Seth Cox

DOS 531
2/26/2017
Head and Neck Assignment
Professor Vann

Group 5:Hypopharynx

Patient presented with malignant neoplasm of overlapping

sites of hypopharynx (T3N2bMO) squamous cell carcinoma
arising from the right hypopharynx.

After identifying a specific case answer the following questions:

1. How was this patient positioned? What positioning
devices/accessories were used, how and why? (5 points)
Patient was placed on the table in a head in supine position on a
neutral headrest. An aquaplast face and shoulder mask was made
to aide in patient immobilization and treatment reproducibility.
Patients arms were folded and resting on abdomen, red knee
sponge was placed under patients legs.

2. What specific avoidance structures were contoured? What

is their tolerance dose? (20 points)

Avoidance structures that were contoured included (Quantec and

RTOG protocol requirements):
Left and right brachial plexus 66 Gy max dose
Brain V12 Gy < 5-10 cc
Brain Stem 54 Gy max dose
Esophagus Mean dose less than 45 Gy
Left and right eyes Max dose less than 50 Gy
Glottic Larynx Mean dose less than 45 Gy
Larynx Mean < 44 Gy Max 63-66 Gy when risk of tumor is limited
Left and right lens Max dose 7 Gy
Lips Mean < 20 Gy for non-oral cavity
Mandible 70 Gy, if not possible then no more than 1 CC to exceed
75 Gy
Optic Chiasm 50 Gy max dose
Left and right Optic Nerve 50 Gy max dose
Oral Cavity Mean dose less than 40 Gy
Left and right Parotid Mean dose of < 26 Gy in at least one gland
or at least 20 CC of combined volume of both will receive < 20 Gy
or at least 50% of one gland will receive < 30 Gy
Spinal Cord 45 Gy max dose
3. What are the anatomical boundaries of the tumor
volume? You should use Radiotherap-e
(http://www.radiotherap-e.com) and other anatomy
references to help you describe this. You can use a
diagram and screen shots of your CT data to point out the
boundaries. (20 points)

With nodal involvement, patient will need to have level II-V and
retropharyngeal nodes treated. The superior border is the skull
base and the inferior border is 1cm below the inferior extent of
the disease. 1

With the shape of the disease and treatment area, a 0.5cm

margin was put around the GTV (the red on the above picture)
giving us a PTV in green.

When including the nodes in the treatment field, the margin

changes:

The dark blue is our treatment area for the nodes within the
neck, as identified within RadioTherap-e while levels two and
three are the only nodal involvements found, we must treat to
level five nodes. 1

4. Are lymph nodes included in the treatment area? If so can

you identify the level nodes use a diagram and screen
 shots to help you label the nodal regions treated. (20
points)

Yes, patient had nodal involved in right level II (upper jugular) and
level III (midjugular) nodes. Involvement was great, as the normal
fat plane between level II nodal group and sternocleidomastoid
muscle group was lost.2

5. What radiation technique is used to treat this patient?

Describe in detail the technique (35 points)

There are two high quality of arc based therapies, tomotherapy

and volumetric modulated arc therapy.3 99% of our treatments
for IMRT are done on our tomotherapy machine as it allows for
image guided radiation therapy, because it is best for with
surrounding normal tissue tolerance is lower than that of the
prescribed radiation dose for the tumor volume.4

Yet, it does not do a good job of allowing for an explanation of

beams, angles and collimators, so we created a plan on our
trilogy linac in order to create a greater understanding of the
needs and the techniques to properly treat this patient.

First, we utilized four 6x-IMRT beams, with four arcs, Two arcs
went in a clockwise motion, two arcs went in the counter-
clockwise rotation.

There were no couch rotations, but, there were gantry rotations

and collimator rotations we needed to use in order to get the
coverage needed and avoid the areas within the hypopharynx
and stay within our tolerance of organs to avoid. Going from 181
to 179 then 179 to 181 kept the beam going into the
hypopharynx region, while sparing the organs at risk. By keeping
the beams only moving from 179 to 181 and back you can
concentrate the treatment area to the front of the neck. By
using collimator rotations you can move your MLC leaves (block)
onto different structures to keep the beam from getting into
different organs.

Beam A had a gantry

rotation of 181 to
179, clockwise, with
a collimator rotation
of 20 degrees.
 Beam B went counter
clockwise from 179-181
with a rotation of the
collimator to 340
degrees.

Beam C was another clockwise

gantry rotation from 181 to 179,
this time with a collimator rotation of
90 degrees.

The final beam was another

counter clockwise beam
from 179 to 181, also with a
90 degree collimator
rotation.
References:

1. Hansen EK, Roach M HANDBOOK OF EVIDENCE-BASED RADIATION

ONCOLOGY Springer 2007, http://www.radiotherap-e.com/#5004642,
Accessed 2/25/2017

2. Vann, Ann Marie. Hypopharynx [Softchalk]. La Crosse, WI: UW-LAX

medical Dosimerty Program; 2016

3. Teoh M, Clark CH, Wood K, Whitaker S, Nisbet A. Volumetric

modulated arc therapy: a review of current literature and clinical use in
practice. The British Journal of Radiology. 2011;84(1007):967-996.
doi:10.1259/bjr/22373346.

4. Gupta T, Narayan CA. Image-guided radiation therapy: Physicians

perspectives. Journal of Medical Physics / Association of Medical
Physicists of India. 2012;37(4):174-182. doi:10.4103/0971-
6203.103602.