Atlases for Organs at Risk (OARs) in Thoracic Radiation Therapy
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1 Atlases for Organs at Risk (OARs) in Thoracic Radiation Therapy Feng-Ming (Spring) Kong MD PhD Leslie Quint MD Mitchell Machtay MD Jeffrey Bradley MD 1
2 Outline of Content Atlas for lung, esophagus, and spinal cord Atlas for brachial plexus Atlas for proximal bronchial tree Atlas for chest wall Atlas for pericardium, heart and great vessels (including normal pericardial recesses) 2
3 RTOG 1106 Required OARs Structure Lungs Heart Esophagus SpinalCord BrachialPlexus Descriptio n Lungs PreGTV (composite of CT1GTV and PETMTV) Heart Esophagus Spinal Canal Brachial Plexus Structure definition and contouring instructions Both lungs should be contoured using pulmonary windows. The right and left lungs can be contoured separately, but they should be considered as one structure for lung dosimetry. All inflated and collapsed, fibrotic and emphysematic lungs should be contoured, small vessels extending beyond the hilar regions should be included; however, pre GTV, hilars and trachea/main bronchus should not be included in this structure. The heart will be contoured along with the pericardial sac. The superior aspect (or base) will begin at the level of the inferior aspect of the pulmonary artery passing the midline and extend inferiorly to the apex of the heart. The esophagus should be contoured from the beginning at the level just below the cricoid to its entrance to the stomach at GE junction. The esophagus will be contoured using mediastinal window/level on CT to correspond to the mucosal, submucosa, and all muscular layers out to the fatty adventitia. The spinal cord will be contoured based on the bony limits of the spinal canal. The spinal cord should be contoured starting at the level just below cricoid (base of skull for apex tumors) and continuing on every CT slice to the bottom of L2. Neuroformanines should not be included. This is only required for patients with tumors of upper lobes. Only the ipsilateral brachialplex is required. This will include the spinal nerves exiting the neuroforamine from top of C5 to top of T2. In contrast to prior RTOG lung studies of contouring the major trunks of the brachial plexus with inclusion of subclavian and axillary vessels, this trial requests contouring the nerves according to the CT anatomy on every other CT slice. The structure should extend at least 3 cm above the PTV. 3
4 RTOG 1106 Optional OARs Structure Description Structure definition and contouring instructions Pericard Greatves Aorta SVC IVC PV PA Great vessels Aorta Superior vena cava Inferior vena cava pulmonary vein pulmonary artery The structure of pericardium includes pericardial fatty tissue, part of great vessels, normal recesses, pericardial effusion (if applicable) and heart chambers. starts at one slice above the top of aortic arch, ends at the last slice of heart apex at diaphragm. includes the heart. The great vessels should be contoured separately from the heart, using mediastinal windowing to correspond to the vascular wall and all muscular layers out to the fatty adventitia (5 mm from the contrast enhanced vascular wall). The great vessel should be contoured starting at least 3 cm above the superior extent of the PTV and continuing on every CT slice to at least 3 cm below the inferior extent of the PTV. For right sided tumors, SVC will be contoured, and for left sided tumors, the aorta will be contoured. The ipsilateral PA will be delineated for tumor of either side. Pbtree CW2cm Proximal Bronchial Tree Chest wall 2 cm outside of lung This structure includes the distal 2 cm of the trachea, the carina, the right and left mainstem