Practice teaching course on head and neck cancer management

Transcription

1 28-29 October Saint-Priest en Jarez, France Practice teaching course on head and neck cancer management IMPROVING THE PATIENT S LIFE LIFE THROUGH MEDICAL MEDICAL EDUCATION EDUCATION

2 Jean-Baptiste GUY France Practical session: Multimodality imaging for target volume and organs at risk delineation or dose adaptation during treatment IMPROVING THE PATIENT S LIFE LIFE THROUGH MEDICAL MEDICAL EDUCATION EDUCATION

3 Multimodality imaging for target volume and organs at risk delineation or dose adaptation during treatment Jean-Baptiste GUY France

4 To get started: Guidelines

5 To get started: Contouring Atlases RTOG : SIRIADE (French Guidelines) :

6 Key Working Scheme Tumor Stage Localisation Involved Lymph Nodes CT Scan, Contrast Agent (Bi-Phasic), Mask (5 Points) Sequential IMRT/VMAT or SIB? Sequential IMRT/VMAT IMRT/VMAT with SIB Target Volumes Determination, Lymph Nodes Levels Delineation : 1) GTV 2) CTV1 3) CTV3 4) PTV Drawings Physical examination CT Scan MRI PET CT Surgical report Pathology report Target Volumes Determination, Lymph Nodes Levels Delineation : 1) GTV 2) CTV1 3) CTV2 4) CTV3 5) PTV Adapted from Lapeyre et al. Dosimetry

7 Radiotherapy Schemes ICLN Concurrent Chemotherapy ICLN Concurrent Chemotherapy ICLN Without Chemotherapy Lapeyre M et al. Cancer Radioth 2011

8 Target Volumes

9 Target Volumes GTV CTV1 (High Risk) : 70 Gy 66 Gy (Post-Op) CTV2 (Intermediate Risk) : 60 Gy CTV3 (Low Risk) : Gy

10 Target Volumes GTV PET-CT +++ MRI (Oral Cavity Oropharynx Salivary Glands) Leclerc M et al. Radioth Oncol 2015

11 Target Volumes GTV CTV1 (High Risk) : 70 Gy 66 Gy (Post-Op) CTV2 (Intermediate Risk) : 60 Gy CTV3 (Low Risk) : Gy GTV or Surgery Bed + Margin +/- Capsular Rupture

12 Target Volumes for Exclusive Chemo-Radiotherapy Adapted from Lapeyre M et al. Cancer Radioth. 2011

13 Target Volumes for Post-Operative Chemo-Radiotherapy Adapted from Lapeyre M et al. Cancer Radioth. 2011

14 Target Volumes GTV CTV1 (High Risk) : 70 Gy 66 Gy (Post-Op) CTV2 (Intermediate Risk) : 60 Gy CTV3 (Low Risk) : Gy SIB Contiguous Volume according to natural cancer history, anatomical barriers, diffusion

15 Oral Cavity CTV2 CTV3 Eisbrusch et al. Sem in Rad Oncol. 2002

16 Oropharynx CTV2 CTV3 Eisbrusch et al. Sem in Rad Oncol. 2002

17 Hypopharynx and Larynx CTV2 CTV3 Eisbrusch et al. Sem in Rad Oncol. 2002

18 Nasopharynx CTV2 CTV3 Eisbrusch et al. Sem in Rad Oncol. 2002

19 V olumes cibles pour les aires Lymph Nodes cervicales N0 II III V I VI IV Classification Robbins et al, 1991 Robbins et al. 1991

