IMRT vs standard Radiation questions

Kimba1505 said:

Radiation
Just met with the radiation oncologist yesterday (partner has stage 4 tonsil). IMRT is the best for head and neck. Hospital where we are going has super-duper proton radiation(I apologize for my lack of accurate clinical names)...I inquired about this. He says super-duper proton is not recommended for head and neck. From what I have learned here on the boards and from what is practiced at NCI hospitals...IMRT is the way to go. Travel to get it if you have to.
Good luck. YOu are couple steps ahead of us. We have primary removal tomorrow, neck dissection next Tuesday. Prayers all around.
Kim

Advanced Radiation Therapay for head and neck cancer
This is the lead article from SPOHNC April 2010, Vol. 19 No 7, everything you always wanted to know about radiation. I scanned it for you and it's a little patchy but you will find your answers here. take the time to read it and subscribe to their news letter. Hope it helps. From my read IMRT is fast becomming "old hat" The new technologies are promising but not time tested yet.





ITEI,YS FROM
S.P.O.H.tr/.C
vol,. 19 NO. 7 SUPPORT FOR PEOPLE WrTIr ORALAND HEAD AND NECK CANCE& rNC. ApRrL 2010
S.P.Ooflo\eQ
APROGRAM OF SUPPORT
FOR
PEOPLEWITH
ORAL AND
HEADAND NECK CANCER
Advanced Radiation
Therapy Techniques For
Head And Neck Cancer
Swapna Manoj, MS- MJ.
Loren IC Me[, M.D.
Radiation therapy (Rf), often in combination wrthchemotherapy and/or
surgery is commonly used to treat head and neck cancer (IINC). It may
be used as adjuvant therapy (following surgery) in patients at risk for
recurrbnce, as the primary treafinent (in place of surgery) to preserve
organ function, or as palliative therapy for metastatic disease. RT is
typically delivered using high-energy photons and/or elecfrons, which
cause cellular DNA damage, preventing tumor growth.
Important responsibilities of the radiation oncologist are to define
the regions that need to be iradiated (i.e., target definition) and determine
the total dose and fractionation (i.e., dose per day), itt order to
ensure maximal probability of tumor control with minimal side effects.
Targets are delineatedbased on knowledge ofthe tumor location and its
particular pattems of spread, such as invasion into surrounding tissues
and spread to lymph nodes in the neck. In many cases, determining the
exact tumor location is difficulg due to limitations in imaging capabilities
and variations in patients'anatomy through the treatrnent course.
Consequently, radiation oncologists often need to apply wide margins
around targets to ensure that tumor is adequately encompassed by the
radiation fields.
A major challenge is to deliver high doses of radiation to the
tumor while minimizing the dose received by critical nearby organs
including the brain, spinal cord, mandible, and major salivary glands,
amongst others. This article will describe the modem technological
advancements that facilitate greater precision in RI delivery that will
hopefrrlly lead to improved therapeutic results.
Conventional Radiation Therapy Ttrhniques
Historically, Rlplanning depended on two-dimensional x-ray images
(2DRT). Radiation oncologists would define the target and verify
patient positioning using skeletal landmarks and metal wires (which
were visible on x-rays). RT was delivered using a limited number of
fields (usually 2-3), which were set up as two opposing lateral fields
through the upper head/neck region, with a matching anterior field
through the lower neck. Critical organs like brain and spinal cord were
blocked using metal shielding.
There are numerous limitations to 2DRT. Fing the target is only
indirectly identified, because it is defined relative to the location of
bony landmarls. These arc not always good surrogates for actual target
location, because ofvariations in patients' anatomy and particular
characteristics of their cancer. Secondly, using a limited number of
fields means that normal organs such as the salivary glands often
receive high radiation doses, leading to side effects like xerostomia
(dry mouth) and dental disease that diminish patients' quality of life.
Furthermore, in patients with tumors lying close to sensitive central
neryous system organs, delivering adequate doses to the tumor was
rislqr or even inpossible.
The advent of computed tomography (gI) in tlre 1980s to 90s
spawned the era of 3D conformal RT (3DCR[), which changed the
practice of radiation oncology signfficantly. New computer technologies
and software tools allowed the details of patients' anatomy to be
directly visualized. Radiation oncologists were ableto define sfiuctures
directly on a CT scan. Dosimetrists could aaange radiation fields at
ffierent angles to create tighfly wrapping, conformal dose distributions
aroundthetargetwhile more effectively avoiding normal organs.
Radiation dose could be calculated precisely in 3D, and this information
was used to guide fteatment planning. Thus, 3DCRT became the
standard for HNC feafinent [1].
Despite this advancement, 3DCRT was still limited in many respects.
Optimizing RT plans was a trial-and-error process. Radiation
oncologists and dosimetrists could choose how to orient beams and
shape blocks, but could not fine-tune RT plans to meet specffic planning
goals. Furthermore,target delineation was inexact. CTs give useftrl
information about the density of ffierent head and neck tissues, but
lack information about functional processes at work in these tissues.
Finally, compared to modem standards, the accuracy in day{o-day
positioning patients was crude, and techniques to account for changing
patient anatomy overthe course of treafrnentwere notdeveloped. Novel
RT technologies have begun to address many of these limitations.
