OAR HEAD AND NECK

1. Challenges in Respecting
OAR
Kanhu Charan Patro

5. A-ANALYZE
B -BROWSE
C -COMMUNICATE
D-DELIVER
E-EXTRA CARE

7. Fun he to mann he

13. Sir Richard Branson

17. 17

18. Side effects are like mother in law

21. DO NOT DARE TO SCARE
OAR NEEDS EXTRA CARE
OTHERWISE
RARE WILL NOT BE RARE

23. PUSHING BACKWARD AND FORWARD AT A TIME
DIFFICULT BUT NOT IMPOSSIBLE
OAR
TARGET
23

24. DOCTOR : WHAT
TRETMENT YOU HAVE
GIVEN , I AM NOT ABLE
TO EAT PANIPURI.
THAT PANIPURI MOMENT
5/17/2019 24

25. 1. TRISMUS
2. DYSGUESIA
3. XEROSTOMIA
4. DYSPHAGIA
5/17/2019 25

26. ZEROING THE
XEROSTOMIA
&
DISCARDING
THE DYSPHAGIA
5/17/2019 26

27. IMPOSSIBLE
5/17/2019 27

30. LEVEL AND WIDTH FOR DELINEATION
WIDTH
LEVEL
A. Brightness refers to the overall lightness or
darkness of the image.
B. Contrast is the difference
in brightness between objects in the image.
30

31. Brightness- window level Contrast- window width
31

33. CORD IS NOT ROD

34. SPINAL CORD RECOVERY
1st DECEMBER 2017/RE-RTCARSTEN NIEDER/IJROBP/2005
1. With time cord starts forgetting the
irradiated dose.
2. Estimating myelopathy based on
cumulative BED.
3. α/β for cervical and thoracic cord is 2 and
lumbar cord is 4
4. 50% recovery when interval is 2 years and
first course received with conventional
fractionation of 45Gy
5. Volume effects:
A. At 2 Gy equivalent, full
circumference cord dose, at least
25% recovery at 6 months
B. With SBRT (partial cord) 13Gy/1 or
20Gy/3 < 1% risk of myelopathy
6. Higher incidence of myelopathy when
A. Cumulative BED is >135.5Gy2
B. Single course BED is >102Gy2
C. When interval between treatment is
< 6 months
Can you guess the gender of spinal
cord? It is male. With time it forgets the
injury. Girls remember everything and
repeatedly spoil your reputation till
your death even a small injury.

37. SPINAL CORD INSULT-CONVENTIONAL VS IMRT
2nd DECEMBER 2017/RE-RTJUST CALCULATE
WITH
CONVENTIONAL
PLANNING CORD
GETS 2Gy/# TILL 22#
BED =88Gy2
WITH IMRT SUPPOSE
CORD IS GETTING
35Gy IN 50Gy/ 25#
MEANS 1.4Gy/#
SO BED =59.9Gy2
IT IS A GOOD THING
FOR REIRRADIATION
AND SPINAL CORD
RECOVERY ALSO
ALWAYS
CHOOSE
ADVANCED
TECHNIQUE
WITH IMRT, SPINAL CORD
NOT ONLY GETTING THE LESS
DOSE BUT ALSO BED IS VERY
LESS COMPARED TO
CONVENTIONAL RT.
LESS INSULT WITH IMRT
[BED CALCULATOR]EQD2.COM
conventionalIMRT
α/β for cervical and thoracic cord is
2 and lumbar cord is 4

49. ARE STEROIDS & NSAIDS ACT AS BALM
FOR DYSPHAGIA PAIN?

58. NOT PAROTID YOU HAVE TO SAVE CAROTID

60. REIRRADIATION-CBOS INDEX
SL PARAMETER YES NO
1 CAROTID INVASION >180 1 0
2 PRESENCE OF ULCERATION 1 0
3 LYMPH NODE AREA
IRRADIATION
1 0
3rd DECEMBER 2017/RE-RTHIDEYA YAMAZAKI /RADIOTHERAPY AND ONCOLOGY/2015
CBOS-CAROTID BLOW OUT SYNDROME
Keep below cumulative
BED of 110Gy
<180
>180

63. Normal tissues of interest: Brachial Plexus
Hall WH et al. IJROBP 2008:72(5):1362-7.
Cervical vertebrae: C1 – C7
Cervical nerves: C1 – C8
Dose constraints:
Very safe: Max < 60 Gy Considered
safe in most studies: Max < 66 Gy
below cricoid Max < 70 Gy above
cricoid

65. CAT STRACTURE FOR LARYNX
•Cricoid
•Aretynoid
•Thyroid

66. v

68. Midline block

69. Normal tissues of interest: Larynx
Dose constraints:
Mean < 40 Gy
Practice varies:
Whole larynx avoidance?
Arytenoids?
Pharyngeal constrictors?

70. Normal tissues of interest: Parotid Gland
Dose Constraints:
Mean < 26 Gy
At least 50% of each gland < 30 Gy At
least 20cc combined < 30 Gy
QUANTEC update:
Single mean < 20 Gy
Bilateral mean < 25 Gy

71. Dose Constraints:
Uninvolved with no IB coverage
Mean < 39 Gy
Normal tissues of interest: Submandibular Gland

72. Normal tissues of interest: Spinal Cord
Dose
Constraints:
Mean < 45 Gy
Max < 50 Gy (0.3 cc)
SBRT Dose Constraints:
Dmax 13 Gy (1 fraction)
Dmax 20 Gy (3
fractions)

73. Normal tissues of interest: Brainstem
Dose Constraints:
Mean < 54 Gy
Max < 60 Gy (0.3 cc)
SBRT Dose Constraints:
Dmax 12.5 Gy (1 fraction)

74. Normal tissues of interest: Cochlea
Often one contour:
Cochlea
Vestibular apparatus

75. Normal tissues of interest: Cochlea
Dose constraints (combo):
Max < 45 Gy
Typically conservative < 35 Gy
Also consider use of cisplatin.
SBRT Dose Constraints:
Dmax 12-14 Gy

76. Normal tissues of interest: Optic Structures
Dose constraints (optic nerves):
Mean < 54 Gy
Max < 60 Gy (0.3 cc)
Dose constraints (lens):
ALARA
Dose constraints (optic chiasm):
Mean < 50 Gy
Max < 55-60 Gy (0.3 cc)

77. Normal tissues of interest: Optic Structures
Dose constraints (optic nerves):
Mean < 54 Gy
Max < 60 Gy (0.3 cc)
Dose constraints (lens):
ALARA
Dose constraints (optic chiasm):
Mean < 50 Gy
Max < 55-60 Gy (0.3 cc)

78. Normal tissues of interest: Optic Structures
Dose constraints (optic nerves):
Mean < 54 Gy
Max < 60 Gy (0.3 cc)
Dose constraints (lens):
ALARA
Dose constraints (optic chiasm):
Mean < 50 Gy
Max < 55-60 Gy (0.3 cc)

79. Normal tissues of interest: Pharyngeal Constrictors
Eisbruch et al.
Pharyngeal constrictors:
Lateral & posterior pharyngeal walls
Superior: To pterygoid plates
Middle: To hyoid bone
Inferior: To thyroid cartilage

80. Normal tissues of interest: Pharyngeal Constrictors

82. Practice brachytherapy
If you really want to respect the OAR
• Start practice brachytherapy in early cancer

84. Sir Richard Branson