RTOG-放疗中胸部危及器官勾画-Organs-at-Risk-(OARs)-in-Thoracic.ppt

Atlases for Organs at Risk(OARs)in Thoracic Radiation Therapy放疗中胸部危机器官勾画放疗中胸部危机器官勾画Feng-Ming(Spring)Kong MD PhDLeslie Quint MDMitchell Machtay MDJeffrey Bradley MDOutline of ContentAtlas for lung,esophagus,and spinal cord肺、食管、脊髓的勾画Atlas for brachial plexus臂丛神经的勾画Atlas for proximal bronchial tree近端支气管树的勾画Atlas for chest wall 胸壁的勾画Atlas for pericardium,heart and great vessels(including normal pericardial recesses)心包、心脏、大血管（包括正常心包凹陷）的勾画RTOG 1106 Required OARsStructureDescriptionStructure definition and contouring instructionsLungLungs PreGTV(composite of CT1GTV and PETMTV)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.HeartHeart&PericardiumThe 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.EsophagusEsophagusThe 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.SpinalcordSpinal CanalThe 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.BrachialplexBrachial PlexusThis 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.RTOG 1106 Optional OARsStructure DescriptionStructure definition and contouring instructionsPericardPericardiumThe structure of pericardium includes pericardial fatty tissue,part of great vessels,normal recesses,pericardial effusion(if applicable)and heart chambers.Pericardium starts at one slice above the top of aortic arch,ends at the last slice of heart apex at diaphragm.Pericardium includes the heart.GreatvesAortaSVCIVCPVPAGreat vesselsAortaSuperior vena cavaInferior vena cavapulmonary veinpulmonary artery 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.PbtreeProximal Bronchial TreeThis 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.CW2cmChest wall 2 cm outside of lungChest 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).结结构构 描述结构定义和勾画说明肺肺双肺 PreGTV(composite of CT1GTV and PETMTV)双肺勾画需要在肺窗勾画.左右肺分开勾画但作为一个器官来评价计量学。所有膨胀的、萎陷的纤维化的气肿的均应勾画，肺门区的小血管应包括在内。然而，preGTV该结构不应包括肺门、气管/大的支气管。心心脏脏心脏&心包 心脏的勾画紧贴心包.上方即心底从肺静脉的下缘开始越过中线延伸到心尖底部.heart.食食管管 食管食管的勾画从环状软骨下缘开始到进入腹腔处的食管胃连接处.在CT纵膈窗勾画食管,以区别粘膜/粘膜下层肌层和外膜的脂肪组织。脊脊髓髓 椎管 脊髓的勾画基于椎管的骨性限制。脊髓的勾画从环状软骨下缘开始（肺尖肿瘤从颅底）依次勾画每一张层面直至L2。椎间孔不应包括在内。臂臂丛丛 臂丛 臂丛的勾画仅仅在上叶肿瘤时勾画。仅仅同侧臂丛神经需要勾画。范围包括C5上缘到T2上缘从椎间孔穿出的脊神经。不同于先前的勾画包括锁骨下和腋血管在内的臂丛主干的RTOG肺癌研究，该研究要求在CT每一层面上依据解剖来勾画。臂丛至少勾画至PTV上3cm。结构描述结构定义与勾画说明心包心包心包包括心包脂肪组织、部分大血管、正常凹陷、心包积液（如果有的话）和心室腔。心包从主动脉弓上缘开始到膈上心尖的最后一层结束。心包包括心脏。大血管（主动脉上腔静脉下腔静脉肺静脉肺动脉）大血管（主动脉、上腔静脉、下腔静脉、肺静脉、肺动脉）大血管应与心脏分开勾画在，在纵隔窗将血管壁和肌层与外膜脂肪组织（对比剂增强后的血管壁外5mm）区别。大血管勾画至少从PTV上3cm开始，依次勾画直至PTV下3cm。对于右侧的肿瘤上腔静脉需要勾画，左侧肿瘤主动脉需要勾画，任意一侧的肿瘤，肺动脉均需勾画。近端支气管树近端支气管树该结构包括气管远端2cm、隆突、双侧主支气管、左右上叶支气管、中间叶支气管、右中叶支气管、舌叶支气管、左右下叶支气管。胸壁2cm 肺外胸壁2cm 胸壁可以自动从同侧肺向外、前、后扩2cm来勾画。前内界为胸骨边缘。后内界为椎体边缘包括脊神经根穿出处。2cm的胸壁包括肋间肌肉、神经，不包括椎体、胸骨、皮肤。