Working Title:

Utilizing skin rind contours to assess tissue loss along the beam path in patients undergoing head and
neck proton therapy

Literature Review:

Malnutrition is an ongoing issue for patients diagnosed with head and neck cancers. Decreased
caloric and water intake, difficulties regarding recovery of invasive procedures, side effects from treatment
and the increased caloric usage from the body's natural healing process are all factors that attribute to
malnutrition. Although malnutrition in the management of head and neck cancers is well known and
1

regulated, approximately 88% of patients still experience some level of taxing side effects. Research has
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been conducted on the best ways to prevent malnutrition in head and neck cancer patients but, as of recent,
there is not a definitive answer to this problem. Along with increasing recovery times and causing long
term harm or death to a patient, malnutrition affects the delivery of radiation therapy as well.
Intensity Modulated Radiation Therapy (IMRT) has become the gold standard of radiation
treatment for patients with head and neck treatment. IMRT handles very sharp dose gradients which rely
on a reproducible tissue volume for the beam to pass through. It has been shown that changes in those
tissue volumes could shift the steep dose gradients away from the target volumes leading to unintended
dosimetric consequences. With treatments volumes getting more conformal and total dosing of radiation
3

therapy treatment increasing, it is paramount importance that the dose is accurately delivered.
Studies have tried to address these issues with tissue changes during a patient’s course of IMRT
by introducing adaptive therapy. Adaptive therapy address the changing tissue from malnutrition and
treatment side effects. Research in adaptive planning has shown that is very effective at sparing dose
4

limiting organs at risk (OAR) and preventing overdosing of target volumes but it is not as effective at
limiting typical side effects like decreased salivary output. Adaptive planning offers physicians the ability
4

to continuously deliver accurate doses of radiation to their patients throughout an entire course of
treatment. The question now is when is adaptive planning necessary in the treatment process?
Studies have attempted to define the best method of determination of adaptive planning, but more
research is needed. Methods such as set amount of weight loss, set periods for replanning, in depth
analysis of daily Image Guided Radiation Therapy (IGRT) scans and image registrations have been used
in the determination of adaptive radiotherapy. These methods range from inaccurate at the worse to time
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and labor intensive at the best. It is for these reasons that we wanted to discover if we could create a
method of determining when adaptive planning was necessary using a method that is accurate, fast and
non-labor intensive.
We believe that the creation of skin rind contours will give therapists, physicians and physicists
the ability to determine daily if the patient needs adaptive planning. Researching the relevant clinical data
for skin rind analysis is of paramount importance if this method will be useful in the clinical setting. This
study will be focused on finding what amount of tissue loss inside of the 20% isodose lines leads to a
deviation in treatment delivery. Utilizing that data, we can then start to build recommended skin rind
analysis settings for daily use on the treatment machine. This method could save the patient from
superfluous appointments and unnecessary extra doses from CT planning scans. Utilizing this method on
the daily IGRT images allows for a continuous monitoring of the treatment volume throughout treatment
and thus an accurate portrayal of when adaptive planning is necessary.

Problem Statement:

There is a lack of guiding indicators to alert the need of adaptive planning due to external tissue loss in
patients treated for head and neck cancer with proton therapy.

Purpose Statement:
The purpose of this study is to determine if a skin contour can be an effective determinant of external
tissue loss leading to clinically significant plan deviations and replanning for head and neck proton
radiotherapy.

Hypothesis Statements:

H1a: Tissue loss within the 20% isodose line will decrease PTV coverage by ≥5% compared to the initial
plan.

H1a0: Tissue loss within the 20% isodose line will not decrease PTV coverage by ≥5% compared to the
initial plan.

H2a: Tissue loss within the 20% isodose line will create a 0.03cc maximum plan dose deviation of ≥5%
compared to the initial plan.

H2a0: Tissue loss within the 20% isodose line will not create 0.03cc maximum plan dose deviations of
≥5% compared to the initial plan.

H3a: A volume of external tissue change inside of 3.0mm depth will produce a deviation of ≥5% in PTV
coverage compared to the initial plan.

H3a0: A volume of external tissue change inside of 3.0mm depth will not produce a deviation of ≥5% in
PTV coverage compared to the initial plan.

H4a: A volume of external tissue change inside of 3.0mm depth will produce a deviation of ≥5% in
0.03cc maximum plan dose compared to the initial plan.

H4a0: A volume of external tissue change inside of 3.0mm depth will not produce a deviation of ≥5% in
0.03cc maximum plan dose compared to the initial plan.

H5a: A volume of external tissue change inside of 5.0mm will produce a deviation of ≥5% in PTV
coverage compared to the initial plan.

H5a0: A volume of external tissue change inside of 5.0mm will not produce a deviation of ≥5% in PTV
coverage compared to the initial plan.

H6a: A volume of external tissue change inside of 5.0mm will produce a deviation of ≥5% in 0.03cc
maximum plan dose compared to the initial plan.

H6a0: A volume of external tissue change inside of 5.0mm will not produce a deviation of ≥5% in 0.03cc
maximum plan dose compared to the initial plan.

Summary:

Current research has shown that malnutrition and tissue changes can have large impacts on the
delivery of therapeutic radiation to patients with head and neck cancer. Adaptive planning is very
prevalent in modern therapy to help ensure physicians are delivering accurate dose to patients. The
problem is that there is a lack of guiding indicators to alert for the need of adaptive planning because of
anatomy changes. We believe that the addition of skin rind contours to the daily imaging scans will give
the treatment team the ability to accurately determine if adaptive planning is necessary without delivering
extra, unnecessary, dose to a patient. Our research will study previously treated patient data sets to
analyze what amount of tissue loss inside of the 3mm and 5mm rind led to a clinically significant change
in dose delivery. Utilization of the 20% isodose line will create a stable metric between patients, no
matter the beam design and weighting. We will be investigating the percentage of target loss coverage at
the prescription isodose line as well as the increase to the hot spot of the treatment plan. Our intention is
to determine a relevant amount of tissue that falls below the 3mm and 5mm lines of external tissue
change so that this can start to be used clinically during image analysis. This method will be more
effective at determining the need to adaptive planning compared to other methods such as monitoring
weight loss. Many patients may experience weight loss, but if their external tissue does not change inside
of the beam path, there may be no deviation to the plan and no need for adaptive planning. Our study will
give concrete, statistical, data on external tissue changes leading to dose deviation that cannot be
determined without a total re-scan and re-plan. That data can then be adapted to skin rind contours that
would then be used daily by the treatment staff to actively monitor external tissue loss leading to a more
accurate adaptive planning schedule in a proton department. Our intention with this method is for it to
serve as a guiding indicator of adaptive planning that has the ability save the patient time, money and
extra, superfluous, dose from unnecessary CT scans.

References

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doi:10.1080/01635581.2017.1367943
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