Head and Neck SIB Rapid Arc

Olivia Rozsits

Patient Information

57 y.o. White male

Squamous cell carcinoma of the left lateral base of tongue

Stage III (T1N1M0)

p16/HPV positive

15 pack per year smoking history

Denies alcohol and drug abuse

History of medullary thyroid carcinoma s/p total thyroidectomy, central neck

dissection, and left lateral neck dissection

No prior chemo or radiation

Etiology and Epidemiology

Smoking tobacco, marijuana

Alcohol

Poor Oral Hygiene

EBV

HPV

Smokeless tobacco

Comprises about 5% of all cancers in the

U.S. annually

Male predominance

3-4:1

Most diagnosed in patients greater than 40

years of age

Planning Objectives

Standardized dose of:

PTV High: 70 Gy
PTV Int: 63 Gy
PTV Low: 56 Gy

35 fractions
Top four priorities are serial organs: spinal cord, brainstem, brachial plexus,
globes, optic nerves, optic chiasm
PTV High
Parallel organs
Goal vs. Limit what the physician hopes to achieve but the limit is the
hardstop

Coverage

PTV

Hotspots

Goal: 97% of PTV receives the prescription dose

Limit: 95% of PTV receives the prescription dose
Goal: 110% hotspot
Limit: 115% hotspot

Cold Spots

Goal: 100% of PTV receives 93% of the prescription dose

Limit: 99% of PTV receives 93% of the prescription dose

Prioritization for Planning

1. Spinal Cord
2. Brainstem
3. Brachial Plexus
4. Globes, Optic Nerves, Chiasm
5. PTVhigh
6. Parotid gland contralateral to primary tumor site
7. OARpharynx
8. Larynx
9. Esophagus
10. Lips
11. Oral Cavity
12. Parotid gland ipsilateral to primary tumor site
13. Mandible
14. Cochlea and Inner ear
15. Submandibular gland
16. PTVint
17. PTVlow

Setup

Q2 Headrest (no longer custom headrest)

Long masks

Want shoulders down and relaxed

(reproducibility)

Planning Structures

Copy all PTVs contoured by physician

Crop back PTVs 3mm from the body contour (for dose buildup)

1mm margin on PTV high to trick optimizer for better coverage

Does the PTV extend into any serial organs?

Crop out serial organ from dosimetrist contour

Will add additional margin on crop (dose fall off of 5% per mm)

PTV high from Brachial Plexus

Planning Structures (cont.)

PTV Int is the largest structure

Overlaps with brachial plexus, but BP max is 66 Gy and PTV int dose is 63 Gy

Parallel organs worried about the mean dose

New structure to subtract parallel organs from PTVs by 2-3mm

This margin is to avoid the structures from sharing pixels that may mess with the
optimizer

Parotids

Will add avoidance structure with a lower mean dose and drive the dose down

Field Size Limitations

HN volume is usually between 18-20 cm long

3 arcs

Varian MLCs can only travel 15cm

1st: treats the superior portion
2nd: treats the inferior portion
3rd: clean up arc

Gantry rotates from 200-160 degrees

Skip every other degree

Avoid the posterior structures (posterior to spinal cord)

Optimization

Lower objectives used only on target volumes

Upper objectives used on OARs and target volumes (to avoid hotspots)
PTV

Mean objectives used on parallel organs and outside PTV

Normal Tissue Objective

100% of the volume receives 95% of the dose

95% of the volume receives 100% of the dose

Acts as a ring to control the 60% isodose curve

Controls and constricts the dose and how fast and far the dose falls off

Normal Tissue Ring

Constricts the 50% isodose curve

Crop anything outside the PTV (in the body contour) by 3cm

Plan Report

Fields

3 arcs
1: G200-160, 6MV, Weight 1.020, Coll 70 deg
2: G 161-201, 6MV, Weight 1.032, Coll 80 deg
3: G200-160, 6MV, Weight 0.986, Coll 350 deg

Normalization Value: 99.9%

Normalization Method: 100% covers 95% of Target Volume
MUs per Field

1: 204 MU
2: 207 MU
3: 198 MU

DVH

Setup Fields

Only use for SSDs

5mm margins from CTV to PTV with conebeam 2x per week

Iso located in middle of PTV

Shifts

If reducing margins need to image daily

Setup fields are 10x10 cm f.s. (standardized)

Conebeam all HN patients

Almost always at least a 3 cm inferior shift (z=-3.5 cm)

Left (x=0.5)
0 ant to post (y=0)

Evaluate SSDs to the skin

Want to evaluate if patient weight changes

Tolerances

Brainstem: 5000 cGy

Spinal Cord: 4700 cGy

Parotids: 3200 cGy

Brachial Plexus: 6600 cGy