Kevin Tsai October Case Study October 25, 13 IMRT/SIB for Nasopharyngeal Mass History of Present Illness: PM is a 56-year-old

female with a history of undifferentiated carcinoma of the left nasopharynx. She noted having left ear pain, loss of hearing on her left side, and epistaxis in the fall of 2010. After biopsy, PM was diagnosed with T1 (stage 1 primary tumor), N0 (no regional lymph nodes), MX (metastases cannot be evaluated), nasopharyngeal carcinoma (NPC). Past Medical History: PM had a left ear surgery myringotomy tube placement to relieve pressure caused by excessive buildup of fluid. Entire family history is negative. Social History: PM lives with her husband and 13-year-old son. She works full time as a janitor at a school. She does not smoke and only drinks alcohol socially. Eighth grade was PMs highest level of education. Medications: PM is on the following medications: Ativan and Dyazide. She has no known allergies. Diagnostic Imaging: PM was seen by her primary care physician who referred her for a magnetic resonance imaging (MRI) scan of the auditory canal on 01/25/2011. The report showed opacification of the left-sided mastoid air cells extending into the middle ear. A soft tissue mass was also seen in the left nasopharynx protruding into the midline and displacing the right-sided structures. PM subsequently underwent a computed tomography (CT) scan of the head and neck on 02/21/2011, which also demonstrated left nasopharyngeal soft tissue mass. The mass measured 2.9 x 3.4 x 2.76 centimeters (cm) and crossed the midline and extended into the superior oropharynx. The patient was seen by her otolaryngologist, who performed a biopsy on 03/07/2011 and a left sided myringotomy tube was also placed for drainage. The biopsy showed a nonkeratinizing undifferentiated nasopharyngeal carcinoma. PM was then recommended to undergo treatment with radiation alone as definitive treatment. Radiation Oncologist Recommendation: After consultation, the radiation oncologist recommended that PM be treated with radiation alone. The nasopharynx is immediately adjacent to the base of the skulls making surgical resection impossible. Radiation therapy has been the sole treatment for nasopharynx carcinoma.1 PM was treated with a simultaneous integrated boost

(SIB) plan using intensity-modulated radiation therapy (IMRT) with 6 megavoltage (MV) photons. Due to the proximity of the planning target volume (PTV) to normal and critical structures, IMRT was used to decrease the dose to dose-limiting structures while maintaining adequate dose and coverage of the PTV. The goal for PM was to eradicate the tumor cells while minimizing dose to critical and normal structures. The Plan (Prescription): PTV3 included the low risk microscopic disease and was treated to 52.8 Gray (Gy) in 1.6 Gy fractions (fx) for 33 fx, the high-risk microscopic disease (PTV2) was treated to 59.4 Gy in 1.8 Gy fx for 33 fx, and the gross tumor volume (GTV) with 0.5 cm margin (PTV1) was treated to 69.96 Gy in 2.12 Gy fx for 33 fx. This plan was treated using the SIB fractionation scheme. Patient Setup / Immobilization: Prior to undergoing treatment, PM underwent a CT simulation for treatment planning purposes. She was scanned in the supine position with both arms to her side. She was immobilized with an alpha cradle around her shoulders and a Lite case around her head (Figure 1). The CT simulation scan and MRI images were used to delineate the GTV. Anatomical Contouring: The CT images obtained from the scan were exported to Eclipse v10 treatment planning system (TPS) for contouring. The radiation oncologist defined the treatment volumes (PTV1, PTV2, PTV3) and the medical dosimetrist contoured all the critical structures around the area. The normal structures concerned with this case were the spinal cord, brainstem, parotid glands, lens, eyes, optic nerves, optic chiasm, oral cavity, mandible, larynx, and esophagus. Beam Isocenter / Arrangement: The PTV1, PTV2, and PTV3 were combined to create a PTVALL structure. The isocenter is placed in the center of the PTV-ALL structure (Figure 2). For this patient, the medical dosimetrist utilized 9 complex treatment beams to created a conformal isodose distribution while sparing normal tissue. The 9 IMRT beam angles were set at 200o, 240o, 280o, 320o, 0o, 40o, 80o, 120o, and 160o with the gantry rotating clock-wise starting at 200o. Treatment Planning: The treatment plan for PM was created on the Varian Eclipse v10 TPS using inverse planning techniques. Ring structures were created for this plan around the target volumes to reduce the dose to normal tissues. The first ring structure was a 0.5 cm margin around the PTV-ALL named GAP (Figure 3). A larger ring structure of 2 cm was put around the PTV-ALL minus the GAP. This structure was called the SHELL (Figure 4) and was used to prevent 90% of the prescription dose to this area. The last ring structure, SKIN-PTV (Figure 5)

