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Brittany Bird
Group Two
February 26, 2017

Head and Neck Assignment

1.) During the course of the treatment, the patient was lying supine on the treatment
couch in a head-first position as displayed in Figure 1. The extended S-frame was
attached to the couch with a C-Silverman clear headrest connected to it. An AccuForm
head cushion was molded to the headrest to match the curvature of the patients neck to
provide additional neck support. By indexing the headrest to the S-frame, it allows the
therapists to recreate the exact neck slant and head height from day-to-day. A head and
neck thermoplastic mask was formed by soaking the mask in warm water and then
conforming it to the patients head and neck area. Once cooled, the mask provides
increased rigidity and secure immobilization during treatment. The mask will maintain
its shape indefinitely. It is important to ensure that the set-up is reproducible daily in
order to maintain the precision of radiation to the treatment field. The patient should
hyperextend their chin in the mask in order to reduce any extra radiation dose to the eye.
A knee bolster was placed under the patients knees to alleviate any back pressure and the
arms were fully extended down by the side, holding onto a large blue ring. Elongating
the arms down by the patients side moves the shoulders out of the treatment field. A bite
block was then attached to the inside of the mask and inserted into the patients mouth to
aid in depressing the tongue out of the treatment field. Reproducible set-ups that are
tolerable to the patient are vital for the accuracy to target the correct tumor volume.
2.) The CT dataset was imported into Velocity, where specific avoidance structures
were contoured. The organs at risk (OR) included the brain, brainstem, esophagus,
external body, eyes, lens, mandible, optic chiasm, optic nerves, oral cavity, parotid
glands, and spinal cord. Table 2 displays a table with the listed critical structures and
their tolerance doses for the entire organ according to Emami.1 It is vital to contour the
critical structures in the treatment area to see what constraints are met. If a structure is
exceeding the dose limit, then the plan must be modified by either adjusting the beam
arrangement, field size, or energy. If a patient needs to be re-treated, dose constraints
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will be evaluated. The PTV margin was reduced for this patient near the area of the eye
to limit maximum dose to the region. The dose should always be kept as low as
reasonably achievable.
3.) The maxillary sinus has specific boundaries to adhere to when designing a
treatment plan as shown in Figure 3.2 The superior boundary lies at the floor of the orbit.
The posterior boundary separates the sinus from the pterygopalatine fossa and
infratemporal fossa. The medial boundary includes the thin walls of the nasal fossa and
extends inferiorly to the alveolar process and hard palate. It is important to include these
boundaries with a margin so that there is no recurrent disease due to the majority of these
tumors being unresectable.
4.) Several upper head and neck lymph nodes were within the area of the treatment
field. The majority of the lymph nodes were at a low risk due to their inferior location
from the treatment field as shown in Figures 4, 5 and 6.3 It is not very common for the
lymphatics to be involved in cases related to the maxillary sinus. If the tumor does
extend into the rich lymphatic supply, the lesions that invade the oral cavity and cheek
drain to the submandibular and upper jugular lymph nodes.2 The retropharyngeal and
superior jugular lymph nodes become involved for tumors that invade through the nasal
fossa and nasopharynx.
5.) The radiation technique used for treating the maxillary sinus on this particular
patient was VMAT. A VMAT technique can improve sparing of the surrounding critical
structures and tissues, especially when the tumor is unresectable and high doses are
needed to eradicate the GTV. The treatment prescription at the site of the maxillary sinus
was listed for a total dose of 7,000 cGy at 200 cGy per fraction for 35 fractions. The
treatment was considered definitive and was being treated with photons at a 6MV energy
on a TrueBeam linear accelerator. A low photon energy is used compared to a higher
photon energy, because the beam isnt traversing through enough tissue as it would be for
a lung treatment. The plan was calculated using the Acuros Algorithm and the
heterogeneity correction factor turned on. A heterogeneity correction factor should be
used because the human body consists of several different tissue densities including fat,
bone, muscle, tissue, and air that need to be taken into consideration during treatment
planning. Varying tissue densities will interact with radiation in a different manner. Dose
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calculations performed without the proper tissue density correction can cause an increase
in planning deviations. The normalization value was set to ensure that the 100% isodose
line covered 95% of the target volume. Two arcs were used, the first arc starting the
gantry at 0 and rotating clockwise to 179 and the second arc starting at 179 and
rotating counter-clockwise to 0 as shown in Figure 7. The collimator for the first arc
was rotated to 15 and the second arc had a 345 collimator rotation. The collimator
angle helped to lessen the beam divergence from the nearby critical structures and
reduced dose to those areas. No couch angles or dynamic wedges were applied in the
treatment plan. Dynamic wedges were not needed due to selecting to use a VMAT
technique, which is highly conformal to the tumor volume. If a 3D conformal technique
was used instead, then wedges could have been applied due to the curvature of the face or
deficits in some cases. If the patient had any deficits from prior surgery, then the use of a
bolus would also be taken into consideration to bring the dose closer to the skin surface
where tissue is missing. Using a VMAT technique for a majority of treatment plans for
patients has become widely popular due to the conformity of the dose distribution seen in
Figures 8 and 9, and a quicker treatment time.




















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References

1. Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic irradiation.

Int J Radiat Oncol Biol Phys. 1991;21(1):109122. http://dx.doi.org/10.1016/0360-
3016(91)90171-Y.

2. Vann A, Dasher B, Chestnut S. Portal Design in Radiation Therapy. 2nd ed. Columbia,
SC: DWV Enterprises; 2006.

3. Systems AI. Radiotherap-e. http://www.radiotherap-e.com/login.aspx?ReturnUrl=%2f.

Accessed February 20, 2017.

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Figures

Figure 1. View of patient head-first supine on the initial CT sim day.

Table 2. TD 5/5 for an Entire Organ

Organ at Risk (OR) TD 5/5 (cGy) End Point

Brain 4500 Necrosis/Infarction
Brainstem 5000 Necrosis/Infarction
Esophagus 5500 Clinical stricture/perforation

Lens 1000 Cataract

Mandible 6000 Limitation of the joint function

Optic Chiasm 5000 Blindness

Optic Nerve 5000 Blindness

Parotid 3200 Xerostomia

Skin 5500 Necrosis/Ulceration
Spinal Cord 4700 Myelitis/Necrosis
Table 2. TD 5/5 for the whole organ according to Emami.

Figure 3. Boundaries of the maxillary sinus.

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Figure 4. Level 4 lymph nodes.

Figures 5 and 6. Varying levels of nodal involvement for treatment of the maxillary sinus.

Figure 7. Planning data for the described VMAT maxillary sinus treatment.
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Figure 8. Dose distribution to the maxillary sinus on a sagittal view.

Figure 9. Dose distribution to the maxillary sinus on a transverse view.