma (SCC)
(Feller & Lemmer, 2012)

 Treatment for oral cavity cancer is usually surgery. EBRT with or without
chemotherapy is used in 3 situations:
 after surgery to enhance loco-regional control

 when the patient is unable to tolerate surgery

 if the disease is recurrent

(Huang & O’Sullivan, 2013)

ANATOMY OF THE ORAL CAVITY

Subsites in the oral cavity:-

 Oral tongue
 Floor of mouth
 Buccal mucosa
 Retromolar trigone
 Mucosa of upper and lower
alveolus
 Hard palate

(NHS Trust, name withheld, 2013)

(National Cancer Institute, 2015)

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 ORGANS AT RISK AND DOSE CONSTRAINTS
Spinal cord (0.1cc < 44Gy) Lenses (Dmax 6Gy)

Brain stem (0.1cc < 54Gy) Parotid glands (unilateral mean 20Gy)
(bilateral mean 24Gy)

Cochlea (Mean 48Gy) Lacrimal glands (Dmax 35Gy)

Optic nerves (Dmax 50Gy) Corneas (Dmax 40Gy)

Optic chiasms (Dmax 50Gy) Pituitary gland (Dmax 45Gy)

Globes (Dmax 45Gy)

(NHS Trust, name withheld, 2013)

TARGET VOLUME DEFINITION

ORAL TONGUE / FLOOR OF MOUTH
Cranial Caudal Anterior Posterior Lateral Medial
Superior aspect Hyoid bone Symphysis menti Anterior oropharyngeal To mandible. Ipsilateral tongue or FoM in well
tongue/mouth bite mucosa Includes ipsilateral parapharyngeal lateralised tumours.
space Contralateral mandible in midline or
advanced tumours

BUCCAL MUCOSA
Cranial Caudal Anterior Posterior Lateral Medial
Inferior aspect Hyoid bone Anterior aspect masseter Oropharyngeal mucosa To mandible. Oropharyngeal mucosa.
zygomatic arch/ hard muscle Includes ipsilateral parapharyngeal Contralateral parapharyngeal space
palate space spared

RETROMOLAR TRIGONE
Cranial Caudal Anterior Posterior Lateral Medial
Superior aspect soft Hyoid bone Junction of posterior Oropharyngeal mucosa To mandible. Oropharyngeal mucosa
palate/hard palate third and anterior two Includes ipsilateral parapharyngeal Contralateral parapharyngeal space
thirds of the tongue space spared

HARD PALATE
Cranial Caudal Anterior Posterior Lateral Medial
Superior aspect of Hyoid bone 10-15mm anterior Anterior aspect To mandible or medial pterygoid muscle To mandible or medial pterygoid muscle
hard palate +10mm margin on GTV into oropharyngeal mucosa on both sides. on both sides.
palate. Includes both parapharyngeal spaces. Includes both parapharyngeal spaces.

*Limits are given for guidance. At least a 1cm margin on the GTV should always be added. (NHS Trust, name withheld, 2013)
** In cases where the extent of the tumour is difficult to visualise use 15mm margins.

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STANDARD RADIOTHERAPY TECHNIQUE
3D CONFORMAL RADIOTHERAPY
Rationale / Justification
 3D conformal radiotherapy technique (3D-CRT)
 Tumour volume in a 3D perspective
 Radiation beams conform to shape of tumour due to
multi-leaf collimators (MLCs)
 MLCs precisely sculpt the tumour whilst shielding normal
tissue
 Minimise healthy tissue being irradiated hence reducing
long term side effects.

STANDARD RADIOTHERAPY TECHNIQUE

3D CONFORMAL RADIOTHERAPY

Beam Arrangements
Site Tongue
 Anterior and posterior oblique fields wedged to produce a
homogeneous dose distribution.
 Deeply infiltrative tumours approaching or invading the midline -
parallel-opposed lateral beams are required to treat the CTV
(Hoskin, 2012)

Beam Modifications
 A mouth bite may be considered to exclude the upper or lower
half of the mouth from the field.
 Bolus may be considered for tumour/ nodal disease extending
close to the skin (NHS Trust, name withheld, 2013)

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 Doses and Prescriptions
Site Dose Fractions Duration Modality Localisation, Category
(Gy) (#s) planning &
immobilisation

Oral Cavity 55 20 26 days Photons IMRT / 3D CT 1

66-70 33-35 40 days conformal
65 30 40 days planning in
thermoplastic
shell

(NHS Trust, name withheld, 2013)

STANDARD RADIOTHERAPY TECHNIQUE

3D CONFORMAL RADIOTHERAPY

Advantages
 Simple and quick QA checks
compared to IMRT plans,
significant impact on
departmental resources
(Saw et al., 2002)
 Lower number of monitor
units in comparison to IMRT
plans, hence lower dose to
the rest of the body (Teoh et
al., 2011)
Disadvantages
 Delivery efficiency by VMAT
plans much higher than
3DCRT plans
 Overall treatment and
verification time longer for
3DCRT plans compared to
VMAT
 Doses to OAR’s e.g. spinal
cord and parotid glands
significantly reduced with
VMAT than 3DCRT plans
(Sakanaka et al., 2013)

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 ADVANCED RADIOTHERAPY TECHNIQUE
VOLUMETRIC MODULATED ARC THERAPY (VMAT)

(varian.com)