bronchi, the right and left upper lobe bronchi, the intermedius bronchus, the right middle lobe bronchus, the lingular bronchus, and the right and left lower lobe bronchi. Chest wall can be autosegmented from the ipsilateral lung with a 2-cm expansion in the lateral, anterior, and posterior directions. Anteriorly and medially, it ends at the edge of the sternum. Posteriorly and medially, it stops at the edge of the vertebral body with inclusion of the spinal nerve root exit site. CW2cm which include intercostal muscles, nerves exclude vertebrate bodies, sternum and skin. This can be accomplished through auto-expansion of the ipsilateral lung (within 3 cm range of PTV). 4
5 Atlas of lung, esophagus, and spinal cord Int J Radiat Oncol Biol Phys (5):
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7 Esophagus starts at the level of cricoid Lung is visible now of the left apex Lung Spinal cord should also start at this level just below the cricord or from the base of skull C1 if scan is available, particularly when the tumors involve neck or apex. 7
8 Esophagus and lung continue Spinal cord The structure of spinal cord should include the entire spinal canal to decrease contouring variations. 8
9 Esophagus, lung and cord continue Great vessels delineation is recommended, but not mandated. SVC=superior vena cava Proximal Bronchial Tree Proximal bronchial tree delineation is recommended, but not mandated. 9
10 Esophagus, lung and cord continue great vessels start from the level of aortic arch SVC=superior vena cava Proximal bronchial tree starts at 2 cm above carina 10
11 Esophagus, lung and cord continue and great vessels, proximal bronchial tree AA=ascending aorta, PA=pulmonary artery, DA=descending aorta, SVC=superior vena cava 11
12 Esophagus, lung, cord, great vessels and proximal bronchial tree AA=ascending aorta, PA=pulmonary artery, DA=descending aorta, SVC=superior vena cava 12
13 Esophagus, lung, cord, great vessels and proximal bronchial tree AA=ascending aorta, PA=pulmonary artery, DA=descending aorta, SVC=superior vena cava 13
14 Esophagus, lung, cord, great vessels and proximal bronchial tree continue AA=ascending aorta, PA=pulmonary artery, DA=descending aorta, SVC=superior vena cava 14
15 Esophagus, lung, cord, great vessels and proximal bronchial tree AA=ascending aorta, PA=pulmonary artery, DA=descending aorta, SVC=superior vena cava 15
16 Esophagus, lung, cord continue DA=descending aorta 16
17 Esophagus ends at gastric-esophageal junction, Lung and cord continue IVC=inferior vena cava, DA=descending aorta 17
18 Lung ends, cord continues until the bottom of L2 Vertebral body IVC=inferior vena cava, DA=descending aorta 18
19 Atlas for Brachial Plexus 19
20 Locating the Brachial Plexus Timmerman s Trick-1 clavicle 1 st rib Vein, artery, and nerve (VAN, anterior to posterior) will go over the 1 st rib and under the clavicle Using coronal images, find the plane where vascular/nerve structures (tubes and wires) pass between the 1 st rib and clavicle Roughly contour these neurovascular tissues in this coronal plane (as shown in yellow) You will use these rough contours in the next step 20
21 Locating the Brachial Plexus Timmerman s Trick-1 V N A Project coronal contours onto axial images (yellow points shown on axial image) In the region between the projected points, identify the VAN on either side. Contour the N as the root(s) of the brachial plexus Note: Finding the brachial plexus on the uninvolved side will help in finding it on the involved side Note: IV contrast greatly facilitates this task (see contrast in artery) 21
22 Brachial plexus starts between C4 C5 22
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30 Vein Nerve Artery 30
