1

Yasmin Ahmed
Clinical Practicum III
November 29, 2015
Head and Neck Case Study
History of Present Illness: Patient MU is a 66-year-old male with a diagnosed stage IV T4N3
invasive squamous cell carcinoma of the supraglottis. He originally presented in January 2015
with a several week history of hemoptysis, a 20-pound weight loss, dysphagia, and hoarseness.
The patient underwent a CT of the chest in January of 2015 that was considered unremarkable.
MU eventually presented to his ENT who did a direct laryngoscopy that demonstrated a lesion in
the supraglottic larynx. In February of 2015 the patient underwent a laryngoscopy biopsy and
tracheotomy. Pathology from the procedure was significant for invasive squamous cell
carcinoma moderately differentiated. The tumor involved the supraglottic larynx down to the true
vocal cords along the anterior commissure and up the laryngeal surface of the epiglottis. A CT of
the neck performed in February of 2015 to evaluate further extent of disease revealed transglottic
neoplastic disease. The findings were worrisome for extralaryngeal spread and possible
perineural invasion along the left superior laryngeal neurovascular bundle. Bilateral
pathologically enlarged lymphadenopathy was demonstrated with extracapsular extension. The
largest lymph node measured 2.1 x 1.6 cm on the left and 1.8 x 1 cm on the right. A CT of the
chest performed in February of 2015 did not demonstrate any evidence of metastatic disease.
Past Medical History: The patient has depression, anxiety, cardiovascular disease, and
hyperlipidemia. Any other medical and surgical history is listed above. The patient has no known
allergies to food or medications.
Social History: MU stated that he has a history of alcohol abuse. He smokes one pack a day and
has been doing so for several years. He is a retired highway paint truck protection driver who
currently lives with his wife.
Medications: MU is currently not taking any medications.
Diagnostic Imaging: As stated above, MU underwent a CT of the chest in January of 2015 that
was considered unremarkable. A CT of the neck performed in February of 2015 to evaluate
further extent of disease revealed transglottic neoplastic disease. The largest lymph node

measured 2.1 x 1.6 cm on the left and 1.8 x 1 cm on the right. A CT of the chest performed in
February of 2015 did not demonstrate any evidence of metastatic disease.
Radiation Oncologist Recommendations: After reviewing MUs past medical history, as well
as pathology reports, the oncologist discussed options for surgery vs. definitive
chemoradiotherapy in an effort to improve the patients local control and for organ preservation.
The oncologist ordered a PET-CT and dental evaluation prior to making a definitive treatment
decision. Once the findings of the PET-CT were available, the oncologist decided to treat with a
definitive chemoradiotherapy regimen. The treatment options, side effects, and potential
complications were discussed with the patient and his wife. The patient and his wife were given
an opportunity to ask questions which were answered to their satisfaction. Informed consent was
then obtained. The patient and his wife were encouraged to contact the oncologist with any
further questions or concerns.
The Plan (prescription): The oncologists treatment recommendation for MU was a volumetric
modulated arc therapy (VMAT) treatment plan with 3 dose painting levels. The total prescription
for the head and neck volume was 7000 cGy at 200 cGy per fraction for 35 fractions daily.
However since this was to be dose painting, there were 3 planning target volumes (PTV) drawn.
The planning parameters were as follows: 7000 cGy in 35 fractions to PTV 7000, 6300 cGy in
35 fractions to PTV 6300, and 5810 cGy in 35 fractions to PTV 5810.
Patient Setup/Immobilization: MU underwent a CT-simulation in the radiation medicine
department. He was placed supine on the couch with the chin hyper-extended and shoulders
pulled down. A headrest was placed under his head and a knee pillow was placed under his legs.
A thermoplastic mask was constructed for immobilization. The isocenter was placed midplane at
the top of the arytenoid cartilages. Three radiopaque markers were placed on the thermoplastic
mask at the isocenter level.
Anatomical Contouring: After completion of the CT-simulation, the images were transferred to
Velocity (Varian Medical Systems, Palo, Alto California) for contouring. The organs at risk (OR)
were drawn by the importing physicist and oncologist. The physicist was to draw the lens, optic
nerves, brainstem, cord, parotids, esophagus, and mandible. The radiation oncologist drew the
brachial plexus and any other desired structures needed for evaluation. Once the oncologist drew
the PTVs, the CT data set and structures were sent to the Eclipse treatment planning system
(TPS).

