Hi friends,

I have a dilemma I could use some help with. I read somewhere that by using a TOMO machine there is a better chance of saving the parotid (salivary) glands. With this as my objective, here is some background information:

I am needing radiation on both sides of the neck as I had two positive lymph nodes. The RO I am thinking about going with (unless your input suggests that I consider something else) at OHSU (a nationally recognized cancer center) emailed me:

"Planning will be done with the goal being all 35 treatments on Tomotherapy. We�ll also have a more traditional IMRT plan for back-up in case the Tomotherapy unit goes down any day. I don�t expect the Tomotherapy machine to go down, but all machines can have technical issues and we don�t have a Tomotherapy unit as back up. We do not want a break in therapy due to any TOMO malfunction."

Coincidentally the RO specializes in head and neck rads. However, since OHSU installed their first TOMO machine only about a month or so ago, my concern is what would happen if the machine fails. Since there is no TOMO backup unit the RO is also wanting to do a more traditional IMRT plan. I am also unsure how experienced the techs are at operating the machine. I know for sure that OHSU is aggressively marketing the TOMO machine in the local area.

My other option is to go to another nearby site (Meridian Park Radiation Oncology), where they've had multiple TOMOs for a long time. I have not yet met the RO at Meridian, but am willing to do this, depending on your input.

On the other hand, a couple of ROs have suggested that TOMO is a marketing buzz-word, and all I really need is traditional IMRT, and really I should not worry about whether or not rads are delivered using a "TOMO" machine, etc. etc.

I do want to increase the odds of saving (as much as possible) my parotid glands, and would appreciate any perspective(s).

Thanks in advance!

Best Regards,
Chetan

Do consider the whole team:
OHSU is a multidisciplinary NCI designated Comprehensive Cancer Center that treats over 400 Oral Cancer patients a year. I don't know about Meridian.

Likewise, where I was treated they only had one TOMO machine and it had a few "bad days" that caused a few delays, but only one missed session. Likewise, they could have transferred to a Varian IMRT unit but that was not necessary and the Varian IMRT units seemed just a problematic as the TOMO.

TOMO seems to have inspired a whole new class of ARC IMRT systems - Varian and Novalis RapidArc/SmartArc and Siemens VMAT system are all similar and perhaps equivalent to TOMO (some say perhaps even a bit better and generally much faster!).

So, I doubt anyone who works at a Center with both standard IMRT and ARC IMRT (TOMO, RapidArc, VMAT) would agree that "ARC based" is just a "buzz-word", but both types of systems effectively kill the cancer (perhaps a bit less collateral damage with ARC).

I would think OHSU's well experienced Dosimetry physicist and RO's know what they want to hit, how hard to hit it and have trained and qualified on the TOMO planning system. TOMO sessions are recorded using real time CT scanning so they know exactly what happens and TOMO's adaptive logic can adjust for errors.

Hi Don,

Thanks very much for your input. I was curious how the TOMO did with your parotid glands. Also on the one day that you missed a session, wasn't there a standard IMRT machine available, or did your RO opt to wait for the TOMO? The reason I ask is my RO is suggesting that if the TOMO is not available I should undergo treatment on the standard machine--I am not sure about the interchange of equipment during the 7-week session. Am I just bettr off asking to wait for the TOMO?

I noticed that you and I you also had SCC in two lymph nodes. Was there any extra capsular extension or perneurial invasion? I did not have ECE but did have perineurial invasion, and have been advised to go with chemo in conjunction with rads.

Best Regards,
Chetan

Chetan,
Keep in mind I was treated several years ago and technology advances quite rapidly.

Concerning the parotid glands, I don't have any dry mouth issues and going in, they felt they would be adequately spared. As I recall they need to keep the grays to/through the parotids under 20 and used TOMO's helical scan rotational ARC delivery to accomplish this.

Never-the-less, parotids suffer some temporary damage at just a few grays, so I initially had some dry mouth. It was moderate to mild the first six month to around a year.

