title: Beam intensity modulation using tissue compensators or dynamic multileaf collimation in three-dimensional conformal radiotherapy of primary cancers of the oropharynx and larynx, including the elective neck.
abstract: BACKGROUND
  The treatment of midline tumors in the head and neck by conventional radiotherapy almost invariably results in xerostomia. This study analyzes whether a simple three-dimensional conformal radiotherapy (3D-CRT) technique with beam intensity modulation (BIM) (using a 10-MV beam of the MM50 Racetrack Microtron) can spare parotid and submandibular glands without compromising the dose distribution in the planning target volume (PTV).
  
  
  METHODS
  For 15 T2 tumors of the tonsillar fossa with extension into the soft palate (To) and 15 T3 tumors of the supraglottic larynx (SgL), conventional treatment plans, consisting of lateral parallel opposed beams, were used for irradiation of both the primary tumor (70 Gy) and the elective neck regions (46 Gy). Separately, for each tumor a 3-D conformal treatment plan was developed using the 3-D computer planning system, CadPlan, and Optimize, a noncommercial program to compute optimal beam profiles. Beam angles were selected with the intention of optimal sparing of the salivary glands. The intensity of the beams was then modulated to achieve a homogeneous dose distribution in the target for the given 3D-CRT techniques. The dose distributions, dose-volume histograms (DVHs) of target and salivary glands, tumor control probabilities (TCPs), salivary gland volumes absorbing a biologically equivalent dose of greater than 40 or 50 Gy, and normal tissue complication probabilities (NTCPs) of each treatment plan were computed. The parameters of the 3D-CRT plans were compared with those of the conventional plans.
  
  
  RESULTS
  In comparison with the conventional technique, the dose homogeneity in the target volume was improved by the conformal technique for both tumor sites. In addition, for the SgL conformal technique, the average volumes of the parotid glands absorbing a BED of greater than 40 Gy (V40) decreased by 23%, and of the submandibular glands by 7% (V40) and 6% (V50). Consequently, the average NTCPs for the parotid and submandibular glands were reduced by 7% and 6%, respectively. For the To conformal techniques, the V40 of the parotid glands was decreased on average by 31%, resulting in an average reduction of the NTCP by 49%. Both the average V50 and the NTCP of the submandibular glands were decreased by 7%.
  
  
  CONCLUSIONS
  For primary tumors of the oropharynx, the parotid glands could be spared to a considerable degree with the 3D-CRT technique. However, particularly the ipsilateral submandibular gland could not be spared. For primary tumors of the larynx, the 3D-CRT technique allows sparing of all salivary glands to a considerable and probably clinically relevant degree. Moreover, the conformal techniques resulted in an increased dose homogeneity in the PTV of both tumor sites.
authors.affiliation: Department of Radiation Oncology, University Hospital Rotterdam--Daniel den Hoed Cancer Center/Dijkzigt Hospital, The Netherlands.
authors.forename: E B
authors.initials: EB
authors.lastname: van Dieren
authors.forename: P J
authors.initials: PJ
authors.lastname: Nowak
authors.forename: O B
authors.initials: OB
authors.lastname: Wijers
authors.forename: J R
authors.initials: JR
authors.lastname: van Sörnsen de Koste
authors.forename: H
authors.initials: H
authors.lastname: van der Est
authors.forename: D P
authors.initials: DP
authors.lastname: Binnekamp
authors.forename: B J
authors.initials: BJ
authors.lastname: Heijmen
authors.forename: P C
authors.initials: PC
authors.lastname: Levendag
mesh_terms: D005240:Feasibility Studies; D006801:Humans; D007822:Laryngeal Neoplasms / Q000532:radiotherapy*; D009959:Oropharyngeal Neoplasms / Q000532:radiotherapy*; D010306:Parotid Gland / Q000000981:diagnostic imaging; D011859:Radiography; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D020266:Radiotherapy, Conformal / Q000379:methods*; D013363:Submandibular Gland / Q000000981:diagnostic imaging