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Clinical Oncology Assignment

Dan Frieling
Directions: Please choose a treatment plan that includes one of the anatomic regions below:

 Primary Head and Neck with lymph nodes

 Primary Lung/Mediastinum or Breast/chest wall with lymph nodes
 Primary Pelvis (any tumor found below L4-L5) with lymph nodes

Find a case in your clinic that you have worked on, or are working on, to research and answer
the corresponding questions regarding the overall treatment plan. (Note: this can be a case that
your clinical instructor is planning or planned but you observed/participated). Please include
any references and helpful screenshots to describe your rationale and to explain the treatment
plan design and process. 5950 5600

Questions:
1. How was this patient positioned for simulation? What positioning devices/accessories
were used, how and why?
a. This patient was simulated in the supine position with his hands at his side.
An S-frame board was utilized with a “B” head rest. The patient was fitted
for a custom head and neck mask. This was done to ensure the patient was in
the same position every treatment. The head and neck mask covered the
shoulders due to the position of the patient’s PTV. If the patient were to
move their upper body in any way, it could affect the dose distribution.
2. Discuss the target dose as defined by your physician and the rationale behind the total
dose and fractionation regimen. Include any references or current research to help
answer the question.
a. The patient’s primary PTV was prescribed 7000 cGy over 35 treatments.
This results in a daily dose of 200 cGy. Two other PTV volumes are being
treated concurrently. They are receiving doses of 5950 cGy and 5600 cGy.
Their primary objective is the treatment of lymph nodes. This is fairly
standard for a head and neck patient. The patient has a malignant neoplasm
of the tonsil. I’ve done some research on the topic, and it seems that this falls
in line with the head and neck protocols. In their article, “Head and Neck
Cancer Treatment Protocols”, Stevenson and Petruzzelli state, “The
radiation dose depends on tumor size; however, for early stage disease, doses
of 66-74 Gy (2.0 Gy/fraction; daily Monday-Friday in 7wk) may be used with
adequate results.”1
3. What specific avoidance structures were contoured? Include a screen shot of your
contoured target and organs at risk. Create and embed a table of OAR tolerance doses
based on your physician prescription and include any associated QUANTEC values. List
the contraindications if tolerance doses were to be exceeded.
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a. Multiple structures were contoured for this patient’s plan. They are listed in
the table below. As one can see by viewing the chart, both parotids are
receiving a substantial amount of dose. This was discussed with the physician
and approved due to the location of the PTV. We debated a plan which
spared the parotids more; however, this brought more dose to the spinal
cord.

Organ at Risk Desired Tolerance Objective Actual Dose Received

Left Parotid Mean Dose < 26 Gy Mean Dose - 54.03 Gy
Right Parotid Mean Dose < 26 Gy Mean Dose - 29.44 Gy
Spinal Cord Max Dose < 45 Gy Max Dose – 33.73 Gy
Brain Stem Max Dose < 54 Gy Max Dose – 37.38 Gy
Esophagus Mean Dose < 35 Gy Mean Dose – 7.2 Gy

4. Identify any involved lymph nodes in your treatment region. Embed a screen shot of the
nodal regions with corresponding labels.
a. This patient is being treated for a malignant neoplasm of the tonsil. The
tonsils are small masses of lymphoid tissue in the throat. Given this fact, the
cervical lymph nodes are often an area of concern when treating tonsil
cancer. This patient is no different. As one can see from the image below, a
large portion of the neck is included in the PTV to include these particular
lymph nodes. The various lymph node areas are displayed below.
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Cervical Lymph Nodes

Level II Lymph Nodes

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Level III Nodes

Level IV Nodes
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5. Use your IMAIOS Subscription: http://www.imaios.com/en and other anatomy

references to describe the anatomical “boundaries” (physical limits) of the area treated.
Embed a diagram and/or screen shot of your CT data to point out the boundaries.
a. The patient’s PTV is rather large to account for the various lymph nodes
included. Superiorly, the patient’s PTV borders the base of skull. Inferiorly,
the PTV extends to the apex of the lungs. In some areas it ends at the
clavicles. The patient’s PTV is in some areas splits into two sections.
Laterally they extend practically to the skin edge. Medially, they converge
near the base of tongue and separate into two sections which medially border
the larynx and trachea. This can be seen in the four pane window below.2

6. Describe, in detail, the radiation treatment technique used to treat this anatomical
region.
a. The patient is being treated using VMAT. VMAT stands for Volumetric Arc
Therapy. In this case, two arcs are being deployed. One starts at a gantry
angle of 181 and rotates clockwise in a full circle around the patient till
gantry angle 179. The second arc starts at gantry angle 179 and rotates
counterclockwise to gantry angle 181. This is done in order to ensure a
seamless transition from arc to arc. By doing this, we can make the treatment
process easier for the therapists and patient.

Field Parameters Arc One Arc Two

Gantry G181 to G179 CW G179 to G181 CCW
Collimator 30.0 deg 330.0 deg
X Jaws X1: 10.8 X2: 9.7 X1: 9.7 X2: 10.8
Y Jaws Y1: 11.7 Y2: 9.6 Y1: 11.7 Y2: 9.6
Table Angle 0.0 deg 0.0 deg
SSD 92.0 cm 92.1 cm
Dose Rate 600 MU/min 600 MU/min
Energy 6 MV 6 MV
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Dose 104.2 cGy 95.8 cGy

7. Include a final DVH of your treatment plan with appropriate labels and discuss your
ability to meet the target and OAR tolerance guidelines.
a. This plan achieved its objective of giving 95% of the PTV 100% of the dose.
When it comes to our OAR’s, this plan does a suitable job. As mentioned
before, the only area of real concern is the parotid glands. It can be seen
below that the left parotid is receiving significantly more of the dose than the
right parotid. This is due to the PTV being located on the left side of the
patient. Both, however, are above our tolerances. This was discussed with the
physician and approved. It can be an unfortunate reality that our desired
dose objectives may not always be attainable. This is particularly true when
treating tumors in delicate locations (i.e. the head and neck).
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References:
1. Stevenson M, Petruzzelli G. Head and Neck Cancer Treatment Protocols. Medscape.
https://emedicine.medscape.com/article/2006216-overview . Updated February 29, 2016. Accessed February 15, 2018.
2. IMAIOS. Head and Neck – CT. https://www.imaios.com/en/e-Anatomy/Head-and-Neck/Head-and-neck-CT . Accessed
February 15, 2018.