Lisa Spanovich

Head & Neck Assignment

Clinical Oncology for Medical Dosimetrists
Group 2: Nasal Cavity or Paranasal Sinus

91 Year old white female.

Left maxillary sinus squamous cell CA. T3 N0
106.2 Malignant neoplasm of maxillary sinus. This is the ICD-9 code, she was treated before the
ICD-10 codes were implemented.
Patient presented with left facial numbness, facial swelling, and drooling.

1. How was this patient positioned? What positioning devices/accessories were used,
how and why? (5 points)

This patient was in the supine position for treatment. A custom mask was made to
immobilize her head. Her head was placed in a neutral position. Extending the neck/chin
was not necessary because the area of interest is above her chin. A head and neck mask
was not required because her treatment is being focused in the sinus/nasal area of her
head. There were no lymph nodes treated, so there was no need to stabilize her neck
region. A custom headrest was fabricated to assist in the reproducibility of her setup. A
thin yoga-type mat was underneath the length of her body, and also a knee sponge, for
comfort. One thing I found odd was that she did not have a bite block. I am not sure if
this is because of her age, or whether or not she had dentures, but I was unable to find out
the reasoning as to why, because she was treated back in 2014.
*Almost all of our head and neck patients are treated on the TomoTherapy unit. I had
difficulty finding a patient for this assignment, but I was able to find this patient from
2014, which is before the department acquired the TomoTherapy unit.

2. What specific avoidance structures were contoured? What is their tolerance dose?
(20 points)

The following is a table that lists the dose intents from the Attending Physician for her
specific treatment. Every IMRT treatment must include a dose intent so that the
dosimetrist is aware what OAR the Physician would like to limit dose to. Even though
there are tolerances to every organ, some Physicians prefer to stay well below certain
limits for different reasons.
 My department puts a 5 mm margin around the spinal cord to allow for possible
movement and daily setup differences. The spinal cord + 5 mm should be less than or
equal to 45 Gy to predict worst case scenario situations. The same goes for the
brainstem and the + 1mm margin. This is standard practice at my clinical site.

Avoidance Structures Tolerance

Right or Left Parotid Mean 26 Gy

Right or Left Parotid 20 cc 20 Gy
Right or Left Parotid V 50% < 30 Gy

Spinal Cord + 0.5 cm 45 Gy

Spinal Cord + 0.5 cm V 50 Gy 1 cc

Brainstem + 0.1 cm 54 Gy
Brainstem + 0.1 cm V 60 Gy 1 cc

Mandible/TM Joint 70 Gy or 1 cc of PTV

75 Gy

Temporal Lobe Brain 60 Gy or 1% of PTV

65 Gy

According to Radiotherap-e website, here are some more dose limiting structures,
and they are as follows:1

Radiotherap-e Tolerance
Avoidance Structures
Lens <10 Gy
Retina <45 Gy
Brain <60 Gy
Optic Chiasm and Nerves <54 Gy
Lacrimal Gland <30-40 Gy
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)

The following pictures depict the borders for her treatment. She did have local invasion
into the surrounding structures. The orange is the CTV, and the red is the PTV.

The superior border of her treatment encompassed the entire orbital region due to local
invasion. Inferiorly, the treatment border goes down to the area of the maxilla. She had a
left maxillectomy, and a left orbital enucleation, so it may be difficult to visual it on the
above picture. Posteriorly, the field extends to the pterygoid area, including the entire
orbital region. Medially, the field extends over the midline, encompassing the nasal fossa,
but avoiding the orbit and lacrimal gland of the right eye.2
 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)

There were no lymph nodes included in her treatment. According to her consultation, she
had 25 lymph nodes removed from her left neck of levels 1-3, and all were negative for
malignancy. Her cancer only had direct extension into the surrounding structures. This
information was verified by my Preceptor, Neil Joyce, CMD.

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.

The patient received 1.8 Gy x 33 fractions, for a total dose of 59.4 Gy. The treatment
technique used was IMRT using 6 MV on a Varian linac. MV CBCT was performed daily
to fine tune the accuracy of her treatment. There were 7 treatment fields used to get good
coverage to her PTV. The following gantry angles were used. There were no collimator
rotation or couch rotations needed.
1_LPO_Gantry_145
2_LPO_Gantry_115
3_LAO_Gantry_85
4_LAO_Gantry_30
5_ANT_Gantry_0
6_RAO_Gantry_335
7_RAO_Gantry_310
This configuration of gantry angles would make sense because she was treated to the left sided
maxillary sinus. So most of the fields enter through that area. There are also two angles that
come in from the RAO and two angles from the LPO, so that a more conformal dose can be
achieved.

This is a picture of the different angles of the treatment fields.

Only the CAX points are shown, so that you can better view the
entry of each angle. It is hard to see, but the yellow
dotted lines correspond to each treatment field angle. Notice how
most of the fields enter through the left side (the affected area).

References
1. Paranasal sinus- maxillary. Radiotherap-e Website. http://radiotherap-e.com/atlas.aspx?
ba=1&np=0&tp=3&ct=1&pid=4383&side=l&eid=5004634. Accessed February 16,
2017.

2. Chao KS, Perez CA, Brady LW. Radiation oncology management decisions. 3rd ed.
Philadelphia, PA: Lippincott Williams & Williams; 2011:232-233.