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Evaluation of Dosimetric Target Volume Changes in Head and Neck Cancer Patients Due
to Weight Loss: A Case Study
Authors: Ryan Clark, B.S., Glenda Longoria, B.S., Nishele Lenards, R.T.(R)(T), M.S., C.M.D.,
FAAMD, Ashley Hunzeker, M.S., C.M.D.
Medical Dosimetry Program at the University of Wisconsin - La Crosse, WI

Abstract:
Introduction: The purpose of this case study was to determine if weight loss during the course
of radiation therapy for head and neck patients affected the dosimetric target volumes if adaptive
planning was not considered.
Case Description: The patient presented in this case study was an ideal candidate due to the
drastic weight loss during the course of treatment. This patient lost a total of 19.5% total body
weight during radiation therapy and was evaluated for an adaptive plan 14 days prior to the
completion of the prescription by receiving a repeat CT simulation for comparison. The new CT
data allowed for further evaluation for present study.
Conclusion: The results from this case study concluded that the patients weight loss did affect
the dosimetric changes in the treatment plan. More specifically, doses to the planning target
volumes (PTVs) exceeded the prescription dose.
Key Words: Head and Neck Cancer, Weight Loss, Adaptive Planning, Target Volume

Introduction
Head and neck cancer represents approximately 6% of all cancer, and includes
malignancies that develop in the nasal cavity, paranasal sinuses, pharynx, larynx, and oral cavity.1
The most common type of head and neck cancer is squamous cell carcinoma, which arises after
long, repeated exposures to carcinogens such as alcohol and tobacco, as well as exposure to human
papilloma virus (HPV). Upon diagnosis, most patients with head and neck cancer are found to
have advanced disease with lymph node involvment as well. Treatment options for these patients
vary depending on the extent and pathology of the cancer, with radiation therapy being a primary
method of control for a majority of these cases.2
Surgery, radiation therapy, and chemotherapy are each significant components of the
treatment approach recommended for patients with cancer of the head and neck.2 During the course

of radiation therapy for head and neck cancer patients, a side effect frequently observed is weight
loss. This can occur as a result of the radiation toxicity making it difficult or painful to swallow,
causing a loss of physical ability to process the food due to physical changes from radiation.3
Intensity modulated radiation therapy (IMRT), and more specifically volume modulated
arc therapy (VMAT) plans, are increasingly used in radiation therapy for cancer of the head and
neck due to the sharp dose fall-off that spares normal surrounding tissue while delivering high
doses to the treatment volume.3 Volume modulated arc therapy treatments are also known to
decrease the side effects that occur with radiation therapy than with 3D conformal radiation
therapy. While IMRT and VMAT planning have many benefits, the problem of weight loss and
tumor reduction during radiation therapy still arises in many cases of head and neck cancer
treatments, thus affecting dose coverage of the targets and surrounding structures.2
The purpose of this case study was to determine how the effect of weight loss can cause
dosimetric changes in regards to the dose coverage of targets and surrounding healthy tissues when
using IMRT planning for head and neck cancer patients.

Case Description
Patient Selection & Set Up
Potential patients that were evaluated for the study were those who lost approximately 5%20% of their body weight during 6-8 weeks of radiation treatments. Unfortunately, many did not
have an adaptive plan evaluation during the course of their treatment, so those cases were omitted.
This case study used data from a single patient who lost approximately 19.5% body weight
throughout the course of radiation treatments.
The subject used for this case study was selected based on several factors. The patient was
diagnosed with cancer of the head and neck of an unknown primary, the weight loss during
radiation therapy was significant, and an adaptive planning CT was performed prior to the
completion of treatment that allowed for testing of the hypothesis for this study. The CT was
performed with the patient in the same position for treatment setup, which allowed for an accurate
fusion of the two scans for analysis.
The patient was diagnosed with squamous cell carcinoma of the head and neck region in
2013. It was determined to be stage IVA (T0N2bM0) at the time of diagnosis as 3 lymph nodes
were positive for metastatic disease, with the largest lymph node measuring 2.7 cm. The patient

underwent a left neck dissection with bilateral tonsillectomies and received concurrent
chemotherapy during the course of radiation therapy.
Once the radiation oncologist consulted with the patient, a CT simulation was ordered to
begin treatment planning. During simulation, the patient was set up in a supine head-first position
on the CT table. An aquaplast mask was fitted to the face for immobilization, with the arms pulled
downward using shoulder straps. For additional comfort, a table pad was placed under the torso
and a knee wedge was placed under the knees. Additionally, 3 reference set-up points were added
to the aquaplast mask for positioning purposes.
Target Delineation
This plan consisted of a gross tumor volume (GTV) volume and 3 PTVs. The radiation
oncologist manually contoured GTV 66, the area to receive 66 Gy, and allowed for a 1 cm margin
around this target to make PTV 66. The PTV 66 also received a dose of 66 Gy. Both the PTV 66
and the GTV 66 encompassed the area of tumor resection. The region labeled PTV 60 represented
the ipsilateral lymph node region prescribed to a dose of 60 Gy and PTV 50 was also added to
represent the region of bilateral neck lymph nodes that was given a prescription of 50 Gy.
Contouring in the critical area of the neck was extremely important as there are many
organs at risk (OR) in this region, such as the the parotid glands, spinal cord, ears, mandible, and
esophagus.

