Head & Neck Contouring Presented by James Wheeler, MD Center for Cancer Care Goshen, IN 46526 September 12, 2014
Special Thanks to: Spencer Boulter, Director of Operations (AAMD) Adam Moore, RT(T), CMD Greg Robinson, RT(T), CMD 9/8/2014 2
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
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
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. 1362-1367, 2008. 9/8/2014 5
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 175. 9/8/2014 6
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Brachial Plexus 9/8/2014 8
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
Brachial Plexus 9/8/2014 10
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Brachial Plexus A typical dose constraint is to not let the brachial plexus exceed 60-66 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. 9/8/2014 36
Normal Structures Parotid Gland: yellow Submandibular Gland: light green Internal Carotid Artery: red Internal Jugular Vein: blue Hyoid Bone: magenta Sternocleidomastoid Muscle: cyano 9/8/2014 37
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Internal carotid artery: red 9/8/2014 41
Internal jugular vein: blue 9/8/2014 42
Parotid gland: yellow 9/8/2014 43
Sternocleidomastoid m.: cyano 9/8/2014 44
Internal carotid artery: red 9/8/2014 45
Internal jugular vein: blue 9/8/2014 46
Sternocleidomastoid m.: cyano 9/8/2014 47
Parotid gland: yellow 9/8/2014 48
Internal carotid artery: red 9/8/2014 49
Internal jugular vein: blue 9/8/2014 50
Sternocleidomastoid m.: cyano 9/8/2014 51
Parotid: yellow 9/8/2014 52
Internal carotid artery: red 9/8/2014 53
Internal jugular vein: blue 9/8/2014 54
Sternocleidomastoid m.: cyano 9/8/2014 55
Normal structures 9/8/2014 56
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Submandibular gland: light green 9/8/2014 60
Submandibular gland: light green 9/8/2014 61
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Submandibular gland: light green 9/8/2014 65
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Submandibular gland: light green 9/8/2014 67
Submandibular gland: light green 9/8/2014 68
Hyoid bone: magenta 9/8/2014 69
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Sternocleidomastoid m.: cyano 9/8/2014 79
Internal carotid artery: red 9/8/2014 80
Internal jugular vein: blue 9/8/2014 81
Normal structures 9/8/2014 82
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Oblique view 9/8/2014 108
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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) 172-181. Clifford Chao, Practical Essentials of Intensity Modulated Radiation Therapy, second edition, 2005, chapter 7, pp. 105-121. 9/8/2014 110
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. 9/8/2014 111
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. 9/8/2014 112
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. 9/8/2014 113
Level Ia: blue; & Level Ib: brown 9/8/2014 114
Level Ia: blue; & Level Ib: brown 9/8/2014 115
Key point: The submandibular gland forms the posterior border of the Level Ib nodal group. 9/8/2014 116
Level Ia: blue; & Level Ib: brown 9/8/2014 117
Level Ia: blue; & Level Ib: brown 9/8/2014 118
Level Ia: blue; & Level Ib: brown 9/8/2014 119
Level Ia: blue; & Level Ib: brown 9/8/2014 120
Level Ia: blue; & Level Ib: brown 9/8/2014 121
Level Ia: blue; & Level Ib: brown 9/8/2014 122
Level Ia: blue; & Level Ib: brown 9/8/2014 123
Level Ia: blue; & Level Ib: brown 9/8/2014 124
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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. 9/8/2014 130
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. 9/8/2014 131
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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. 9/8/2014 146
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Key point The bottom of the hyoid bone marks the border between level II and level III. 9/8/2014 159
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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 9/8/2014 162
Level III Receives lymph from Level II & V, retropharyngeal, pretracheal, & recurrent laryngeal nodes. At risk: oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx. 9/8/2014 163
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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. 9/8/2014 175
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. 9/8/2014 176
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 9/8/2014 177
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 9/8/2014 178
Level V At risk: primary cancers of the nasopharynx, oropharynx, thyroid gland, skin of the posterior scalp. 9/8/2014 179
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Dose constraints Spinal cord: 45 Gy is common, but some protocols allow 48-50 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) 9/8/2014 213
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) 9/8/2014 214
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) 9/8/2014 215
LN at risk: clinical N0 TVC (T1-2): TVC (T3-4): Supraglottic Hypopharynx none Bilat (II-V) Bilat (II-V) Bilat (II-V, RPLN) 9/8/2014 216
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