放疗中胸部危及器官勾画.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,*,Atlases for Organs at Risk(OARs)in Thoracic Radiation Therapy,放疗中胸部危机器官勾画,Feng-Ming(Spring)Kong MD PhD,Leslie Quint MD,Mitchell Machtay MD,Jeffrey Bradley MD,1,Outline of Content,Atlas 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,2,RTOG 1106 Required OARs,Structure,Description,Structure definition and contouring instructions,Lung,Lungs 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.,Heart,Heart&Pericardium,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.,Esophagus,Esophagus,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.,Spinalcord,Spinal Canal,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.,Brachialplex,Brachial Plexus,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,RTOG 1106 Optional OARs,Structure,Description,Structure definition and contouring instructions,Pericard,Pericardium,The 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.,Greatves,Aorta,SVC,IVC,PV,PA,Great vessels,Aorta,Superior vena cava,Inferior vena cava,pulmonary vein,pulmonary 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.,Pbtree,Proximal Bronchial Tree,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.,CW2cm,Chest wall 2 cm outside of lung,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,结构,描述,结构定义和勾画说明,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,。,5,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）,6,Atlas of lung,esophagus,and spinal cord,肺、食管、脊髓勾画,Int J Radiat Oncol Biol Phys.2011 81(5):1442-57,7,8,Esophagus starts at the level of cricoid,Lung is visible now of the left apex,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,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。,Lung,9,The 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,Esophagus and lung continue,食管和肺继续向下勾画,Spinal cord,10,Esophagus,lung and cord continue,Great vessels delineation is recommended,but not mandated.,大血管、近端支气管推荐勾画但不强求,SVC=superior vena cava,Proximal bronchial tree delineation is recommended,but not mandated.,Proximal Bronchial Tree,11,Esophagus,lung and cord continue,SVC=superior vena cava,great vessels start from the level of aortic arch,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,2cm,开始,12,Esophagus,lung and cord continue,and great vessels,proximal bronchial tree,AA=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,13,Esophagus,lung,cord,great vessels,and proximal bronchial tree,AA=ascending aorta,PA=pulmonary artery,DA=descending aorta,SVC=superior vena cava,14,Esophagus,lung,cord,great vessels,and proximal bronchial tree,AA=ascending aorta,PA=pulmonary artery,DA=descending aorta,SVC=superior vena cava,15,Esophagus,lung,cord,great vessels,and proximal bronchial tree continue,AA=ascending aorta,PA=pulmonary artery,DA=descending aorta,SVC=superior vena cava,16,AA=ascending aorta,PA=pulmonary artery,DA=descending aorta,SVC=superior vena cava,Esophagus,lung,cord,great vessels,and proximal bronchial tree,17,Esophagus,lung,cord continue,DA=descending aorta,18,Esophagus ends at gastric-esophageal junction,Lung and cord continue,IVC=inferior vena cava,下腔静脉,DA=descending aorta,19,Lung ends,cord continues until the bottom of L2 Vertebral body,肺结束，脊髓继续直到,L2,椎体,IVC=inferior vena cava,DA=descending aorta,20,Atlas for Brachial Plexus,臂丛勾画,21,Locating the Brachial Plexus,定位臂丛,Vein,artery,and nerve(VAN,anterior to posterior)will go over the 1,st,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 1,st,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,1,st,rib,clavicle,Timmermans Trick-1,22,Locating 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,A,N,Timmermans Trick-1,23,Brachial plexus starts between C4 C5,臂丛从,C4C5,开始,24,25,26,27,28,29,30,31,Vein,Artery,Nerve,32,Brachial plexus not visible any more,33,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,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),34,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.,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 0813,35,PBT starts at 2 cm above carinaPBT,从隆突上,2cm,开始,36,Proximal Bronchus Tree continues,37,Proximal Bronchus Tree continues,38,Proximal Bronchus Tree Continues,39,Proximal Bronchus Tree continues,40,41,42,43,44,45,46,47,48,49,50,51,Proximal Bronchus Tree Ends,at the level of lobar bronchus bifurcating,into segmental bronchus,52,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.,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 print,Supported 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 print,53,Chest Wall(CW),Chest wall,CW 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。,54,Chest Wall,The superior end of PTV,PTV,CW refers to CW2cm which include intercostal muscles,nerves,exclude vertebral bodies,sternum and skin.,55,Chest Wall,The superior end of GTV,GTV,PTV,CW refers to CW2cm which include intercostal muscles,nerves,exclude vertebral bodies,sternum and skin.,56,Chest Wall,CW refers to CW2cm which include intercostal muscles,nerves,exclude vertebral bodies,sternum and skin.,Chest wall contours around GTV,.,57,Chest Wall,The inferior end of PTV,3 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。,58,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),59,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。,60,Anatomy of Pericardium,Pericardial sac and normal recesses,61,Pericardial Normal Recesses,Groell et al,Radiology,1999,Vesely et al,1986,62,AA,AA=ascending aorta,SVC=superior vena cava,SVC,63,AA,Posterior superior anterior recesses(pSAR),AA=ascending aorta,V=superior vena cava,SVC,64,SVC,AA,DA,AA=ascending aorta,DA=descending aorta,SVC=superior vena cava,65,AA,V,DA,Anterior superior aorta recess(aSAR),AA=ascending aorta,DA=descending aorta,SVC=superior vena cava,Posterior superior,aorta recess(pSAR),Pericardium,66,AA,DA,AA,SVC,PA,AA=ascending aorta,DA=descending aorta,SVC=superior vena cava,PA=pulmonary artery,Pericardium,Anterior superior aorta recess(aSAR),Posterior superior,aorta recess(pSAR),67,MPA,DA,AA,AA=ascending aorta,DA=descending aorta,MPA=main pulmonary artery,Pericardium,Pericardium,Pericardium,68,DA,AA,SVC,PA,LA,Left 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 atrium,Pericardium,Pericardium,69,DA,AA,SVC,LA,RA,MPA,E,Pericardium,Posterior Pericardial recess(PPR),Pericardium,Pericardium,Right 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=esophagus,70,DA,AA,LA,RA,RV,E,LV,Pericardium,Pericardium,Pericardium,Oblique sinus(OS),RA=right atrium,RV=right ventricle,心室,LV=left ventricle,LA=Left atrium,AA=aortic arch,DA=descending aorta,E=esophagus,71,Pericardium,Pericardium,RV,LV,LA,RA=right atrium,RV=right ventricle,LV=left ventricle,LA=Left atrium,AA=Ascending Aorta,RA,AA,72,Pericardium,Pericardium,Pericardium effusion(PEFF),RV,LV,DA,LA,RA,RA=right atrium,RV=right ventricle,LV=left ventricle,LA=Left atrium,AA=aortic arch,73,DA,LA,RA,RV,E,LV,Pericardium,Pericardium,Pericardium,Pericardial effusion(PEFF),RA=right atrium,RV=right ventricle,LV=left ventricle,LA=Left atrium,74,LIVER,Pericardial effusion(PEFF),Pericardium,Pericardium,LV,75,Atlas for Heart and Pericardium,心脏心包图解,Pericardium:based on anatomy,Heart:based on consensus contours of most RTOG centers/previous trials,actually including part of pericardium,76,Pericardium starts,Pericardium,A,Pericardium 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。,Pericardium,Brachiocephalic vein,Left carotid artery,Innominate artery,Subclavian,artery,77,Pericardium continues,Pericardium,Pericardium,Aortic Arch,Aortic Arch,SVC,SVC,SVC=superior vena