1 Amanuel Negussie DOS 731 - July Case Study July 2013 Volumetric Modulated Arc Therapy (VMAT) Treatment

for a Base of Tongue Cancer History of Present Illness: JJ is an 82-year-old gentleman with a squamous cell carcinoma of the base of tongue. He developed a left neck mass in February 2013. The patient was seen by a primary care doctor as he noticed swelling of the anterior upper neck submandibular region. The mass was slowly getting worse. The patient had an MRI of the neck in May 2013. The MRI demonstrated an infiltrating soft tissue mass at the base of tongue measuring 2.9 x 4.2 x 4.5 centimeter (cm). It also showed bilateral lymphadenopathy involvement and multilevel cervical spondylosis. An ultrasound guided fine needle aspiration (FNA) and core biopsy was obtained in May 2013. The result showed non-small cell cancer favoring poorly differentiated squamous cell carcinoma. The cancer was staged T3 (stage 3 primary tumor), N2 (stage 2 regional lymph nodes, M0 (no metastasis) post biopsy. The patient was unable to have a PET/CT (positron emission tomography/ computed tomography) scan for a staging, as he was unable to lie flat due to pulmonary problems. He complained of secretions in the back of his throat when laying down, which caused acute respiratory distress. The patient is currently being treated for pulmonary fibrosis with Prednisone. The patient was not a surgical or chemotherapy candidate due to his pulmonary disease. Therefore, definitive radiation therapy was recommended. Past Medical History: JJ has a past medical history of pulmonary fibrosis, hypertension, transient cerebral edema, rib fracture, cataract, and carcinoma in situ of the skin. He is also allergic to CT contrast dye. Social History: JJ is married with two children. He drinks two beers per week. He smoked onehalf pack cigarette per day for 40 years. He quit smoking in 1982. He has a family history of heart disease but not cancer. Medication: JJ is currently taking Aggrenox, Amlodipine, Fluticasone inhaler, and Predinisone. Diagnostic Imaging Studies: An MRI of the neck was obtained with no contrast. The scan demonstrated a soft tissue mass at the base of the tongue centered to the left of midline but appearing to cross the midline. The mass measured approximately 2.9 x 4.2 x 4.5 cm. Multilevel cervical spondylosis was noted. There was extensive lymphadenopathy bilaterally including level I through IV and VI. The muscles of mastication were symmetric. The parapharyngeal fat

2 plane was maintained. The submandibular glands and the vocal cords were unremarkable in appearance. The preglottic fat was not infiltrated. The trachea and esophagus were normal in appearance. The lung apices were clear. Radiation Oncologist Recommendations: The radiation oncologist discussed with the patient the rationale for adjuvant radiation therapy to the oral cavity, oropharynx, and bilateral neck for optimizing local control. Potential benefits and risks associated with definitive radiation therapy for base of tongue cancer were reviewed in detail with the patient. He had numerous questions all of which were answered to his satisfaction. The patient agreed to proceed with treatment as recommended. The Plan (Prescription): After a discussion with the patient, reviewing the chart, and examining the diagnostic studies, the radiation oncologist decided to treat using volume modulated arc therapy (VMAT). The treatment was prescribed to 5000 centigray (cGy) at 200 cGy per fraction to the base of the tongue and bilateral neck followed by a boost of 2000 cGy at 200 cGy per fraction to the base of tongue. Patient Setup/Immobilization: JJ was simulated in a supine slightly inclined position. Due to his respiratory problems, the patient was not able to lay flat on the CT couch. Therefore, a wing board was used to lift his head and chest up (Figure1). A Vac-Lok was used to form a custom mold of the patient set up position. A timo headset was used under the patients head. A shoulder strap was used to pull the shoulders away from the treatment area. An aquaplast mask was made by warming a thermoplastic mesh in a warm bath and stretching it over the patients face. The customized mask was used to reproduce the same head position and restrict movement during treatment. A sponge was placed under his knees for comfort. No bite block was used to immobilize the tongue. In patients who are being treated for the base of the tongue with IMRT and where the contralateral neck is clinically negative, bite blocks should not be used in order to spare the contralateral parotid gland.1 A General Electric (GE) Lightspeed 4 slice CT unit was used for the simulation. The head and neck images were taken at 2.5 mm slices. Anatomic Contouring: After the simulation was completed, the CT scan slices were imported into Varian Eclipse version 10 treatment planning system (TPS). The medical dosimetrist contoured all the normal structures including the brain, brain stem, left and right eye, total lung, left and right inner ear, left and right parotid, spinal cord, mandible, and oral cavity. The

