Head & Neck Contouring
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1 Head & Neck Contouring Presented by James Wheeler, MD Center for Cancer Care Goshen, IN September 12, 2014
2 Special Thanks to: Spencer Boulter, Director of Operations (AAMD) Adam Moore, RT(T), CMD Greg Robinson, RT(T), CMD 9/8/2014 2
3 Special Dedication Kian Ang, MD, PhD Gilbert H. Fletcher Memorial Distinguished Chair Professor of Radiation Oncology at the University of Texas M. D. Anderson Cancer Center Radiation Therapy Oncology Group Mentor and friend 9/8/2014 3
4 Objectives: Review contouring guidelines of the brachial plexus. Review contouring of various normal structures. Review lymph node stations. Review sample dose constraints. Review LN at risk for harboring metastatic disease based on the primary site. 9/8/2014 4
5 References: Hall et al., 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, Int. J. Radiation Biol. Phys., vol 72, No 5, pp , /8/2014 5
6 Brachial plexus image references Netter, Frank H. Atlas of Human Anatomy, 5 th Edition. 2011; plate 418. Harnsberger, Osborn, Macdonald, Ross. Diagnostic and Surgical Imaging Anatomy: Brain, Head & Neck, Spine. 2006; page /8/2014 6
7 (2)
8 Brachial Plexus 9/8/2014 8
9 Method Contour C5, T1, and T2 Contour anterior and middle scalene muscles Using a 5 mm contouring tool, contour from the neural foramina to in between the ant & mid scalene m. For the levels where there is no neural foramina, contour only the small space between the scalene muscles. Stop 1-2 slice below clavicle head. 9/8/2014 9
10 Brachial Plexus 9/8/
11 Brachial Plexus 9/8/
12 Brachial Plexus 9/8/
13 Brachial Plexus 9/8/
14 Brachial Plexus 9/8/
15 Brachial Plexus 9/8/
16 Brachial Plexus 9/8/
17 Brachial Plexus 9/8/
18 Brachial Plexus 9/8/
19 Brachial Plexus 9/8/
20 Brachial Plexus 9/8/
21 Brachial Plexus 9/8/
22 Brachial Plexus 9/8/
23 Brachial Plexus 9/8/
24 Brachial Plexus 9/8/
25 Brachial Plexus 9/8/
26 Brachial Plexus 9/8/
27 Brachial Plexus 9/8/
28 Brachial Plexus 9/8/
29 Brachial Plexus 9/8/
30 Brachial Plexus 9/8/
31 Brachial Plexus 9/8/
32 Brachial Plexus 9/8/
33 Brachial Plexus 9/8/
34 Brachial Plexus 9/8/
35 Brachial Plexus 9/8/
36 Brachial Plexus A typical dose constraint is to not let the brachial plexus exceed Gy. MRI can visualize the brachial plexus much better than CT, but most radiotherapy patients are planned from CT. The contouring guidelines only approximate the brachial plexus. 9/8/
37 Normal Structures Parotid Gland: yellow Submandibular Gland: light green Internal Carotid Artery: red Internal Jugular Vein: blue Hyoid Bone: magenta Sternocleidomastoid Muscle: cyano 9/8/
38 Parotid 9/8/
39 Parotid 9/8/
40 Parotid 9/8/
41 Internal carotid artery: red 9/8/
42 Internal jugular vein: blue 9/8/
43 Parotid gland: yellow 9/8/
44 Sternocleidomastoid m.: cyano 9/8/
45 Internal carotid artery: red 9/8/
46 Internal jugular vein: blue 9/8/
47 Sternocleidomastoid m.: cyano 9/8/
48 Parotid gland: yellow 9/8/
49 Internal carotid artery: red 9/8/
50 Internal jugular vein: blue 9/8/
51 Sternocleidomastoid m.: cyano 9/8/
52 Parotid: yellow 9/8/
53 Internal carotid artery: red 9/8/
54 Internal jugular vein: blue 9/8/
55 Sternocleidomastoid m.: cyano 9/8/
56 Normal structures 9/8/
57 Normal structures 9/8/
58 Normal structures 9/8/
59 Normal structures 9/8/
60 Submandibular gland: light green 9/8/
61 Submandibular gland: light green 9/8/
62 Submandibular gland: light green 9/8/
63 Submandibular gland: light green 9/8/
64 Submandibular gland: light green 9/8/
65 Submandibular gland: light green 9/8/
66 Submandibular gland: light green 9/8/
67 Submandibular gland: light green 9/8/
68 Submandibular gland: light green 9/8/
69 Hyoid bone: magenta 9/8/
70 Hyoid bone: magenta 9/8/
71 Hyoid bone: magenta 9/8/
72 Hyoid bone: magenta 9/8/
73 Hyoid bone: magenta 9/8/
74 Hyoid bone: magenta 9/8/
75 Hyoid bone: magenta 9/8/
76 Hyoid bone: magenta 9/8/