Intensity Modulated Radiation Therapy
Intensity modulated RT (IMRT) is an advanced technology in which
beam intensities are optimized to maximize radiation dose to the
target and minimize dose to normal tissues. Akey feature of IMRI is
the use of "invene planning," whereby specified dose constraints are
ADVANCED RADIATION TIIERAPY continued on page 2
$opoQoH.N.C P.O. Box 53 Locust Valley, NY 11560-0053 r-800-377-0928
Page2 April 2010
defined in advance, and computerized algorithms are used to choose
the best solution to meet these constraints. Although inverse planning
is not essential for IMRT (beam intensities may be modulated manually,
so-called'Torward-planned" IMRT), it is the most common IMRT
approach for HNC.
The major advancement with IMRI (that gives rise to its name)
is the ability to modulate the intensity of the beams used in ffeatrnent.
The most corlmon technique to modulate intensity is with multi-leaf
collimators (MLCs). A collimator is a device mounted on the head of
the radiation machine (gantry) that shapes the radiation beam. MLCs
ae comprised of many tiny leaves each of which can be placed under
cortrol of computerized motors that move them in and out of the path
of the beam. IMRI plans are therefore composed of thousands of tiny
"bearnlets" that are optimized for each patient's anatomy. MLCs may
be designed to move while the beam is off (static) or on (dynamic).
Another way to modulate intensity is with compensators, which are
customized metal alloys that allow varying amounts of radiation to
pass through. Both MlC-based and compensator-based IMRT have
advanAges and disadvantages. MlC-based IMRT is used most commonly.
It is more convenient fhan compensators, but requires expensive
software and hardware, and may result in more leakage radiation and
longer delivery times.
Arecent advancement in IMRT is rotational (arc)*q&py, which
allows Rf to bedehveredwhile the gantry is moving in an barqund
tbe pali€nt Studmd IMRIis delivened wift a fixed set of gantry ang)ds;-
wift tbe gantry mtat€d to a new position after each angle is finished.
ArcIMRTallowsthecomputerto take advantage of many more angles
ffim whEi to ctrftver ihe radiadon potenFally resulting in faster anO
more conformal treafrnentdelivery. Examples of clinically available arc
therapy systems include Tomotherapy@ and RapidArc@. ,.r'-
Many steps are involved in the IMRI planning and deliverylrrdss.
Fint, a CT simulation scan is obtained with the patient immo6ilized in
fte heamentposition. Immobilizationis necessaryto ensure thatpatients
are setup inthe same way eachdayanddo notmove duringteafinent.
The planning CT is hansferred to the treament planning systern, where
target and critical organs are contoured. In patients with visible tumor,
fu radiation oncologist will oufline a gross trmor volume (GTV), which
includes any tumff visible on tlre planning images. MRI and/or pET
scans may be used to assist with target volume delineation on the planning
CT scan. The clinical target volume (CTV) is a larger target that
includes the GTVplus anypotential areas of microscopic tumor spread.
Hnally, a planning target volume (PIV) is which includes
the CTV plus an additional margin (qpically 3-5 mm) to account for
daily variations in target position. Radiation dose is prescribed to the
PTV. Once the PTV is created, aphysicist and/or dosimefist designs an
IMRTplan. Aftertheradiation oncologis approves the plan, physicists
run quality assurance tests to verify that the dose delivery is accurate.
Finally, the plan is ready to be detvered. The entire planning process
may take several days or more.
IMRT planning can significantly reduce dose to organs like the
parotid gland, cochlea (inner em), eye, brain, and spinal cord, while
maintaining sufflcient dose to the target. One sophisticated application of
IMRT is called "dose painting" or "simultaneous integrated boost (SIB)".
A boost treafrnent is an extra dose given to part of the targe! such as a
large tumor. in order to increase the probability of tumor control. Boost
IMPROVED TREAIIVIENTS continued on page 3
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Executive Director
MEDICALADVISORY BOARD
W.EiselgMD,FACS
Unittersity of Califomia San Frumcisco
IlaYdG.mq,MD
Mennrial kwtKmfinq fur Catcr
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NEWSLETTER EDITOR
NancyE. I-eupoldMA
WEBMASTER
Ross Mahler
News From SPOIINC is a publication of
Support for People with Oral and Head and Neck Cancer, Inc.
Copyright @2008-20@
DISCLAIMER: Support for People with Oral and Head and Neck Cancer, Inc.
not endorse any treatments or products mentioned in rhis newsleser. [t your physician before using any treatments or Droducts.
Caregivers Corner..........
Depression in Head and Neck Cancer Patients..........................8
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$opoQofl.
IMPROVED TREAIMENTS from page 2
doses are usually given sequentially, following
feafrnent of the larger target. SIB technique
allows portions of the target to receive higher
doses simultaneously, so that the entire target
is freated each day, shortening the freaftnent
course, and delivering higher doses per day to
the gross tumor.
Several studies have reported high rates of
survival and disease control in patients freated
with IMRT [2-4]. Two clinical studies have
also shown that IMRT reduces the risk of side
effects. Kam et al. [5] conducted a randomized
trial to compare xerostomia between 2DRT
and IMRT in 50 patients with nasopharyngeal
carcinoma. One year after the completion of
treafrnent, the incidence of severe xerostomia
was lower in patients who received IMRT
(39V0) compared to 2DRT (827o). Recently,
the PARSPORT tial, conducted.in 94 HNC
patients, found that at 18 months following
