Setup Discrepancies in Head and Neck Radiation Therapy: A

Comparison between Custom and MTSilver Head Rests

Jackson Baumgartner
Introduction
The successful treatment of head and neck cancers is highly dependent upon the accuracy of
patient setup when performing intensity modulated radiation therapy. IMRT field design for head
and neck treatments usually has very steep dose gradients and the potential clinical benefit for
dose reduction to critical structures can have a dramatic impact on patient wellbeing and life
function(4). In order for the patient to benefit from these dose reducing techniques that IMRT
treatment plans offer, it requires that IMRT delivery plans are accurately delivered in 3D space
throughout the entirety of treatment (which usually lasts for 25-35 fractions)(4). Many structures
are deployed in order to accomplish this task: different patient immobilization devices (i.e.
thermoplastic masks), imaging techniques (i.e. 2D orthogonal imaging and 3D CBCT imaging),
and couch position (i.e. couch kicks) to name the primary methods. Many studies have been
performed to discover what the best methods are for the delivery of IMRT treatments in head and
neck cancer patients. One study concluded that rotational errors in a patient’s setup contributed
to setup error (although they found that there was only a minor dosimetric influence). It was
concluded that when IGRT methods are only accounting for the setup errors in the X, Y, and Z
direction, and not the Pitch, Roll, and Yaw of the couch(2).
Another study on the use of different types of thermoplastic masks compared the
differences in setup errors between a mask only fastened to the head of the patient with three
fixation points, a mask with four fixation points to immobilize the head and the shoulders, and
finally a mask created by the researchers with a fifth fixation point(3). Their conclusion was that
when the isocenter is placed at the head and neck level then all three masks gave similar results,
however, when the isocenter was placed on the lower head and neck region, then the five point
fixation head and shoulder mask produced better setups(3). Lastly, many studies have also been
conducted to learn whether 3D CBCT or 2D orthogonal imaging is more effective in the setup of
head and neck treatments. One study concluded that 3D CBCT imaging led to higher
detectability of rotational deviations and thus more consistent and better sparing of organs at
risk(1) and the other study came to similar conclusions but also indicated that further study should
be conducted on the benefit of additional immobilization devices that could be used to account
for the curvature of the neck and the fact the head and neck region simply is not a rigid part of
the body that can be easily reproduced every single treatment(5). This leads nicely into the
discussion of this paper. While many studies have addressed the use of mask immobilizations,
imaging techniques and rotational discrepancies for head and neck IMRT setups, none could be
found to address the issue of the curvature of the neck and lack of rigidity of the head and neck
region. Surprisingly, no studies were found that directly addressed the use of different types of
head rests in the use of head and neck treatments, specifically the use of custom headrests.
Custom head rests are commonly used in the clinic today. However, they have been
known to break down over time. This research proposal will primarily focus on the use of
custom head rests in the clinic and whether or not they serve any true benefit in the long term
compared to using a MTSilver C or B head rest every time.

Research Question/Hypothesis
Q2+Custom head rests are commonly used in the treatment of head and neck patients
here at the James Cancer Hospital. The blue head rest is customized by injecting water into the
head rest and flattening it down, then having the patient rest their head on top of it while it is in
the Q2 head rest on the table. The therapist’s job is to mold it around the natural shape of the
patient’s head and neck while it hardens and takes the patient’s form. This is then used for the
duration of the treatment. However, I speculate that these head rest, just like vacloc bags, have a
tendency to break down over the duration of a patient’s treatment. My hypothesis is that the
angle of curvature of the patient’s neck will be different between the beginning and end of their
treatment if they use a custom headrest due to the head resting breaking down over the course of
their treatment. I believe that this will lead to larger deviations in a patient’s setup between the
beginning and end of their treatment, thus causing their setup to be less reproducible than if they
used a regular MTSilver C or B headrest.

