Digital Planning of Craniomaxillofacial Radiation Therapy

  • Gido Bittermann
  • Marc C. Metzger
  • Rainer Schmelzeisen


Computer-assisted surgery alone is insufficient in delineating tumour margins located at intervals of hard tissue. We demonstrate the use of visual three-dimensional image processing in combination with computer-assisted navigation techniques and conventional tissue marking with titanium clips as a useful adjunct to reduce irradiation volume.


Computer-aided navigation Tumour bed delineation Radiation treatment Margins Head and neck cancer Computer assisted surgery (CAS) 


  1. 1.
    Messmer P, Gross T, Suhm N, Regazzoni P, Jacob AL, Huegli RW. Modality-based navigation. Injury. 2004;35(Suppl 1):S-A24–9.CrossRefGoogle Scholar
  2. 2.
    Caldwell CB, Mah K, Skinner M, Danjoux CE. Can PET provide the 3D extent of tumor motion for individualized internal target volumes? A phantom study of the limitations of CT and the promise of PET. Int J Radiat Oncol Biol Phys. 2003;55(5):1381–93.CrossRefPubMedGoogle Scholar
  3. 3.
    Beyer T, Townsend DW, Brun T, Kinahan PE, Charron M, Roddy R, et al. A combined PET/CT scanner for clinical oncology. J Nucl Med. 2000;41(8):1369–79.PubMedGoogle Scholar
  4. 4.
    Feichtinger M, Pau M, Zemann W, Aigner RM, Karcher H. Intraoperative control of resection margins in advanced head and neck cancer using a 3D-navigation system based on PET/CT image fusion. J Craniomaxillofac Surg. 2010;38(8):589–94.CrossRefPubMedGoogle Scholar
  5. 5.
    Binahmed A, Nason RW, Abdoh AA. The clinical significance of the positive surgical margin in oral cancer. Oral Oncol. 2007;43(8):780–4.CrossRefPubMedGoogle Scholar
  6. 6.
    Liao CT, Chang JT, Wang HM, Ng SH, Hsueh C, Lee LY, et al. Surgical outcome of T4a and resected T4b oral cavity cancer. Cancer. 2006;107(2):337–44.CrossRefPubMedGoogle Scholar
  7. 7.
    Loree TR, Strong EW. Significance of positive margins in oral cavity squamous carcinoma. Am J Surg. 1990;160(4):410–4.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Schramm A, Suarez-Cunqueiro MM, Barth EL, Essig H, Bormann KH, Kokemueller H, et al. Computer-assisted navigation in craniomaxillofacial tumors. J Craniofac Surg. 2008;19(4):1067–74.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Bittermann G, Scheifele C, Prokic V, Bhatt V, Henke M, Grosu AL, et al. Description of a method: computer generated virtual model for accurate localisation of tumour margins, standardised resection, and planning of radiation treatment in head & neck cancer surgery. J Craniomaxillofac Surg. 2012;41:279–81.CrossRefPubMedGoogle Scholar
  10. 10.
    Essig H, Rana M, Meyer A, Eckardt AM, Kokemueller H, von See C, et al. Virtual 3D tumor marking-exact intraoperative coordinate mapping improve post-operative radiotherapy. Radiat Oncol. 2011;6:159.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Guijarro-Martinez R, Gellrich NC, Witte J, Tapioles D, von Briel C, Kolotas C, et al. Optimization of the interface between radiology, surgery, radiotherapy, and pathology in head and neck tumor surgery: a navigation-assisted multidisciplinary network. Int J Oral Maxillofac Surg. 2013;43:156–62.CrossRefPubMedGoogle Scholar
  12. 12.