20 Anatomy

21 Levels Ia Ib Levels II, III, IV Levels Ia Ib

22 Level V Level VI Level VII (Retropharyngeal Nodes, Level VIIb Level VIII Level IX

23 Lymph Nodes Delineation Slice Location(cm): Transverse: Page 1 of 1

24 Lymph Nodes Delineation Slice Location(cm): Transverse: Page 1 of 1

25 Lymph Nodes Delineation Slice Location(cm): Transverse: Page 1 of 1

26 Lymph Nodes Delineation Slice Location(cm): Transverse: Page 1 of 1

27 Lymph Nodes Delineation Slice Location(cm): Transverse: Page 1 of 1

28 Lymph Nodes Delineation Slice Location(cm): Transverse: Page 1 of 1

29 Lymph Nodes Delineation Slice Location(cm): Transverse: Page 1 of 1

30 Lymph Nodes Delineation Slice Location(cm): Transverse: Page 1 of 1

31 Lymph Nodes Delineation Slice Location(cm): Transverse: Page 1 of 1

32 Lymph Nodes Delineation Slice Location(cm): Transverse: Page 1 of 1

33 Lymph Nodes Delineation Slice Location(cm): Transverse: Page 1 of 1

34 Lymph Nodes Delineation Slice Location(cm): Transverse: Page 1 of 1

35 Lymph Nodes Delineation Slice Location(cm): Transverse: Page 1 of 1

36 Lymph Nodes Delineation Slice Location(cm): Transverse: Page 1 of 1

37 Lymph Nodes Delineation Slice Location(cm): Transverse: Page 1 of 1

38 Lymph Nodes Delineation Slice Location(cm): Transverse: Page 1 of 1

39 Lymph Nodes Target Volumes

40 Lymph Nodes: Key Principles For cases of lateralized cancer in which only the ipsilateral neck would ordinarily require therapy, contralateral neck treatment is always added when the ipsilateral neck involvement is greater than N1. Levels IB and IV are treated in all cases in the neck side with clinical involvement of Levels II or III. Level V is treated in the neck side with involvement of Levels II-IV, in all cases. The retropharyngeal nodes are treated bilaterally in all cases of oropharyngeal and hypopharyngeal cancer with clinical involvement of Levels II-IV (in cases of early lateralized oro- pharyngeal tumors with small N1 disease, treat ipsilaterally). Level VI nodes are treated in all cases with clinical involvement of Level IV nodes. Eisbrusch et al. Sem in Rad Oncol. 2002

41 Oral Cavity Lapeyre M et al. Cancer Radioth 2014

42 Oropharynx and Nasopharynx Lapeyre M et al. Cancer Radioth 2014

43 Hypopharynx and Larynx Lapeyre M et al. Cancer Radioth 2014

44 Organs at risk

45 OARs! Anterior segment of the eyeball Posterior segment of the eyeball Lacrimal gland Parotid glands Submandibular glands Extended oral cavity Buccal mucosa Lips Mandible Cochlea Pharyngeal constrictor muscles (PCM) Supraglottic larynx Glottic area Arytenoids Cricopharyngeal inlet Cervical esophagus Brachial plexus Thyroid gland Brain Brainstem Pituitary gland Optic chiasm Optic Nerve Lung Retina

46 Anatomical Help Brouwer C. et al Radioth Oncol 2015

47 OAR: Dose Tolerance Source : QUANTEC / IJROBP / Cancer Radioth V

48 OAR: Dose Tolerance (2) Source : QUANTEC / IJROBP / Cancer Radioth V

49 OAR: Dose Tolerance (3) Source : QUANTEC / IJROBP / Cancer Radioth V

50 OAR: Dose Tolerance (4) Source : QUANTEC / IJROBP / Cancer Radioth V

51 P. C. LEVENDAG, Radiother oncol 2007 J. WERBROUCK, IntJROBP 2 Pharyngeal constrictor muscles Werbrouck J et al. IJROBP 2007

52 Plexus Brachial Hall W et al. IJROBP 2008

53 Margins

54 Margins CTV to PTV : - TrueBeam / Brainlab : 3 mm kv/kv : Daily - Linac / Acufix : 5 mm IGRT : CBCT : J1 J2 J3 + Weekly

55 References Delineation of the neck node levels for head and neck tumors: A 2013 update. DAHANCA, EORTC, HKNPCSG, NCIC CTG, NCRI, RTOG,TROG consensus guidelines. Gre goire V et al. Radiotherapy and Oncology 110 (2014) Delineation of the lymph nodes for head neck cancers. Lapeyre M el al. Cancer/Radiothe rapie 18 (2014) Anatomical bases for the radiological delineation of lymph node areas. Major collecting trunks, head and neck. Lengelé B et al. Radiotherapy and Oncology 85 (2007) Intensity-Modulated Radiation Therapy for Head and Neck Cancer: Emphasis on the Selection and Delineation the Targets. Eisbruch A el al. Seminars in Radiation Oncology, Vol 12, No 3 (July), 2002: pp Squamous cell carcinoma of the head and neck: EHNS ESMO ESTRO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Grégoire V et al. Annals of Oncology 21 (Supplement 5): v184 v186, 2010 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. Brouwer C et al. Radiotherapy and Oncology 117 (2015) Primary tumor delineation based on 18FDG PET for locally advanced head and neck cancer treated by chemo-radiotherapy. Leclerc M et al. Radiotherapy and Oncology 116 (2015) Development and validation of a standardized method for contouring the brachial plexus: preliminary dosimetric analysis among patients treated with imrt for head-and-neck cancer. Hall W et al. Int. J. Radiation Oncology Biol. Phys., Vol. 72, No. 5, pp , 2008 Target volume delineation for head and neck cancer intensity-modulated radiotherapy. Lapeyre M et al. Cancer/Radiothe rapie 15 (2011)

56 Thank you for your attention

57 Take-home message Multimodal imaging Rigor in dose fractionation Rigor in target volume definition