Basics of Head and Neck IMRT Planning and Anatomy - ASTRO
Basics of Head and Neck IMRT Planning and Anatomy - ASTRO
Basics of Head and Neck IMRT Planning and Anatomy - ASTRO
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<strong>Basics</strong> <strong>of</strong> <strong>Head</strong> <strong>and</strong> <strong>Neck</strong> <strong>IMRT</strong><br />
<strong>Planning</strong> <strong>and</strong> <strong>Anatomy</strong><br />
Kenneth H M D<br />
Kenneth Hu, M.D.<br />
Beth Israel Medical Center, NY<br />
Assoc. Pr<strong>of</strong>essor<br />
Albert Einstein College <strong>of</strong> Medicine
No Disclosures
Learning Learning Objectives<br />
Objectives<br />
• To review basic anatomy <strong>and</strong> nodal target<br />
delineation<br />
• To underst<strong>and</strong> dosimetric parameters<br />
associated with improved functional/QOL<br />
outcomes outcomes—xerostomia, xerostomia swallowing swallowing, dental<br />
morbidity <strong>and</strong> neurologic function<br />
• TTo review i pathways th <strong>of</strong> f perineural i l spread<br />
d
<strong>Basics</strong> <strong>of</strong> Contouring<br />
• GTV by imaging/physical exam/endoscopy<br />
– CT neck st<strong>and</strong>ard for nodal <strong>and</strong> primary<br />
– PET/CT to guide equivocal<br />
– MRI for NPC, paranasal cavity tumors to<br />
evaluate intracranial spread, mucus, RP<br />
nodes, parapharyngeal, clivus, perineural<br />
• CTV margin 5mm PTV Margins 3-5mm—<br />
trim based on skin, air <strong>and</strong> bone along<br />
with compartments
References for Lymph Node<br />
Delineation<br />
• CT-Based Delineation <strong>of</strong> Lymph y p Node Levels<br />
<strong>and</strong> Related CTV in Node Negative <strong>Neck</strong><br />
Dahanca, EORTC, GORTEC,NCIC,RTOG<br />
– GGregoire, i et t al. l RRadiotherapy di th <strong>and</strong> d OOncology, l 65 2003 2003,<br />
227-236<br />
• Proposal for the delineation <strong>of</strong> the nodal CTV in<br />
Node-positve <strong>and</strong> the post-operative neck<br />
– Gregoire, et al. Radiotherapy <strong>and</strong> Oncology, 79 2006,<br />
15 15-20 20<br />
• RTOG Website www.rtog.org
Percentage Incidence <strong>and</strong> Distribution <strong>of</strong><br />
PPathologically th l i ll IInvolved l d NNodes d iin a Cli Clinical i l<br />
Node Negative <strong>Neck</strong> After Elective Radical<br />
N<strong>Neck</strong> k Di Dissection ti<br />
Oropharynx<br />
n=48<br />
Hypopharynx<br />
n=24<br />
Larynx<br />
n=79<br />
Oral Cavity<br />
NN=192 192<br />
I II III IV V<br />
2 25 19 8 2<br />
0 13 13 0 0<br />
5 19 20 9 25 2.5<br />
20 17 9 3 0.5<br />
Shah, J.P et al. The patterns <strong>of</strong> cervical lymph node metastases from<br />
squamous carcinoma <strong>of</strong> the oral cavity. Cancer, 1990. 66(1): p. 109-13
Percentage g Incidence <strong>and</strong> Distribution <strong>of</strong><br />
Pathologically Involved Nodes in a Clinical<br />
Node Positive after Therapeutic p Radical<br />
<strong>Neck</strong> Dissection<br />
I II III IV V<br />
Oropharynx<br />
n=165<br />
14 71 42 28 9<br />
Larynx n=183 7 57 59 29 4<br />
Hypopharynx yp p y<br />
n=104<br />
Oral Cavity<br />
n=324<br />
10 76 73 46 11<br />
46 43 33 15 3<br />
Shah, J.P., Patterns <strong>of</strong> cervical lymph node metastasis from squamous<br />
carcinomas <strong>of</strong> the upper aerodigestive tract. Am J Surg, 1990. 160(4): p. 405-9.
Image-Based <strong>Neck</strong> Node Level Classification<br />
Som et al, AJR, 2000
Nodal LN in LN- LN vs LN+<br />
• Pt with an unknown primary with<br />
Pt with an unknown primary with<br />
T0N2bM0 involving the right neck
Upper Ib,II,Va<br />
CTV <strong>of</strong> LN+<br />
J foramen<br />
Sup constrictor<br />
spared on L<br />
ICA ICA, IJV<br />
L Lat<br />
RP LN<br />
C1 TVP<br />
Sparing <strong>of</strong><br />
parotid p in LN-
Ib,IIa/b<br />
Ia LN spared<br />
Subm<strong>and</strong>ib gl<br />
IIa/b<br />
Lx, SMG, mid<br />
constrictors
L III/Va LN, Lx,<br />
inf constrictors
L IV,Vb LN, Lx,<br />
cricopharyngeus<br />
L IV,SCL LN, trachea,<br />
cervical esoph
L IV,SCL LN, L IV,<br />
cervical esoph
Coverage <strong>of</strong> Nodal Volumes<br />
• Retropharyngeal Nodes—<br />
– Skull Base down to hyoid bone<br />
– LLateral t l RP LN iinvolved l d fi first t ( (spare constrictors) t i t )<br />
– Medial RP LN if lateral RP LN+<br />
• Cervical Nodal<br />
– LN- Inferior margin <strong>of</strong> C1 Transverse <strong>and</strong> selective<br />
nodal<br />
– jugular foramen if LN+ <strong>and</strong> comprehensive<br />
nodal treatment<br />
• Level VI (pre-tracheal/delphian) (pre tracheal/delphian) for subglottic<br />
tumor/hypopharynx/thyroid<br />
• Level VII (superior mediastinum) with level IV IV,<br />
thyroid, cervical esophagus
<strong>IMRT</strong> Improved Xerostomia:<br />
PASSPORT Trial<br />
• 94 pts with OP/HP cancer r<strong>and</strong>omized to <strong>IMRT</strong> vs 3DRT<br />
• Whole contralateral parotid p < 24Gy y<br />
Lent SOMA Score EORTC Dry Mouth Subscale<br />
Nutting CM et al, Lancet Oncol 2011, 12:127
Subm<strong>and</strong>ibular Gl<strong>and</strong> Sparing<br />
• 36 pts OPX ( (n=28) 28) NPX treated d with i h RT<br />
• Case matched—18pts with SMG sparing<br />
<strong>and</strong> d18 18 without. ith t<br />
• SMG spared had lower N stage (no N2b-<br />
3) vs SMG non-spared d group (59% N2b N2b-3) 3)<br />
Saarilahti et al Radiotherapy <strong>and</strong> Oncology78 (2006) 270–75.
