Cancer Res Treat.  2021 Jan;53(1):45-54. 10.4143/crt.2020.572.

Development of a Tongue Immobilization Device Using a 3D Printer for Intensity Modulated Radiation Therapy of Nasopharyngeal Cancer Patients

• Ju SG
• Ahn YC
• Kim Yb
• Park SG
• Choi Ym
• Na CH
• Hong CS
• Oh D
• Kwon DY
• Kim CC
• Kim DH

• KMID: 2510646
• DOI: http://doi.org/10.4143/crt.2020.572

Abstract

Purpose
This study aimed to reduce radiation doses to the tongue, a patient-specific semi-customized tongue immobilization device (SCTID) was developed using a 3D printer for helical tomotherapy (HT) of nasopharyngeal cancer (NPCa). Dosimetric characteristics and setup stability of the SCTID were compared with those of a standard mouthpiece (SMP).
Materials and Methods
For displacement and robust immobilization of the tongue, the SCTID consists of four parts: upper and lower tooth stoppers, tongue guider, tongue-tip position guide bar, and connectors. With the SCTID and SMP, two sets of planning computed tomography and HT plans were obtained for 10 NPCa patients. Dosimetric and geometric characteristics were compared. Position reproducibility of the tongue with SCTID was evaluated by comparing with planned dose and adaptive accumulated dose of the tongue and base of the tongue based on daily setup mega-voltage computed tomography.
Results
Using the SCTID, the tongue was effectively displaced from the planning target volume compared to the SMP. The median mucosa of the tongue (M-tongue) dose was significantly reduced (20.7 Gy vs. 27.8 Gy). The volumes of the M-tongue receiving a dose of 15 Gy, 30 Gy, and 45 Gy and the volumes of the mucosa of oral cavity and oropharynx (M-OC/OP) receiving a dose of 45 Gy and 60 Gy were significantly lower than using the SMP. No significant differences was observed between the planned dose and the accumulated adaptive dose in any dosimetric characteristics of the tongue and base of tongue.
Conclusion
SCTID can not only reduce the dose to the M-tongue and M-OC/OP dramatically, when compared to SMP, but also provide excellent reproducibility and easy visual verification.

Keyword

Tongue immobilization device; 3D printing; Head and neck cancer; Tomotherapy; Radiation therapy

Figure

• 

  Fig. 1 Side (A) and front (B) views of the 3D model for the semi-customized tongue immobilization device. It was printed using a three-dimensional printer with a biocompatible material (C). Commercially available standard mouthpiece (D), which has been the most commonly used device in head and neck cancer radiation therapy.

• 

  Fig. 2 Isodose distributions for the standard mouthpiece (SMP, upper) and semi-customized tongue immobilization device (SCTID plans, lower). The tongue was effectively stuck out along the tongue guider by using the SCTID, it led to displacement of the mucosa of the tongue (M-tongue) from target (green arrows) while a partial volume of the M-tongue received a high dose equivalent to the prescribed dose (red arrows) in the SMP plan because depression of tongue caused the tongue to push back toward posterior neck region.

• 

  Fig. 3 Mean DVHs for mucosa of the tongue (M-tongue, green) and oral cavity and oropharynx (M-OC/OP, orange) dramatically decreased using a semi-customized tongue immobilization device (SCTID, dotted line) compared with standard mouthpiece (SMP, solid line), but mean DVHs for the targets showed almost same shape between two groups. M-OC/OP, mucosa of the oral cavity and oropharynx; M-tongue, mucosa of the tongue; P-cord, planning spinal cord; P-CTV, planning clinical target volume; P-GTV, planning gross target volume.

• 

  Fig. 4 In most patient, shape and position of the tongue in daily setup mega-voltage computed tomography (MVCT) image (red) matched well with original one in plan computed tomography image (grey) (A). (B) The mean accumulated-adaptive-DVH (AA-DVH) for tongue (orange dotted line) was almost in line with the mean planned DVH (P-DVH) for tongue (blue solid line), while the mean AA-DVH for tongue base (green dotted line) was slightly higher than the mean P-DVH for tongue base (red solid line), but no significant differences was observed between two groups (p > 0.05).

