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Katrina Lee
April Case Study
April 30, 2014
Radiation to Reduce Salivary Function Caused by ALS
History of Present Illness: Patient H is a 65 year old male undergoing external beam radiation
therapy treatment to his left parotid and submandibular glands. In May 2013, the patient was
diagnosed with bulbar Amyotrophic Lateral Sclerosis, or ALS. ALS, which is occasionally
referred to as Lou Gehrig's disease, is a neurodegenerative disease that affects the motor system.
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ALS is a debilitating disease that result in many side effects including sialorrhea, which is the
excessive production of saliva. Approximately half of the patients diagnosed with ALS
experience reduced salivary control, which leads to drooling.
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The patient's quality of life has been significantly affected by the copious amounts of saliva
emitted from the salivary glands. The patient carries paper towels to constantly wipe away drool
from his mouth and is forced to sleep completely upright to avoid choking. The patient consulted
with a radiation oncologist to help reduce sialorrhea caused by the progression of the disease.

Treatment methods for patients experiencing sialorrhea widely varies among physicians.
Recently, more treatment options have emerged in the medical management of reducing saliva
production in ALS patients, to prevent or diminish drooling.
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Anticholinergic drugs, such as
atropine and scopolamine, block the action of the neurotransmitter acetylcholine.
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Botulinum
toxin injections can also be used treat sialorrhea in ALS patients.
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Patient H was referred to a radiation oncologist to discuss treatment to target the parotid and
submandibular glands. The patient experienced no relief from treatment regimes including
atropine, scopolamine, suction to extract saliva and Botulinum toxin injections. The radiation
oncologist suggested that the patient receive radiation treatment to one side, unilaterally. The
physician discussed the risks, benefits, and potential side effects caused by external beam
radiation. After consideration, the patient elected to undergo treatment.
Past Medical History: After the patient was diagnosed with ALS, the patient's motor-neuron
function digressed quickly. The patient began to develop speech disorders including aphonia
(inability to produce voice) and dysarthria (inability to control muscles in face/mouth). The
patient also has a history of rheumatoid arthritis, high blood pressure, long term use of NSAIDs,
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abnormal glucose tolerance, astigmatism, cataracts, peripheral sensory neuropathy,
gastroesophageal reflux disease, depression, thoughts of suicide, and joint replacement surgery.
Social/Family History: Patient H is a divorced, retired Vietnam veteran who volunteered and
helped other veterans prior to the progression of the disease. The patient's three children, former
wife, and brother help with daily tasks at home.
Medications: Patient H uses the following medications: Chlorhexidine gluconate mouthwash,
Ergocalciferol, Feeding bag with pump, Lansoprozole, Nutritional supplement osmolite (6
times/day), Nutritional supplement Twocal (5 times/day), Nystain (2 times/day),
Onabotulinumtoxina, Sucralfate.
Diagnostic Imaging: The patient does not have a cancer diagnosis, therefore image studies were
not necessary. There are no definitive tests to diagnose ALS. Diagnostic studies for ALS patients
are based on excluding treatable symptoms.
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ALS patients undergo a variety of blood tests, nerve
tests, and neuromuscular tests.
Radiation Oncologist Recommendations: The radiation oncologist recommended that the
patient undergo a palliative dose of radiation directed to one side of the patient's salivary glands,
including the parotid and submandibular glands. The patient's left parotid and left submandibular
glands were selected to be treated with radiation, as they seemed to produce the most saliva.
The Plan (prescription): The radiation oncologist prescribed 800 cGy to be delivered in one
fraction with the option to treat again at a later date.
Patient Setup/Immobilization: The patient was positioned supine on the CT simulation couch
with the head placed on a head rest. The patient's head was turned towards the right and taped to
target the left salivary glands. No aquaplast mask was used, per the patient's request. The head
was taped into position and measurements and photographs were taken for the therapists to use
for reference (shown in Figure 1). Further into the planning process, a 0.5 cm bolus was added to
the plan.
Anatomical Contouring: The CT data set was sent and uploaded onto the Phillips Pinnacle 9.0
treatment planning system, TPS. The radiation oncologist contoured the targeted treatment area
(L Sal Gland). The medical dosimetrist contoured the organs at risk (OR) that would be
evaluated on the dose volume histogram, DVH. The OR included the brain, brainstem, spinal
cord, mandible, oral cavity, optic chiasm. Also the left globe, lens, optic nerve, and lacrimal
gland were contoured.
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Beam Isocenter/Arrangement: The radiation oncologist placed the isocenter on the CT data set
in the CT simulation, shown in Figure 1. The physician discussed different beam energies for the
dosimetrist to plan and evaluate for treatment to the targeted area, including 6 MV photons, 12
and 16 MeV electrons. Ultimately the physician decided to treat the target with 12 MeV electron
energy using a left anterior oblique field at a 46 angle.
Treatment Planning: The radiation oncologist prescribed a palliative dose of radiation to the
left parotid and left submandibular salivary glands to reduce sialorrhea caused by ALS. The
physician drew the block on the treatment planning system and the digitally reconstructed
radiograph (DRR) was printed for a radiation therapist to cut and pour the custom cerrobend
electron block. The DRR is shown in Figure 2.
The medical dosimetrists added a 0.5 cm bolus to the plan and inserted a prescription point (New
12 MeV pxpt) onto the CT data set to a depth of 2.85 cm, shown in Figure 3. The point was
selected to a known, calculated depth in which a 12 MeV electron beam reaches full dose. A
dose grid was drawn around the patient and the plan was calculated using CC Convolution
algorithm, shown in Figure 4.
The physician evaluated the isodose lines and determine that the 90% isodose line fully covered
the targeted treatment volume. The DVH was used to evaluate the contoured OAR, shown in
Figure 5.
Quality Assurance/Physics Check: The monitor units (MUs) were double checked for the
treatment plan using the MU check program. The acceptable tolerance at the hospital between
the TPS and the MU check program is a 3% difference. Figure 6 shows the MU check for the
treatment field used to treat the patient's left salivary glands. Also, a pre-port film was taken to
verify the patient was in the correct treatment position.
Conclusion: Radiation therapy treatments generally require that the patient has been diagnosed
with cancer. Scientific research has facilitated the use of external beam radiation as a treatment
modality to help alleviate sialorrhea in ALS patients. The sparse literature regarding this type of
treatment makes planning difficult for physicians. Because this is an unusual type of treatment,
the radiation oncologist and other members of the department reviewed and discussed the
available literature prior planning. After all the research and discussion, the physician decided to
begin with a conservative approach, leaving open the possibility for further treatment at a later
date.
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The patient was scheduled to return to the radiation oncology clinic a month following treatment.
This follow up appointment was set to evaluate the salivary output and determine whether the
patient would undergo further treatment. The patient did not return to the clinic, was placed on
home Hospice care, and there were no further appointments.



