(BODY subtract GAP+SHELL), was used to help prevent 75% of the prescription dose to all normal tissues outside the SHELL. Without these ring structures, high doses can be seen outside of the PTV and inside normal tissues. Constraints and priorities were set on the target volumes and critical structures by the medical dosimetrist. An optimization was run on the TPS to create the most optimal and conformal dose distribution by changing the leaf speed of the multileaf collimators (MLC). Once the plan finished optimizing, the radiation oncologist evaluated the plan using the dose volume histogram (DVH) (Figure 6) and isodose lines. The treatment planning goals for this PM was to have the at least one of the parotid glands V26<50%, spinal cord maximum (max) dose 45 Gy, brainstem max dose < 54 Gy, eyes max dose 45 Gy, optic nerve max dose 54 Gy, cochlea mean dose < 45 Gy, oral cavity mean dose 40 Gy, larynx mean dose 37 Gy, and esophagus mean dose 40 Gy. The medical dosimetrist was able to stay under most of the doctors organ constraints except the oral cavity (mean dose = 48.1 Gy) and esophagus (mean dose = 43.5 Gy). The mean dose for the oral cavity and esophagus are slighter higher because parts of the PTV are extending into them (Figure 7). The normalization was set so that 100% of the target volume will receive at least 95% of the prescription dose. Quality Assurance / Physics Check: The monitor units (MU) from the treatment plan were exported to RadCalc v6.0 for calculations and comparisons. The calculation comparison between the treatment plan and RadCalc were under 3% therefore passing. The treatment plan and MU calculations were imported to Arias Record & Verify system so the medical physicist could review and check the plan. A plan verification was also created by the medical dosimetrist and exported to the treatment machine for IMRT QA on the Matrixx phantom. The entire plan was delivered to the Matrixx phantom and the fluences tested and were all within tolerance. Conclusion: Some of the advantages of SIB-IMRT for head and neck cancers are better target conformity, less dose to critical structures, moderate treatment acceleration with reduced total treatment time, and the option of dose escalation in the gross tumor volume.2 For this patient, the PTV had great coverage and most of the critical structures were spared expect the esophagus and oral cavity. The SIB-IMRT technique is very effective and safe when it comes to tumor response and normal tissue tolerance.

Figures

Figure 1. Patient position at simulation

Figure 2. Isocenter in the middle of red box

Figure 3. GAP. Area between the yellow and red line

Figure 4. SHELL (orange). Used to prevent 90% of the prescription dose to this area.

Figure 5. Skin-PTV (Green). Used to help prevent 75% of the prescription dose to all normal tissues outside of the SHELL.

Figure 6. Dose Volume Histogram of the PTV and critical structures

Figure 7. PTV extending into oral cavity.

References 1. Chao C, Perez C, Brady L. Radiation Oncology Management Decisions. 3rd ed. PA: Lippincott Williams and Wilkins; 2011: 2. Studer G, Huguenin P, Davis J, et al. IMRT using simultaneously integrated boost (SIB) in head and neck cancer patients. Rad Onc. 2006;1(7):1-7.