7/28/2019 730 855 Hu Head Neck

1/44

Basics of Head and Neck IMRT

enne u, . .

Beth Israel Medical Center, NY

Assoc. Professor

Albert Einstein College of Medicine

7/28/2019 730 855 Hu Head Neck

2/44

7/28/2019 730 855 Hu Head Neck

3/44

delineation

associated with improved functional/QOL , ,

morbidity and neurologic function

o rev ew pa ways o per neura sprea

7/28/2019 730 855 Hu Head Neck

4/44

Basics of Contouring

GTV by imaging/physical exam/endoscopy

CT neck standard for nodal and primary PET/CT to guide equivocal

MRI for NPC, paranasal cavity tumors to

evaluate intracranial spread, mucus, RPnodes, parapharyngeal, clivus, perineural

CTV margin 5mm PTV Margins 3-5mm

trim based on skin, air and bone alongwith compartments

7/28/2019 730 855 Hu Head Neck

5/44

References for Lymph Node

Delineation CT-Based Delineation of L m h Node Levels

and Related CTV in Node Negative NeckDahanca, EORTC, GORTEC,NCIC,RTOG rego re, e a . a o erapy an nco ogy, ,

227-236

Pro osal for the delineation of the nodal CTV inNode-positve and the post-operative neck Gregoire, et al. Radiotherapy and Oncology, 79 2006,

- RTOG Website www.rtog.org

7/28/2019 730 855 Hu Head Neck

6/44

Percentage Incidence and Distribution of

a o og ca y nvo ve o es n a n ca

Node Negative Neck After Elective Radical

ec ssec on

Oropharynx

n=48 2 25 19 8 2Hypopharynx

n=240 13 13 0 0

n=79 .

Oral Cavity20 17 9 3 0.5

=Shah, J.P et al. The patterns of cervical lymph node metastases from

squamous carcinoma of the oral cavity. Cancer, 1990. 66(1): p. 109-13

7/28/2019 730 855 Hu Head Neck

7/44

Percentage Incidence and Distribution ofPathologically Involved Nodes in a Clinical

Node Positive after Therapeutic Radical

Neck Dissection

I II III IV V

Oropharynx 14 71 42 28 9

Larynx n=183 7 57 59 29 4

H o har nx

n=104

Oral Cavity

n=32446 43 33 15 3

Shah, J.P., Patterns of cervical lymph node metastasis from squamous

carcinomas of the upper aerodigestive tract.Am J Surg, 1990. 160(4): p. 405-9.

7/28/2019 730 855 Hu Head Neck

8/44

Image-Based Neck Node Level Classification

Som et al, AJR, 2000

7/28/2019 730 855 Hu Head Neck

9/44

-

T0N2bM0 involving the right neck

7/28/2019 730 855 Hu Head Neck

10/44

Sparing of

arotid in LN-

CTV of LN+J foramen

,

spared on L

L Lat

RP LN

Upper Ib,II,Va C1 TVP

7/28/2019 730 855 Hu Head Neck

11/44

Ib,IIa/b Submandib gl

IIa/b

Ia LN spared

Lx, SMG, mid

constrictors

7/28/2019 730 855 Hu Head Neck

12/44

L III/Va LN, Lx,

inf constrictors

7/28/2019 730 855 Hu Head Neck

13/44

L IV,Vb LN, Lx,

cricopharyngeus

L IV,SCL LN, trachea,

cervical esoph

7/28/2019 730 855 Hu Head Neck

14/44

L IV,SCL LN, L IV,

cervical esoph

7/28/2019 730 855 Hu Head Neck

15/44

Coverage of Nodal Volumes Retropharyngeal Nodes

Skull Base down to hyoid bone

a era nvo ve rs spare cons r c ors

Medial RP LN if lateral RP LN+

LN- Inferior margin of C1 Transverse and selective

nodal jugular foramen if LN+ and comprehensive

nodal treatment

-tumor/hypopharynx/thyroid

,thyroid, cervical esophagus

7/28/2019 730 855 Hu Head Neck

16/44

7/28/2019 730 855 Hu Head Neck

17/44

IMRT Improved Xerostomia:IMRT Improved Xerostomia:

PASSPORT TrialPASSPORT Trial 94 pts with OP/HP cancer randomized to IMRT vs 3DRT Whole contralateral arotid < 24G

Lent SOMA Score EORTC Dry Mouth Subscale

Nutting CM et al, Lancet Oncol 2011, 12:127

7/28/2019 730 855 Hu Head Neck

18/44

Submandibular Gland Sparing

pts n= treate w t

Case matched18pts with SMG sparing

an w ou . SMG spared had lower N stage (no N2b-

vs non-spare group -

Saarilahti et al Radiotherapy and Oncology78 (2006) 27075.

