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PRESENTATION
Marina Cousins, Sherikah Paskaran and Jay Varma
CONTENT
Introduction to the oral cavity and its anatomy
The associated OARs and Target Volumes
The dose prescription for the oral cavity
The rationale and justification behind the standard and advanced
radiotherapy technique for treating the oral cavity
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INTRODUCTION
The medical term for the mouth is the oral cavity
Oral cancer is the 16th most common cancer worldwide, and makes up
between 60-85% of all head & neck cancers (cancerresearchuk.org
2015)
More than 90% of all oral cancers are squamous cell carcinoma (SCC)
(Feller & Lemmer, 2012)
Treatment for oral cavity cancer is usually surgery. EBRT with or without
chemotherapy is used in 3 situations:
after surgery to enhance loco-regional control
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ORGANS AT RISK AND DOSE CONSTRAINTS
Spinal cord (0.1cc < 44Gy) Lenses (Dmax 6Gy)
Brain stem (0.1cc < 54Gy) Parotid glands (unilateral mean 20Gy)
(bilateral mean 24Gy)
BUCCAL MUCOSA
Cranial Caudal Anterior Posterior Lateral Medial
Inferior aspect Hyoid bone Anterior aspect masseter Oropharyngeal mucosa To mandible. Oropharyngeal mucosa.
zygomatic arch/ hard muscle Includes ipsilateral parapharyngeal Contralateral parapharyngeal space
palate space spared
RETROMOLAR TRIGONE
Cranial Caudal Anterior Posterior Lateral Medial
Superior aspect soft Hyoid bone Junction of posterior Oropharyngeal mucosa To mandible. Oropharyngeal mucosa
palate/hard palate third and anterior two Includes ipsilateral parapharyngeal Contralateral parapharyngeal space
thirds of the tongue space spared
HARD PALATE
Cranial Caudal Anterior Posterior Lateral Medial
Superior aspect of Hyoid bone 10-15mm anterior Anterior aspect To mandible or medial pterygoid muscle To mandible or medial pterygoid muscle
hard palate +10mm margin on GTV into oropharyngeal mucosa on both sides. on both sides.
palate. Includes both parapharyngeal spaces. Includes both parapharyngeal spaces.
*Limits are given for guidance. At least a 1cm margin on the GTV should always be added. (NHS Trust, name withheld, 2013)
** In cases where the extent of the tumour is difficult to visualise use 15mm margins.
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STANDARD RADIOTHERAPY TECHNIQUE
3D CONFORMAL RADIOTHERAPY
Rationale / Justification
3D conformal radiotherapy technique (3D-CRT)
Tumour volume in a 3D perspective
Radiation beams conform to shape of tumour due to
multi-leaf collimators (MLCs)
MLCs precisely sculpt the tumour whilst shielding normal
tissue
Minimise healthy tissue being irradiated hence reducing
long term side effects.
Beam Arrangements
Site Tongue
Anterior and posterior oblique fields wedged to produce a
homogeneous dose distribution.
Deeply infiltrative tumours approaching or invading the midline -
parallel-opposed lateral beams are required to treat the CTV
(Hoskin, 2012)
Beam Modifications
A mouth bite may be considered to exclude the upper or lower
half of the mouth from the field.