可以通过同侧肺自动外扩来完成（PTV3cm范围内）Atlas of lung,esophagus,and spinal cord 肺、食管、脊髓勾画肺、食管、脊髓勾画 Int J Radiat Oncol Biol Phys.2011 81(5):1442-57Esophagus starts at the level of cricoidLung is visible now of the left apex食管从环状软骨开始，此时左侧肺尖可见食管从环状软骨开始，此时左侧肺尖可见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.脊髓亦应从环状软骨下一层开始，或脊髓亦应从环状软骨下一层开始，或从颅底从颅底C1脊髓可见时开始，尤其是当肿瘤侵犯颈部和肺尖时。脊髓可见时开始，尤其是当肿瘤侵犯颈部和肺尖时。LungThe structure of spinal cord should include the entire spinal canal to decrease contouring variations.脊髓应该包括整个椎管，且向下勾画的轮廓在变化脊髓应该包括整个椎管，且向下勾画的轮廓在变化Esophagus and lung continue食管和肺继续向下勾画食管和肺继续向下勾画Spinal cord Esophagus,lung and cord continueGreat vessels delineation is recommended,but not mandated.大血管、近端支气管推荐勾画但不强求大血管、近端支气管推荐勾画但不强求SVC=superior vena cavaProximal bronchial tree delineation is recommended,but not mandated.Proximal Bronchial TreeEsophagus,lung and cord continueSVC=superior vena cavagreat vessels start from the level of aortic arch大血管从主动脉弓层面开始大血管从主动脉弓层面开始Proximal bronchial tree starts at 2 cm above carina近端支气管树从隆突上近端支气管树从隆突上2cm开始开始 Esophagus,lung and cord continueand great vessels,proximal bronchial treeAA=ascending aorta升主动脉,PA=pulmonary artery肺动脉,DA=descending aorta降主动脉,SVC=superior vena cava上腔静脉Esophagus,lung,cord,great vessels and proximal bronchial treeAA=ascending aorta,PA=pulmonary artery,DA=descending aorta,SVC=superior vena cavaEsophagus,lung,cord,great vessels and proximal bronchial treeAA=ascending aorta,PA=pulmonary artery,DA=descending aorta,SVC=superior vena cavaEsophagus,lung,cord,great vessels and proximal bronchial tree continueAA=ascending aorta,PA=pulmonary artery,DA=descending aorta,SVC=superior vena cavaAA=ascending aorta,PA=pulmonary artery,DA=descending aorta,SVC=superior vena cavaEsophagus,lung,cord,great vessels and proximal bronchial tree Esophagus,lung,cord continueDA=descending aortaEsophagus ends at gastric-esophageal junction,Lung and cord continue IVC=inferior vena cava下腔静脉下腔静脉,DA=descending aortaLung ends,cord continues until the bottom of L2 Vertebral body肺结束，脊髓继续直到肺结束，脊髓继续直到L2椎体椎体IVC=inferior vena cava,DA=descending aortaAtlas for Brachial Plexus臂丛勾画臂丛勾画Locating the Brachial Plexus定位臂丛定位臂丛Vein,artery,and nerve(VAN,anterior to posterior)will go over the 1st rib and under the clavicle静脉、动脉、神经（VAN，后前位）从第1肋和锁骨间经过Using coronal images,find the plane where vascular/nerve structures(tubes and wires)pass between the 1st rib and clavicle用冠状位图像，找到血管神经穿过第1肋和锁骨处的层面Roughly contour these neuro-vascular tissues in this coronal plane(as shown in yellow)在冠状位上粗步勾画这些神经血管组织You will use these rough contours in the next step下一步要用到粗步勾画的轮廓1st ribclavicleTimmermans Trick-1Locating the Brachial Plexus Project coronal contours onto axial images(yellow points shown on axial image)将冠状位勾画的轮廓投影到轴位In the region between the projected points,identify the VAN on either side.Contour the“N”as the root(s)of the brachial