Clinical Oncology Assignment

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Primary Head and Neck with Lymph Nodes
Head and neck cancers are one of the more difficult cancers to treat due to these
tumors being proximal to so many critical structures. The patient whose treatment plan
will be reviewed here, was diagnosed with a primary neoplasm of the base of the
tongue. The cell histology showed this tumor is a squamous cell carcinoma, poorly
differentiated, 4 cm at the largest point. The secondary diagnosis is an unspecified
malignant neoplasm of the head and neck. This patient is “p16+” which shows an
improved chance of survival and he is also positive for HPV. There is a different staging
method for HPV positive patients. This primary tumor was deemed a stage 3 cancer
meaning that it is larger than 4 cm or is growing into the epiglottis/base of tongue, or the
larynx, tongue muscle, or nearby bones.1,2 The physician included in the staging the
nocal stage, N2c, which mean that the cancer has spread to at least one lymph node on
both sides of the neck (none longer than 6 cm). The classification of M0 was also
included in the patient note indicating that there were no distant metastases.1,2

Patient Setup
For treatment simulation, the patient was set up with a Qfix headrest and couch
board. Connected to this, we used a custom thermoplastic mask with a bite block to
separate the lips and maintain proper jaw and tongue placement. The patient was also
laid on a pad to keep his legs and hips in proper alignment. There were hand grips
used, indexed on the table, for the patient to hold onto. Using these grips keeps the
patient's shoulders, neck, torso, and arms fixated and also provides the patient with a
more comfortable lying position. They also make sure that the patient's arms and
shoulders remain out of the treatment area to minimize unnecessary dose. The patient's
knees were supported with a foam positioner and their toes were banded. Both of these
positioning devices allow the patient to completely relax without needing to hold their
legs from falling to the side or off the table. Below, there are images of similar
fixation/positioning devices to that which were used in this treatment plan (Figure 1). All
of these fixation devices are used to provide a reproducible, safe, and accurate patient
setup and to make the patient as comfortable as possible.
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Figure 1: Qfix positioning devices. Alta Multipurpose device with thermoplastic mask,
foot ring, and knee supports.3

Primary Target Dose Regimen

The target dose, to the primary CTV, prescribed by the physician is 70Gy, or
7000cGy. This is delivered in daily increments of 2 Gy, or 200cGy, and will take 35
fractions to complete the treatment course. The prescription to the secondary CTV
(nodes), is 56Gy, or 5600cGy. This will be delivered in the same 35 fractions, but only
1.6Gy, or 160cGy per day. This treatment regimen is based on the standard
chemo-radiotherapy treatment method where 70Gy is delivered in 35 fractions to the
patient every day for seven weeks.4 The standard, low-dose nodal treatment is 56Gy
delivered in 35 fractions in seven weeks. Comparatively, some research suggests that
hyperfractionated treatment regimens are most effective for treating head and neck
cancers. This method, called HARDWINS accelerated radiotherapy delivers 64Gy in 40
fractions over four weeks but the patients receive two treatments per day. The radiation
oncologists at my clinical site agree that this accelerated method may be more effective
at killing cancer cells, but that it causes more severe reactions and side effects, often
requiring patients to take extended breaks from treatment, which is actually
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counterproductive.5 For this reason, we use the standard fractionation regimen to

minimize side effects for patients and keep them under treatment without delay.

Avoidance Structures
Below I have included a chart based on a script we use in our TPS, called
ClearCheck (Figure 2). This script allows the organs-at-risk dose data to be read, and
more easily visualized, for analysis. The dose constraints we used for this head and
neck treatment are based on the RTOG 0522 research trial on stage 3 and stage 4
head and neck squamous cell carcinomas.6 All of the structures listed were contoured
on the patient. Additional structures which were contoured on the patient include the left
and right cochleas, the skin, and a structure called “spinal cord + 0.5” which is a half
centimeter margin on the spinal cord, in all directions. The spinal cord constraint and the
skin contours are used by the physics department to analyze the treatment plan. The
cochlea contours are used to monitor their dose, because we refer any patient with a
cochlea dose greater than 45Gy to the audiologist for evaluation. This plan met all the
necessary requirements for the primary and nodal CTVs. It also met most other
constraints. The right brachial plexus, oral cavity, and larynx constraints did not meet.
This was approved by the physicists and physicians because to treat the tumor volume
properly, there was not another option. We must also consider that a structure like the
oral cavity will never meet the typical dose constraint when the tumor volume is in the
same location. Both the larynx and the right and left brachial plexus were found inside
the supraclavicular treatment field. The larger right neck nodule requires more dose to
treat it, therefore the right side did have a harder time meeting constraints.