77 Hyoid bone: magenta 9/8/
78 Hyoid bone: magenta 9/8/
79 Sternocleidomastoid m.: cyano 9/8/
80 Internal carotid artery: red 9/8/
81 Internal jugular vein: blue 9/8/
82 Normal structures 9/8/
83 Normal structures 9/8/
84 Normal structures 9/8/
85 Normal structures 9/8/
86 Normal structures 9/8/
87 Normal structures 9/8/
88 Normal structures 9/8/
89 Normal structures 9/8/
90 Normal structures 9/8/
91 Normal structures 9/8/
92 Normal structures 9/8/
93 Normal structures 9/8/
94 Normal structures 9/8/
95 Normal structures 9/8/
96 Normal structures 9/8/
97 Normal structures 9/8/
98 Normal structures 9/8/
99 Normal structures 9/8/
100 Normal structures 9/8/
101 Normal structures 9/8/
102 Normal structures 9/8/
103 Normal structures 9/8/
104 Normal structures 9/8/
105 Normal structures 9/8/
106 Normal structures 9/8/
107 Normal structures 9/8/
108 Oblique view 9/8/
109 Oblique view 9/8/
110 Contouring the Lymph Nodes Reference: Vincent Grégoire, Kian Ang, et al, Delineation of the neck node levels for head and neck tumors: a 2013 update. DAHANCA, EORTC, HKNPCSG, NCIC, CTG, NCRI, RTOG, TROG consensus guidelines, Radiotherapy and Oncology 110 (2014) Clifford Chao, Practical Essentials of Intensity Modulated Radiation Therapy, second edition, 2005, chapter 7, pp /8/
111 Level Ia Submental group: midline region between the anterior belly of the right & left digastric m. Drains the skin of the chin, mid-lower lip, tip of the tongue, anterior mandibular alveolar ridge, and the floor of the mouth. 9/8/
112 Level Ib Submandibular group: space between the inner side of the mandible laterally and the digastric muscle medially; from the symphysis menti anteriorly to the submandibular gland posteriorly. Drain the submental nodes, lower nasal cavity, the hard and soft palate, the maxillary and mandibular alveolar ridges, the cheek, both lips, and most of the anterior tongue. 9/8/
113 Simplified version Stroking a cat. The midline space is the region of level Ia The space next to the jaw is the region of level Ib. 9/8/
114 Level Ia: blue; & Level Ib: brown 9/8/
115 Level Ia: blue; & Level Ib: brown 9/8/
116 Key point: The submandibular gland forms the posterior border of the Level Ib nodal group. 9/8/
117 Level Ia: blue; & Level Ib: brown 9/8/
118 Level Ia: blue; & Level Ib: brown 9/8/
119 Level Ia: blue; & Level Ib: brown 9/8/
120 Level Ia: blue; & Level Ib: brown 9/8/
121 Level Ia: blue; & Level Ib: brown 9/8/
122 Level Ia: blue; & Level Ib: brown 9/8/
123 Level Ia: blue; & Level Ib: brown 9/8/
124 Level Ia: blue; & Level Ib: brown 9/8/
125 Level Ib: brown 9/8/
126 Level Ib: brown 9/8/
127 Level Ib: brown 9/8/
128 Level Ib: brown 9/8/
129 Level Ib: brown 9/8/
130 Level II Upper jugular group: lie in the space between the deep (medial) surface of the sternocleidomastoid muscle (SCM) laterally, and the medial edge of the internal carotid artery and the scalenius muscle medially; this space extends from the posterior edge of the submandibular gland anteriorly to the posterior edge of the SCM posteriorly, and from the lateral process of the first cranial vertebra to the caudal edge of the hyoid bone. 9/8/
131 Level II Receives from the face, parotid gland, submandibular, submental, & retropharyngeal nodes. Drains from nasal cavity, oral cavity, nasopharynx, oropharynx, larynx, major salivary glands. Involvement is more common from oropharynx and nasopharynx than oral cavity, larynx, or hypopharynx. 9/8/
132 Level II 9/8/
133 Level II 9/8/
134 Level II 9/8/
135 Level II 9/8/
136 Level II 9/8/
137 Level II 9/8/
138 Level II 9/8/
139 Level II 9/8/
140 Level II 9/8/
141 Level II 9/8/
142 Level II 9/8/
143 Level II 9/8/
144 Level II 9/8/
145 Level II 9/8/
146 Key points: Sternocleidomastoid muscle establishes the lateral and posterior borders of level II Medial border of the internal carotid artery establishes the medial border of level II. Posterior edge of the submandibular gland establishes the anterior border of level II. 9/8/
