Borders, Doses, & TD 5/5
TD 5/5 Testes
100 cGy
Hemoglobin normal range
13.2-16.9
Platelets normal range
140,000-390,000
TD 5/5 Lung
1750 cGy
Inverted Y - Lateral borders
2 cm beyond pelvic inlet (exclude as much of the pelvis as possible while leaving adequate margin around lymphatics)
Nasopharynx - # of fields
2-3 (laterals and AP)
TD 5/5 Ovary
200 cGy
TD 5/5 Kidney
2300 cGy
TD 5/5 Pancreas
2500 cGy
WBC normal range
3.9-10.0 thousand
TD 5/5 Bone Marrow (segmental)
3000 cGy
TD 5/5 Liver
3000 cGy
Hodgkin's - Total dose & fx
3000-3600 (microscopic disease) 3600-4400 cGy (gross disease) 180-200 cGy ~20 fx
Hematocrit normal range
38.5-49%
RBC normal range
4.2-5.7 million
TD 5/5 Brain
4500 cGy
TD 5/5 Intestines
4500 cGy
TD 5/5 Pituitary
4500 cGy
TD 5/5 Spinal Cord
4500 cGy
TD 5/5 Bone
6000 cGy
TD 5/5 Brain - partial
6000 cGy
TD 5/5 Esophagus
6000 cGy
TD 5/5 Oral cavity
6000 cGy
TD 5/5 Pharynx
6000 cGy
TD 5/5 Thyroid Cartilage
6000 cGy
Larynx total dose & fx
6600-7000 cGy (early tumors) 7000-7500 cGy (advanced tumors) *off cord at 4500 cGy for lateral fields 200 cGy/33-35 fx (not including boost)
TD 5/5 Larynx
7000 cGy
TD 5/5 Muscle
>10,000 cGy
TD 5/5 Breast
>5000 cGy
T1 Larynx - Posterior border
Anterior margin of the vertebral bodies
Nasopharynx - Superior border
Entire sphenoid sinus, cavernous sinus, base of skull (with at least 0.5 cm margin)
Breast Sclav - Superior border
Extends laterally across the neck and trapezius to the acromial process
Mantle - Lateral
Fall-off, to include axillary nodes
Breast Sclav - Lateral border
From the acromioclavicular joint, bisecting the humeral head, to exclude as much of the shoulder as possible. A custom cut block may be used to block humeral head.
Breast - Blocking
Humeral head, thyroid, lung, heart
T2 Larynx - Inferior border
Infraglottic extension and 2-3 cm margin
Larynx - Lymphatics
Jugulodigastric, mid-jugular, low jugular *no nodal involvement in early stage
Paraaortic - Inferior border
L4/L5
Nasopharynx - Anterior border
Posterior 2 cm of nasal cavity (or 2 cm beyond tumor extension), posterior 1/3 of the maxillary sinus, posterior ethmoid sinuses, and posterior or 1/4 of orbit
Nasopharynx - Lymphatics
Retropharyngeal, deep cervical, jugulodigastric, superior jugular, mid-jugular
Hodgkin's Side Effects - Acute
Skin changes (erythema, dry + moist desquamation), N/V, fatigue, loss of appetite, weight loss, diarrhea, low CBC
Breast Side Effects - Acute
Skin changes (erythema, dry + moist desquamation), fatigue, rib fracture, mastitis, cellulitis
Nasopharynx - Blocking
Spinal cord, base of brain, mandible, eye, mouth, midline block on anterior field
T2 Larynx - Superior border
Surpaglottic extension and 2-3 cm margin
Larynx - Blocking
T1: no blocking necessary T2: spinal cord, mandible, oral tongue T3/T4: mandible, tongue, posterior aspect of brain, spinal cord Supraglottic: same as T3/T4
Mantle - Inferior border
T9/T10 interspace or insertion of diaphragm
Nasopharynx Side Effects - Chronic
Tissue fibrosis, necrosis
Larynx Side Effects - Chronic
Tissue fibrosis, voice changes, necrosis
T1 Larynx - Superior border
Top of thyroid cartilage
Paraaortic - Lateral border
Usually 9-10 cm wide (blocks may be cut to encompass spleen or splenic pedicles)
Breast Sclav - Inferior border
1st costal interspace, abutting the tangential breast field
Inverted Y - Inferior border
2 cm below ischial tuberosity to include femoral nodes
Larynx - # of fields
2-3 (parallel opposed laterals/AP for advanced)
Hodgkin's - Energy
6 MV
Larynx - Energy
6 MV
Nasopharynx - Energy
6 MV
Breast - Energy
6 MV or higher depending on patient separation
Breast Tangents - Inferior border