Materials/Methods
For this study to be significant and hold any weight, 1000 patients with head and
neck cancer should be enrolled and each patient should be receiving the same exact type of
treatment with the same equipment. 6MV photons will be used on a Varian Truebeam linear
accelerator. A head and shoulder Aquaplast mask will be fabricated for all patients enrolled.
Patients who have a low stage (≤ 2 on the AJCC scale) tumor will be enrolled and only a cancer
that physicians predict will have little impact on a patient’s ability to eat regular meals (to reduce
setup deviations as a result of weight loss). Only patients who do not require customized
mouthpieces, precise bites, or dental work to be removed with be enrolled. 1000 total head and
neck patients will be randomly enlisted and randomly assigned to be fitted for a Q2+Custom
head rest or for a MTSilver headrest. 500 will be assigned to have a custom head rest fabricated
while the other 500 will be assigned the regular head rest for their treatments. Any number of
shims will be used.
CBCT IGRT will be utilized for the patient’s treatment and 1 lateral Orthogonal image
will be acquired weekly starting to measure deviations in the patient’s neck curvature throughout
the treatment (compared to a reference image). On the patient’s CT simulation day, they will also
be sent to a linear accelerator to receive a lateral image in their daily setup, this image will serve
as the reference image for the remainder of their treatments. Once treatments begin, the patient
will receive another lateral image from the same position as their reference image, and this will
be taken every 5 treatments. To measure the deviations between the setups, a line will be drawn
from the end of the Spinous processes of C1 to C7 on the image and then another line will be
drawn perpendicular up to the tip of the Spinous process of C4. The distance between C1 and C7
will be measured in centimeters (cm) and the height of C4 will also be measured in centimeters
(cm). Using these values, a geometry calculation will be performed to determine the curvature
angle at C4 and the values will be recorded every single week and compared to one another. At
the end of the study, significance tests will be performed to determine if the findings are
statistically significant and whether further research should be conducted.

Possible Results
At the end of the study, I expect that the patients with custom head rests fabricated will
have a larger deviation from their first treatment to their last treatment than the patients using
MTSilver headrests, thus their setups will be less reproducible and cause more setup
discrepancies. The chart below utilizes made up measurements to illustrate the point:
 Cervical Curvature Cervical Curvature
(Custom) (MTSilver)
1. 35 degrees 1. 35 degrees
2. 36 degrees 2. 35 degrees
3. 37 degrees 3. 36 degrees
4. 38 degrees 4. 36 degrees
5. 39 degrees 5. 37 degrees

It is likely that there will be some level of discrepancy between the first day and last day
for the MTSilver head rests, however, I still expect the differences to be greater for the custom
headrests. It should be noted again that these are by no means accurate measurements nor do
they represent the results of a true test, they are merely to help illustrate the point that I believe a
custom head rest would cause a greater difference in neck curvature between the first and last
days of treatment due to headrest breakdown.
 Works Cited

1) Ciardo D, Alterio D, Jereczek-Fossa BA, et al. Set-up errors in head and neck cancer
patients treated with intensity modulated radiation therapy: Quantitative comparison
between three-dimensional cone-beam CT and two-dimensional kilovoltage images.
Physica Medica. 2015;31(8):1015-1021. doi:10.1016/j.ejmp.2015.08.004.

2) Fu W, Yang Y, Yue NJ, Heron DE, Huq MS. Dosimetric influences of rotational setup
errors on head and neck carcinoma intensity-modulated radiation therapy treatments.
Medical Dosimetry. 2013;38(2):125-132. doi:10.1016/j.meddos.2012.09.003.

3) Gilbeau L, Octave-Prignot M, Loncol T, Renard L, Scalliet P, Grégoire V. Comparison

of setup accuracy of three different thermoplastic masks for the treatment of brain and
head and neck tumors. Radiotherapy and Oncology. 2001;58(2):155-162.
doi:10.1016/s0167-8140(00)00280-2.

4) Hong TS, Tomé WA, Chappell RJ, Chinnaiyan P, Mehta MP, Harari PM. The impact of
daily setup variations on head-and-neck intensity-modulated radiation therapy.
International Journal of Radiation Oncology*Biology*Physics. 2005;61(3):779-788.
doi:10.1016/j.ijrobp.2004.07.696.

5) Li H, Zhu XR, Zhang L, et al. Comparison of 2D Radiographic Images and 3D Cone

Beam Computed Tomography for Positioning Head-and-Neck Radiotherapy Patients.
International Journal of Radiation Oncology*Biology*Physics. 2008;71(3):916-925.
doi:10.1016/j.ijrobp.2008.01.008.

6) Manning MA, Wu Q, Cardinale RM, et al. The effect of setup uncertainty on normal
tissue sparing with IMRT for head-and-neck cancer. International Journal of Radiation
Oncology*Biology*Physics. 2001;51(5):1400-1409. doi:10.1016/s0360-3016(01)01740-
0.