Research Proposal

Title: Sparing the ipsilateral submandibular gland and level 1B lymph nodes for treatment of
oropharynx cancer.
Problem Statement: For oropharynx treatment (tonsil, BOT), the level 1B node is typically
included in the PTV. This is unnecessary since oropharynx cancer doesn't drain into the level 1B
node. The submandibular gland (SMG) is also included in the PTV because of its location to the
1B node and does not have any nodal drainage function. Radiation of the SMG causes
xerostomia which leads to a diminished quality of life for the patient. The goal is to investigate if
the ipsilateral level 1B and SMG can be spared during treatment to improve patient quality of
life post radiation treatment.
Literature Review: There have been studies documenting the possibility of sparing the
submandibular gland and level 1B nodes. Historically, level 1B node have been included in the
treatment volume, however, as Lee et al2 demonstrated, the percentage of 1B node involvement
is rare. Their results showed for 102 patients observed from 2010 to 2016, only 4.3% had 1B
involvement.2 With such a small percentage affected, perhaps it is not necessary to irradiate the
SMG and 1B unless there is involvement. The results from Jackson et al1 and Lee et al2 shows
how rare 1B involvement is and that it is possible to spare the contralateral side. An article by
Francis Ho et al4 states that for level 1B nodes there is only a 2.7% chance of node involvement.
Even with a standardized atlas in place there is still no consensus to the volume for irradiating
the neck, especially for patients without nodal involvement. The study by Jing Chen et al5 tried to
spare the level 1B nodes but did it without restricting dose to the submandibular gland and calls
for proper dose constraints for future studies. Finally, Giuseppe Sanguineti et al6 stated that level
1B nodes have less than a 5% risk of involvement. They stated that their practice is to limit
treatment to level 1B nodes and question the involvement of the 1B/SMG in the target
volume.6 One study by Jackson et al1 demonstrated for the at-risk contralateral SMG and 1B that
it was possible to spare the SMG by maintaining a mean dose of ≤39 Gy. Gensheimer et al7added
to this body of research by stating in their study that SMG sparing is feasible in the majority of
patients and can significantly reduce xerostomia. By adhering to the dose constraints of ≤39 Gy,
it would decrease the risk of xerostomia and improve patients’ quality of life.1 Therefore, this
study will aim at testing the possibility of sparing irradiation to the ipsilateral SMG and 1B
node.
Hypothesis: Oropharynx treatment (tonsil, BOT) can be effectively treated while sparing the
ipsilateral level 1B nodes and submandibular gland.
Materials and Methods: Our goal is to re-plan the treatments aimed at sparing the ipsilateral 1B
and SMG without decreasing dose to the PTV. For this study, several patients with oral
squamous cell carcinoma that have no nodal involvement will be re-planned to spare the level 1B
nodes and SMG. Patients will need to have had a computed tomography simulation with a
thermoplastic mask as an external immobilization device. Any patients who have undergone
chemotherapy, have metastasis or are node positive will be excluded from this study. To expand
on the research of sparing the SMG with the level 1B node, guidelines for dose requirements will
follow the Radiation Therapy Oncology Group-1008, to replicate the same standards as Jackson
et al.1 The dose constraint for the SMG was a mean dose of <39 Gy to preserve salivary function
after radiation therapy while the dose constraints for other organs at risk are as follows: “parotid
gland mean dose of <24 Gy, uninvolved oral cavity mean dose of <30 Gy, lips V35 of 5%,
larynx mean of <20 Gy, superior pharyngeal muscle constrictors mean of <50 Gy, and inferior
pharyngeal muscle constrictors mean of <20 Gy.”1 Re-planning will be performed using a
VMAT technique using 2 arcs or more for oral squamous cell carcinoma. VMAT with 2 arcs has
shown to have a greater dose homogeneity than IMRT and maintain lower doses to the oral
cavity and mandible.3 Some techniques to avoid dose to these structures include contouring the
level 1B and SMG as avoidance structures to minimize dose as much as possible.
 References
1. Jackson WC, Hawkins PG, Arnould GS, Yao J, Mayo C, Mierzwa M. Submandibular
gland sparing when irradiating neck level 1B in the treatment of oral squamous cell
carcinoma. Med Dosimetry. 2018. In press. doi:10.1016/j.meddos.2018.04.003
2. Lee NC, Kelly JR, Park HS, Yarbrough WG, Burtness BA, Husain, ZA. (2017). The risk
of level IB nodal involvement in oropharynx cancer: Guidance for submandibular gland
sparing irradiation. Pract Radiat Oncol. 2017;7(5): e317-
e321. doi:10.1016/j.prro.2017.02.004
3. Dai X, Zhao Y, Liang Z, et al. Volumetric-modulated arc therapy for oropharyngeal
carcinoma: A dosimetric and delivery efficiency comparison with static-field
IMRT. Physica Medica. 2015;31(1):54-59. doi:10.1016/j.ejmp.2014.09.003.
4. Ho FCH, Tham IWK, Earnest A, Lee KM, Lu JJ. Patterns of regional lymph node
metastasis of nasopharyngeal carcinoma: A meta-analysis of clinical evidence. SpringerLink.
https://link.springer.com/article/10.1186/1471-2407-12-98. Published March 21, 2012.
Accessed May 2, 2019.
5. Chen J, Ou D, Hu C. Sparing level Ib lymph nodes by intensity-modulated radiotherapy
in the treatment of nasopharyngeal carcinoma. SpringerLink.
https://link.springer.com/article/10.1007/s10147-013-0650-6. Published December 12, 2013.
Accessed May 2, 2019.
6. Sanguineti G, Califano J, Zhou J, et al. Defining the Risk of Involvement for each Neck
Nodal Level in Patients with Early T-stage/Node-positive Oropharyngeal
Carcinoma. International Journal of Radiation Oncology*Biology*Physics.
2008;72(1). doi:10.1016/j.ijrobp.2008.06.506.
7. Gensheimer MF, Liao JJ, Garden AS, Laramore GE, Parvathaneni U. Submandibular
gland-sparing radiation therapy for locally advanced oropharyngeal squamous cell
carcinoma: patterns of failure and xerostomia outcomes. Radiation Oncology. 2014;9(1).
doi:10.1186/s13014-014-0255-x.