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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 throughout the
course of radiation therapy for head and neck cancer 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 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 the 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 (H&N) cancer accounts for approximately 6% of all cancers, and includes
cancer that develops in the paranasal sinuses, nasal cavity, pharynx, larynx, and oral cavity.1
Squamous cell carcinoma is the most common form of H&N cancer, 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 H&N cancer are found to have
advanced disease with lymph node involvement as well. Treatment options for these patients
vary depending on the extent and pathology of the cancer with radiation therapy being a
principal 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 diagnosed with H&N cancer.2 During the course
of radiation therapy for H&N cancer patients, a side effect frequently observed is weight loss.

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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 H&N cancer 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 compared to 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 H&N cancer treatments, thus affecting dose
coverage of the targets and surrounding structures.2
The purpose of this case study was to evaluate how weight loss during radiation
treatments can cause dosimetric changes to the dose coverage of targets and surrounding healthy
tissues when using IMRT planning for H&N 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 therapy.
The subject used for this case study was selected based on several factors. The patient
was diagnosed with H&N cancer 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 used for the adaptive
plan was performed with the same patient setup, allowing for a more accurate image fusion and
analysis of the two data sets.
The patient was diagnosed with squamous cell carcinoma of the head and neck region in
2013. The H&N cancer 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.

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The patient underwent a left neck dissection with bilateral tonsillectomies and received
concurrent chemotherapy and radiation therapy.
Once the radiation oncologist consulted with the patient, a CT simulation was ordered to
begin the treatment planning process. Upon simulation, the patient was set up in a supine headfirst 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) and 3 PTVs, seen in Figure 1. 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 important as there are many organs at risk
(OR) in this region, such as the parotid glands, spinal cord, ears, mandible, and esophagus.4 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 (TPS) used in this case study and
both plans were customized for treatment delivery on a Varian iX linear accelerator using VMAT
technology. Each PTV received a customized plan that utilized an energy of 6 MV and
appropriate jaw sizes to encompass each target. Each plan for the patient utilized 2-3 full arcs
with different collimator angles for additional multileaf collimation (MLC) modulation and
better dose conformity. The dose constraints for OR were used as guidelines during the
optimization phase of treatment planning to stay within tolerance of the surrounding critical
structures. The OR 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 50 Gy in 25 fractions. Additional sequential boost fields were added to the patient
prescription to deliver 10 Gy in 5 fractions to PTV 60 which included the ipsilateral lymph nodes
and tumor site PTVs, then a final boost to deliver an additional 6 Gy 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.
Once it was determined that the patient experienced significant weight loss prior to the
completion of radiation therapy, an adaptive planning CT was performed to establish if there
were significant volume changes to the tumor and surrounding structures that could impact the
treatment doses. For comparison, the two CT scans were fused together and the PTVs and OR
were transferred to the newly fused CT for evaluation. Upon analyzing the new scan, it was
decided by the radiation oncologist that while there were indeed volume changes that occurred in
the surrounding tissues, but there was not enough significant tumor volume change to utilize the
adaptive planning CT for the boost fields in this case.
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.
Plan Analysis and Evaluation
When comparing both plans side by side, the changes seemed minimal; however, once a
plan evaluation was performed, the differences were certain. Figure 2 illustrates the tumor
volume and dose coverage changes on the two different CT scans from before and after weight
loss. The variations in dose distribution can be observed when comparing these two data sets,
therefore substantiating the effect caused by weight loss.
Figure 3 presents the dose volume histograms (DVH) of both plans created for the patient
allowing for a visual comparison between the treatment plan created prior to weight loss and the
treatment plan created post weight loss. The recorded difference in the dose coverage for the
PTV's, right submandibular gland, and right parotid gland can be clearly identified in the DVH
comparison. The DVH shows both the average and maximum doses to be greater when