3 radiation oncologist contoured the gross tumor volume (GTV), clinical target volume (CTV), and planning target volume (PTV). Beam Isocenter/ Arrangement: A Varian 21 IX linear accelerator (Linac) was used to treat the patient. During simulation, the radiation oncologist set an isocenter within the treatment site. For The initial treatment, three rotational arcs were arranged, two in clockwise (CW) direction and one in counter clockwise (CCW) direction. The first beam was set to rotate in a CW direction from 235o to 105o with 5o collimator angle and 15 x 17.1 cm field size (Figure 2). The second beam was set to rotate in CCW direction from 105o to 235o with 355o collimator angle and 15 x 17.5 cm field size (Figure 3). The third beam was set to rotate in CW direction from 235o to 105o with 270o collimator angle and 16 x 21.5 cm field size (Figure 4). The couch rotation was set at 0o for all arcs. The boost treatment was delivered using a 3 dimensional conformal radiation therapy (3D-CRT). A right anterior oblique (RAO) and left anterior oblique (LAO) field arrangement was used. The RAO beam was set at gantry angle of 280o and collimator angle of 55o (Figure 5). The LAO beam was set at a gantry angle of 92o and collimator angle of 33o (Figure 6). A 6 megavoltage (MV) photon beam was used for both initial and boost fields. Treatment Planning: The medical dosimetrist started the initial plan by setting the appropriate gantry rotation, collimator angle, and field size. These were carefully arranged to allow full PTV exposure for each arc. The dental artifacts were contoured and assigned a density equivalent to water. Metal artifacts can distort dose distribution by creating cold and hot spots.2 This correction method can help reduce such complications. The spinal cord was expanded by 3 millimeter (mm) in all directions. Avoidance structures were created for organs at risk (OR) that overlapped with the target with 2 mm margin around the PTV. This included left parotid, right parotid, mandible, and oral cavity. An avoidance structure was also created for each shoulder. A 1cm thick ring was constructed 2 cm away from the PTV. The purpose of the ring was reduce beam streaking and increase dose conformity. The inverse planning process included clinical goals to the PTV and planning constraints to the ring, the avoidance structures, and OR. The progressive resolution optimizer (PRO) algorithm within the Eclipse software generated an ideal intensity map with optimal weighting of each control point. The MLC segments, the gantry speeds, and the dose rates of each control point were generated from the ideal intensity map. The plan was reviewed after each

4 optimization and weightings of the objectives were adjusted based on the information retrieved from the dose volume histogram (DVH) and the isodose lines. The final three dimension (3D) dose distribution was evaluated using DVH analysis as well as viewing the 3D dose distribution in multi-plane view and on individual CT slices. The final dose calculation was performed using the analytical anisotropic algorithm (AAA). The plan was finalized with the 95% isodose line covering the PTV with a mean dose of 5120 cGy and maximum dose of 5440 cGy located within the PTV (Figure 7 and 8). All of the clinical goals and planning objectives were met (Figure 9). After careful revision, the physician accepted the treatment plan. The boost was planned using 3 dimentional conformal radiation therapy (3DCRT) technique to reduce dose to the oral cavity, shoulders, and spinal cord. Two lateral oblique off cord fields were used. A 1 cm margin was set around the PTV. A 45o enhanced dynamic wedge (EDW) was used on the RAO to account for the curvature of the head and reduce the hot spot. The weighting was adjusted to 51% for the RAO and 49% for the LPO. The plan was finalized with the 95% isodose line covering the PTV with a mean dose of 2073 cGy and a maximum dose of 2147 cGy located within the PTV (Figure 10 and 11). The initial and boost composite plan was carefully reviewed and approved with all the OR constraints met (Figure 12). Quality Assurance / Physics Check: A monitor unit (MU) check was performed with RadCalc. At this facility, a 5% deviation in MU is the tolerance for all plans (Figure 9). Anything outside of this range needs to be recalculated and fixed by the medical dosimetrists or physicists prior to the first treatment. The initial and boost plans were approved with an individual MU difference less than 2% (Figure 13 and 14). The rapid arc QAs were generated using the AAA of each arc. The intensity maps were calculated in a flat solid water phantom. The intensity maps were exported to be compared to measurements obtained with the SunNuclear MapCheck device. The plan passed the QA with 95.3% at 3% differentiation. Conclusion: This plan presented challenges, primarily due to the patients inability to lay flat on the table. Since the patient was positioned in an inclined plane, the shoulders were not completely out of the treatment field. As a result, a shoulder strap was used to pull them away from the treatment area as much as possible. A precaution was taken when planning the initial treatment to minimize the dose to the shoulders. This was achieved by setting a hard constraint to

5 the shoulders avoidance structures. The boost was also delivered with oblique lateral fields as an additional safety measure to minimize the dose to the shoulders, oral cavity, and spinal cord.

6 Figures

Figure 1 a and b. Patients setup position with a wingbord, Vac-Loc, headrest, shoulder strap, and customized aquaplast mask.

Figure 2. Collimator angle and field size of the first arc that rotated in a CW direction

Figure 3. Collimator angle and field size of the second arc that rotated in a CCW direction

Figure 4. Collimator angle and field size of the third arc that rotated in a CW direction

Figure 5. Beams eye view (BEV) of the off cord RAO boost field demonstrating blocked field to conform to PTV (blue) and spare spinal cord (red)

Figure 6. BEV of the off cord LAO boost field demonstrating blocked field to conform to PTV (blue) and spare spinal cord (red)

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Figure 7. Transverse, coronal, and sagittal view of dose distribution. The 95% isodose line (orange) conformity around the PTV (blue)

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Figure 8. Dose wash representation of the 95% dose distribution of the initial plan

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Figure 9. DVH of the initial plan demonstrating dose distribution to PTV and OR

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Figure 10. Transverse, coronal, and sagittal view of the dose distribution. The 95% isodose line (orange) conformity around the PTV (blue)

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Figure 11. Dose wash representation of the 95% dose distribution of the boost plan

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Figure 12. Sum DVH of the initial and boost plan. PTV 1 represents the target that received both the initial and boost treatment. PTV 2 represents the target that received only the initial treatment

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Figure 13. MU check of the initial plan

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Figure 14. MU check of the boost plan

18 References 1. Harrison LB, Sessions RB, Hong WK. Head and Neck Cancer: A Multidisciplinary Approach. 3rd ed. Philadelphia, PA. Lippincott Williams and Wilkins; 2009: 331-332. 2. Kim Y, Tome WA, Todd MB, et al. The impact of metal artifacts on head and neck IMRT dose distribution. Radiotherapy and Oncology. 2006;79(2):198-202.