Mean SMG
• 78 pts III/IV Opx prospectively followed<br />
after <strong>IMRT</strong> designed to spare bilateral<br />
parotids parotids, oral cavity, cavity contralateral SMG<br />
• Pt <strong>and</strong> observer reported xerostomia<br />
surveys <strong>and</strong> salivary collection up to 2yrs<br />
Little Little, et al, al IJROBP In press
Mean Oral Cavity
Dysphagia<br />
RTOG-0129 RTOG 0129 Cisplatin + RT<br />
PEG dependence 1yr 30%<br />
Measures <strong>of</strong> dysphagia:<br />
Feeding tube dependence<br />
vide<strong>of</strong>luoroscopy/silent py aspiration p<br />
dysphagia qol surveys
Pharyngeal<br />
Constrictors<br />
Superior<br />
Mid<br />
Inferior<br />
Werbrouch J et al, IJROBP 2009,<br />
73:1187<br />
Courtesy Dr. Eisbruch/Le
Levendag PC, et al. Radiother Oncol. 2007
.6<br />
.5<br />
.2 .3 . .4<br />
0 .1<br />
Probability Swallowing Problems<br />
Cyberknife (3x + 4x)<br />
Brachytherapy y py implant p<br />
No BT / No Cyberknife<br />
3x<br />
0 10 20 30 40 50 60 70 80<br />
Dose superior constrictor muscle (Gy)<br />
4x<br />
Levendag PC, et al. Radiother Oncol. 2007
Constrictors Mean Dose
73 III/IV Opx 70Gy/7wks + taxol/carbo/wk<br />
Med F/U 36mo 3yr LRC 96% DFS 88%<br />
Feng JCO 2010
PEG dependence 1.4% at 1yr<br />
Dysphagia related to dose to PC PC,Lx, Lx Esoph<br />
<strong>Neck</strong> dissection/smoking/t-stage<br />
5 t ith t i t<br />
• 5 pts with strictures<br />
• 8 pts with pneumonia—all silent aspirators
Eisbruch<br />
(IJROBP,2011)<br />
( , )<br />
Caudell<br />
(IJROBP (IJROBP,2010) 2010)<br />
Mean Tolerance Doses <strong>and</strong><br />
Swallowing Complications<br />
PEG-<br />
depend<br />
LX
Caveats Caveats- Other Causes <strong>of</strong><br />
Dysphagia<br />
T-Stage Tumor Location<br />
Machtay M et al, JCO 26:3582<br />
<strong>Neck</strong> Dissection<br />
Courtesy Dr. Le
Dosimetric Factors For Dental<br />
Events<br />
M<strong>and</strong>ible<br />
MSKCC, N=168 pts Med f/u 37mos ORN 1% (2/168pts)<br />
Dental caries 9% Decreased if Mean parotid p dose < 26Gyy<br />
Dental Extraction 12% Decreased if Mean m<strong>and</strong>ible < 38Gy or<br />
Gomez IJROBP 81, No. 4, pp. e207–13, 2011<br />
Max M<strong>and</strong>ible < 68Gy
Truong, Radiographics,RSNA 2010<br />
Brachial plexus
Temporal Lobe Necrosis<br />
• V55
Cochlea<br />
Tolerance
Perineural Invasion<br />
• Noncontiguous spread along the nerve<br />
endoneurium d i ffrom a ttumor<br />
• Skin cancers, Parotid (adenoid cystic),<br />
Nasopharynx<br />
Caldemeyer, Radiographics 1998
Relation <strong>of</strong> CN VII <strong>and</strong> V<br />
GLUCK et al. IJROBP Vol. 74, No. 1, pp. 38–46, 2009
Neur<strong>of</strong>oramina <strong>of</strong> CN V<br />
VC<br />
F. Ovale<br />
F. Ovale<br />
SOF<br />
VC<br />
F<br />
RRotundum t d<br />
Caldemeyer, Radiographics 1998
G. Ganglion g<br />
CN 7 pathway<br />
Horizontal CN 7<br />
DescendingCN 7<br />
Caldemeyer, Radiographics 1998
Skin Cancer <strong>and</strong><br />
PNI
T4 Adenoid Cystic Ca <strong>of</strong> L<br />
Deep lobe<br />
Parotid<br />
Pterygoid<br />
mm<br />
Desc CN 7 Desc CN 7<br />
IAC<br />
Auriculotemporal<br />
nn
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