Clinical Oncology for Medical Dosimetrists

Primary Head and Neck with Lymphadenopathy

Tara L Goffic
University of Wisconsin La Crosse
April 24, 2022
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Introduction

Bud is a 69-year-old disabled veteran who came in for consultation on February 3, 2022.
Unfortunately, he has been diagnosed with squamous cell carcinoma of the anterior two-thirds of
the oral cavity tongue. He presented to urgent care 4 months ago, in October, complaining of
sharp pain in his tongue and ringing in his right ear. A hard mass was noted in the right side of
his tongue, worrisome for malignancy, and an urgent ENT referral was made. The ENT doctor
ordered a punch biopsy and CT scan of the neck. A mass was seen on the CT, measured 3.4 x
2.0 x 2.2 cm and was located in the right side of the tongue. Pathology from the biopsy showed
hemitongue cancer and a PET CT scan was ordered. Results from the PET CT showed a hyper
metabolic mass in the right hemitongue with possible extension into the right lateral pharyngeal
wall and floor of the mouth. There was also a single non enlarged right station III lymph node,
suggestive of regional lymph node metastasis.

Patient underwent surgery in January of this year. Pathology revealed an invasive

squamous cell carcinoma, moderately differentiated, 3.8 cm in size, with 21 mm depth of
invasion, margins uninvolved by dysplasia or carcinoma, though the tumor was 1 mm from the
lateral soft tissue margin. Perineural and lymphovascular space invasion were present, 1 of 22
lymph nodes was involved with metastasis and that lymph node was from the levels 2 and 3
dissection, measured 1.8 cm, and no extranodal extension was present. Stage is III (pT3 N1 M0)
squamous cell carcinoma of the right anterior two-thirds of the tongue, grade 2, moderately
differentiated squamous cell carcinoma of the right oral tongue, anterior two-thirds. Following
NCCN guidelines we recommended adjuvant radiation therapy to the patient's oral cavity and
neck. Dental extractions were done and the patient was sent back to us after 2 weeks of healing.

Simulation

Patient was positioned supine on the S-frame, which is indexed onto the CT table, with a
pad underneath him and his arms by his side. An indexed head holder with a moldable cushion
positions the patients head properly for treatment and provides comfort. Handles were locked
onto the table for the patient to grip. Handles give the patient a place for his hands and can
sometimes relax shoulders out of the treatment field. A large wedge was placed underneath his
knees to decrease discomfort in the lumbar region. Mouth guard with tongue blade was used to
depress the patient's tongue and separate it from the upper mouth. This helps keep the tongue in
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a fixed position for treatment and also gives separation to keep dose away from other areas. An
IMRT thermoplastic mask was warmed and placed over the patient, with mouth guard indexed
into it, then locked onto the S-frame. The mouth guard, moldable cushion and mask are all built
to the patient and are a one-time use. This setup increases stability and reproducibility because it
is patient specific. Scan included the entire head through the carina and the Isocenter was placed
on the anterior edge of the C4 vertebral body.

The patient successfully completed his simulation scan without any issues, but when he
returned for treatment he was unable to use the mouth guard due to the high level of pain it
caused. We rescanned him that day, using a different type of mouth guard that was more pliable.
Unfortunately, this was a new item in our clinic and we were unaware that the mouth guard had a
different density than our previous types. This meant we had to fuse the old scan onto our new
scan, copy the PTV volumes and OAR’s, then start planning from scratch. We called the
manufacturer and verified that the density was 1.5 HU which was the same as what we were
showing on the TPS.