1.5 cm below inframammary fold
T1 Larynx - Anterior border
1.5-2 cm beyond the thyroid cartilage
T2 Larynx - Anterior border
1.5-2 cm beyond the thyroid cartilage
T3/T4 Larynx - Anterior border
1.5-2 cm beyond the thyroid cartilage
Breast Tangents - Superior border
1st costal interspace
TD 5/5 Heart
4000 cGy
TD 5/5 Stomach
4500 cGy
TD 5/5 Thyroid gland
4500 cGy
TD 5/5 Lens
500 cGy
TD 5/5 Cornea
5000 cGy
TD 5/5 Ear
5000 cGy
TD 5/5 Lymph nodes
5000 cGy
TD 5/5 Optic chiasm
5000 cGy
TD 5/5 Salivary glands
5000 cGy
Breast Tangents - Total dose & fx
5000 cGy 6000 cGy (boost) 200 cGy or 267 fx 25 fx plus boost or 15 fx plus boost
Breast Sclav - Total dose & fx
5000 cGy 200 cGy 25 fx
TD 5/5 Retina
5500 cGy
TD 5/5 Skin
5500 cGy
Paraaortic - Superior border
Approx mid-T10, with an appropriate gap from mantle field
Breast - Lymphatics
Axillary, supraclavicular, infraclavicular, subclavian, internal mammary
Nasopharynx - Posterior border
Behind the spinous processes to include the retropharyngeal nodes, posterior pharyngeal wall, deep cervical nodes, or posterior cervical nodes.
T1 Larynx - Inferior border
Below the cricoid cartilage
T3/T4 Larynx - Inferior border
Below the cricoid cartilage
Supraglottic Larynx - Inferior border
Bottom of the cricoid cartilage and 2 cm below the lowest extent of disease
Nasopharynx - Inferior border
Cricoid cartilage
Nasopharynx - Total dose & fx
Initial laterals: 5040 cGy (off cord at 4500 cGy) Boost: 6500 cGy (T1-T2) 7000-7500 cGy (T3-T4) Anterior neck field: 4500-5000 cGy 180 cGy Initial laterals: 28 fx With boost: 36-42 fx Anterior neck field: 25-28 fx
Inverted Y - Superior border
L5 with an appropriate gap from abdominal port
Mantle - Superior border
Lower mandible and the mastoid tips (chin must be extended so that high cervical and submandibular nodes are included in the port, without treating mouth.
Hodgkin's - Blocking
Mantle: Humeral heads, lungs, occipital, anterior larynx, spinal cord Inverted Y: spinal cord, left kidney (when treating spleen), liver, ovaries, gonads, femoral heads, bladder, rectum
Hodgkin's - Lymphatics
Mantle: cervical, submandibular, axillary, supraclavicular, infraclavicular, mediastinal, hilar Paraaortic & Pelvic: retroperitoneal, paraaortic, pelvic, splenic hilar, femoral
Breast Tangents - Lateral border
Mid-axillary line (2 cm beyond all breast tissue)
T2 Larynx - Posterior border
Mid-vertebral bodies
Breast Tangents - Medial border
Midline
Breast Side Effects - Chronic
Necrosis, secondary cancer
T3/T4 Larynx - Superior border
Node negative: 2 cm above the angle of the mandible to treat the jugulodigastric nodes Node positive: Above the mastoid process to cover the entire jugulodigastric lymph node chain (the hyoid bone and epiglottis are included to incorporate the pre-epiglottic space)
T3/T4 Larynx - Posterior border
Node negative: Behind the mastoid process to include the midjugular nodes Node positive: Behind the spinous process to include the posterior cervical lymph nodes
Nasopharynx Side Effects - Acute
Skin changes (erythema, dry + moist desquamation), fatigue, hoarseness, mucositis, xerostomia, weight loss, low CBC, dysphagia/odynophagia
Larynx Side Effects - Acute
Skin changes (erythema, dry + moist desquamation), fatigue, loss of appetite, hoarseness/sore throat, weight loss, low CBC, dysphagia/odynophagia
Hodgkin's Side Effects - Chronic
Tissue fibrosis, necrosis, fistula
Breast Sclav - Medial
Vertical 1 cm across midline (or at midline) extending from the 1st costal interspace to the thyro-cricoid groove, medial to the sternocleidomastoid muscle to include the lower lymph nodes of the cervical chain.