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Dosimetric Evaluation of Collimator Angles to Reduce Laryngeal Dose in Base of Tongue

Treatment Planning for Volumetric Modulated Arc Therapy
Brianna V. Niemuth BS RT; David A. Ahoobim RT (R)(CT)(T) Haley M. Kroeplin B.S. RT(R)
(T)
Medical Dosimetry Program, University of Wisconsin- La Crosse, La Crosse, Wisconsin

Introduction
Cancers of the head and neck (H&N) region can pose significant challenges when it
comes to radiotherapy treatment. Standard H&N treatments require a higher therapeutic dose of
50-70 Gy to reduce risk of locoregional failure, however limiting dose to adjacent organs at risk
(OAR) is a primary treatment planning concern.1 The H&N region contains multiple OAR, all
with varying levels of radiosensitivity. The challenge is delivering adequate dose to the treatment
volume while still sparing the surrounding normal tissue. Surrounding OAR often receive a
significant amount of dose, which can lead to a multitude of debilitating side effects. Even when
dose constraints are met, such as those listed in the Quantitative Analysis of Normal Tissue
Effects in the Clinic (QUANTEC) report, patients may still suffer from acute or chronic side
effects.2 One such OAR that can cause severe side effects is the larynx. 
Head and neck radiotherapy side effects can affect patients mentally, emotionally, and
physically.  Specifically, toxicities of the larynx can have a profound impact on a patient’s
quality of life.  One of the more prevalent side effects that patients experience during and post
treatment is dysphagia. An estimated 50% of H&N cancer patients will develop some degree of
acute or chronic dysphagia.3,4  Depression, anxiety, social isolation, and malnutrition have all
been linked to radiation induced dysphagia.4,5   The impacts of dysphagia on a patient’s life can
range from percutaneous endoscopic gastrostomy (PEG) tube dependency to life threatening
pneumonia due to dysphagia related aspiration.4,5,6 In order to minimize these associated side
effects, radiotherapy treatment plans should aim to reduce the mean laryngeal dose to under 55
Gy using volumetric modulated arc therapy (VMAT).  Due to the severe impact dysphagia has
on a patient’s quality of life, it is essential to continue investigating ways to reduce the mean
laryngeal dose in radiotherapy treatments. 
The severity of side effects of VMAT radiation, such as dysphagia, could potentially be
diminished with different collimator angles used during treatment.7 Ahn et al7 noted that the
ability to shape the desired dose distribution during optimization and therefore block out OAR
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can be determined by the collimator angle. According to Kim et al8 utilizing various collimator
angles can limit the undesirable interleaf leakage during plan optimization. Often, H&N
treatment fields are long and uneven in shape, making collimator angles even more critical.
Therefore, further research is required to determine if collimator angles can reduce dose to OAR,
specifically the larynx, while still allowing for full dose coverage of the target.
Radiation therapy has the feasibility to provide lifesaving treatment to those diagnosed
with base of tongue (BOT) cancer. By limiting the dose to the larynx using collimator angles, the
side effects patients experience, such as dysphagia, could likely be reduced and their quality of
life could dramatically improve. It is recommended that a mean laryngeal dose less than 55 Gy
be achieved while delivering full dose to the BOT in order to reduce the chance of dysphagia.
The problem is that current VMAT techniques result in higher laryngeal doses that cause
profound side effects such as dysphagia. The purpose of this study is to determine if VMAT
collimator angles of 90° or 0° can further limit the dose to the larynx while still providing full
dose coverage of the treatment volume. The researchers will test the hypothesis (H1A) VMAT
plans with 3 arcs that utilize collimator angles of 30°, 330° and 90° will reduce mean laryngeal
dose for BOT patients. 
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