Treatment Recommendations

The Radiation Oncologist held a full PARQ with the patient that included the treatment
planning process, short and long-term side-effects including, but not limited to, decreased
salivary function, temporary loss of taste, thickened saliva during the course of treatment, pain
from radiation induced dermatitis and esophagitis and pharyngitis, long-term complications of
potential swallowing difficulties which rarely can lead to inability to swallow, permanent
damage to the salivary function and a permanent dry mouth, and subsequent risk of changes to
the teeth and gums. He also warned the patient that if something in his mouth were to require
surgical intervention in the future that he could lose the mandible after radiation therapy and
special care will be needed to monitor his oral health. Patient agrees to go forward with the
radiation treatment and keep a close eye on his teeth and gums for any changes. He is aware that
he will see our doctor every Tuesday while he is under treatment, but if there are any significant
changes to his health he can always speak with a therapist and they will follow up with the nurse
or doctor immediately.

Adjuvant radiation therapy was recommended, per NCCN guidelines, but the patient
declined chemotherapy and would only agree to RT. We are planning to treat the oral tongue
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and right neck to 60 Gy in 30 treatment fractions and also treat the left neck and supraclavicular
fossa to a lower dose per fraction, giving at least 54 Gy in 30 treatment fractions. Patient will
possibly have a conedown, to boost the area of close margin, to a total of 66 Gy in 33 treatment
fractions total. VMAT treatment planning and daily image guidance is medically necessary due
to multiple close critical structures. This is a standard regimen to treat microscopic disease post
operatively.

Tumors in the head-and-neck region represent an example in which IMRT has replaced
3D conformal techniques for the most part. This includes tumors arising in the oral cavity, the
nasopharynx, and the oropharynx. These tumors are often inoperable and are close to a variety of
radiosensitive structures. These include the saliva secreting glands as well as structures related to
swallowing and speech. Thus, radiotherapy to cancers of the head and neck is associated with
acute und long-term side effects that seriously impact quality of life. Examples of these side
effects are mouth dryness, dental decay, and swallowing dysfunction. IMRT allows for sparing
of the parotid glands and carefully distributing dose in normal tissues. Furthermore, IMRT
allows for complex dose prescriptions that are standard of care today. Nowadays, treatment
protocols often use three dose levels, in which 70 Gy is delivered to the gross tumor volume
(GTV), 60 Gy to high-risk lymph nodes, and 54 Gy to low-risk nodal stations. This type of dose
painting approach would be very difficult to Figure 1. Oropharynx
mimic using forward planning techniques
and 3D conformal radiotherapy.4

To demonstrate anatomical
boundaries, this image shows the location of
the base of the tongue within the
oropharynx. The oropharynx is divided into
the following sites: base of the tongue,
tonsillar region, soft palate, and pharyngeal
walls.2
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The table shown below lists the planning goals that were used with this patient.

Figure 2. Providence Medford Medical Center, Planning Goals

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Critical Structures

Per our MD – Parotid glands, salivary glands, maxilla and mandible, esophagus, as well
as the posterior pharyngeal constrictions and spinal cord are critical structures that need to be
contoured to track the doses. The following image shows our clinical goals. We were unable to
reach three of them. The mouth is the area that we are treating so we are unable to meet that
goal, and the left submandibular is too close to the target to keep under 36 Gy.
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Lymph Nodes

The base of the tongue is bounded anteriorly by the circumvallate papillae, laterally by
the glossotonsillar sulci and the glossopharyngeal sulci posteriorly. Inferiorly, the base of tongue
region encompasses the vallecula and is bounded by the superior surface of the hyoid bone.6 Our
patient only had one positive lymph node that was removed during surgery. The fact that he had
a positive node puts him at higher risk for recurrence and that is why we treat the opposing side
lymph nodes also. The images on this page are from the online program IMAIOS and are a good
reference for lymph nodes of concern when treating the base of the tongue.

