Ciara Russell

03/07/21

Clinical Oncology Assignment

Introduction & Diagnosis

The patient that my assignment is focused on is a 61-year-old male who presented with a
slowly enlarging mass in the right side of the neck. This patient was found to have oropharyngeal
cancer, specifically in the base of tongue with metastasis to the right neck. Ultrasound revealed a
3.8 x 2.8 cm mass in the right level 3 zone of the neck and a 2.5 x 1.2 cm mass in the right level
2 zone. CT revealed a 1.7 cm enhancing mass in the right pre-epiglottic region with displacement
of the epiglottis to the left. CT also revealed several level 2 and 3 enlarged lymph nodes.
PET/CT revealed a hypermetabolic mass in the right pre-epiglottic space obliterating the right
vallecula measuring 1.7 x 1.8 cm, and another hypermetabolic level 2 lymph node measuring 3.6
x 3.4 cm. The pathology was found to be HPV mediated squamous cell carcinoma, clinical stage
I disease. The 8th edition American Joint Committee on Cancer clinical and pathological staging
system introduced a separate staging system for HPV- associated oropharyngeal cancers.1 This
new staging system eliminated stage IV disease (with the exception of distant metastasis),
significantly changing the overall TNM stage grouping.1 It was decided that the treatment plan
for the patient would be to receive external beam radiation therapy with concurrent
chemotherapy. It has been confirmed by research that patients with HPV associated disease have
higher response rates after chemoradiation treatment, leading to a lower risk of progression.1

Simulation and Patient Set-up

For CT simulation, the patient was in the supine position with a thermoplastic head and
neck mask, head holder, knee cushion, and a black strap holding his arms down. The purpose of
the thermoplastic head and neck mask is to immobilize his head, neck, and shoulders so that they
are in the same position each treatment. The strap holding his arms down is used to keep his
arms at his side and his shoulders down and out of the field, although his shoulders did not end
up being down far enough during the simulation. The knee cushion and head holder are used to
help with patient comfortability. These positioning devices and accessories help to make a
reproducible set-up for daily treatments.

Target Doses and Fractionation

For external beam radiation therapy, the physician chose to treat the patient to a total dose
of 7000 cGy in 35 fractions. The physician contoured three PTV’s, each with a different dose, to
be treated simultaneously. PTV 1, the high-risk volume, was to be treated to 7000 cGy at 200
cGy per day. PTV 2, the intermediate volume, was to be treated to 5940 cGy at 169.7 cGy per
day. PTV 3, the low risk volume, was to be treated to a total of 5400 cGy, at 154.3 cGy per day.
The physician decided to use this dose and fractionation based on current research which
recommends that for definitive cases, three volumes should be treated. The gross tumor volume,
including primary tumor and involved regional lymph nodes should be treated to 70 Gy, while
both the primary tumor site and involved levels of the ipsilateral neck be treated to 60 Gy.2 A
low risk tumor volume, which includes the uninvolved and non-surgically violated ipsilateral
neck, can be treated to 50-54 Gy.2

Avoidance Structures
Specific avoidance structures that were contoured for this patient were the brain, brainstem, the
right and left cochlea, the constrictors, esophagus, larynx, spinal cord, both parotids and a
bilateral parotid contour. Below are screenshots of the contoured targets and organs at risk in
each viewing plane.
Below is a table of organ at risk tolerance doses based on the physician’s prescription and the
associated QUANTEC values. 

Brain D0.03cc [Gy] <=60 Constrictors Mean [Gy] <=50

Brainstem D0.03cc [Gy] <=54 Larynx D0.03cc [Gy] <=66
Cochlea L Mean [Gy] <=45 Larynx V50Gy [%] <=27
Cochlea R Mean [Gy] <=45 Larynx Mean [Gy] <=44
Esophagus Mean [Gy] <=34 Spinal Cord D0.03cc [Gy] <=50
Esophagus V35Gy [%] <=50 Parotid Bi Mean [Gy] <=25
Esophagus V50Gy [%] <=40 Parotid L Mean [Gy] <=20
Esophagus V70Gy [%] <=20 Parotid R Mean [Gy] <=20

Lymph Node Regions

The patient treatment volumes included the neck lymph node levels IB, II, III, IV, and the lateral
retropharyngeal nodes. Level IB lymph nodes are the submandibular nodes, level II contain the
upper jugular nodes, level III contain the middle jugular nodes, and level IV contains the lower
jugular nodes. The patient had several enlarged level II and III lymph nodes. CTV 2 includes the
involved levels (II-IV) of the ipsilateral neck, and the lateral retropharyngeal nodes.2 The CTV 3
low risk volume should include contralateral uninvolved levels II-IV or II-V.1 Below are screen
shots of labeled lymph node levels on the patient CT, with the target contours. The red contour is
PTV 1, the orange contour is PTV 2, and the green contour is PTV 3.
Anatomy
Below are screen shots of the patient’s CT data to point out the anatomical boundaries of the
treatment volumes.

The anatomical boundary anteriorly is defined by the maxillary sinuses and the mandible. The
posterior anatomical boundary is marked by the vertebral bodies. The inferior anatomical
boundary is the clavicle, and the superior anatomical boundary is the temporal bone. The lateral
treatment volumes include the bilateral neck.

Treatment Technique
The treatment technique that was used for this patient’s treatment plan was VMAT. It included
three arcs with an energy of 6MV and did not contain any wedges or couch rotations. Arc 1
rotated from the 200 degree angle to the 90 degree angle and had a collimator rotation of 345
degrees. The second arc started at the 160 degree angle and ended at the 270 degree angle. It had
a collimator rotation of 15 degrees. Arc 3 rotated from the 270 degree angle to the 90 degree
angle with a collimator rotation of 90 degrees. These arc rotations were chosen to give the
majority of dose both anteriorly and laterally, and to spare normal tissues and the spinal cord
posteriorly. Arc 1 had a weighting of 1.332, while arc 2 had a weighting of 1.143 and arc 3 had a
weighting of 0.752. The first arc was weighted more because PTV 1 and 2 were more right sided.
The patient was large, and his shoulders were not pulled down as much as they could have been.
The collimator angles were designed to include the target, while avoiding the shoulders. The
dynamic MLC pattern was altered so that the MLC’s would close when the beam was entering
through the shoulder.
DVH Analysis
All organ at risk tolerance QUANTEC constraints were met. The target volumes were able to
easily meet the prescription coverage constraint. The plan was normalized so that the 100%
isodose line covered 97% of the target volume. Below is the final DVH for the treatment plan.

Conclusion
In conclusion, this was a great treatment plan for the patient. Every organ at risk tolerance
constraint, and target dose constraint was able to be met. It was interesting and informative to
research and understand the reasoning and decisions that go into both the target dose and
simulation.
References
1. Chao KSC, Perez CA, Wang TJC. Radiation Oncology: Management Decisions. 4th ed.
Philadelphia: Wolters Kluwer; 2019: 297-301.
2. Patel SH, Xu AJ, Sine K, Lee NY, Fox P. Oropharyngeal Cancer. Practical Guides in Radiation Oncology.
2017:131-139. https://link.springer.com/chapter/10.1007/978-3-319-42478-1_6. Accessed February 20,
2021. doi:10.1007/978-3-319-42478-1_6.