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References
1. Kiernan M, Vucic S, Cheah B, et al. Amyotrophic lateral sclerosis. The Lancet. 2011;
377(9769): 942-955. doi: http://dx.doi.org/10.1016/s0140-6736(10)61156-7
2. Maurique D. Application of botulinum toxin to reduce the saliva in patients with
amyotrophic lateral sclerosis. Rev Bras Otorrinolaringol.2005; 71(5): 566-569.
3. Kasarskis E, Hodskins J, St. Clair W. Unilateral parotid electron beam radiotherapy as
palliative treatment for sialorrhea in amyotrophic lateral sclerosis. J of Neurol Sci. 2011;
308(1-2): 155-157. doi: http://dx.doi.org/10.1016/j.jns.2011.06.016
4. Gupta A, Singh-Radcliff N. Pharmacology in Anesthesia Practice. New York, NY:
Oxford University Press; 2013: 91.
5. Mehta N, Maloney G, Bana D. Head, Face, and Neck Pain Science, Evaluation, and
Managment: An Interdisciplinary Approach. Hoboken, NJ: Wiley-Blackwell; 2009.




















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Figures

Figure 1. Patient set up to treat the left parotid and submandibular glands.


Figure 2. The DRR showing the custom block used for treatment.


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Figure 3. A prescription point (New 12 MeV Px Pt) was placed 2.85 cm from the surface of the
0.5 cm bolus.
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Figure 4. Computed treatment plan of 800 cGy to the patient's left salivary glands. The green
line shows the 90% isodose line.
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Figure 5. The DVH for the treatment plan.
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Figure 6. MU check for the treatment plan