Head and Neck Treatment

Question 1

Day 1 Considerations

Answer 1

Patient understanding of procedure
Chemotherapy status
Possible teeth removal
Prophylactic Tube Insertion (NG or PEG)
Claustrophobia, Anxiety (support mechanisms)

Question 2

Potential Support Mechanisms for Anxious Patients

Answer 2

OT assistance
Breathing techniques
Stress balls
Music
Relaxant medications

Question 3

Why Verification of isocentre positioning is vital

Answer 3

Maintain accuracy of treatment (minimise dose to NTT, maximise dose to planned targets)

Question 4

Why is it important to balance accuracy with efficiency?

Answer 4

The longer the imaging process, the more likely the patient is to move from setup position -> result in less accurate treatment

Question 5

Head and Neck Treatment Imaging

Answer 5

CBCT and kV imaging is most commonly used

Question 6

Advantages of EPI imaging

Answer 6

Ease of image acquisition
Fast image acquisition
Online correction is feasible
Convenient image storage
Good soft tissue imaging

Question 7

Disadvantages of EPI

Answer 7

Image quality
Clarity of detailed anatomy
Visualisation of structures

Question 8

Why are EPIs taken

Answer 8

To verify isocentre position (e.g., ant/post or lateral)

Question 9

Advantages of kV imaging

Answer 9

Ability to take images that mimic diagnostic images

Better image quality and definition, particularly bony detail, compared to EPI

Question 10

Advantages of CBCT

Answer 10

Can better estimate patient position
Provides volumetric tissue information
Allows for the rationale of VMAT and IMRT
Can perfrom with full arc or partial arc (dependent on area being treated)

Question 11

MVCT application in Head and Neck

Answer 11

Volumetric image produced by TomoTherapy
Can choose reconstructed slice thickness
Typical scan time is 2-4 minutes

Question 12

Different Methods used for Isocentre Verification

Answer 12

Software matching methods
Anatomical match points
verification tolerances

Question 13

Software matching methods

Answer 13

Involves an overlay image and template matching
Use of measuring tools to measure from different anatomical locations

Question 14

CBCT image matching

Answer 14

Can use various methods (manual tools, soft tissue matching, bony matching)

Can define areas with a clip box (typically most critical area)

Can use viewing tools (image blending, spy glass, checkerboard, image cut)

Provides displacement in 6 different planes (sup/inf, ant/post, left/right, pitch, roll, yaw)

Question 15

Anatomical Match Points

Answer 15

RO indicates a match point based on information about the tumour

Useful to know when all anatomical points of interest do not align in relation to one another when matching

Examples: Cervical Vertebrae, Clivus

Question 16

Appropriate anatomical points to use when image matching

Answer 16

Base of skull
Spinous processes
Dens
Vertebrae
Nasal septum
Orbits
Clavicles

Question 17

Verification tolerances (action level)

Answer 17

Tolerance at which the displacement indicated requires action (e.g., moving the patient to correctly position the isocentre

For HN, common is 3mm

Question 18

What to do when nothing matches in the images

Answer 18

No one size fits all

You may go in and re position the patient if necessary, check the setup notes, ask advice of other RTs or RO

Question 19

Advantages of SGRT for HN

Answer 19

Non-invasive
Doesnt utilise ionising radiation for image capture
Decreases magnitude and errors of translational couch shifts
Improved set up accuracy
Reduction in patient set up time

Question 20

Common Acute side effects of HN

Answer 20

 Lethargy
 Nausea and vomiting
 Skin reaction (erythema, dry and moist desquamation)
 Dysphagia
 Mucositis
 Altered taste
 Altered saliva consistency

 Coated, ‘furry’ tongue
 Dry, cracked lips
 Husky or raspy voice
 Reddened patches within the mouth
 Swollen tissues
 Mouth ulcers
 Mouth and throat pain
 Bleeding from gums, lips, mouth and throat

Question 21

Common Late Side Effects

Answer 21

Xerostomia
 Radiation caries
 Alopecia
 Trismus
 Second malignancy
 Mucosal atrophy

Question 22

Methods to overcome Sore Mouth and Throat

Answer 22

 Regular mouth washes (salt, bi carb soda)
 Carry a water bottle (keep mouth moist)
 Eat soft, bland foods (avoid spicy and acidic foods)
 Avoid eating and drinking anything that is too hot or
cold
 Brush teeth with a soft toothbrush and mild toothpaste
 Rest your voice as much as possible
 Can be given ‘pink lady’ (zylocane) to numb painful
throat to assist with eating

Question 23

Methods to overcome dysphagia

Answer 23

Notify nursing and medical staff

Question 24

Methods to overcome dry mouth and thickened saliva

Answer 24

Drink plenty of fluids
 Carry a water or spray bottle around to moisten mouth
 Use a dry mouth gel
 Maintain good dental and mouth care
 Drink soda water then rinse mouth out with water
 Smoking, alcohol and coffee all increase mouth dryness

Question 25

Nutritional Issues

Answer 25

Eat protein rich foods (dairy, eggs, legumes, meat) to
help maintain weight
 See a dietician regularly (usually organised through the
department)
 Alcohol not recommended as it can further irritate and
dry mouth lining
 Patients may require a nasogastric tube or a PEG
inserted to increase nutritional intake

Question 26

Methods to overcome Fatigue

Answer 26

 This can be a side effect that surprises patients with how
much it effects them
 Important that patients learn to ‘listen to their body’ –
take things easier when they need to
 Fatigue can last a lot longer after the completion of
treatment than many patients realise also

Question 27

Methods to care for skin reactions

Answer 27

Keep skin clean and dry
 Gentle bathing with warm water and mild unscented
soap (baby soap)
 Avoid very hot or cold water
 No talc or deodorant in the treatment area
 Wash hair with baby shampoo
 Do not rub skin – pat dry with soft towel
 Shaving only to be done with electric razor
 Apply moisturizing cream to area (aqueous or
something similar)

Question 28

How can weight loss, skin reactions and patient wellbeing affect treatment

Answer 28

Weight loss – dose change, replan, shell not fitting to achieve adequate immobilisation

 Skin reaction – patient not able to reach or maintain original position

 General patient wellbeing – reduction in treatment compliance