plexus将所投影的点之间的区域内在每一层内找到血管神经，勾画出神经作为臂丛的神经根Note:Finding the brachial plexus on the uninvolved side will help in finding it on the involved side找到不涉及臂丛的层面有助于找到臂丛Note:IV contrast greatly facilitates this task(see contrast in artery)静脉用对比剂用利于勾画V VA AN NTimmermans Trick-1Brachial plexus starts between C4 C5臂丛从臂丛从C4C5开始开始VeinArteryNerveBrachial plexus not visible any morePBT 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应该包括器官远端2cm、隆突、左右主支气管、左右上叶支气管、中间支气管、右中叶支气管、舌叶支气管、和左右下叶支气管。Proximal Bronchial Tree(PBT)近端支气近端支气管树管树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)Proximal Bronchial TreeThe 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.PBT用CT扫描的纵隔窗勾画，可以显示粘膜、粘膜下、软骨环、气道及相关结构。作为一个结构来勾画，包括气管最远端2层cm和双侧临近气道。叶支气管的勾画应该在段支气管分叉处结束。Recommendation based on Timmerman et al for RTOG 0236 and RTOG 0618,Bezjak et al for RTOG 0813 PBT starts at 2 cm above carinaPBT starts at 2 cm above carinaPBTPBT从隆突上从隆突上从隆突上从隆突上2cm2cm开始开始开始开始Proximal Bronchus Tree continues Proximal Bronchus Tree continuesProximal Bronchus Tree ContinuesProximal Bronchus Tree continuesProximal Bronchus Tree Ends at the level of lobar bronchus bifurcatinginto segmental bronchusChest Wall ContoursChest 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.胸壁可以自动从同侧肺向外、前、后扩2cm来勾画。前内界为胸骨边缘。后内界为椎体边缘包括脊神经根穿出处。This recommendation was:based on Kong et al,Int J Radiat Oncol Biol Phys.2010 Oct 7.Epub ahead of printSupported by“CW2cm consistently enabled better prediction of CW toxicity than CW3cm”in Mutter et al,Int J Radiat Oncol Biol Phys.2011 Aug 23.Epub ahead of printChest Wall(CW)Chest wallCW contouring starts at 3 cm above the PTV胸壁从PTV上3cm开始勾画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).2cm的胸壁包括肋间肌肉、神经，不包括椎体、胸骨、皮肤。可以通过同侧肺自动外扩来完成。Chest Wall The superior end of PTVPTVCW refers to CW2cm which include intercostal muscles,nerves exclude vertebral bodies,sternum and skin.Chest WallThe superior end of GTVGTVPTVCW refers to CW2cm which include intercostal muscles,nerves exclude vertebral bodies,sternum and skin.Chest WallCW refers to CW2cm which include intercostal muscles,nerves exclude vertebral bodies,sternum and skin.Chest wall contours around GTV.Chest WallThe inferior end of PTV3 cm below PTV CW refers to CW2cm which include intercostal muscles,nerves exclude vertebral bodies,sternum and skin.CW ends at 3cm from the inferior edge of PTV.胸壁在PTV下3cm结束。Pericardium/Heart,Great Vessels,Heart Chambers,and Normal Pericardial Recesses心包/心脏、大血管、心腔、正常心包凹陷 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)Pericardium,normal recesses and heart chambers心包、正常凹陷和心腔The structure of pericardium includes pericardial fatty tissue,part of great vessels,normal recesses,pericardial effusion(if applicable)and heart chambers.心包的结构包括心包脂肪组织、部分大血管、正常凹陷、心包积液和心腔。