Use your Discussion Group placement in the Clinical Oncology course to determine
the Head and Neck region below to research.
Find a case in your clinic that presents with a primary lesion in the:
Group 4: Oropharynx
Patient presented with cT2N2c p16+ squamous cell carcinoma of the right base of
tongue. The patient is receiving 70 Gy to the GTV, 63 Gy to CTV1, and 56 Gy to CTV2
using a simultaneous integrated boost technique in 35 fractions.
The patient was positioned supine on the conformal board using a C headrest
in order to hyperextend the head along with a knee sponge for comfort. An
aquaplast mask was made for immobilization and a custom dental stent was
used in order to separate the tongue and the hard palate. Hand pegs were
placed at position 9 so that the shoulders could be pulled as far out of the
treatment area as possible.
3. What are the anatomical boundaries of the tumor volume? You should use
Radiotherap-e (http://www.radiotherap-e.com) and other anatomy
references to help you describe this. You can use a diagram and screen shots
of your CT data to point out the boundaries. (20 points)
Tumor Volume:
Superior boundary: Level of the Right tonsillar pillar or the middle of the
dens.
Inferior boundary: Just superior to the hyoid bone at the level of C4
Bounded posteriorly by the cavity of the oropharynx and the right
pharyngeal constrictor muscle
Extends anteriorly 1.5-2.0 cm towards the right submandibular gland.
Dens
Beginning of Hyoid
Tonsillar Pharyngeal
Pillar constrictor
Saggital view with dose to show 2 cm margin anteriorly into the oral tongue. Also
shows superior inclusion of the skull base and mastoid.
Ian Zoller
4. Are lymph nodes included in the treatment area? If so can you identify the
level nodes use a diagram and screen shots to help you label the nodal
regions treated. (20 points)
Ian Zoller
Yes, lymph nodes are included. Regions receiving different doses are broken
down below:
70 Gy - Rt base of tongue, Rt level II, and Lt level II LNs.
63 Gy - Bilateral retropharyngeal nodes, Rt levels, I, II, III, IV, V and Lt
levels II, III, V
56 Gy - Rt level IV (lower) and Lt level II (upper), IV
Level I: Submental,
Level II: Submandibular
Jugulodigastric
Retropharyngeal
nodes
Level V: Spinal
accessory
Ian Zoller
5. What radiation technique is used to treat this patient? Describe in detail the
technique (35 points)
If IMRT How many beams? What are the beam angles? Is there collimator
rotation? Is there a couch rotation? If so, which direction and why? Include
all specific setup information.
If 3D conformal How many beams? Are half beam (split field) beams used?
Is there collimator rotation? Is there a couch rotation? If so, which direction
and why? Include all specific setup information.
This treatment uses a total of three arcs with no table kicks. Arc 1 is
oriented with the MLCs running horizontally to treat the entire PTV. Arc 2
has the collimator turned so that the MLCs run vertically. This beam uses a
smaller field size and treats the superior extent of the PTV. The reason for
the smaller field size is that with Varian linacs, the MLCs are only allowed 15
cm of overtravel. The field size is limited so that no part of the PTV is left
open during treatment delivery. Arc 3 is similar to Arc 2, however the lower
half of the field is treated in this rotation. In addition to the smaller field size,
having the collimator turned so that the MLCs run vertically helps to better
shield midline structures such as cord. A total of three arcs also helps
improve the conformity of the plan.
Ian Zoller
Arc 3 MLCs