fteatrnent, xerostomia was reduced in patients
receiving IMRT compared to conventional
techniques (20% v s. SlVo) 16l.
Al*rough IMRThas become the standard
RT approach for HNC, it has some disadvantages.
IMRT is more costly and generally
increases low dose radiation to the rest of the
body. Therc is cmcem thet some sitle effects
may be increased as a resulg particularly
when chemotherapy is given concurrently.
For example, inthePARSPORT study, fatigue
was increased in patients receiving IMRT.
Increased radiation dose to other parts of the
body may increase the risk of late secondary
cancers. Ongoing study is important to ensure
the longterm safety and superiority of IMRT
over conventional techniques.
Image-guided Radiation
Therapy
Image-guided RT (IGRT) refers to a constellation
of new imaging technologies used to
guide RI planning and delivery. Most radiation
oncologists in the United States are now using
IGRT, and its utilization appears to be increasing
[7-8]. There are two broad categories of
IGRT. One uses imaging to locate tumor and
identi$ its functional properties, to better guide
target delineairjon. The second uses imaging to
ensure accurate patient positioning and monitor
changes taking place dwing treatrnent, to guide
treatment delivery.
CT is limited in these capacities because it
only shows contast between tissues of differing
densities (like a 3D x-ray). Increasing availabiJity
of sophisticated imagng technologies
such as magnetic resonance imagng (IvRD,
positron emission tomography (PET), and
single photon emission computed tomography
(SPECT), has increased our ability to localize
and characterize tumors. MRI and PET have
been especially usefirl for target delineation in
HNC. Bottr PET and MRI images may be fused
with tlre simulation CT, allowing a combination
of ffierent types of information to be used in
RT planning. Approximately 4OVo of radiatton
oncologists in the U.S. curently use MRI and
7 0Vo use PEI for RT target delineation [7].
MRI can distinguish different chemical
properties of tissues, lgading to better soft tissue
contrast compared to CT. It is especially
usefrrl in imaging tumors of the nasophary.nx
and base of tongue, and tumors located near the
brain and skull, where CT has more difficulty
distinguishing from surrounding structures.
PET, on the other hand, can be used to image
various biochemical properties of cells; for
example, 1 8-fluoro-deoxy-glucose (FDG).
PET is usefirl for imagng cells with increased
metabolic activity, like tumor cells. Cells use
glucose to create energy; tumor cells use more
glucose because they are dividing frequently.
With FDG-PET, a patient is injected with a
rdiectively labeled ghrcme mlecule, which
collects in metabolically active cells. Apanel
in the PET scarmer detects the emission of
positrons by the radioactive molecule (more
precisely, the photons generated by such
positrons), allowing tumor visualization. By
helping to identify tumor extent lymph node
involvement, PETmay alterthe RTplanin approximately
one quarter ofpatients [9]. Highly
sophisticated applications of PET and MRI
can be used to image other tumor properties
such as low oxygen (hypoxia) or high cellular
reproduction. These exciting applications are
currenfly investigational.
Once in the treatment room, it is important
to verify the patient is in the proper position
prior to delivering RT. Tiaditionally, this was
accomplished by kking a 'port film". With
portal imaging, the radiation beam is tumed
on briefly, exposing a film placed behind the
patientwithhigh-energy (lt4egavoltage orMV)
x-rays. The bone anatomy and block shape
are compared to the planning image to verify
position. This process requiredpersonnel to go
in and out of the room to set up the film and
develop it. A signifi cant technological advancement
was the Electronic Portal Imaging Device
GPD), which stores portal images digita[y,
allowing verification to be done elecffonically.
One limitation of MV port images, however, is
the poor confrastbetween bone and soft tissue.
Low energy (kilovoltage or kV) x-rays, such as
are usedfor diagnosis ratherthan therapy, show
better contrast. Newer radiation machines have
kV x-ray imagers in the fteatrnent room, either
mounted in the wall or onto the gantry, a[owing
diagnostic quality films forpositioning verification.
Examples of such technologies include
CyberKnife@, Novalis@, XVI@and OBI@.
An altemative to x-ray imaging for setup
verification is video alignment. The advantage
ofvideo is that it does not add undesirable radiation
exposure. In additioq video monitoring
of a patient's surface contour dwing treafinent
may obviate the needforuncomfortable masks
currently used for immobilization. Several
video systems are now available and are becoming
increasingly implemented in radiation
oncology clinics.
Amajor advancement is in-room 3D imaging.
This is an exciting technology because it
can allow better visualization of the anatomy,
in the same way a CT scan provides more information
than a plain x-ray. It also allows the
potential to adapt radiation plans "on-the-fly'' to
changes that occur during treafrnent. However,
such adaptive radiation *riques require further
studybefore gainingroutine use. Currently,
3D imaging is used to guide patient setup, to
ensure highly accurate treatment delivery.
One technology (CT-on-rails) connects a CT
scanner to the ffeafrnent table via a set ofrails
so that CT images can be acquired without the
patient changing position. A drawback of CT
on rails is that the patient must be moved from
under the accelerator ganfiy to the CT ganty
and then back again which is cumbersome and
time consuming. Another technology (cone
beam CT (CBCT) uses a kV CBCT scanner
mounted to the gantry, so that a scan can be
taken while the machine rotates around the
