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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 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 (HNC) 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 HNC, 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 HNC 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 HNC.2 During the course of
radiation therapy for HNC 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 HNC 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 HNC treatments, thus affecting dose coverage of
the targets and surrounding structures.2
The purpose of this case study was to evaluate how weight loss, while undergoing
treatment, can cause dosimetric changes in regards to the dose coverage of targets and
surrounding healthy tissues when using IMRT planning for HNC 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 HNC 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. 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 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.

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 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 in this case study and both plans
were customized 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
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 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 adaptive 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.
Plan Analysis and Evaluation
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. The variations in dose distribution can be observed when
comparing Figures 2 and 3, therefore substantiating the effect caused by weight loss.
Figure 4 presents the dose volume histograms (DVH) of both plans created for the patient
allowing for a visual comparison between the treatment plan made 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

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 shrinkage and weight loss in the radiation therapy treatment area did change 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 in fact receiving more dose when using the updated scan for
planning. The areas that were most affected by the amount of weight loss were 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.
The rise in dose that is seen in the OR and target structures can be contributed by the
reduced amount of radiation attenuation due to tissue loss. Numerous studies analyzing HNC
patients have found that tumor volumes and parotid glands can decreased by 1.8% and 0.6%
each day respectively.2 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 our case study, which increased by 2.4%, 1.5%
and 1.0% respectively. The similarities in values between the two studies shows how dosimetric
changes can be deviated for IMRT treatment plans due to significant weight loss.
In another study consisting of 23 patients treated for HNC, 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 volume, as well as regional nodes
and structures.5 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. This study 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, allowing the patient to have extra movement
during imaging and treatment. The recommendations from this study are to encourage weight
and diet monitoring for HNC patients during their treatment course to prevent excessive weight
loss. It is also recommended that patients with HNC be rescanned at least one time during their
treatment to assess for adaptive planning. This 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 HNC 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 HNC 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 have to 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 HNC treatment, doses
can drastically deviate within only a few millimeters making it probable for patients who have
experienced significant weight loss to have received suboptimal treatment if an adaptive plan is
not considered.
This case study consisted of only one patients data, limiting the information gathered
and posed a drawback for this research. Also, since the data was 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 HNC patients altered dosimetric target volumes, and the findings suggest that adaptive
planning and weight monitoring for HNC patients should be considered prior to starting radiation

therapy treatments. Taking account for these factors will ensure that all possible measures are
being taken for optimal treatment and that doses are properly delivered for better patient
outcomes. While HNC was the focus for this case study, further research could be done to
analyze how weight loss could affect other 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;371:1695-1709. 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):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 view demonstrating target volumes and isodose lines before weight loss.

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

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

7.5%