Anatomy of PericardiumPericardial sac and normal recessesPericardial Normal Recesses Groell et al,Radiology,1999Vesely et al,1986AAAA=ascending aorta,SVC=superior vena cavaSVCAAPosterior superior anterior recesses(pSAR)AA=ascending aorta,V=superior vena cavaSVCSVCAADAAA=ascending aorta,DA=descending aorta,SVC=superior vena cavaAAVDAAnterior superior aorta recess(aSAR)AA=ascending aorta,DA=descending aorta,SVC=superior vena cavaPosterior superior aorta recess(pSAR)PericardiumAADAAASVCPAAA=ascending aorta,DA=descending aorta,SVC=superior vena cava,PA=pulmonary arteryPericardiumAnterior superior aorta recess(aSAR)Posterior superior aorta recess(pSAR)MPADAAAAA=ascending aorta,DA=descending aorta,MPA=main pulmonary arteryPericardiumPericardiumPericardiumDAAASVCPALALeft pulmonic recess(LPR)Right superior aortic recess(rSAR)AA=ascending aorta,DA=descending aorta,V=superior vena cava,PA=main pulmonary artery,PA=right pulmonary artery,LA=left atriumPericardiumPericardiumDAAASVCLARAMPAEPericardiumPosterior Pericardial recess(PPR)PericardiumPericardiumRight pulmonic recess(RPR)RA=right atrium心房,AA=aortic arch,LV=left ventricle,LA=Left atrium,MPA=main pulmonary artery,DA=descending aorta,E=esophagusDAAALARARVELVPericardiumPericardiumPericardiumOblique sinus(OS)RA=right atrium,RV=right ventricle心室,LV=left ventricle,LA=Left atrium,AA=aortic arch,DA=descending aorta,E=esophagusPericardiumPericardiumRVLVLARA=right atrium,RV=right ventricle,LV=left ventricle,LA=Left atrium,AA=Ascending AortaRAAAPericardiumPericardiumPericardium effusion(PEFF)RVLVDALARARA=right atrium,RV=right ventricle,LV=left ventricle,LA=Left atrium,AA=aortic archDALARARVELVPericardiumPericardiumPericardiumPericardial effusion(PEFF)RA=right atrium,RV=right ventricle,LV=left ventricle,LA=Left atriumLIVERPericardial effusion(PEFF)PericardiumPericardiumLVAtlas for Heart and Pericardium心脏心包图解Pericardium:based on anatomyHeart:based on consensus contours of most RTOG centers/previous trials,actually including part of pericardium Pericardium startsPericardiumAPericardium starts at 1-2 slices(5-6 mm)above the superior end of the aortic arch心包的勾画从主动脉弓上表面上1-2层（5-6mm）开始。PericardiumBrachiocephalic veinLeft carotid arteryInnominate arterySubclavian arteryPericardium continuesPericardiumPericardiumAortic ArchAortic ArchSVCSVCSVC=superior vena cavaPericardium continuesPericardiumPericardiumSVCSVCAortic ArchAortic ArchSVC=superior vena cavaPericardium continuesPericardiumAAPericardiumDASVCSVCAortic ArchSVC=superior vena cavaPericardium continuesPericardiumAADAPericardiumAADASVCSVCSVC=superior vena cavaAA=Ascending aortaDA=Descending aortaPericardium continuesPericardiumAADAPAPericardiumAADAPASVCSVCSVC=superior vena cavaPA=Pulmonary arteryAA=Ascending aortaDA=Descending aortaPericardiumAADAPAPericar