Reference

References

1. Kubicek GJ, Machtay M. New advances in high-technology radiotherapy for head and neck cancer. Hematol Oncol Clin North Am. 2008; 22:1165–80.

2. Bhide SA, Nutting CM. Advances in radiotherapy for head and neck cancer. Oral Oncol. 2010; 46:439–41.

3. Gregoire V, Langendijk JA, Nuyts S. Advances in radiotherapy for head and neck cancer. J Clin Oncol. 2015; 33:3277–84.

4. Little M, Schipper M, Feng FY, Vineberg K, Cornwall C, Murdoch-Kinch CA, et al. Reducing xerostomia after chemo-IMRT for head-and-neck cancer: beyond sparing the parotid glands. Int J Radiat Oncol Biol Phys. 2012; 83:1007–14.

5. Sapir E, Tao Y, Feng F, Samuels S, El Naqa I, Murdoch-Kinch CA, et al. Predictors of dysgeusia in patients with oropharyngeal cancer treated with chemotherapy and intensity modulated radiation therapy. Int J Radiat Oncol Biol Phys. 2016; 96:354–61.

6. Jacobi I, Navran A, van der Molen L, Heemsbergen WD, Hilgers FJ, van den Brekel MW. Radiation dose to the tongue and velopharynx predicts acoustic-articulatory changes after chemo-IMRT treatment for advanced head and neck cancer. Eur Arch Otorhinolaryngol. 2016; 273:487–94.

7. Eisbruch A, Kim HM, Terrell JE, Marsh LH, Dawson LA, Ship JA. Xerostomia and its predictors following parotid-sparing irradiation of head-and-neck cancer. Int J Radiat Oncol Biol Phys. 2001; 50:695–704.

8. Chao KS, Majhail N, Huang CJ, Simpson JR, Perez CA, Haughey B, et al. Intensity-modulated radiation therapy reduces late salivary toxicity without compromising tumor control in patients with oropharyngeal carcinoma: a comparison with conventional techniques. Radiother Oncol. 2001; 61:275–80.

9. Kil WJ, Kulasekere C, Derrwaldt R, Bugno J, Hatch C. Decreased radiation doses to tongue with “stick-out” tongue position over neutral tongue position in head and neck cancer patients who refused or could not tolerate an intraoral device (bite-block, tongue blade, or mouthpiece) due to trismus, gag reflex, or discomfort during intensity-modulated radiation therapy. Oncotarget. 2016; 7:53029–36.

10. Fleming TJ, Rambach SC. A tongue-shielding radiation stent. J Prosthet Dent. 1983; 49:389–92.

11. Qin WJ, Luo W, Lin SR, Sun Y, Li FM, Liu XQ, et al. Sparing normal oral tissues with individual dental stent in radiotherapy for primary nasopharyngeal carcinoma patients. Ai Zheng. 2007; 26:285–9.

12. Kitamori H, Sumida I, Tsujimoto T, Shimamoto H, Murakami S, Ohki M. Evaluation of mouthpiece fixation devices for head and neck radiotherapy patients fabricated in PolyJet photopolymer by a 3D printer. Phys Med. 2019; 58:90–8.

13. Zhang L, Garden AS, Lo J, Ang KK, Ahamad A, Morrison WH, et al. Multiple regions-of-interest analysis of setup uncertainties for head-and-neck cancer radiotherapy. Int J Radiat Oncol Biol Phys. 2006; 64:1559–69.

14. Johnson B, Sales L, Winston A, Liao J, Laramore G, Parvathaneni U. Fabrication of customized tongue-displacing stents: considerations for use in patients receiving head and neck radiotherapy. J Am Dent Assoc. 2013; 144:594–600.