patient. Another technology is Tomotherapy@,
in which the radiation is delivered in a rotational
pattem much the same way that a CT scan is
obtained. This machine can also acquire inroomMVCTimages.
IGRT technologies have substantially
increased the precision in treaftnent of HNC.
However, there are some concems about widespread
use of IGRL These include the extra
time and expense, inconvenience to patients,
additional radiation exposure, and uncertainty
about its overall benefits. Moreover, imagng
quality has still not advanced to levels where
microscopic tumor cells can be accurately
IMPROVED TREATMENTS on page 4
$opoQoH.N.C http://www. spohnc.org E-mail-- info@ spohnc.org
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located. High-techimaging such as MRIis not
yet available in the treatrnent room. Developing
new IGRT applications and evaluating
their clinical benefits are ongoing endeavors
in radiation research.
Stereotactic Body
Radiation Therapy
A recent advancement in HNC is stereotactic
body RI (SBRI), including stereotactic radio.
surgery (SRS). The term "stereotactic" refers
to ulffa-precise target localization in 3-D space
(within about 1 mm). This technology has long
been used to treat brain tumors, in order to
deliver high radiation doses in one or a few fractions
(hypofractionation), employing tightplanning
margins to minimize collateral damage.
Classically this technique requires rigid patient
immobilization in a head frame, multi-angle
beam delivery and high quality imaging for
target localization may occur in several ways.
At the University of Califomia San Diego
(UCSD), HNC patients are positioned in a
non-invasive head frame with ablockinserted
in the mouth to ensure head rigidity. The block
is localized in the freatment room by infrared
sensors to position the patient with high accupreviously
irradiated patients with recurrence.
They found that a dose of 44 Gy in 5 fractions
was well{olerated without severe toxicity[l 1].
Siddiqui et al.[12] studied SBRT in 44 patients
wittr pdmary or recunent HNC, using 13-18
Gyinasingle-fraction or 3648 Gyin 5-8 fractions.
Tumor contol rates at I year were 83Vo
andffio in the primary and recurrent groups,
rc.lpectively.
Conclusion
Advanced radiation therapy technologies have
revolutionized HNC fieatment and are providing
mpcedent€d levels of RT precision.
Research to iryrove the quality of imaging
and RI delivery techniques is ongoing. Many
sndi€s s4pcrttbe use of 6ese technologies, but
frnft€r sdy is needed to evaluare their ultimare
benefit for HNC patients.
Dr. Swapw Manaj specinlizes in h.ead and neck
surgical oru:ology and is cunently a visiting research
fellnw at the UCSD Center for Advanced
Radiotlvrapy Teclanbgies. Her research focuses
on oulcones for hcad and ncck concer using IMRT
and adaptive IG RT te chrc bgie s.
of aphase Itr multicenterrandomized connolled frial
of intensity modulated (IMRI) versus conventional
radiotherapy @T) in headand neckcancer (absf.)"/
Clin Orcol 20fl9:27 :l8s suppl: LBA6006.
7. Simpson DR" l,awson JD, Narh SK Rose BS,
MundtAJ, Mell LK. Utilization of advanced imaging
technologies for target delineation in radiation
oncology. J Am Coll Radiol?-N9;6:876-883.
8. Simpson DR, Lawson JD, Nath SI( Rose BS,
MundtAJ, Mell LI( A suwey of image-guided radialo1r_
rlerapy in the United S"rates. CZnier.ln press.
9. Kolarova I, Vanasek J, Odrazka K Petruzelka L,
Dolezel M, Nechvil J. Use of PET/CT examination
inhead andneckcancerradiotherapy planrmg. Klin
Onl<nl2W;22:98-103.
10. Kavanagh BD, Timmerman RD. Stereotactic
body radiation therapy. Lippincott Williams &
Wilkins, Philadelphia 2005.
11. Heron DE, Ferris RL, Karamouzis M, et al. Stereolacticbody
radiotherapy for recurrent squamous
cell carcinoma of the head and neck: results of a
phase I dose-escalationtrial.lnt J Radint Oncol Biol
Plrys?ffi;751493-1500.
12. Siddiqui F, Patel M, Khan M, er al. Stereotactic
hAy raaiatm tberapy for primary, recurrent, and
metastalic [ s in ftehead-and-neekre$on. Int J
Radia Oncol Biol Phys 2W ;1 4:lM7 -t6$.
target localiafon[10]. Hypofractionatiol has tul-tor\ Nde: Dr Iomn MeIl potential is o,tassisto, tp Ses_ advantages overstandardtechniquel *rarn oryo**gRdiainorcology att, suchashighertumorcellhllandshorteroverall Univenity g elifonia tut Diego eCSb W_
ffeatrnent duration. It is most suitable for targef cializing in luad ad ,Eck otreoloi!. He dircc*'tlre
With advances in in-room imaging tech- UCSD R1d; yn Oncology DewrfiEnt and sentes
nologies, it is possible to position patients to a: +slqate Dj*!":of .tne.!79 fgl Advanced
volumes less than about 5 cm[3]. clinical otd translaioul rcxmch prcgwtfor the
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tumors (e.g., SBRT). Patient positioning and sity_nadulatedradiationtherapy(IMRf)i.
racy. Kilovoltage CBCT images are obtained RHEREhICF^S
toveriffpositioning.An|MRTorarctherapy 1.'Timm:rmaa R,4"g L. Ilnage-Guided and
plan is' delivere4 q'p*.xl rn:i-^u^u*{^ tffi -Hffit ffffilalippincott
williams
using the Trilogy@ system. At UCSD, we have i. O" aooO" ff,, n h O1g aune I, et al. Intensiw_
startedusingvideotechnologytoteatpatients modulated radiation therapy fol the neatment 6f
with SBRT without a head frame or bite block oropharyngeal_caciooma the Memorial Sloan Ketorlrer
SBRT rechnologi* ;d"d" cd;K"if". WrffiffiffiY. Int J Radiat oncot
and Novalis@. The CyberKnife@ system obtains 3. t ee N Xia f, eulvey ffvf, et al. Intensib/_modu_
highly conformal dose distributions by rotat- Iatedradiolberapyintheteamentofnasophbryngeal
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positioning. Novalis@ uses fine beam shaping chemotherapyandiotr*ity-*oairut"o*on"trr"*py
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ratface said:

