Jeanette Keil

SIB Split X-jaw VMAT Planning for Head and Neck

I. History of Present Illness

a. 74 y.o. male
b. 1/15/2018 - underwent left carotid endarterectomy
i. Surgeon found concerning lymph node
ii. Was removed for pathology
1. Squamous cell carcinoma
c. Symptoms
i. Noted left side ear pain
ii. Denied lump on neck prior to surgery
iii. Denied dysphagia or odynophagia
d. 1/31/2018 – met up with Ear, Nose and Throat surgeon
i. Performed fiberoptic laryngoscopy
1. Found 1.5 cm fungating lesion at base of tongue
e. 2/8/2018 – PET/CT
i. Hypermetabolism along base of tongue consistent with malignancy
ii. No metastasis seen
f. January 2018 – met with Medical Oncology and Radiation Oncology
i. Recommended concurrent Cetuximab and radiotherapy
II. Past Medical History
a. CVA
b. Carotid artery disease
c. Dyspnea
d. Hypertension
e. Hyperlipidemia
f. Leg edema
g. Sciatica
III. Past Surgical History
a. Angiogram
b. Endarterectomy – left carotid
c. Lumbar spine surgery
 Jeanette Keil

IV. Social History

a. Married
i. 3 children
b. Retired factory worker
i. Hazardous material exposure to chemicals
c. Never smoker
d. Social drinker
e. Non-contributory family history of cancer
V. Medications
a. Atorvastatin
b. Metoprolol
c. Senna
d. Plavix
e. Lisinopril
f. Oxycodone
g. Aspirin
VI. Diagnostic Imaging
a. PET/CT – 2/8/2018
i. No metastasis
VII. Radiation Oncologist Recommendations
a. NCCN guidelines
i. Definitive external beam radiotherapy
ii. Concurrent with systemic therapy
VIII. The Plan (Prescription)
a. SIB Plan – 7000cGy / 35 fractions
i. PTV High – 7000cGy in 200cGy fractions
ii. PTV Intermediate – 6125cGy in 175cGy fractions
iii. PTV Low – 5775cGy in 165cGy fractions
b. VMAT plan
c. Simulated 2/6/2018
d. Started course on 2/26/2018 and will end on 4/16/2018
 Jeanette Keil

IX. Patient Setup/Immobilization

a. IV contrast for simulation
b. Supine on IMRT board w/arms down in shoulder retractors
c. Short Aquaplast mask and Accuform head rest
d. Knee sponge
e. Three point marks made on mask and shifts made first day of treatment
X. Anatomical Contouring
a. Eclipse treatment planning system
b. Dosimetrist contours
i. All OARs in the head and neck region including: brain, brainstem, cord,
esophagus, eyes, lens, lips, mandible, optic nerve, oral cavity, parotids, all
PRV structures needed, and OPTI structures.
c. Physician contours
i. Target Volumes
1. GTV, CTVs and PTVs
2. Reviews dosimetrist contouring
XI. Beam Isocenter/ Arrangement
a. Varian Truebeam machine
i. 6MV rapid arc plan
b. Isocenter placed to cover all PTV 5775
i. Used arc geometry tool to help
c. Arc geometry tool chooses width that will cover entire PTV 5775 with 2 full arcs
i. Copy and pasted each field and closed x-jaw on one side of each field so
that the width was only 15 cm
ii. Ended up with 4 full arcs
1. 2 arcs – CW 181-179
a. X-jaw shifted on each arc
i. 15 cm width each
2. 2 arcs – CCW 179-181
a. X-jaw shifted on each arc
i. 15 cm width each
 Jeanette Keil

XII. Treatment Planning

a. Varian Eclipse v 13.5
b. Planned based off of prescription and the plan orders given by physician
c. VMAT proposed at time of simulation
d. No plan sum needed because SIB plan
e. Evaluate DVH
i. Presented physician with spreadsheet of constraints that are met and not
met
1. Oral cavity-PTV not met
XIII. Quality Assurance/ Physics Check
a. Plan checked using MOBIUS program
i. Evaluates
1. Target coverage
2. DVH limits
3. 3D Gamma
4. Deliverable
XIV. Conclusion
a. Use technique for large or wide target volumes
b. Splitting the arcs to cover whole PTV advantages and disadvantages
i. Advantages
1. Better conformality
2. Lower max dose
ii. Disadvantages
1. Longer treatment times
a. 4 arcs vs. 2 arcs
c. Things I struggled with
d. Things I learned