1. How was this patient positioned? What positioning devices/ accessories
were used, how and why?
Patient was positioned supine on a shoulder board and C-
headrest to extend the neck. Aquaplast mask was used over head and shoulders to immobilize the patient. Bite block was used to move the tongue out of the treatment field.
2. What specific avoidance structures were contoured? What is their
tolerance dose?
Avoidance Tolerance Dose
Structure Orbit Max < 50 Gy, mean < 35 Gy Lens Max < 25 Gy Optic nerve Max < 54 Gy Optic chiasm Max < 54 Gy Cochlea V55 < 5% TMJ Max < 70 Gy Parotid Mean < 26 Gy, V30 < 50% (for one), V20 < 20cc (for both)
Submandibular Mean < 39 Gy
Brainstem Max < 54 Gy Oral cavity Mean < 40 Gy Mandible Max < 70 Gy Spinal cord Max < 45 Gy Larynx Mean < 45 Gy Lungs V20 < 37%, mean < 20 Gy 3. What are the anatomical boundaries of the tumor volume?
Anatomical Boundaries
Sup: sphenoid bone
Inf: roof of soft palate Ant: posterior openings of nasal cavity and posterior bony nasal septum Post: clivus and C1-C2 vertebral bodies
Treatment Field Boundaries
Sup: sphenoid sinus, cavernous sinus, base of skull
Inf: treat LAN supraclavicular and lower cervical nodes Ant: posterior 2 cm of nasal cavity, posterior 1/3 of maxillary sinus, posterior of orbit Post: behind spinous processes, posterior pharyngeal wall 4. Are lymph nodes included in the treatment area? If so can you identify the level nodes use a diagram and screen shots to help you label the nodal regions treated. Lymph nodes included in the treatment area were: Supraclavicular and lower cervical nodes (Level Vb) Retropharyngeal nodes, posterior cervical nodes (Level Va) Deep cervical nodes (Level IV)
5. What radiation technique is used to treat this patient? Describe in
detail the technique. VMATtechnique was used to treat the nasopharyngeal portion of the tumor volume and AP/PA technique was used for the LAN. Mono-isocentric technique was used to avoid shifting the patient between treatment of the two regions. VMAT: 2 full arcs (energy of 6x) were used for the treatment 1 counter-clockwise and 1 clockwise; there were no couch kicks; collimator rotation of 35 and 320 was used to minimize the interleaf MLC leakage. Simultaneous integrated boost (SIB) technique was used to deliver the dose of 5,940 cGy to the initial PTV, while delivering 7,020 cGy to the smaller (boost) PTV volume. AP/PA technique (6x photons) was used to deliver the 5,940 cGydose to the supraclavicular nodes. Because mono-isocentric set up was used and isocenter for the LAN was the same as for the cervical irradiation, half-beam block technique was implemented to avoid divergence into the cervical fields. Collimator rotation of 90 was used to achieve better conformity of the MLCs to the tumor volume. There were no couch kicks.