31 Brachial plexus not visible any more 31
32 Proximal Bronchial Tree (PBT) PBT should include the distal 2 cm of the trachea, the carina, the right and left mainstem bronchi, the right and left upper lobe bronchi, the intermedius bronchus, the right middle lobe bronchus, the lingular bronchus, and the right and left lower lobe bronchi (a, b, c, d, e, f, g in the figure) PBT can be contoured by autosegmenting the airspace of the central airway with 3 mm expansion (2 mm for lobar bronchus, 3 mm for main bronchus, 4 mm for trachea) 32
33 Proximal Bronchial Tree The proximal bronchial tree can be contoured using mediastinal windows on the CT scan to correspond to the mucosal, submucosa, and cartilage rings and airway channels associated with these structures. It can be contoured as one structure, including the most inferior 2 cm of distal trachea and the proximal airways of both sides. Contouring the lobar bronchi should end immediately at the level of a segmental bifurcation. Recommendation based on Timmerman et al for RTOG 0236 and RTOG 0618, Bezjak et al for RTOG
34 PBT starts at 2 cm above carina 34
35 Proximal Bronchus Tree continues 35
36 Proximal Bronchus Tree continues 36
37 Proximal Bronchus Tree Continues 37
38 Proximal Bronchus Tree continues 38
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50 Proximal Bronchus Tree Ends at the level of lobar bronchus bifurcating into segmental bronchus 50
51 Chest Wall Contours Chest wall can be autosegmented from the ipsilateral lung with a 2-cm expansion in the lateral, anterior, and posterior directions. Anteriorly and medially, it ends at the edge of the sternum. Posteriorly and medially, it stops at the edge of the vertebral body with inclusion of the spinal nerve root exit site. This recommendation was: based on Kong et al, Int J Radiat Oncol Biol Phys Oct 7. [Epub ahead of print] Supported by CW2cm consistently enabled better prediction of CW toxicity than CW3cm in Mutter et al, Int J Radiat Oncol Biol Phys Aug 23. [Epub ahead of print] 51
52 Chest Wall (CW) CW refers to CW2cm which include intercostal muscles, nerves exclude vertebral bodies, sternum and skin. This can be accomplished through auto-expansion of the ipsilateral lung (within 3 cm range of PTV). Chest wall CW contouring starts at 3 cm above the PTV 52
53 Chest Wall CW refers to CW2cm which include intercostal muscles, nerves exclude vertebral bodies, sternum and skin. PTV The superior end of PTV 53
54 Chest Wall CW refers to CW2cm which include intercostal muscles, nerves exclude vertebral bodies, sternum and skin. PTV GTV The superior end of GTV 54
55 Chest Wall CW refers to CW2cm which include intercostal muscles, nerves exclude vertebral bodies, sternum and skin. Chest wall contours around GTV. 55
56 Chest Wall CW refers to CW2cm which include intercostal muscles, nerves exclude vertebral bodies, sternum and skin. The inferior end of PTV 3 cm below PTV CW ends at 3cm from the inferior edge of PTV. 56
57 , Heart, Great Vessels, Heart Chambers, and Normal Pericardial Recesses Feng-Ming (Spring) Kong (RTOG), Leslie Quint (ACRIN), Jeffrey Bradley (RTOG), Suresh Senan (EORTC), Ritsuko Komaki (RTOG), Laurie Gaspar (SWOG), Luying Xu (UM), Chengbo Han (UM), Jun Liu (UM), Weili Wang (UM), Robin Marsh (UM), Randall Ten Haken (UM), Charles Thomas (SWOG), Jeffrey Bogart (CALGB), Mitchell Machtay (RTOG) 57
58 , normal recesses and heart chambers The structure of pericardium includes pericardial fatty tissue, part of great vessels, normal recesses, pericardial effusion (if applicable) and heart chambers. 58
59 Anatomy of Pericardial sac and normal recesses 59
60 Pericardial Normal Recesses Vesely et al, 1986 Groell et al, Radiology,