    Metzger MC, Rafii A, Holhweg-Majert B, Pham AM, Strong B. Comparison of 4 registration strategies for computer-aided maxillofacial surgery. Otolaryngol Head Neck Surg. 2007;137(1):93–9.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Lubbers HT, Jacobsen C, Matthews F, Gratz KW, Kruse A, Obwegeser JA. Surgical navigation in craniomaxillofacial surgery: expensive toy or useful tool? A classification of different indications. J Oral Maxillofac Surg. 2011;69(1):300–8.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Oh JL, Nguyen G, Whitman GJ, Hunt KK, Yu TK, Woodward WA, et al. Placement of radiopaque clips for tumor localization in patients undergoing neoadjuvant chemotherapy and breast conservation therapy. Cancer. 2007;110(11):2420–7.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Kirby AM, Evans PM, Nerurkar AY, Desai SS, Krupa J, Devalia H, et al. How does knowledge of three-dimensional excision margins following breast conservation surgery impact upon clinical target volume definition for partial-breast radiotherapy? Radiother Oncol. 2010;94(3):292–9.CrossRefPubMedGoogle Scholar
  16. 16.
    Kirova YM, Castro Pena P, Hijal T, Fournier-Bidoz N, Laki F, Sigal-Zafrani B, et al. Improving the definition of tumor bed boost with the use of surgical clips and image registration in breast cancer patients. Int J Radiat Oncol Biol Phys. 2010;78(5):1352–5.CrossRefPubMedGoogle Scholar
  17. 17.
    Choi S, Schwartz DL, Farwell DG, Austin-Seymour M, Futran N. Radiation therapy does not impact local complication rates after free flap reconstruction for head and neck cancer. Arch Otolaryngol Head Neck Surg. 2004;130(11):1308–12.CrossRefPubMedGoogle Scholar
  18. 18.
    Chen TC, Wang CP, Ko JY, Yang TL, Lou PJ. The impact of pathologic close margin on the survival of patients with early stage oral squamous cell carcinoma. Oral Oncol. 2012;48(7):623–8.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Nemeth Z, Somogyi A, Takacsi-Nagy Z, Barabas J, Nemeth G, Szabo G. Possibilities of preventing osteoradionecrosis during complex therapy of tumors of the oral cavity. Pathol Oncol Res. 2000;6(1):53–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Wang Z, Qiu W, Huang G. Influence of radiotherapy on reconstruction flaps in oral and maxillofacial regions. Zhonghua Er Bi Yan Hou Ke Za Zhi. 1999;34(3):177–9.PubMedGoogle Scholar
  21. 21.
    Kirby AN, Jena R, Harris EJ, Evans PM, Crowley C, Gregory DL, et al. Tumour bed delineation for partial breast/breast boost radiotherapy: what is the optimal number of implanted markers? Radiother Oncol. 2013;106(2):231–5.CrossRefPubMedGoogle Scholar
  22. 22.
    Yang TJ, Tao R, Elkhuizen PH, van Vliet-Vroegindeweij C, Li G, Powell SN. Tumor bed delineation for external beam accelerated partial breast irradiation: a systematic review. Radiother Oncol. 2013;108(2):181–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Chao AH, Chang DW, Shuaib SW, Hanasono MM. The effect of neoadjuvant versus adjuvant irradiation on microvascular free flap reconstruction in sarcoma patients. Plast Reconstr Surg. 2012;129(3):675–82.CrossRefPubMedGoogle Scholar
  24. 24.
    Baker SR, Krause CJ, Panje WR. Radiation effects on microvascular anastomosis. Arch Otolaryngol. 1978;104(2):103–7.CrossRefPubMedGoogle Scholar
  25. 25.
    Zafereo ME, Weber RS, Lewin JS, Roberts DB, Hanasono MM. Complications and functional outcomes following complex oropharyngeal reconstruction. Head Neck. 2009;32(8):1003–11.CrossRefGoogle Scholar
  26. 26.
    Ohdaira T, Nagai H. Intraoperative localization of early-stage upper gastrointestinal tumors using a magnetic marking clip-detecting system. Surg Endosc. 2007;21(5):810–5.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Gido Bittermann
    • 1
  • Marc C. Metzger
    • 1
  • Rainer Schmelzeisen
    • 1
  1. 1.Department of Craniomaxillofacial SurgeryUniversity of FreiburgFreiburgGermany

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