An implementation strategy for IMRT of ethmoid sinus cancer with bilateralsparing of the optic pathways

Purpose: To develop a protocol for the irradiation of ethmoid sinus cancer, with the aim of sparing binocular vision, of developing a strategy of inte nsity-modulated radiation therapy (IMRT) planning that produces dose distri butions that (1) are consistent with the protocol prescriptions and (2) are deliverable by static segmental IMRT techniques within a 15-minute time sl ot; of fine tuning the implementation strategy to a class solution approach that is sufficiently automated and efficient, allowing routine clinical ap plication; of reporting on the early clinical implementation involving 11 p atients between February 1999 and July 2000. Patients and Methods: Eleven consecutive TI-4N0M0 ethmoid sinus cancer pati ents were enrolled in the study. For Patients 1-8, a first protocol was imp lemented, defining a planning target volume prescription dose of 60 to 66 G y in 30-33 fractions and a maximum dose (Dmax) of 50 Gy to optic pathway st ructures and spinal cord and limit of 60 Gy to brainstem. For Patients 9-11 , an adapted (now considered mature) protocol was implemented, defining a ( planning target volume) prescription dose of 70 Gy in 35 fractions and a Dm ax to optic pathway structures and brainstem of 60 Gy and to spinal cord of 50 Gy. Results: The class solution-directed strategy developed during this study r educed the protocol translation process from a few days to about 2 hours of planner time. The mature class solution involved the use of 7 beam inciden ces (20-37 segments), which could be delivered within a 15-minute time slot . Acute side effects were limited and mild. None of the patients developed dry eye syndrome or other visual disturbances. The follow-up period is too short for detection of retinopathy or optic nerve and chiasm toxicity. Conclusion: Conventional radiotherapy of ethmoid sinus tumors is associated with serious morbidity, including blindness. We hypothesize that IMRT has the potential to save binocular vision. The dose to the optic pathway struc tures can be reduced selectively by IMRT. Further enrollment of patients an d longer follow-up will show whether the level of reduction tested by the c linical protocol is sufficient to save binocular vision. An adaptive strate gy of IMRT planning was too inefficient for routine clinical practice. A cl ass solution-directed strategy improved efficiency by eliminating human tri al and error during the IMRT planning process. (C) 2001 Elsevier Science In c.