When speaking to the physicians and physicists about this plan, and the factors
they consider when evaluating it, there seemed to be a common sentiment. They all told
me that you must always protect the patient from any unnecessary exposure. In this
particular case, the tumor volume must be treated to rid the patient of cancer and bring
them back to good health. It is a more favorable option to exceed some of the
structures, at risk of side effects, to get rid of the cancer. We also spoke about why they
did not alter the dose to meet the constraints. They explained that the treatment
regimen, the patient is on, is quite effective. Lowering the dose could help us meet a
couple more constraints, but it increases the chance that the cancer could recur. If this
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were to happen, there is not much you can do since the area has already been treated.
For this reason, they approved the most effective treatment plan possible.

Critical Structure/Organ at Desired Planning Planning Objective Met or Not Met?

Risk (OAR) Objective Outcome (Y/N)
CTV (Primary) D95%≥100-98% 100% Y
CTV (Nodes-Primary) D95%≥100-98% 100.52% Y
Right Brachial Plexus D5%≤ 6000 𝑐𝐺𝑦 6018.8 cGy N
Left Brachial Plexus D5%≤ 6000 𝑐𝐺𝑦 5244.1cGy Y
Parotids D20cc≤ 2000 cGy 1962.6 cGy Y
Oral Cavity D50%≤ 3000 𝑐𝐺𝑦 7030.9 cGy N
Spinal Cord Max ≤ 4500 𝑐𝐺𝑦 4085.2 cGy Y
Mandible D50% ≤ 5000 𝑐𝐺𝑦 4621.8 cGy Y
Larynx Mean ≤ 4500 𝑐𝐺𝑦 5926.3 cGy N
Pharyngeal Constrictor D90%≤ 4000 𝑐𝐺𝑦 2933.6 cGy Y
Right Lung D20% ≤ 3000 𝑐𝐺𝑦 258 cGy Y
Left Lung D20% ≤ 3000 𝑐𝐺𝑦 516.6 cGy Y
Esophagus Mean ≤ 3400 𝑐𝐺𝑦 1437.3 cGy Y

Figure 2: Dose constraints and outcomes from H&N treatment plan based on RTOG
0522 research trial .6

Involved Lymph Nodes

For this head neck treatment plan, the physician had ordered that a PET scan be
fused with the CT scan for tumor and nodal localization. We included level one through
level five of the cervical lymph node chains and the supraclavicular nodes. There were
areas that were PET positive, so we included the areas which showed metabolic
activity. These nodal chains are also known to be areas of spread for H&N cancers so
we include them as a precautionary measure. Below, in figure 3, I have included images
of the nodal CTV (pink) and PTV (green). The nodal PTV did not include the primary
PTV, and any areas of overlap were removed. This ensures that the primary CTV
receives the full 70Gy and the nodes receive 56Gy. One interesting thing that my clinical
preceptor explained to me was that they used to draw each group of lymph nodes
separately and then combine them into one CTV. They did this to more specifically
monitor the dose that each group received, but they determined that it was a very
inefficient way to make head and neck plans. The lymph node chains that we included
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in this plan were intended to receive 56Gy, based upon the standard fractionation
regimen.4 This planning objective was met.

Figure 3: Involved lymph node chains from H&N treatment plan.

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Anatomical Field Boundaries

It is important to have clearly defined field boundaries when planning and treating
with radiation therapy. This ensures that you are not treating too much healthy tissue,
but you are getting proper coverage of the areas that need to be treated. When head
and neck cancers were treated with 3D conformal fields, it was much easier to define
the field boundaries. They were usually treated with lateral and anterior ports which had
blocks. With the introduction of IMRT and MLCs, the arcs have a different field size
constantly. We still limit what areas are treated by what we include in our CTV/PTV. For
this treatment plan, the superior border was the hard palate and the middle of C1
vertebra. The medial portion of the field was bordered posteriorly by the vertebral
bodies, while the lateral portions of the head and neck field went as far posteriorly as
the spinous processes. Inferiorly, the treatment field was bordered by the clavicle. The
anterior border of the field was in front of the tumor volume up to the included margin.
As seen in figure 4, there is not a very definite field boundary because of the IMRT
treatment method, but these general boundaries are sufficient for explanation.

