Oral Cavity Katie Budge Feb.

2017
In our clinic, I found a case with a primary lesion of adenoid cystic carcinoma of the hard palate.
1. How was this patient positioned? What positioning devices/accessories were used, how and
why? (5 points)

This patient positioned head first, supine. The positioning devices are mask, blue
accuForm, and bite block. The mask helps holding the patients head completely still. Blue
AccuForm enhances repositioning, comfort, and stability. So the treatment delivery can be
more precise. The purpose of the bite block for this patient is to hold the tongue away from
the treatment area.

2. What specific avoidance structures were contoured? What is their tolerance dose? (20
points)The specific avoidance structures and their tolerance doses are listed on the table
below:
Sources: The National Comprehensive Cancer Network (NCCN), QUANTEC, RTOG, and AAPM
Task Group 101.
Brain Dmax < 72Gy to partial brain;

Brainstem Dmean < 50 Gy; Dmax < 55Gy.

Chiasm Dmean < 50 Gy; Dmax < 55Gy.

Ears_inner (L, R) Dmax < 45Gy

Optic nerves (L,R) Dmax < 55 Gy;

Eyes (L, R) Dmean < 35 Gy; Dmax < 50 Gy

Spinal cord Dmax < 45 Gy

Parotid gland 50% of volume < 30 Gy

Mandible Dmax < 50 Gy

Submandibular glands (L,R) Dmax < 60 Gy

Esophagus 33% of volume, 45 Gy

Larynx Dmax < 66 GY

lens (L,R) Dmax < 7 Gy

 Oral Cavity Dmean < 20 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 tumor volume lies in the roof of the oral cavity. Anterior and lateral portions of the
hard palate is bordered by the maxillary teeth and gums. The left hard palate is bounded
by alveolar arches and gums in front and at the sides. Posteriorly, the soft palate is
connected to the left hard palate. Posterior border of the tumor volume is horizontal plates
of palatine bones. (Please see Figure 1a, 1b, 1c, 1d and Figure 2)

Figure 1a PTV Source: St. Paul Cancer Center, MN

Figure 1b CTV Source: St. Paul Cancer Center, MN

Figure 1c PTV Source: St. Paul Cancer Center, MN

Figure 1d PTV Source: St. Paul Cancer Center, MN

Figure 2 Source: Medical websites and e-learning for healthcare
https://www.imaios.com/en/e-Anatomy/Head-and-Neck/Face-CT Accessed 25 Feb 2017.

4. Are lymph nodes included in the treatment area? If so can you identify the level nodes use
a diagram and screenshots to help you label the nodal regions treated. (20 points)
Yes. The treatment area includes submandibular nodes, retropharyngeal nodes and a
14mm left level 2A/2B lymph node. (Please see figure 3.)

igure 3 Source: Medical websites and e-learning for healthcare

F
https://www.imaios.com/en/e-Anatomy/Head-and-Neck/Face-CT Accessed 25 Feb 2017.

5. What radiation technique is used to treat this patient? Describe in detail the technique (35
points)

The radiation technique used in the treatment planning is VMAT. All beam energy levels
are 6X. Two arcs are one clockwise and one counterclockwise. For the counterclockwise
arc, collimator rotates 355 degree in 155 MU; for the clockwise arc, collimator rotates 5
degree in 158 MU. Two arcs SSD are 91.4 cms. The static setup include KV right lateral
with 270 degree gantry rotation; KV left lateral with 90 degree gantry rotation; and KV
posterior with 180 degree gantry rotation; cone beam CT with 180 degree gantry rotation
for localization and increasing accuracy. Respectively, four static SSDs (Rt Lat, KV Lt
Lat, kV Post and CBCT) are 92.5 cms, 94.7 cms 91.4 cms and 91.4 cms. (Please see Table 1
below.)
The reason why two arcs are used, instead of one arc, is for better conformality, better
coverage of treatment areas, and shortening the treatment time. Above are the same
reasons why different collimator rotations.

Table 1 Source: St. Paul Cancer Center, MN