Advanced Radiation Therapay for head and neck cancer
This is the lead article from SPOHNC April 2010, Vol. 19 No 7, everything you always wanted to know about radiation. I scanned it for you and it's a little patchy but you will find your answers here. take the time to read it and subscribe to their news letter. Hope it helps. From my read IMRT is fast becomming "old hat" The new technologies are promising but not time tested yet.





ITEI,YS FROM
S.P.O.H.tr/.C
vol,. 19 NO. 7 SUPPORT FOR PEOPLE WrTIr ORALAND HEAD AND NECK CANCE& rNC. ApRrL 2010
S.P.Ooflo\eQ
APROGRAM OF SUPPORT
FOR
PEOPLEWITH
ORAL AND
HEADAND NECK CANCER
Advanced Radiation
Therapy Techniques For
Head And Neck Cancer
Swapna Manoj, MS- MJ.
Loren IC Me[, M.D.
Radiation therapy (Rf), often in combination wrthchemotherapy and/or
surgery is commonly used to treat head and neck cancer (IINC). It may
be used as adjuvant therapy (following surgery) in patients at risk for
recurrbnce, as the primary treafinent (in place of surgery) to preserve
organ function, or as palliative therapy for metastatic disease. RT is
typically delivered using high-energy photons and/or elecfrons, which
cause cellular DNA damage, preventing tumor growth.
Important responsibilities of the radiation oncologist are to define
the regions that need to be iradiated (i.e., target definition) and determine
the total dose and fractionation (i.e., dose per day), itt order to
ensure maximal probability of tumor control with minimal side effects.
Targets are delineatedbased on knowledge ofthe tumor location and its
particular pattems of spread, such as invasion into surrounding tissues
and spread to lymph nodes in the neck. In many cases, determining the
exact tumor location is difficulg due to limitations in imaging capabilities
and variations in patients'anatomy through the treatrnent course.
Consequently, radiation oncologists often need to apply wide margins
around targets to ensure that tumor is adequately encompassed by the
radiation fields.
A major challenge is to deliver high doses of radiation to the
tumor while minimizing the dose received by critical nearby organs
including the brain, spinal cord, mandible, and major salivary glands,
amongst others. This article will describe the modem technological
advancements that facilitate greater precision in RI delivery that will
hopefrrlly lead to improved therapeutic results.
Conventional Radiation Therapy Ttrhniques
Historically, Rlplanning depended on two-dimensional x-ray images
(2DRT). Radiation oncologists would define the target and verify
patient positioning using skeletal landmarks and metal wires (which
were visible on x-rays). RT was delivered using a limited number of
fields (usually 2-3), which were set up as two opposing lateral fields
through the upper head/neck region, with a matching anterior field
through the lower neck. Critical organs like brain and spinal cord were
blocked using metal shielding.
There are numerous limitations to 2DRT. Fing the target is only
indirectly identified, because it is defined relative to the location of
bony landmarls. These arc not always good surrogates for actual target
location, because ofvariations in patients' anatomy and particular
characteristics of their cancer. Secondly, using a limited number of
fields means that normal organs such as the salivary glands often
receive high radiation doses, leading to side effects like xerostomia
(dry mouth) and dental disease that diminish patients' quality of life.
Furthermore, in patients with tumors lying close to sensitive central
neryous system organs, delivering adequate doses to the tumor was
rislqr or even inpossible.
The advent of computed tomography (gI) in tlre 1980s to 90s
spawned the era of 3D conformal RT (3DCR[), which changed the
practice of radiation oncology signfficantly. New computer technologies
and software tools allowed the details of patients' anatomy to be
directly visualized. Radiation oncologists were ableto define sfiuctures
directly on a CT scan. Dosimetrists could aaange radiation fields at
ffierent angles to create tighfly wrapping, conformal dose distributions
aroundthetargetwhile more effectively avoiding normal organs.
Radiation dose could be calculated precisely in 3D, and this information
was used to guide fteatment planning. Thus, 3DCRT became the
standard for HNC feafinent [1].
Despite this advancement, 3DCRT was still limited in many respects.
Optimizing RT plans was a trial-and-error process. Radiation
oncologists and dosimetrists could choose how to orient beams and
shape blocks, but could not fine-tune RT plans to meet specffic planning
goals. Furthermore,target delineation was inexact. CTs give useftrl
information about the density of ffierent head and neck tissues, but
lack information about functional processes at work in these tissues.
Finally, compared to modem standards, the accuracy in day{o-day
positioning patients was crude, and techniques to account for changing
patient anatomy overthe course of treafrnentwere notdeveloped. Novel
RT technologies have begun to address many of these limitations.
Intensity Modulated Radiation Therapy
Intensity modulated RT (IMRT) is an advanced technology in which
beam intensities are optimized to maximize radiation dose to the
target and minimize dose to normal tissues. Akey feature of IMRI is
the use of "invene planning," whereby specified dose constraints are
ADVANCED RADIATION TIIERAPY continued on page 2
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Page2 April 2010
defined in advance, and computerized algorithms are used to choose
the best solution to meet these constraints. Although inverse planning
is not essential for IMRT (beam intensities may be modulated manually,
so-called'Torward-planned" IMRT), it is the most common IMRT
approach for HNC.
The major advancement with IMRI (that gives rise to its name)
is the ability to modulate the intensity of the beams used in ffeatrnent.
The most corlmon technique to modulate intensity is with multi-leaf
collimators (MLCs). A collimator is a device mounted on the head of
the radiation machine (gantry) that shapes the radiation beam. MLCs
ae comprised of many tiny leaves each of which can be placed under
cortrol of computerized motors that move them in and out of the path
of the beam. IMRI plans are therefore composed of thousands of tiny
"bearnlets" that are optimized for each patient's anatomy. MLCs may
be designed to move while the beam is off (static) or on (dynamic).
Another way to modulate intensity is with compensators, which are
customized metal alloys that allow varying amounts of radiation to
pass through. Both MlC-based and compensator-based IMRT have
advanAges and disadvantages. MlC-based IMRT is used most commonly.
It is more convenient fhan compensators, but requires expensive
software and hardware, and may result in more leakage radiation and