Once GTV and PTV volumes were drawn, the medical dosimetrist contoured all

necessary structures for this plan, which included: the body, right and left brachial plexus, brain,
brain stem, optic chiasm, cochleae, eyes, lenses, optic nerves, esophagus, larynx, mandible, oral
cavity, parotid glands, submandibular glands, spinal cord, and upper left and right lungs.
Treatment Planning
Varian Eclipse was the treatment planning software used for the treatment planning and
was created for treatment delivery on a Varian iX linear accelerator using VMAT technology.
Each PTV had a separate plan created that utilized an energy of 6 MV and had the jaw sizes to
encompass the entirety of each target volume. Each plan for the patient utilized 2-3 arcs with
different collimator angles for additional multileaf collimation (MLC) modulation and better dose
conformity. The dose constraints were used as guidelines during the optimization phase of the
treatment planning to stay within tolerance of the surrounding critical structures. The structures at
risk in the head and neck remained under tolerance doses.

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The first plan that contributed the most dose was designated to treat PTV 50 to a total dose

of 5000 cGy in 25 fractions. Additional sequential boost fields were added to the patient
prescription to deliver 1000 cGy in 5 fractions to PTV 60 which included the ipsilateral lymph
nodes and tumor site PTVs, then a final boost to deliver an additional 600 cGy to PTV 66, the area
of tumor resection, in 3 fractions. These plans were summed together for the purpose of this study
to analyze the total intended dose for entirety of the patients treatment course.
The CT scan that was performed before completion of treatment was ordered by the
radiation oncologist to determine if there were significant tumor volume change, and also to
evaluate the need for a new plan for the boost fields. After the CT was performed, the physician
decided that an adaptive plan was not necessary for the last three fractions, based on the minimal
changes to the tumor volume. The sequential boost fields were then created using the original CT
simulation, which reflected images prior to weight loss.
For the purpose of this study, the new CT that was performed for possible adaptive planning
provided this case study with valuable information necessary for plan comparison while
incorporating the factor of the patients weight loss. The images were fused into the treatment
plans that were utilized for this patient; the targets and OR were adjusted accordingly. The
adjustments allowed for a visual representation of the possible variations in tumor dose coverage
for the plan if no adaptive plan was used.

Results
When comparing both plans side by side, the changes seem minimal; however once a plan
evaluation was performed, the differences were certain. Figure 2 illustrates the tumor volume dose
coverage on the original CT scan before the patient had any weight changes. Figure 3 demonstrates
the tumor volume dose coverage after weight loss on the new CT image using the original
treatment plan. When comparing the isodose lines in the Figures 2 and 3, the difference in dose
distribution is clear.
Figure 4 demonstrates the dose volume histograms (DVH) as a plan comparison between
the 2 plans. The recorded difference in the dose coverage for each PTV can be seen in the DVH
figure and shows the dose to be greater when incorporating the patient CT scan that was taken
after weight loss. The mean amount of dose is in excess for each of the PTVs and contralateral
glands as shown in Table 1.

Discussion
Tumor shrinkage and weight loss in the radiation therapy treatment area did, in fact, change
the dosimetric calculated doses for the patient. After analyzing the results to determine the
calculated differences between the 2 plans, it was determined that once the patient lost weight and
body mass, the target areas were in fact receiving more dose when using the updated scan for
planning. The areas most affected were the contralateral glands located in the patients neck,
receiving up to 5.7% more than the prescribed dose.

Conclusion
Given the fact that this case study consisted of only one patients data, the information was
limited and posed a drawback for this research. However, the knowledge gained during this study
confirmed the theory that weight loss can lead to dosimetric changes in the target volumes for
patients with cancer of the head and neck. Depending on the area of treatment, the changes that
occur during radiation therapy as a result of weight loss may have a more significant impact on
surrounding structures. Adaptive planning and weight monitoring for head and neck patients
should be considered before they begin radiation therapy to ensure that all possible measures are
being taken for optimal treatment.

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References

1. Argiris A, Karamouzis M V, Raben D, et al. Head and neck cancer. The Lancet.
2008;371:1695-1709. http://dx.doi.org/10.1016/S0140-6736(08)60728-X
2. Chen C, Fei Z, Chen L, et al. Will weight loss cause significant dosimetric changes of
target volumes and organs at risk in nasopharyngeal carcinoma treated with intensitymodulated radiation therapy. Med Dos. 2014;39(1):34-37.
http://doi:10.1016/j.meddos.2013.09.002
3. Ghadjar P, Hayoz S, Zimmermann F, et al. Impact of weight loss on survival after
chemoradiation for locally advanced head and neck Cancer: secondary results of a
randomized phase III trial (SAKK 10/94). Radiat Oncol. 2015;10:21.
http://doi:10.1186/s13014-014-0319-y
4. Vann AM, Dasher B, Chestnut SK, et al. Portal Design in Radiation Therapy. 2nd ed.
Columbia, SC: R.L. Bryan Company; 2006.

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Figures

Figure 1. Gross tumor volume is outlined in red. The planning target volumes being treated to 66,
60, and 50 Gy are outlined in green, blue, and orange respectively.

Figure 2. Axial view demonstrating target volumes and isodose lines before weight loss.

Figure 3. Axial view demonstrating target volumes and isodose lines after weight loss.

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Figure 4. A dose volume histogram (DVH) for the right parotid gland (purple), right
submandibular gland (pink), PTV 50 (Orange), PTV 60 (blue), PTV 66 (yellow), and the GTV 66
(Red). The lines with triangles represent before weight loss occurred and the lines with square
represent the plan after weight loss.

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Tables

Table 1. Comparison in mean dose for targets and nearby structures for before and after weight
loss occurred.
Parameter

Before Weight Loss

cGy

After Weight Loss

cGy

% Mean Difference

PTV 66

6879

6948

1%

PTV 60

6552

6648

1.5%

PTV 50

6213

6384

2.4%

R submandibular
gland

5095

5285

3.7%

R parotid gland

2450

2632

5.3%