ADVANCED RADIOTHERAPY TECHNIQUE

(VMAT)
Rationale / Justification
 Is an advanced form of IMRT
 Delivers a precisely sculpted 3D dose distribution
 Achieved by simultaneously changing
 the rotational speed of the gantry,
 shape of treatment by manipulating the MLCs
 and delivery of dose rate (Alvarez-Moret et al., 2010)
 VMAT allows for different PTVs to be treated to different
doses within the same plan instead of separate phases
 (Dobbs et al., 2009)

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 ADVANCED RADIOTHERAPY TECHNIQUE
VMAT
Advantages Disadvantages
 Rapid delivery  Lengthy planning process due to
complexity of VMAT plans
 Improved patient comfort
 Integral dose will be an issue
 Reduced intrafraction due to the arc effect
motion, and
 May increase the risk of
 Increased patient throughput secondary malignancies
(Studenski et al., 2013)
(Studenski et al., 2013)
 Need for accurate volume
delineation (Bhide et al., 2012)

3DCRT vs. IMRT

Huang & O’Sullivan, 2013

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 3DCRT vs. IMRT
Eisbruch et al., 1996, 1998
 In the first Phase I/II studies to spare salivary gland tissue in
Head & Neck patients, IMRT reduced the radiation dose to the
contralateral parotid gland to 32% compared with 93% for the
standard plans
Chen et al., 2009
 Patients receiving IMRT had significantly less moderate to
severe xerostomia and dysphagia than those receiving 3DCRT:
 3DCRT - 82% for xerostomia, and 59% for dysphagia
 IMRT - 36% for xerostomia and 21% for dysphagia

CONCLUSION
 The aim of radiotherapy is to maximise dose to the tumour whilst
minimising the dose to surrounding healthy tissue and OARs
 The oral cavity is surrounded by numerous critical structures
which are in close proximity to the target volume
 Therefore it is vital that high conformality of dose to the target
volume is achieved to minimise dose to the critical organs and to
reduce side effects
 Advancements in radiotherapy has resulted in new techniques to
achieve this e.g. VMAT
 Rotational arc(s) with dynamic MLCs, to shape the field, delivers
an intensity modulated beam that allows for high conformality, and
optimised dose distribution across the tumour volume

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THANK YOU FOR LISTENING

References
 Bhide, S., Newbold, K., Harrington, K. and Nutting, C. (2012). Clinical
evaluation of intensity-modulated radiotherapy for head and neck cancers.
BJR, 85(1013), pp.487-494.

 Cancerresearchuk.org, (2015). The mouth and oropharynx | Cancer

Research UK. [online] Available at: http://www.cancerresearchuk.org/about-
cancer/type/mouth-cancer/about/the-mouth-and-oropharynx [Accessed 15
Jan. 2015].

 Chen, W., Hwang, T., Wang, W., Lu, C., Chen, C., Chen, C., Weng, H., Lai,
C. and Chen, M. (2009). Comparison between conventional and intensity-
modulated post-operative radiotherapy for stage III and IV oral cavity cancer
in terms of treatment results and toxicity. Oral Oncology, 45(6), pp.505-510.

 Eisbruch, A., Marsh, L., Martel, M., Ship, J., Ten Haken, R., Pu, A., Fraass,
B. and Lichter, A. (1998). Comprehensive irradiation of head and neck
cancer using conformal multisegmental fields: assessment of target
coverage and noninvolved tissue sparing. International Journal of Radiation
Oncology*Biology*Physics, 41(3), pp.559-568.

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 References
 Eisbruch, A., Ship, J., Martel, M., Ten Haken, R., Marsh, L., Wolf, G., Esclamado,
R., Bradford, C., Terrell, J., Gebarski, S. and Lichter, A. (1996). Parotid gland
sparing in patients undergoing bilateral head and neck irradiation: Techniques and
early results. International Journal of Radiation Oncology*Biology*Physics, 36(2),
pp.469-480.

 Feller, L. (2012). Oral Squamous Cell Carcinoma: Epidemiology, Clinical

Presentation and Treatment. Journal of Cancer Therapy, 03(04), pp.263-268.

 Huang, S. and O Sullivan, B. (2013). Oral cancer: Current role of radiotherapy and
chemotherapy. Med Oral, pp.e233-e240.

 National Cancer Institute, (2015) Lip and Oral Cavity Cancer Treatment (PDQ®).
Available at: http://www.cancer.gov/cancertopics/pdq/treatment/lip-and-oral-
cavity/Patient/page1 (Accessed: 13 January 2015).

 NHS Trust (Name withheld, 2013) Work instruction, Radiotherapy in Head and
Neck cancer

 Oralcancerfoundation.org, (2015). The Oral Cancer Foundation. [online] Available

at: http://www.oralcancerfoundation.org/ [Accessed 16 Jan. 2015].

References
 Sakanaka, K., Mizowaki, T., Sato, S., Ogura, K. and Hiraoka, M. (2013).
Volumetric-modulated arc therapy vs conventional fixed-field intensity-modulated
radiotherapy in a whole-ventricular irradiation: A planning comparison
study. Medical Dosimetry, 38(2), pp.204-208

 Saw, C., Ayyangar, K., Zhen, W., Yoe-sein, M., Pillai, S. and Enke, C. (2002).
Clinical implementation of intensity-modulated radiation therapy. Medical
Dosimetry, 27(2), pp.161-169.

 Teoh, M., Clark, C., Wood, K., Whitaker, S. and Nisbet, A. (2011). Volumetric
modulated arc therapy: a review of current literature and clinical use in
practice. BJR, 84(1007), pp.967-996.

 Varian.com, (2015). Varian Medical Systems. [online] Available at: http://varian.com

[Accessed 16 Jan. 2015].

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