Figure 3
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The following images show

the lymph nodes that we are treating
on our patient. Lymphatic drainage
from the base of the tongue goes into
the jugulodigastric, low cervical, and
retropharyngeal nodes.1 Luckily, our
patient only had one positive lymph
node on his right side, at level III,
which was removed surgically.
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The isodose distribution on our patient clearly shows that we are treating the right side
nodal region to a higher dose, 6000 cGy, than the left side nodal region. The area shown in
yellow is the 100% isodose line. The pink isodose distribution is 5400 cGy and includes the left
side.
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Radiation Treatment Technique

The main risk factor for H&N cancer remains current or past tobacco use. Concurrent
alcohol use significantly augments the risk. H&N cancer patients have often decreased or already
quit smoking by the time they are seen by their healthcare team. However, relapse back to
smoking remains high. Strong recommendations for quitting and remaining quit are essential to
help improve treatment outcomes, and most healthcare providers are good at asking and
providing this advice.3 Before starting any patient with a course of radiation therapy, we make
sure they are invested in their own health. We offer smoking cessation classes and guidance
towards a healthier lifestyle.

Head and necks are usually planned with IMRT. We used VMAT for our patient, which
is a type of IMRT that rotates around the patient while delivering dose. In order to get the best
coverage of the target and spare our critical organs from high dose used three arcs. Beam 04 is a
clockwise arc with the collimator at 30°. This beam starts at 185°, ends at 175°, and has 89
segments to deliver a total of 121.16 MU/fx. Beam 05 is a counterclockwise arc with the
collimator set at 330°. This beam starts at 175°, ends at 185°, and has 89 segments to deliver a
total of 174.20 MU/fx. Beam 06 is the final beam in this plan and has a collimator set for 90°.
By using a 90° collimator we have more options for blocking dose to the spinal cord and other
OARS. This is a clockwise arc that starts at 190°, ends at 170°, and has 86 segments to deliver a
total of 205.53 MU/fx. The patient couch is set at 0.0° for all three arcs. The therapists will
obtain a CBCT before each treatment which allows the doctor and therapists to verify patient
position before beaming on.

Beam Details
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Beam 04 Details

Beam 05 Details
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Beam 06 Details
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The DVH below shows the amount of dose per volume that each target is receiving.
We have good coverage of our CTV. The DVH shows that 99% of the volume of the CTV is
receiving at least 5965 cGy or greater. The Supraclavicular nodes are receiving at least 5375
cGy to 99% of the volume. Our PTV 5400 has 99% coverage of the volume to at least 5325 cGy
or greater and the CTV Neck Nodes have 99% of the volume covered by at least 5387 cGy.
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The DVH below shows the amount of dose per volume that each OAR is receiving. The
most important organ of interest is the spinal cord. The spinal cord is a serial organ and
exceeding the dose to this organ can cause paralysis in the patient.
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Conclusion

We have a good treatment plan built and are ready to begin treatment on our patient.
This has been a difficult road due to some communication issues with other clinics and
appointments. At one point in time Bud wanted to quit and refuse treatment, but we have offered
him some extra support with gas cards and meal tickets so he has resources available to him. We
also had to rescan him at the last minute because his mouth guard was too painful, so I had to
replace all my images within this paper. Such a tedious process, but it shows the quality of our
treatment plan.
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References

1. Washington C, Leaver D, Trad M. Head and Neck Cancers. In: Lozano R. Washington and
Leaver’s Principles and Practices of Radiation Therapy. 5th ed. St. Louis, MO. Elsevier;
2021:571-612.

2. Vann A. Oropharynx. [SoftChalk]. La Crosse, WI: UW-L Medical Dosimetry Program; 2022

3. Khan F, Gibbon J, Sperduto P. Khan's Treatment Planning in Radiation Oncology. 4th ed.
Wolters Kluwer, 2016

4. Khan F, Gibbon J, Sperduto P. The Rational for IMRT: Concave Target Volumes. In:
Unkelbach J,ed. Khan's Treatment Planning in Radiation Oncology. 4th ed. Philadelphia, PA.
Wolters Kluwer Health; 2016:123-125

5. Figure 3: IMAIOS. https://www.imaios.com/en/e-Anatomy/Head-and-Neck/Head-and-neck-

CT. Accessed April 22, 2022.

6. Chao, K. S., C. et al. Radiation Oncology Management Decisions. Available from: Wolters
Kluwer, (4th Edition). Wolters Kluwer Health, 2018.