61 SVC AA AA=ascending aorta, SVC=superior vena cava 61
62 SVC AA Posterior superior anterior recesses (psar) AA=ascending aorta, V=superior vena cava 62
63 SVC AA DA AA=ascending aorta, DA=descending aorta, SVC=superior vena cava 63
64 Anterior superior aorta recess (asar) V AA DA Posterior superior aorta recess (psar) AA=ascending aorta, DA=descending aorta, SVC=superior vena cava 64
65 Anterior superior aorta recess (asar) SVC AA PA Posterior superior aorta recess (psar) DA AA=ascending aorta, DA=descending aorta, SVC=superior vena cava, PA= pulmonary artery 65
66 AA MPA DA AA=ascending aorta, DA=descending aorta, MPA=main pulmonary artery 66
67 Right superior aortic recess (rsar) AA SVC PA LA Left pulmonic recess (LPR) DA AA=ascending aorta, DA=descending aorta, V=superior vena cava, PA=main pulmonary artery, PA=right pulmonary artery, LA=left atrium 67
68 Right pulmonic recess (RPR) RA SVC AA MPA LA E DA Posterior Pericardial recess (PPR) RA=right atrium, AA=aortic arch, LV=left ventricle, LA=Left atrium, MPA=main pulmonary artery, DA=descending aorta, E=esophagus 68
69 RV RA AA LV LA E DA Oblique sinus (OS) RA=right atrium, RV=right ventricle, LV=left ventricle, LA=Left atrium, AA=aortic arch, DA=descending aorta, E=esophagus 69
70 RA RV AA LA LV RA=right atrium, RV=right ventricle, LV=left ventricle, LA=Left atrium, AA=Ascending Aorta 70
71 effusion (PEFF) RV RA LA LV DA RA=right atrium, RV=right ventricle, LV=left ventricle, LA=Left atrium, AA=aortic arch 71
72 Pericardial effusion (PEFF) RV RA LV LA E DA RA=right atrium, RV=right ventricle, LV=left ventricle, LA=Left atrium 72
73 LIVER LV Pericardial effusion (PEFF) 73
74 Atlas for Heart and : based on anatomy Heart: based on consensus contours of most RTOG centers/previous trials, actually including part of pericardium 74
75 starts Innominate artery Brachiocephalic vein Left carotid artery Subclavian artery A starts at 1-2 slices (5-6 mm) above the superior end of the aortic arch 75
76 continues SVC SVC SVC=superior vena cava 76
77 continues SVC SVC SVC=superior vena cava 77
78 continues SVC SVC AA DA SVC=superior vena cava 78
79 continues SVC SVC AA AA DA DA SVC=superior vena cava AA=Ascending aorta DA=Descending aorta 79
80 continues SVC SVC AA AA PA DA PA DA SVC=superior vena cava PA=Pulmonary artery AA=Ascending aorta DA=Descending aorta 80
81 SVC SVC AA AA PA DA PA DA SVC=Superior vena cava PA=Pulmonary artery AA=Ascending aorta DA=Descending aorta 81
82 Continues AA SVC SVC AA PA DA PA DA SVC=Superior vena cava PA=Pulmonary artery AA=Ascending aorta DA=Descending aorta 82
83 Continues SVC AA PA PA SVC AA PA PA DA DA CT-GTV SVC=superior vena cava PA=Pulmonary artery AA=Ascending aorta DA=Descending aorta 83
84 Continues SVC AA PA SVC AA PA CT-GTV DA PA CT-GTV DA PA SVC=Superior vena cava PA=Pulmonary artery AA=Ascending aorta DA=Descending aorta 84
85 Continues SVC AA PA SVC0 AA PA PV DA PA PV CT-GTV DA CT-GTV SVC=Superior vena cava PA=Pulmonary artery AA=Ascending aorta DA=Descending aorta 85
86 continues Heart contour starts at this level, 1 slice below pulmonary artery trunk passing the midline Heart Heart AA PA AA PA PV SVC PA PV CT-GTV DA PV SVC PA PV CT-GTV DA Heart and pericardium are to be overlapped. 86
87 Heart and pericardium continue Heart Heart AA PA AA PA PV PA SVC CT-GTV LA PV DA PA PA SVC CT-GTV LV LA PV DA AA=Ascending Aorta, PA=pulmonary artery, RA=right atrium, RV=right ventricle, LV=left ventricle, LA=Left atrium, PV=pulmonary vein, DA=descending aorta, SVC=superior vena cava 87
88 and Heart continue Heart Heart RA PA CT-GTV PA AA LV LA PV DA RA CT-GTV PA AA LV LA DA RA=right atrium, RV=right ventricle LV=left ventricle, LA=Left atrium DA=descending aorta 88