15. Bodard AG, Racadot S, Salino S, Pommier P, Zrounba P, Montbarbon X. A new, simple maxillary-sparing tongue depressor for external mandibular radiotherapy: a case report. Head Neck. 2009; 31:1528–30.

16. Kaanders JH, Fleming TJ, Ang KK, Maor MH, Peters LJ. Devices valuable in head and neck radiotherapy. Int J Radiat Oncol Biol Phys. 1992; 23:639–45.

17. Hong CS, Oh D, Ju SG, Ahn YC, Na CH, Kwon DY, et al. Development of a semi-customized tongue displacement device using a 3D printer for head and neck IMRT. Radiat Oncol. 2019; 14:79.

18. Brouwer CL, Steenbakkers RJ, Bourhis J, Budach W, Grau C, Gregoire V, et al. CT-based delineation of organs at risk in the head and neck region: DAHANCA, EORTC, GORTEC, HKNPCSG, NCIC CTG, NCRI, NRG Oncology and TROG consensus guidelines. Radiother Oncol. 2015; 117:83–90.

19. Li K, Yang L, Hu QY, Chen XZ, Chen M, Chen Y. Oral mucosa dose parameters predicting grade ≥3 acute toxicity in locally advanced nasopharyngeal carcinoma patients treated with concurrent intensity-modulated radiation therapy and chemotherapy: an independent validation study comparing oral cavity versus mucosal surface contouring techniques. Transl Oncol. 2017; 10:752–9.

20. Sini C, Broggi S, Fiorino C, Cattaneo GM, Calandrino R. Accuracy of dose calculation algorithms for static and rotational IMRT of lung cancer: a phantom study. Phys Med. 2015; 31:382–90.

21. Zhao Y, Qi G, Yin G, Wang X, Wang P, Li J, et al. A clinical study of lung cancer dose calculation accuracy with Monte Carlo simulation. Radiat Oncol. 2014; 9:287.

22. Chen M, Chen Y, Chen Q, Lu W. Theoretical analysis of the thread effect in helical TomoTherapy. Med Phys. 2011; 38:5945–60.

23. Paddick I. A simple scoring ratio to index the conformity of radiosurgical treatment plans. Technical note. J Neurosurg. 2000; 93(Suppl 3):219–22.

24. Zhu J, Bai T, Gu J, Sun Z, Wei Y, Li B, et al. Effects of megavoltage computed tomographic scan methodology on setup verification and adaptive dose calculation in helical TomoTherapy. Radiat Oncol. 2018; 13:80.

25. Mossman KL. Gustatory tissue injury in man: radiation dose response relationships and mechanisms of taste loss. Br J Cancer Suppl. 1986; 7:9–11.

26. Shi HB, Masuda M, Umezaki T, Kuratomi Y, Kumamoto Y, Yamamoto T, et al. Irradiation impairment of umami taste in patients with head and neck cancer. Auris Nasus Larynx. 2004; 31:401–6.

27. Schwartz DL, Hutcheson K, Barringer D, Tucker SL, Kies M, Holsinger FC, et al. Candidate dosimetric predictors of long-term swallowing dysfunction after oropharyngeal intensity-modulated radiotherapy. Int J Radiat Oncol Biol Phys. 2010; 78:1356–65.

28. Chung Y, Yoon HI, Ha JS, Kim S, Lee IJ. A feasibility study of a tilted head position in helical tomotherapy for fractionated stereotactic radiotherapy of intracranial malignancies. Technol Cancer Res Treat. 2015; 14:475–82.

29. Musha A, Saitoh JI, Shirai K, Kubota Y, Shimada H, Abe T, et al. Customized mouthpieces designed to reduce tongue mucositis in carbon-ion radiotherapy for tumors of the nasal and paranasal sinuses. Phys Imaging Radiat Oncol. 2017; 3:1–4.