longer delivery times.
Arecent advancement in IMRT is rotational (arc)*q&py, which
allows Rf to bedehveredwhile the gantry is moving in an barqund
tbe pali€nt Studmd IMRIis delivened wift a fixed set of gantry ang)ds;-
wift tbe gantry mtat€d to a new position after each angle is finished.
ArcIMRTallowsthecomputerto take advantage of many more angles
ffim whEi to ctrftver ihe radiadon potenFally resulting in faster anO
more conformal treafrnentdelivery. Examples of clinically available arc
therapy systems include Tomotherapy@ and RapidArc@. ,.r'-
Many steps are involved in the IMRI planning and deliverylrrdss.
Fint, a CT simulation scan is obtained with the patient immo6ilized in
fte heamentposition. Immobilizationis necessaryto ensure thatpatients
are setup inthe same way eachdayanddo notmove duringteafinent.
The planning CT is hansferred to the treament planning systern, where
target and critical organs are contoured. In patients with visible tumor,
fu radiation oncologist will oufline a gross trmor volume (GTV), which
includes any tumff visible on tlre planning images. MRI and/or pET
scans may be used to assist with target volume delineation on the planning
CT scan. The clinical target volume (CTV) is a larger target that
includes the GTVplus anypotential areas of microscopic tumor spread.
Hnally, a planning target volume (PIV) is which includes
the CTV plus an additional margin (qpically 3-5 mm) to account for
daily variations in target position. Radiation dose is prescribed to the
PTV. Once the PTV is created, aphysicist and/or dosimefist designs an
IMRTplan. Aftertheradiation oncologis approves the plan, physicists
run quality assurance tests to verify that the dose delivery is accurate.
Finally, the plan is ready to be detvered. The entire planning process
may take several days or more.
IMRT planning can significantly reduce dose to organs like the
parotid gland, cochlea (inner em), eye, brain, and spinal cord, while
maintaining sufflcient dose to the target. One sophisticated application of
IMRT is called "dose painting" or "simultaneous integrated boost (SIB)".
A boost treafrnent is an extra dose given to part of the targe! such as a
large tumor. in order to increase the probability of tumor control. Boost
IMPROVED TREAIIVIENTS continued on page 3
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BOARD OFDIRECTORS
Nancy E. Leupold, MA, President
James J. Sciubba, D.M.D, Ph.D., Vice President
Walter E. Boehmler, Treasurer
Maria DeMarco Begley, Esq.
Gail Fass
Karrie Zampini, LCSW
MaryAnn Caputo
Executive Director
MEDICALADVISORY BOARD
W.EiselgMD,FACS
Unittersity of Califomia San Frumcisco
IlaYdG.mq,MD
Mennrial kwtKmfinq fur Catcr
JedFoIa*,MI)
Iorg Islmd Rdiaian OrwfuW;
JatmJ.Sttubbe,DMD,Iil)
Grcaer fultinnre Medial Cater
RandalS.W@,MD,FACS
MD Anfunon Corcer Center
Eiliot W. Shons MD, FAC$ Enerihs
fe Martin-Ilarris, PhD,CCCSLP
cal Universiry ofSouth Carolinn
Kelle6M.D.,FACS
t Shore-Ul Health Svstem
Uruu. of Pittsburgh $cfunloflledichrc North Share-LIJ Henlth System I]avidMFsioreL,MD,FACS EverettE Vokes,MD -
New York Universiry University ofChicago Medical Center
16a1ds Zsnpini, LCSW
Figltting Chance, Sag Harbor NY
NEWSLETTER EDITOR
NancyE. I-eupoldMA
WEBMASTER
Ross Mahler
News From SPOIINC is a publication of
Support for People with Oral and Head and Neck Cancer, Inc.
Copyright @2008-20@
DISCLAIMER: Support for People with Oral and Head and Neck Cancer, Inc.
not endorse any treatments or products mentioned in rhis newsleser. [t your physician before using any treatments or Droducts.
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IMPROVED TREAIMENTS from page 2
doses are usually given sequentially, following
feafrnent of the larger target. SIB technique
allows portions of the target to receive higher
doses simultaneously, so that the entire target
is freated each day, shortening the freaftnent
course, and delivering higher doses per day to
the gross tumor.
Several studies have reported high rates of
survival and disease control in patients freated
with IMRT [2-4]. Two clinical studies have
also shown that IMRT reduces the risk of side
effects. Kam et al. [5] conducted a randomized
trial to compare xerostomia between 2DRT
and IMRT in 50 patients with nasopharyngeal
carcinoma. One year after the completion of
treafrnent, the incidence of severe xerostomia
was lower in patients who received IMRT
(39V0) compared to 2DRT (827o). Recently,
the PARSPORT tial, conducted.in 94 HNC
patients, found that at 18 months following
fteatrnent, xerostomia was reduced in patients
receiving IMRT compared to conventional
techniques (20% v s. SlVo) 16l.
Al*rough IMRThas become the standard
RT approach for HNC, it has some disadvantages.
IMRT is more costly and generally
increases low dose radiation to the rest of the
body. Therc is cmcem thet some sitle effects
may be increased as a resulg particularly
when chemotherapy is given concurrently.
For example, inthePARSPORT study, fatigue
was increased in patients receiving IMRT.
Increased radiation dose to other parts of the
body may increase the risk of late secondary
cancers. Ongoing study is important to ensure
the longterm safety and superiority of IMRT
over conventional techniques.
Image-guided Radiation
Therapy
Image-guided RT (IGRT) refers to a constellation
of new imaging technologies used to
guide RI planning and delivery. Most radiation
oncologists in the United States are now using
IGRT, and its utilization appears to be increasing
[7-8]. There are two broad categories of
IGRT. One uses imaging to locate tumor and
identi$ its functional properties, to better guide
target delineairjon. The second uses imaging to
ensure accurate patient positioning and monitor
changes taking place dwing treatrnent, to guide
treatment delivery.
CT is limited in these capacities because it
only shows contast between tissues of differing
densities (like a 3D x-ray). Increasing availabiJity
of sophisticated imagng technologies
such as magnetic resonance imagng (IvRD,
positron emission tomography (PET), and
single photon emission computed tomography
(SPECT), has increased our ability to localize
and characterize tumors. MRI and PET have
been especially usefirl for target delineation in
HNC. Bottr PET and MRI images may be fused
with tlre simulation CT, allowing a combination
of ffierent types of information to be used in
RT planning. Approximately 4OVo of radiatton
oncologists in the U.S. curently use MRI and
7 0Vo use PEI for RT target delineation [7].
MRI can distinguish different chemical
properties of tissues, lgading to better soft tissue
contrast compared to CT. It is especially
usefrrl in imaging tumors of the nasophary.nx
and base of tongue, and tumors located near the
brain and skull, where CT has more difficulty
distinguishing from surrounding structures.
PET, on the other hand, can be used to image
various biochemical properties of cells; for