7/28/2019 730 855 Hu Head Neck

19/44

Mean SMG

7/28/2019 730 855 Hu Head Neck

20/44

after IMRT designed to spare bilateral, ,

Pt and observer reported xerostomia

, ,

7/28/2019 730 855 Hu Head Neck

21/44

7/28/2019 730 855 Hu Head Neck

22/44

Mean SMG

7/28/2019 730 855 Hu Head Neck

23/44

-

PEG dependence 1yr 30%

Measures of dysphagia:Feeding tube dependence

videofluorosco /silent as iration

dysphagia qol surveys

7/28/2019 730 855 Hu Head Neck

24/44

PharyngealPharyngeal

ConstrictorsConstrictors

Superior

Mid

Inferior

Courtesy Dr. Eisbruch/LeWerbrouch J et al, IJ ROBP 2009,73:1187

7/28/2019 730 855 Hu Head Neck

25/44

Levendag PC, et al. Radiother Oncol. 2007

7/28/2019 730 855 Hu Head Neck

26/44

.6

Probability Swallowing Problems

.5

3

.4

Cyberknife (3x + 4x)

Brach thera im lant

.2

.

No BT / No Cyberknife

.1

3x

4x

0 10 20 30 40 50 60 70 80

Dose superior constrictor muscle (Gy)

Levendag PC, et al. Radiother Oncol. 2007

7/28/2019 730 855 Hu Head Neck

27/44

Constrictors Mean Dose

7/28/2019 730 855 Hu Head Neck

28/44

Med F/U 36mo 3yr LRC 96% DFS 88%

Feng JCO 2010

7/28/2019 730 855 Hu Head Neck

29/44

PEG dependence 1.4% at 1yr

, ,Neck dissection/smoking/t-stage

p s w s r c ures

8 pts with pneumoniaall silent aspirators

M T l D d

7/28/2019 730 855 Hu Head Neck

30/44

Mean Tolerance Doses and

PEG- Aspiration Stricture

EisbruchIJROBP,2011

Lx

7/28/2019 730 855 Hu Head Neck

31/44

CaveatsCaveats-- Other Causes ofOther Causes of

T-Stage Tumor Location

Neck Dissection

Machtay M et al, J CO 26:3582Courtesy Dr. Le

7/28/2019 730 855 Hu Head Neck

32/44

Dosimetric Factors For Dental

Events

Mandible

MSKCC, N=168 pts Med f/u 37mos ORN 1% (2/168pts)

Dental caries 9% Decreased if Mean arotid dose < 26G

Dental Extraction 12% Decreased if Mean mandible < 38Gy or

Max Mandible < 68GyGomez IJROBP 81, No. 4, pp. e20713, 2011

7/28/2019 730 855 Hu Head Neck

33/44

Truong, Radiographics,RSNA 2010

7/28/2019 730 855 Hu Head Neck

34/44

7/28/2019 730 855 Hu Head Neck

35/44

Temporal Lobe NecrosisTemporal Lobe Necrosis

V55

7/28/2019 730 855 Hu Head Neck

36/44

Cochlea

Tolerance

7/28/2019 730 855 Hu Head Neck

37/44

Noncontiguous spread along the nerve

en oneur um rom a umor

Skin cancers, Parotid (adenoid cystic),

Nasopharynx

Caldemeyer, Radiographics 1998

7/28/2019 730 855 Hu Head Neck

38/44

GLUCK et al. IJROBP Vol. 74, No. 1, pp. 3846, 2009

7/28/2019 730 855 Hu Head Neck

39/44

F. Ovale SOF

VC

F. Ovale

F

o un um

VC

Caldemeyer, Radiographics 1998

7/28/2019 730 855 Hu Head Neck

40/44

G. Gan lion

Horizontal CN 7

DescendingCN 7

Caldemeyer, Radiographics 1998

7/28/2019 730 855 Hu Head Neck

41/44

Skin Cancer and

T4 Adenoid Cystic Ca of L

7/28/2019 730 855 Hu Head Neck

42/44

T4 Adenoid Cystic Ca of L

Deep lobe

Pterygoid

mm

Auriculo-

temporal nn

Desc CN 7 Desc CN 7

IAC

7/28/2019 730 855 Hu Head Neck

43/44

7/28/2019 730 855 Hu Head Neck

44/44