I believe a lot and perhaps most on the forum members seem to get over dry mouth after a year or two. So perhaps TOMO just shortens the process.

At the CCC where I was treated a day's break in treatment was considered acceptable if you were far enough along cumulatively.
I was far enough and the "machine down" day was added to the end. I should add that the lost day was after a weekend TOMO upgrade.

There were several other days when the TOMO was acting up and my treatment was significantly delayed. One day the TOMO didn't like something it saw, and ejected me! I also lost a days due to extreme nausea/vomiting and had a three day holiday week-end.

My initial treatment planning scans were done on dedicated Planning CT, not the TOMO and it would have been the same for the CCC's Varian or Novalis units. There is a standard data interchange between most system and then the TOMO planning system optimizes that input for helical ARC delivery and figures out options to avoid sensitive structure (i.e. parotids, Larynx, carotids, etc.). Of course the dosimetry group reviews and tweaks the TOMO planning options and a RO must approve everything as with standard IMRT plans.

My nodes were small with no adverse characteristics. They were surgically removed because I have bad kidneys and after consultation with MD Anderson the recommendation was to go without Chemo. The tumor board was satisfied that any remaining microscopic cancer could be effective dealt with by radiation alone (hope so).

I had an unknown primary so the oral radiation fields were larger and more extensive. That was the main reason for the TOMO. The CCC that treated me uses Novalis Systems for most Oral Cancer, but the TOMO group isn't shy about saying TOMO has advantages and they seem to run more than enough OC to stay proficient.

Chetan,
I think I told you that my parotids were spared, it is written into my plan. I had quite a bit of saliva for most of treatment until the last week and then afterwards, it seemed not at all. Anyway it has been scant until last week (not quite 3 months out of treatment)when I was learning to do lymphedema therapy on myself & they directed me how to "decongest" in my mouth. Then I got a bunch of saliva from my parotid. It has been consistent since then. (I just posted about this on another thread) As far as I know what I had was IMRT. They had so many machines, if two were unavailable they still had another to use, so I never missed anything. The technicians would tell me, "same exact machine, same program".

I don't know much about it but I'd say it is not so much dependent upon TOMO but upon whether or not they are able to spare your parotids. Sounds like Don gave you some good advice.
Hope this helps as well.
Anne

chetan, just finished Tomo for cancer of larynx 10 days ago.Every other treatment I looked at (RO) said they would probably zap my salaviary glands and do some dental damage. The Tomo spared my glands completely and No dental problems.I had 30 treatments and the machine did go down twice.Once I did a double treatment 6 hours apart and the other time also a double. They had to fly apart in from N.Y. (I am in Denver) but it was up the next day. All in all I was impressed with the TOMO therapy and would recommend it. Steve Hurlock

[quote=AnneO]Chetan,
I think I told you that my parotids were spared, it is written into my plan.... As far as I know what I had was IMRT...
I don't know much about it but I'd say it is not so much dependent upon TOMO but upon whether or not they are able to spare your parotids...
Anne [/quote]

FYI - TOMO is IMRT, just delivered in a 360 degree rotational ARC, rather than standard step & shoot IMRT that is usually delivered from 5 to 9 static positions.

In addition to TOMO, now there is Varian and Novalis RapidARC/SmartARC and Siemens VMAT. All are similar.

It is probably impossible to develop and optimise a Parotid sparing plan with standard IMRT that is equivalent to one with ARC, because with ARC the modulated treatment beam is moving and has infinite entry and exit points as it passes through the isocenter.

None of three major CCC's in the San Diego area seem to be using standard IMRT for OC anymore - all have upgraded to ARC.

Hi All,

Thanks for all your input regarding TOMO.

I wanted to update you that I finished the simulation today and got the mask done. Hopefully I will start treatment soon after planning is done.

Thanks,
Chetan

That's great!! In a hurry up and get rid of this kind of way - good luck!