147 Level II 9/8/
148 Level II 9/8/
149 9/8/
150 Level II 9/8/
151 Level II 9/8/
152 Level II 9/8/
153 Level II 9/8/
154 Level II 9/8/
155 Level II 9/8/
156 Level II 9/8/
157 Level II 9/8/
158 Level II 9/8/
159 Key point The bottom of the hyoid bone marks the border between level II and level III. 9/8/
160 Level II 9/8/
161 Level II 9/8/
162 Level III Middle jugular lymph nodes: extends from the caudal edge of the body of the hyoid to the caudal edge of cricoid cartilage. Anterior limit: the anterior edge of the SCM or the posterior third of the thyro-hyoid muscle. Posterior limit: the posterior edge of SCM. Lateral limit: deep surface of SCM. Medial: medial edge of common carotid artery & scalene muscles 9/8/
163 Level III Receives lymph from Level II & V, retropharyngeal, pretracheal, & recurrent laryngeal nodes. At risk: oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx. 9/8/
164 Level III 9/8/
165 Level III 9/8/
166 Level III 9/8/
167 Level III 9/8/
168 Level III 9/8/
169 Level III 9/8/
170 Level III 9/8/
171 Level III 9/8/
172 Level III 9/8/
173 Level III 9/8/
174 Level III 9/8/
175 Level IV: Caudal jugular LN Can be divided into IVa (lower jugular LN) and Ivb (medial supraclavicular LN) At risk: IVa: hypopharynx, larynx, thyroid, and cervical esophagus. At risk IVb: hypopharynx, sub-glottic larynx, trachea, thyroid, and cervical esophagus. 9/8/
176 Level IV Cranial: lower margin of cricoid cartilage Caudal: 2 cm cranial to sternoclavicular joint (N0) or sternoclavicular joint (N+). Anterior: posterolateral edge of SCM muscle Posterior: anterior edge of paraspinal muscle Lateral: lateral border of SCM Medial: medial border of vessel bundle, lateral border of thyroid. 9/8/
177 Level V: Posterior triangle group Dorsal cervical LN along the spinal accessory nerve. Va: upper posterior triangle nodes Vb: lower posterior triangle nodes Vc: lateral supraclavicular nodes 9/8/
178 Level V Cranial: base of skull Caudal: transverse cervical vessels, cranial border of clavicle (noncontrast CT) Anterior: posterior edge of SCM muscle Posterior: anterior edge of trapezius muscle Lateral: platysma muscle, skin Medial: paraspinal muscle 9/8/
179 Level V At risk: primary cancers of the nasopharynx, oropharynx, thyroid gland, skin of the posterior scalp. 9/8/
180 Levels IV & V 9/8/
181 Levels IV & V 9/8/
182 Levels IV & V 9/8/
183 Levels IV & V 9/8/
184 Levels IV & V 9/8/
185 Levels IV & V 9/8/
186 Levels IV & V 9/8/
187 Levels IV & V 9/8/
188 Levels IV & V 9/8/
189 Levels IV & V 9/8/
190 Levels IV & V 9/8/
191 Levels IV & V 9/8/
192 Levels IV & V 9/8/
193 Levels IV & V 9/8/
194 Levels IV & V 9/8/
195 Levels IV & V 9/8/
196 Levels IV & V 9/8/
197 Levels IV & V 9/8/
198 Levels IV & V 9/8/
199 Levels IV & V 9/8/
200 Levels IV & V 9/8/
201 Levels IV & V 9/8/
202 Levels IV & V 9/8/
203 Levels IV & V 9/8/
204 Levels IV & V 9/8/
205 Levels IV & V 9/8/
206 Levels IV & V 9/8/
207 Levels IV & V 9/8/
208 Levels IV & V 9/8/
209 Levels IV & V 9/8/
210 Levels IV & V 9/8/
211 Levels IV & V 9/8/
212 Levels IV & V 9/8/
213 Dose constraints Spinal cord: 45 Gy is common, but some protocols allow Gy. Brainstem: 50 Gy Lips: 25 Gy (non-oral cavity primary) Lips: 45 Gy (oral cavity primary) Oral cavity: 30 Gy (for non-oral cavity primary) Parotid gland: 26 Gy (mean dose) 9/8/
214 LN at risk: clinical N0 Nasopharynx: Maxillary sinus (T1-2): Maxillary sinus (T3-4): Oral tongue (T3-4): Floor of mouth: Buccal, RMT (T1-2): (Ib-V, RPLN) none Ipsilat (I, II, RPLN) Bilat (I-V) Bilat (I-V) Ipsi (I-III) 9/8/
215 LN at risk: clinical N0 Tonsil (T1-2): Tonsil (T3-4): Base of tongue: Ipsi (Ib-V) Bilat (Ib-V, RPLN) Bilat (Ib-V, RPLN) 9/8/
216 LN at risk: clinical N0 TVC (T1-2): TVC (T3-4): Supraglottic Hypopharynx none Bilat (II-V) Bilat (II-V) Bilat (II-V, RPLN) 9/8/
217 Questions 9/8/
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