example, 1 8-fluoro-deoxy-glucose (FDG).
PET is usefirl for imagng cells with increased
metabolic activity, like tumor cells. Cells use
glucose to create energy; tumor cells use more
glucose because they are dividing frequently.
With FDG-PET, a patient is injected with a
rdiectively labeled ghrcme mlecule, which
collects in metabolically active cells. Apanel
in the PET scarmer detects the emission of
positrons by the radioactive molecule (more
precisely, the photons generated by such
positrons), allowing tumor visualization. By
helping to identify tumor extent lymph node
involvement, PETmay alterthe RTplanin approximately
one quarter ofpatients [9]. Highly
sophisticated applications of PET and MRI
can be used to image other tumor properties
such as low oxygen (hypoxia) or high cellular
reproduction. These exciting applications are
currenfly investigational.
Once in the treatment room, it is important
to verify the patient is in the proper position
prior to delivering RT. Tiaditionally, this was
accomplished by kking a 'port film". With
portal imaging, the radiation beam is tumed
on briefly, exposing a film placed behind the
patientwithhigh-energy (lt4egavoltage orMV)
x-rays. The bone anatomy and block shape
are compared to the planning image to verify
position. This process requiredpersonnel to go
in and out of the room to set up the film and
develop it. A signifi cant technological advancement
was the Electronic Portal Imaging Device
GPD), which stores portal images digita[y,
allowing verification to be done elecffonically.
One limitation of MV port images, however, is
the poor confrastbetween bone and soft tissue.
Low energy (kilovoltage or kV) x-rays, such as
are usedfor diagnosis ratherthan therapy, show
better contrast. Newer radiation machines have
kV x-ray imagers in the fteatrnent room, either
mounted in the wall or onto the gantry, a[owing
diagnostic quality films forpositioning verification.
Examples of such technologies include
CyberKnife@, Novalis@, XVI@and OBI@.
An altemative to x-ray imaging for setup
verification is video alignment. The advantage
ofvideo is that it does not add undesirable radiation
exposure. In additioq video monitoring
of a patient's surface contour dwing treafinent
may obviate the needforuncomfortable masks
currently used for immobilization. Several
video systems are now available and are becoming
increasingly implemented in radiation
oncology clinics.
Amajor advancement is in-room 3D imaging.
This is an exciting technology because it
can allow better visualization of the anatomy,
in the same way a CT scan provides more information
than a plain x-ray. It also allows the
potential to adapt radiation plans "on-the-fly'' to
changes that occur during treafrnent. However,
such adaptive radiation *riques require further
studybefore gainingroutine use. Currently,
3D imaging is used to guide patient setup, to
ensure highly accurate treatment delivery.
One technology (CT-on-rails) connects a CT
scanner to the ffeafrnent table via a set ofrails
so that CT images can be acquired without the
patient changing position. A drawback of CT
on rails is that the patient must be moved from
under the accelerator ganfiy to the CT ganty
and then back again which is cumbersome and
time consuming. Another technology (cone
beam CT (CBCT) uses a kV CBCT scanner
mounted to the gantry, so that a scan can be
taken while the machine rotates around the
patient. Another technology is Tomotherapy@,
in which the radiation is delivered in a rotational
pattem much the same way that a CT scan is
obtained. This machine can also acquire inroomMVCTimages.
IGRT technologies have substantially
increased the precision in treaftnent of HNC.
However, there are some concems about widespread
use of IGRL These include the extra
time and expense, inconvenience to patients,
additional radiation exposure, and uncertainty
about its overall benefits. Moreover, imagng
quality has still not advanced to levels where
microscopic tumor cells can be accurately
IMPROVED TREATMENTS on page 4
$opoQoH.N.C http://www. spohnc.org E-mail-- info@ spohnc.org
-:*--+-
located. High-techimaging such as MRIis not
yet available in the treatrnent room. Developing
new IGRT applications and evaluating
their clinical benefits are ongoing endeavors
in radiation research.
Stereotactic Body
Radiation Therapy
A recent advancement in HNC is stereotactic
body RI (SBRI), including stereotactic radio.
surgery (SRS). The term "stereotactic" refers
to ulffa-precise target localization in 3-D space
(within about 1 mm). This technology has long
been used to treat brain tumors, in order to
deliver high radiation doses in one or a few fractions
(hypofractionation), employing tightplanning
margins to minimize collateral damage.
Classically this technique requires rigid patient
immobilization in a head frame, multi-angle
beam delivery and high quality imaging for
target localization may occur in several ways.
At the University of Califomia San Diego
(UCSD), HNC patients are positioned in a
non-invasive head frame with ablockinserted
in the mouth to ensure head rigidity. The block
is localized in the freatment room by infrared
sensors to position the patient with high accupreviously
irradiated patients with recurrence.
They found that a dose of 44 Gy in 5 fractions
was well{olerated without severe toxicity[l 1].
Siddiqui et al.[12] studied SBRT in 44 patients
wittr pdmary or recunent HNC, using 13-18
Gyinasingle-fraction or 3648 Gyin 5-8 fractions.
Tumor contol rates at I year were 83Vo
andffio in the primary and recurrent groups,
rc.lpectively.
Conclusion
Advanced radiation therapy technologies have
revolutionized HNC fieatment and are providing
mpcedent€d levels of RT precision.
Research to iryrove the quality of imaging
and RI delivery techniques is ongoing. Many
sndi€s s4pcrttbe use of 6ese technologies, but
frnft€r sdy is needed to evaluare their ultimare
benefit for HNC patients.
Dr. Swapw Manaj specinlizes in h.ead and neck
surgical oru:ology and is cunently a visiting research
fellnw at the UCSD Center for Advanced
Radiotlvrapy Teclanbgies. Her research focuses
on oulcones for hcad and ncck concer using IMRT
and adaptive IG RT te chrc bgie s.
of aphase Itr multicenterrandomized connolled frial
of intensity modulated (IMRI) versus conventional
radiotherapy @T) in headand neckcancer (absf.)"/
Clin Orcol 20fl9:27 :l8s suppl: LBA6006.
7. Simpson DR" l,awson JD, Narh SK Rose BS,
MundtAJ, Mell LK. Utilization of advanced imaging
technologies for target delineation in radiation
oncology. J Am Coll Radiol?-N9;6:876-883.
8. Simpson DR, Lawson JD, Nath SI( Rose BS,
MundtAJ, Mell LI( A suwey of image-guided radialo1r_
rlerapy in the United S"rates. CZnier.ln press.
9. Kolarova I, Vanasek J, Odrazka K Petruzelka L,
Dolezel M, Nechvil J. Use of PET/CT examination
inhead andneckcancerradiotherapy planrmg. Klin
Onl