Beam Isocenter/Arrangement: For this plan, the beams were placed at the marked isocenter.
For the head and neck volume, two full arc beams were utilized to create a volumetric arc
radiation therapy (VMAT) plan. The reason for using VMAT fields was to reduce treatment time
as well as the time the patient needs to be on the table. The two arc beams had rotation angles of
179.9 to 180.1 counter clockwise and 180.1 to 179.9 clockwise. Each arc was assigned an
energy of 6 megavoltage (MV) photons. The collimator was set to 10 for the first arc and 350
for the other. Although VMAT plans take longer to calculate during planning, they reduce
delivery time as well as the risk of patient motion during treatment.1
Treatment Planning: MUs plan was completed on the Eclipse TPS. The radiation oncologist
entered all planning directives in Mosaiq for the medical dosimetrist to refer to. The prescription
outlined a treatment technique of IMRT with dose painting. The prescription in the TPS was set
to deliver 200 cGy daily x 35 fractions. The oncologists target goals for the plan were entered
into Mosaiq for reference. These goals were as follows:
OR
Parotid (ipsilateral)
Parotid (contralateral)
Brainstem
Brainstem+0.5 cm expansion
Spinal cord
Spinal cord+0.5 cm expansion
Esophagus
Mandible
Optic nerve left
Optic nerve right
Retina left
Retina right

Constraint
Mean dose < 26 Gy
Mean dose 15-24 Gy
V45 Gy < 0.1cc
V52 Gy < 0.03cc
V45 Gy < 0.1cc
V48 Gy < 0.03cc
D33 < 45 Gy; D15 < 60 Gy;

Constraint met
No
No
Yes
Yes
Yes
Yes
Yes

Mean dose < 35 Gy

V66 Gy < 0.1cc
V54 Gy < 0.1cc
V54 Gy < 0.1cc
Mean dose < 25 Gy
Mean dose < 25 Gy

No
Yes
Yes
Yes
Yes

Below are the dose volume histogram (DVH) and images of the plan.

As shown in the first image, the maximum dose location was located in PTV 7000. The
maximum was 7422.7 cGy, which is 106% of the prescription dose of 7000 cGy. The location of
this maximum dose was favorable since it was contained within the PTV. You can also see from
the images that the 95% isodose line for PTV 7000 spills over somewhat into the PTV 6300
volume. The same goes for the 95% isodose line for PTV 6300, as it somewhat spills into the
PTV 5810 volume. This is unavoidable due to dose fall-off.
Conclusion: This case was very challenging for me to plan. I find head and neck plans to be the
most challenging cases to plan, especially when dose painting is involved. Before starting
optimization, the most important thing to do is to crop any ORs out of the PTV. I also had to crop
each PTV volume out of each other with a margin, since there were 3 volumes receiving
different doses. After I initially optimized the plan, there were several hot spots in places where I
did not want them. It took me several attempts to get rid of the hot spots while still maintaining
coverage. The most difficult thing about head and neck cases is planning the large treatment
volume while minimizing dose to the large number of ORs in close proximity. I realized that
often the oncologist must decide whether coverage must be sacrificed in order to spare an OR. In
this plan the constraints for the mandible and both parotids were not met. However, the
dosimetrist told me that this often happens and as long as it is not too much out of the required
constraints, the oncologist is often okay with the plan. Overall, this was a great plan to work on
and really challenged me. The dosimetrist stated that these types of plans are not easy to tackle
and they take time to learn and perfect. He said that it is important to find a technique that works
for you and to stick with that. I hope planning these cases will become easier for me over time.

References
1. Studenski MT, Bar-Ad V, Siglin J, et al. Clinical experience transitioning from IMRT to
VMAT for head and neck cancer. Med Dosim. 2013; 38(2): 171-175. http://dx.doi.org/
10.1016/j.meddos.2012.10.009