89 and Heart continue Heart Heart CT-GTV PA RA AA LV LA DA PV PA RA CT-GTV RV LV LA DA PV AA=Ascending Aorta, PA=pulmonary artery, RA=right atrium, RV=right ventricle LV=left ventricle, LA=Left atrium, PV=pulmonary vein, DA=descending aorta 89
90 Heart and pericardium continue Heart Heart RV RV RA LV RA LV CT-GTV LA DA PV CT-GTV LA DA PV RA=right atrium, RV=right ventricle LV=left ventricle, LA=Left atrium DA=descending aorta 90
91 Heart and pericardium continue Heart Heart RV RV RA LV RA LV LA LA CT-GTV DA PV CT-GTV DA RA=right atrium, RV=right ventricle LV=left ventricle, LA=Left atrium DA=descending aorta 91
92 Heart and pericardium continue Heart Heart RV RV RA LV RA LV LA LA CT-GTV DA CT-GTV DA RA=right atrium, RV=right ventricle LV=left ventricle, LA=Left atrium DA=descending aorta 92
93 Heart and pericardium continue Heart Heart RV RV RA LA LV RA LV CT-GTV DA CT-GTV DA RA=right atrium, RV=right ventricle LV=left ventricle, LA=left atrium DA=descending aorta 93
94 Heart and pericardium continue Heart Heart RV RV RA LV RA LV IVC CT-GTV DA CT-GTV DA IVC=inferior vena cava RA=right atrium, RV=right ventricle LV=left ventricle DA=descending aorta 94
95 Heart and pericardium continue Heart Heart RV RV RA IVC LV RA IVC LV DA DA CT-GTV CT-GTV IVC=inferior vena cava RA=right atrium, RV=right ventricle LV=left ventricle DA=descending aorta 95
96 Heart and pericardium continue Heart Heart RV RV RA LV RA LV IVC IVC DA DA CT-GTV CT-GTV IVC=inferior vena cava RA=right atrium, RV=right ventricle LV=left ventricle DA=descending aorta 96
97 Heart and pericardium continue Heart Heart RA LV LV IVC IVC DA DA IVC=inferior vena cava RA=right ventricle LV=left ventricle DA=descending aorta 97
98 Heart and pericardium continue Heart Heart LV LV IVC IVC DA DA IVC=inferior vena cava LV=left ventricle DA=descending aorta 98
99 Heart and pericardium end at diaphragm Heart LV IVC DA IVC DA IVC=inferior vena cava LV=left ventricle DA=descending aorta 99
100 Chest Wall Contours Chest wall can be autosegmented from the ipsilateral lung with a 2-cm expansion in the lateral, anterior, and posterior directions. Anteriorly and medially, it ends at the edge of the sternum. Posteriorly and medially, it stops at the edge of the vertebral body with inclusion of the spinal nerve root exit site. This recommendation was: based on Kong et al, Int J Radiat Oncol Biol Phys Oct 7. [Epub ahead of print] Supported by CW2cm consistently enabled better prediction of CW toxicity than CW3cm in Mutter et al, Int J Radiat Oncol Biol Phys Aug 23. [Epub ahead of print] 100
101 Chest Wall (CW) CW refers to CW2cm which include intercostal muscles, nerves exclude vertebrate bodies, sternum and skin. This can be accomplished through auto-expansion of the ipsilateral lung (within 3 cm range of PTV). Chest wall CW contouring starts at 3 cm above the PTV 101
102 Chest Wall CW refers to CW2cm which include intercostal muscles, nerves exclude vertebral bodies, sternum and skin. PTV The superior end of PTV 102
103 Chest Wall CW refers to CW2cm which include intercostal muscles, nerves exclude vertebral bodies, sternum and skin. PTV GTV The superior end of GTV 103
104 Chest Wall CW refers to CW2cm which include intercostal muscles, nerves exclude vertebral bodies, sternum and skin. Chest wall contours around GTV. 104
105 Chest Wall CW refers to CW2cm which include intercostal muscles, nerves exclude vertebral bodies, sternum and skin. The inferior end of PTV 3 cm below PTV CW ends at 3cm from the inferior edge of PTV. 105
106 Acknowledgement We are grateful for pictures prepared by Leslie Quint MD, Steven Kronenberg, Daniel Tatro, Dr. Chenbo Han, Dr. Weili Wang and Paul Stanton. 106
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