PII S0360-3016(00)01627-3 CLINICAL INVESTIGATION Head and Neck AN IMPLEMENTATION STRATEGY FOR IMRT OF ETHMOID SINUS CANCER WITH BILATERAL SPARING OF THE OPTIC PATHWAYS FILIP CLAUS, M.D.,* WERNER DE GERSEM,IR.,* CARLOS DE WAGTER,IR., PH.D.,* ROBERT VAN SEVEREN, R.N.,* ILSE VANHOUTTE, M.D.,* WIM DUTHOY, M.D.,* VINCENT REMOUCHAMPS, M.D.,* BART VAN DUYSE,IR.,* LUC VAKAET, M.D., PH.D.,* MARC LEMMERLING, M.D., PH.D., † HUBERT VERMEERSCH, M.D., ‡ AND WILFRIED DE NEVE, M.D., PH.D.* Divisions of *Radiotherapy, † MRI Imaging, and ‡ Head and Neck Surgery, Ghent University Hospital, Ghent, Belgium Purpose: To develop a protocol for the irradiation of ethmoid sinus cancer, with the aim of sparing binocular vision; of developing a strategy of intensity-modulated radiation therapy (IMRT) planning that produces dose distributions that (1) are consistent with the protocol prescriptions and (2) are deliverable by static segmental IMRT techniques within a 15-minute time slot; of fine tuning the implementation strategy to a class solution approach that is sufficiently automated and efficient, allowing routine clinical application; of reporting on the early clinical implementation involving 11 patients between February 1999 and July 2000. Patients and Methods: Eleven consecutive T1– 4N0M0 ethmoid sinus cancer patients were enrolled in the study. For Patients 1– 8, a first protocol was implemented, defining a planning target volume prescription dose of 60 to 66 Gy in 30 –33 fractions and a maximum dose (Dmax) of 50 Gy to optic pathway structures 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 Dmax 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 reduced 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 incidences (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 structures can be reduced selectively by IMRT. Further enrollment of patients and longer follow-up will show whether the level of reduction tested by the clinical protocol is sufficient to save binocular vision. An adaptive strategy of IMRT planning was too inefficient for routine clinical practice. A class solution– directed strategy improved efficiency by eliminating human trial and error during the IMRT planning process. © 2001 Elsevier Science Inc. Radiotherapy, Ethmoid sinus, IMRT, Optic, Clinical implementation. INTRODUCTION Ethmoid sinus cancer is often diagnosed at a locally ad- vanced stage, with extensions through the bony walls of the paranasal sinuses, the orbit, the sphenoid, and the anterior skull base. In most patients, tumor volumes are close (with- in 0 –3 mm) to optic structures, such as the retinae, the optic nerves, and the optic chiasm. Surgical resection is usually followed by local relapse, in spite of the use of wide-field excision by a team of head-and-neck, neuro-, and recon- structive (plastic) surgeons (1, 2). The degree of mutilation and morbidity with such surgery, which may involve enu- cleation of the eye and removal of head facial bones and parts of the skull, is substantial. Reprint requests to: F. Claus, Ghent University Hospital, De- partment of Radiotherapy, De Pintelaan 185, 9000 Ghent, Bel- gium. Tel: 32-92403074; Fax: 32-92403863; E-mail: filip@krtkg1. rug.ac.be The project “Conformal Radiotherapy Ghent University Hospi- tal” is supported by the Belgische Federatie tegen Kanker and by grants from the Fonds voor Wetenschappelijk Onderzoek Vlaan- deren (Grants FWO G.0049.98, G.0039.97), the University of Ghent (BOF 01112300, 011V0497, 011B3300), the Sportverenig- ing tegen Kanker and the Centrum voor Studie en Behandeling van Gezwelziekten. Acknowledgments—F. Claus and W. Duthoy (011F1700) are research assistants at the FWO. We thank ADAC Laboratories for providing the Pinnacle System. The Ghent University Hospital is a member of the Elekta IMRT Consortium. E. Achten, M.D., Ph.D., is acknowledged for technical expertise. Received Dec 4, 2000, and in revised form Feb 26, 2001. Accepted for publication Apr 19, 2001. Int. J. Radiation Oncology Biol. Phys., Vol. 51, No. 2, pp. 318 –331, 2001 Copyright © 2001 Elsevier Science Inc. Printed in the USA. All rights reserved 0360-3016/01/$–see front matter 318