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Treatment Planning

Nasopharynx
T1N2B

Volumes:
GTV Tumour + Gross Nodes Visible
CTV GTV+0.5cm margin; + Base of skull; cavernous sinus; ½ lower sphenoidal sinus; 1/3 ant clivus; 1/3 post nasal cavity; 1/3 post ethmoid sinus; whole Nasopharynx; upper oropharynx
Nodes Bilat Ib-V; + ipsi lower SupraClav + RP


Tonsil
T2N2B

GTV Tumour + Gross Nodes
For nodes any enlarged nodes + any 1cm LN adjacent to >1cm nodes
CTV ipsi Base of tongue; ant and post tonsillar pillar; post wall of oropharynx; ipsi soft palate
Nodes ipsi Ib-IV ( lower IV )
Contra II-IV
Floor of Mouth
Post-op T2N0 ( ipsi LN dissection  pN0
Nodes  bilat I-III
Surgical Bed full dose ( 60Gy )


Melanoma in-transit recurrence
Skin is CTV
50/25
Melanoma recurrent in LN
Intraparotid
( Head and Neck )
LN dissection ( II, III, IV )
CTV Ipsilateral intraparotid/ periauricular/ II-V
50Gy to CTV 70/35  Surgical Bed + intraparotid + II ( where LN + existed )


Buccal Mucosa
T2(3cm)N1(Facial node ) no ECE Node 1.4cm
Post-op  High dose to tumor bed
Low dose to ipsi Ia-IV
Laryngeal T4; post induction chemo

For PTV70 Add 0.5cm to CTV70
CTV70 
1- GTV
2- GTV+margin 0.7mm or when reaches a barrier
3- Larynx
4- Thyroid Cartilage ( whole ipsi – half contra )
CTV56
1- CTV70
2- Bilat LN
a. Ipsi II-V
i. II ipsi from jugular foramen
ii. II contra from C1 transverse process
b. Contra II-IV
c. VI ( as pre-chemo tumour / residual tumor present in Level VI )


Prostate High risk

Simulation
• Supine
• Full Bladder  less small bowel in the field
• Empty rectum ( only during simulation not treatment )  how ???
o That will be the worse case scenario for rectum
o Difficult to do and no need during the treatment
Nodes, start at distal common iliac L5
7mm around vessels  trim for normal tissue( bone, bowel )
Pre-sacral nodes from S1-S3
Obturator LN stop as soon as you see Seminal Vesicles
RTOG  symphysis pubis
Prostate + SV proximal If SV +( that will be included in higher dose volume )

Direct post field for bone Mets/ cord compression

Dr LE  width of field 10cm for lumbar area; 8cm for Thorax;
Dr RM  Check the bone and give a margin

Know attenuation (fall off)  6MV:
Know Penumbra for different energies
Know build up for different energies

POP  Nausea
Direct Post  less homogeneity

If cervical vertebrae  Face Mask/Shell for immobilization
If possible two lateral ( if shoulders are not in the way )
Otherwise  POP
Side effects  hoarseness, dysphagia


Extensive Small Cell
Post chemo  good response to chemo; brain mets resolved after chemo
XRT to Brain WBRT  25Gy/10
XRT consolidation to peri-hilar mass
GTV post-chemo
Dose  30/10

Small Cell limited stage usually concurrent CRT except
• Frail patient
• Volume is too big  V20 > ~40
• Wonder if patients is extensive? Questionable mets?

Pelvic Ewing Sarcoma  post-op ( operation post chemo )
We know these(pelvic) have worse prognosis

Close margins  2.5 & 3.5 mm
CTV volume for post op  PRE-OP chemo
OAR  Femur Head
Uterus
Overies
Bladder
Rectum


T3N1 Rectal Ca
10-11cm from anal verge
Simulation
• Prone
• Bellyboard
• Full bladder  how ???
• Oral Contrast  how ???
CTV 45  Post border  a bit ( 1mm ) of sacrum included
Ant border
Superior  Sacral Promontery
Inf  ??? Pelvic floor
CTV50  margin around visible tumor
Include the rectum wall at the level or only margin
Sup and inf 
Radial margin 
Dose and Fractionation
• In two volumes
o 45Gy/25fractions
o 5.4Gy/3fractions


Breast Ca Left