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incorporating the patient CT scan that was taken after weight loss. The values for the difference
in the mean amount of dose for each of the PTVs and contralateral glands are shown in Table 1.
Tumor reduction and weight loss in the radiation therapy treatment area changed the
dosimetric calculated doses for the patient. Upon 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 receiving more dose when using the updated scan for
planning. The areas that were most affected by the amount of weight loss included the
contralateral glands located in the patients neck. The right submandibular gland had an
increased mean dose of 1.9 Gy; 3.7% over the initial plan. The right parotid gland had an
increased mean dose of 1.8 Gy; 7.5% over the initial plan.
While there were no departmental standards established at the facility for this type of
occurrence, it was at the discretion of the physician to determine the best plan of care for each
individual case of whether to use an adaptive plan. The information gathered from this case
study provided valuable data necessary to evaluate the dosimetric effects from substantial weight
loss. Mean doses increased by almost 2 Gy in some of the OR for this case study; given another
situation where OR are close to their limit, adaptive planning might be necessary to keep doses
within normal tissue tolerances.
The rise in dose that is seen in the OR and target structures can be attributed to reduced
amount of radiation attenuation due to tissue loss. Chen et al2 conducted a study analyzing H&N
cancer patients and found that tumor volumes and parotid glands can decrease in size by 1.8%
and 0.6% each day respectively. A study consisting of 249 head and neck CT scans used
planning models to shrink the external patient contours by 2, 3, and 5 millimeters each to
represent weight loss.2 The computer-based model showed that weight loss could increase the
dose delivered to target volumes by 1.9% to 2.9%. These theoretical values correlate closely to
the adaptive plan's mean doses of the PTV 50, PTV 60, and PTV 66 of the case study, which
increased by 2.4%, 1.5% and 1.0% respectively. The similarities in values between the two
studies demonstrated how dosimetric changes can be deviated for IMRT treatment plans due to
significant weight loss.
In a study conducted by Ahn et al5, it was conclusive that of 23 patients who were treated
for H&N cancer, 15 were determined to have benefitted from adaptive planning during radiation
therapy based upon the dosimetric comparisons and suboptimal doses to the spinal cord, tumor

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volume, as well as regional nodes and structures. Of these 15 patients, 2 patients received 2
adaptive plans during their course of radiation therapy as a consequence of potential underdose
to the GTV and PTV, 1 patient required 2 adaptive plans for excess dose to the parotid gland, and
2 patients required 2 adaptive plans for spinal cord overdose factors. Ahn and colleagues5 also
validated the relationship that a decrease in skin separation in the treatment area as a
consequence of weight loss or other factors results in higher doses to the mandible, parotid
glands, and spinal cord.
In addition to the dosimetric changes that occur with weight loss, other complications
also arise such as set-up errors and variances in image alignment. This can happen as a result of
the immobilization devices not fitting properly, thus allowing the patient to have extra movement
during imaging and treatment. The recommendations from this study are to encourage weight
and diet monitoring for H&N cancer patients during the treatment course to prevent excessive
weight loss. It is also recommended that patients with H&N cancer be rescanned at least one
time during their treatment to assess for adaptive planning. If properly monitored, these
precautions will allow the physicians and radiation oncology team to assess for dosimetric
changes in the treatment area to ensure optimal treatment.
Conclusion
Radiation-induced toxicities when treating H&N cancer patients with radiation therapy
can cause unwanted side effects to patients. Side effects such as dysphagia and xerostomia often
lead to poor diet and malnutrition during and after the course of treatment resulting in weight
loss. The findings from this research confirms that a significant amount of weight loss during the
course of radiation therapy can cause dosimetric deviations to target volumes and OR to the point
of considering adaptive planning as a viable option. The research does not imply this will occur
for all H&N cancer patients, but rather demonstrates the importance of diet and weight
monitoring during radiation therapy to ensure the accuracy of doses delivered.
When considering the tight borders and constraints that must be met in dosimetry
planning, it is crucial to track weight loss to ensure proper doses are being delivered to the areas
of interest. Even with IMRT techniques being utilized more frequently in H&N cancer
treatment, doses can drastically deviate within a few millimeters making it probable for patients

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who have experienced significant weight loss to receive suboptimal treatment if an adaptive plan
is not considered.
This case study consisted of data for 1 patient, limiting the information gathered and
posed a drawback for this research. Since the data were gathered at only one facility, exploring
other facilities and the measures they take to address the situation of weight loss during treatment
can also be beneficial to future studies. Further research into this topic should include data from
a larger number of qualifying subjects, as well as recurrence rates, dietary information, and
survival rates.
This case study aimed to establish if weight loss during the course of radiation therapy
for H&N cancer patients altered dosimetric target volumes, and the findings suggest that
adaptive planning and weight monitoring for H&N cancer patients should be considered prior to
starting radiation therapy treatments. Taking into account these factors will ensure that all
possible measures are considered for optimal treatment and that doses are properly delivered for
better patient outcomes. While H&N cancer was the focus for this case study, further research
could include how weight loss affects other disease sites and cases that are treated using
radiation therapy.

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References
1. Argiris A, Karamouzis MV, Raben D, et al. Head and neck cancer. The Lancet.
2008;371(9625):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 intensity-modulated
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):1-7.
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.
5. Ahn PH, Chen CC, Ahn AI, et al. Adaptive planning in intensity-modulated radiation therapy
for head and neck cancers: single-institution experience and clinical implications. Int J
Radiat Oncol Biol Phys. 2011;80(3):677-685. http://doi:10.1016/j.ijrobp.2010.03.014

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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.

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

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Figure 3. A dose volume histogram 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

Pre Weight Loss

(cGy)

Post Weight Loss

(cGy)

Mean Diff
(%)

PTV 66

6879

6948

PTV 60

6552

6648

1.5

PTV 50

6213

6384

2.4

R submand gland

5095

5285

3.7

R parotid gland

2450

2632

7.5