Figure 4: Field boundaries (with CTV/PTV) from axial, sagittal, coronal, and BEV
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Treatment Technique: VMAT

This treatment plan was set up using volumetric modulated arc therapy, or
VMAT. This is a technique that is similar to IMRT, but allows the simultaneous
variation of dose rate, gantry speed, and aperture shape during the treatment.7,8
This provides superior dose conformality leading to increased tumor volume
coverage and sparing of normal tissues. For this plan, we used two, 6 MV
beams. The first arc rotated around the patient from 195 degrees to 155 degrees,
clockwise. The second arc rotated from 155 degrees to 195 degrees in the
counterclockwise direction. By avoiding the area between 155 and 195, in the
posterior, it provided better protection for the spinal cord since we do not treat
straight through it. The first arc had a collimator rotation of 20 degrees and the
second had 340-degree rotation (both 20 degrees off from 0). This allows the
MLCs to most accurately follow the intricate contours of the PTV. In this particular
plan, we did not feel that using couch rotations were necessary, so the couch
remained at zero degrees for both arcs. Figure 5 shows the arc geometry in the
axial, sagittal, and coronal views as well as the field and MLC shape from the
BEV.

Figure 5: Treatment plan demonstrating the arc geometry and MLC modulation/shaping
around PTV.
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Treatment Plan DVH

The dose volume histogram (DVH) is another way that we are able to evaluate
our treatment plan, by getting data on the dose received by each structure. The DVH
gives the dose received, related to the volume of a specific structure that received the
dose. For instance, we have normalized the primary and nodal CTVs, where 95 percent
of the structure (volume) receives 100 percent of the dose. Seen in figure 6, the “CTV
(Primary)” line intersects where 100 percent of the prescribed dose, 7000cGy, and 95
percent of the structure volume meet. This helps us visualize that the target meets the
set goal for treatment. We can see each structure on the DVH, so this helps us evaluate
the plan for safety, and effectiveness. All of the data that is displayed in the DVH is what
we see in the ClearCheck document mentioned previously. By observing this data, we
can compare the dose received to the dose constraints and determine if the plan is
safe. In some cases, like this one, some structures are found within the treatment field,
and do not meet the dose constraints. It is then the decision of the physician, whether or
not to proceed with the treatment. The DVH allows us to see by how much the dose
constraint was exceeded and provides the doctor with information about what side
effects may occur. This is important as this information is used to inform and prepare the
patient for what to expect during their course of treatment. The DVH is a critical tool for
planning and evaluation.
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Figure 6: Treatment plan dose volume histogram (DVH) used for target and OAR dose
analysis.

Conclusion
This head and neck patient was one of the first that I have been exposed to in
such detail. By doing more research about the patient’s diagnosis, simulation setup,
treatment dose and method, and dose constraints, I have a better grasp on the
complexity of these treatment plans. Each step, from the types of positioning devices, to
the method used for optimization, affects the treatment plan accuracy and can change
the outcome of the treatment course. I also understand how to properly evaluate these
plans as I am working on them. I look forward to using this knowledge as I move
forward, creating more of these treatment plans in the future, and applying it to my skills
as a dosimetrist.
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References

1. Oral cavity and oropharyngeal cancer stages. American Cancer Society.

https://www.cancer.org/cancer/oral-cavity-and-oropharyngeal-cancer/detection-di
agnosis-staging/staging.html. Accessed April 27, 2023.
2. Oral and oropharyngeal cancer - stages and grades. Cancer.Net.
https://www.cancer.net/cancer-types/oral-and-oropharyngeal-cancer/stages-and-
grades. Published April 10, 2023. Accessed April 27, 2023.
3. Qfix. Alta Multipurpose Device Brochure. 2022.
4. PMH Clinical Practice Guidelines template - uhn. University Health Network.
https://www.uhn.ca/PrincessMargaret/Health_Professionals/Programs_Departme
nts/Documents/CPG_HeadNeck_Hypopharynx.pdf. Published July 2019.
Accessed April 27, 2023.
5. Budach W, Hehr T, Budach V, Belka C, Dietz K. A meta-analysis of
hyperfractionated and accelerated radiotherapy and combined chemotherapy
and radiotherapy regimens in unresected locally advanced squamous cell
carcinoma of the head and neck. BMC Cancer. 2006;6(1).
doi:10.1186/1471-2407-6-28
6. Ang KK, Zhang Q, Rosenthal DI, et al. Randomized phase III trial of concurrent
accelerated radiation plus cisplatin with or without cetuximab for stage III to IV
head and neck carcinoma: RTOG 0522. J Clin Oncol. 2014;32(27):2940-2950.
doi:10.1200/JCO.2013.53.5633
7. Teoh M, Clark CH, Wood K, Whitaker S, Nisbet A. Volumetric modulated arc
therapy: a review of current literature and clinical use in practice. Br J Radiol.
2011;84(1007):967-996. doi:10.1259/bjr/22373346
8. Khan FM, Gibbons JP. The Physics of Radiation Therapy. 6th Philadelphia, PA:
Lippincott, Williams & Wilkins; 2020