title: Comprehensive irradiation of head and neck cancer using conformal multisegmental fields: assessment of target coverage and noninvolved tissue sparing.
abstract: OBJECTIVE
  Conformal treatment using static multisegmental intensity modulation was developed for patients requiring comprehensive irradiation for head and neck cancer. The major aim is sparing major salivary gland function while adequately treating the targets. To assess the adequacy of the conformal plans regarding target coverage and dose homogeneity, they were compared with standard irradiation plans.
  
  
  METHODS
  Fifteen patients with stage III/IV head and neck cancer requiring comprehensive, bilateral neck irradiation participated in this study. CT-based treatment plans included five to six nonopposed fields, each having two to four in-field segments. Fields and segments were devised using beam's eye views of the planning target volumes (PTVs), noninvolved organs, and isodose surfaces, to achieve homogeneous dose distribution that encompassed the targets and spared major salivary gland tissue. For comparison, standard three-field radiation plans were devised retrospectively for each patient, with the same CT-derived targets used for the clinical (conformal) plans. Saliva flow rates from each major salivary gland were measured before and periodically after treatment.
  
  
  RESULTS
  On average, the minimal dose to the primary PTVs in the conformal plans [95.2% of the prescribed dose, standard deviation (SD) 4%] was higher than in the standard plans (91%, SD 7%; p = 0.02), and target volumes receiving <95% or <90% of the prescribed dose were smaller in the conformal plans (p = 0.004 and 0.02, respectively). Similar advantages of the conformal plans compared to standard plans were found in ipsilateral jugular nodes PTV coverage. The reason for underdosing in the standard treatment plans was primarily failure of electron beams to fully encompass targets. No significant differences were found in contralateral jugular or posterior neck nodes coverage. The minimal dose to the retropharyngeal nodes was higher in the standard plans. However, all conformal plans achieved the planning goal of delivering 50 Gy to these nodes. In the conformal plans, the magnitude and volumes of high doses in noninvolved tissue were significantly reduced. The main reasons for hot spots in the standard plans (whose dose calculations included missing tissue compensators) were photon/electron match line inhomogeneities, which were avoided in the conformal plans. The mean doses to all the major salivary glands, notably the contralateral parotid (receiving on average 32% of the prescribed dose, SD 7%) were significantly lower in the conformal plans compared with standard radiation plans. The mean dose to the noninvolved oral cavity tended to be lower in the conformal plans (p = 0.07). One to 3 months after radiation, on average 60% (SD 49%) of the preradiation saliva flow rate was retained in the contralateral parotid glands and 10% (SD 16%) was retained in the submandibular/sublingual glands.
  
  
  CONCLUSIONS
  Planning and delivery of comprehensive irradiation for head and neck cancer using static, multisegmental intensity modulation are feasible. Target coverage has not been compromised and dose distributions in noninvolved tissue are favorable compared with standard radiation. Substantial major salivary gland function can be retained.
authors.affiliation: Department of Radiation Oncology, University of Michigan Medical Center, Ann Arbor 48109, USA.
authors.forename: A
authors.initials: A
authors.lastname: Eisbruch
authors.forename: L H
authors.initials: LH
authors.lastname: Marsh
authors.forename: M K
authors.initials: MK
authors.lastname: Martel
authors.forename: J A
authors.initials: JA
authors.lastname: Ship
authors.forename: R
authors.initials: R
authors.lastname: Ten Haken
authors.forename: A T
authors.initials: AT
authors.lastname: Pu
authors.forename: B A
authors.initials: BA
authors.lastname: Fraass
authors.forename: A S
authors.initials: AS
authors.lastname: Lichter
mesh_terms: D002294:Carcinoma, Squamous Cell / Q000532:radiotherapy*; D006258:Head and Neck Neoplasms / Q000532:radiotherapy*; D006801:Humans; D011879:Radiotherapy Dosage; D011881:Radiotherapy, Computer-Assisted / Q000379:methods*; D012463:Saliva / Q000378:metabolism; D012469:Salivary Glands / Q000502:physiology / Q000528:radiation effects