Treatment
I had 36 straight daily rounds of Tomotherapy brand of IMRT. It delivered the radiation in a circular motion, whereas is would complete 31 rotations around my head as I lay in the tube with the mask. I would on even days count from one to thirty one....on odd days count from 31 to 1. I can recall toward the end of treatment becoming so angry and frustrated because I so bonkers that I couldn't remember if it was an odd...count down day...or an even day. Tried anything to keep me sane.
Larry

Greg53 said:

Happy Place
I had similar treatment as Cajun. Mine was 35 treatments, 5 days a week. Two of my friends went thru similar treatments. They both told me to find a "Happy Place" to go to during rad treatments. I would have a vacation or really pleasant experience in mind and start re-living it as soon as they bolted me down to the table. (Needless to say several were of fishing trips).
Greg

Oops
Ignore reference to fishing trips. My wife saw my previous pic I was using (me fishing) and said I looked like a hillbilly, so she made me change it.

Skiffin16 said:

Fishin Trips
Greg,

I decided to change my photo just so you can change yours back now....fishing can be the photo theme for the month, LOL....

Welcome to the hills brother...except not many hills here in Florida, just a few Grouper, Pompano, Snapper, Redfish, Snook, Cobia, Trout, Flounder, Bass, Crappie (Specks here).

John

photo of the month theme
john there is no way i am holding a wriggly gross fish and taking a picture. lol. eeewwie.

Skiffin16 said:

Sweet Exception
OK Sweet, you can just hold up a can of Tuna Fish, LOL....

thank you
if you did not give me a pass for that, next month the photo of the month was going to be wear your favorite stilletos! i had a pair of red heels you coulda borrowed if your wife didn't have a pair for you. ;-)

Skiffin16 said:

Fishin Trips
Greg,

I decided to change my photo just so you can change yours back now....fishing can be the photo theme for the month, LOL....

Welcome to the hills brother...except not many hills here in Florida, just a few Grouper, Pompano, Snapper, Redfish, Snook, Cobia, Trout, Flounder, Bass, Crappie (Specks here).

John

Note to Skiffen
John,
Great pic! Only Largemouth, Smallies, Specs, Cats, Pike, Walleye, 'gills, Muskie, and White Bass to fish for up here and Trout if you go to the state parks. Fishin' is fishin' though and a good escape from dealing with daily problems. Keep your line tight!
Greg