Bolus may be considered for tumour/ nodal disease extending
close to the skin (NHS Trust, name withheld, 2013)
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Doses and Prescriptions
Site Dose Fractions Duration Modality Localisation, Category
(Gy) (#s) planning &
immobilisation
Advantages Disadvantages
Simple and quick QA checks Delivery efficiency by VMAT
compared to IMRT plans, plans much higher than
significant impact on 3DCRT plans
departmental resources Overall treatment and
(Saw et al., 2002) verification time longer for
3DCRT plans compared to
Lower number of monitor VMAT
units in comparison to IMRT
plans, hence lower dose to Doses to OAR’s e.g. spinal
the rest of the body (Teoh et cord and parotid glands
al., 2011) significantly reduced with
VMAT than 3DCRT plans
(Sakanaka et al., 2013)
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ADVANCED RADIOTHERAPY TECHNIQUE
VOLUMETRIC MODULATED ARC THERAPY (VMAT)
(varian.com)
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ADVANCED RADIOTHERAPY TECHNIQUE
VMAT
Advantages Disadvantages
Rapid delivery Lengthy planning process due to
complexity of VMAT plans
Improved patient comfort
Integral dose will be an issue
Reduced intrafraction due to the arc effect
motion, and
May increase the risk of
Increased patient throughput secondary malignancies
(Studenski et al., 2013)
(Studenski et al., 2013)
Need for accurate volume
delineation (Bhide et al., 2012)
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3DCRT vs. IMRT
Eisbruch et al., 1996, 1998
In the first Phase I/II studies to spare salivary gland tissue in
Head & Neck patients, IMRT reduced the radiation dose to the
contralateral parotid gland to 32% compared with 93% for the
standard plans
Chen et al., 2009
Patients receiving IMRT had significantly less moderate to
severe xerostomia and dysphagia than those receiving 3DCRT:
3DCRT - 82% for xerostomia, and 59% for dysphagia
IMRT - 36% for xerostomia and 21% for dysphagia
CONCLUSION
The aim of radiotherapy is to maximise dose to the tumour whilst
minimising the dose to surrounding healthy tissue and OARs
The oral cavity is surrounded by numerous critical structures
which are in close proximity to the target volume
Therefore it is vital that high conformality of dose to the target
volume is achieved to minimise dose to the critical organs and to
reduce side effects
Advancements in radiotherapy has resulted in new techniques to
achieve this e.g. VMAT
Rotational arc(s) with dynamic MLCs, to shape the field, delivers
an intensity modulated beam that allows for high conformality, and
optimised dose distribution across the tumour volume
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THANK YOU FOR LISTENING
References
Bhide, S., Newbold, K., Harrington, K. and Nutting, C. (2012). Clinical
evaluation of intensity-modulated radiotherapy for head and neck cancers.
BJR, 85(1013), pp.487-494.
Chen, W., Hwang, T., Wang, W., Lu, C., Chen, C., Chen, C., Weng, H., Lai,
C. and Chen, M. (2009). Comparison between conventional and intensity-
modulated post-operative radiotherapy for stage III and IV oral cavity cancer
in terms of treatment results and toxicity. Oral Oncology, 45(6), pp.505-510.
Eisbruch, A., Marsh, L., Martel, M., Ship, J., Ten Haken, R., Pu, A., Fraass,
B. and Lichter, A. (1998). Comprehensive irradiation of head and neck
cancer using conformal multisegmental fields: assessment of target
coverage and noninvolved tissue sparing. International Journal of Radiation
Oncology*Biology*Physics, 41(3), pp.559-568.
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References
Eisbruch, A., Ship, J., Martel, M., Ten Haken, R., Marsh, L., Wolf, G., Esclamado,
R., Bradford, C., Terrell, J., Gebarski, S. and Lichter, A. (1996). Parotid gland
sparing in patients undergoing bilateral head and neck irradiation: Techniques and
early results. International Journal of Radiation Oncology*Biology*Physics, 36(2),
pp.469-480.
Huang, S. and O Sullivan, B. (2013). Oral cancer: Current role of radiotherapy and
chemotherapy. Med Oral, pp.e233-e240.
National Cancer Institute, (2015) Lip and Oral Cavity Cancer Treatment (PDQ®).
Available at: http://www.cancer.gov/cancertopics/pdq/treatment/lip-and-oral-
cavity/Patient/page1 (Accessed: 13 January 2015).
NHS Trust (Name withheld, 2013) Work instruction, Radiotherapy in Head and
Neck cancer
References
Sakanaka, K., Mizowaki, T., Sato, S., Ogura, K. and Hiraoka, M. (2013).
Volumetric-modulated arc therapy vs conventional fixed-field intensity-modulated
radiotherapy in a whole-ventricular irradiation: A planning comparison
study. Medical Dosimetry, 38(2), pp.204-208
Saw, C., Ayyangar, K., Zhen, W., Yoe-sein, M., Pillai, S. and Enke, C. (2002).
Clinical implementation of intensity-modulated radiation therapy. Medical
Dosimetry, 27(2), pp.161-169.
Teoh, M., Clark, C., Wood, K., Whitaker, S. and Nisbet, A. (2011). Volumetric
modulated arc therapy: a review of current literature and clinical use in
practice. BJR, 84(1007), pp.967-996.
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