25 chan contouring treatment - ucsf cme · 2021. 4. 22. · contouring and treatment planning...

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Contouring and Treatment Planning ConsensusGuidelines for Head and Neck and Skin Cancers

Jason Chan, MDUCSF Radiation OncologyAssistant Professor

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Disclosures

None

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ObjectivesBecome familiar with recent consensus guidelines on the following topics

Dose prioritization

OARs

Targets

‐ Primary tumor (CTVp) for OC, OPX, LX, HPX; NPC

‐ Post-op and flaps

‐ Perineural

‐ Elective nodes

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Dose prioritization

OARs

Targets



‐ Perineural

‐ Elective nodes


AW Lee, WT Ng, JJ Pan, CL Chiang, SS Poh, HC Choi… - International Journal of …, 2019K Jensen, J Friborg, CR Hansen, E Samsøe… - Radiotherapy and Oncology, 20205

Dose Prioritization

AW Lee, WT Ng, JJ Pan, CL Chiang, SS Poh, HC Choi… - International Journal of …, 20196

NPC Dose PrioritizationGenerally prioritize tumor coverage over most OARs

Three PTV levels all priority 2

AW Lee, WT Ng, JJ Pan, CL Chiang, SS Poh, HC Choi… - International Journal of …, 2019K Jensen, J Friborg, CR Hansen, E Samsøe… - Radiotherapy and Oncology, 20207

PTV1 ObjectivesNot meeting these parameters are considered major deviations

PTV1 Dose Ref.

0.03 cc 117% HN004

0.03 cc 115% HN005

1.8 cc 110% DAHANCA

10% 107% NPC

20% 105% NPC

PTV1 Dose Ref.

D100% 90% DAHANCA

D99% 90% HN005

D95% 95% DAHANCA

GTV Dose (Gy) Ref.

D100% 95% (66.5) NPC

AW Lee, WT Ng, JJ Pan, CL Chiang, SS Poh, HC Choi… - International Journal of …, 2019K Jensen, J Friborg, CR Hansen, E Samsøe… - Radiotherapy and Oncology, 2020W De Neve, Y Wu, G Ezzell - Image-guided IMRT, 2006

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PTV2 and 3 ObjectivesMuch fewer QA parameters

No hot spot constraints PTV2/3 Dose Ref.

D95% 95% HN004/5

CTV2/3 Dose (Gy) Ref.

D95% 95% DAHANCA

Overlapping PTVs are optimized as the higher dose level


K Jensen, J Friborg, CR Hansen, E Samsøe… - Radiotherapy and Oncology, 20209

DAHANCA Dose PrioritizationDifferent priorities for PTV1 and elective targets PTV2 and PTV3

1. Critical OARS, potentially lethal complicationSpinalCordBrainStem

2. TargetsGTVCTV1

3. Critical serial OARsEyeFront and EyeBackChiasm

4. TargetsPTV1CTV2 and CTV3PTV2 and PTV3

5. Remaining OARs…LarynxSGLarynx GOralCavityBuccalMucPCM…

6. Avoid overdosage of PTV2 and PTV3

Which other OARs should be higher priority than PTV2 and PTV3?

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Dose prioritization

OARs

Targets



‐ Perineural

‐ Elective nodes

R Mir, SM Kelly, Y Xiao, A Moore, CH Clark… - Radiotherapy and Oncology, 2020CL Brouwer, RJHM Steenbakkers, J Bourhis… - Radiotherapy and Oncology, 2015

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OARsAccurate OAR contouring is just as important as target delineation

MEMC Christianen, JA Langendijk, HE Westerlaan… - Radiotherapy and Oncology, 201112

OARs Involved in Swallowing

Superior and middle PCM should be contoured separately


econtour.org13

Superior/Middle (SMPCM)

Cricopharyngeus muscle

Inferior (IPCM)

EIM (first 1 cm) and cervical esophagus

OARS involved in SwallowingPterygoid plates

Hyoid bone

1st slice caudal to hyoid bone

Arytenoids

1st slice caudal to arytenoids

1st slice caudal to cricoid cartilage

Cricoid cartilageThoracic inlet

I Petkar, K Rooney, JWG Roe, JM Patterson… - BMC cancer, 201614

CRUK/14/014 (DARS)Phase III IMRT ± Dysphagia Optimization

Dmean < 50 Gy SMPCM outside CTV_6500

Dmean < 20 Gy (OP) or < 40 Gy (HPX) IPCM outside CTV_6500

Do not spare overlap within PTV_6500 margin

Dose prioritization: critical OARS (spinal cord and brainstem); PTV_6500; constrictors; PTV_5400; other OARs

C Nutting, K Rooney, B Foran, L Pettit, M Beasley… - ASCO 202015

CRUK/14/014 (DARS)Phase III IMRT ± Dysphagia Optimization

112 patients. T1-4 N0-3 M0 OP (97%)/HPX cancer. 84% CCRT

Standard vs. Dysphagia-optimized IMRT

Median mean S/MPC 57 vs. 50 Gy; IPC 50 vs. 28 Gy

Median mean 1y MDADI 70 vs. 78

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Dose prioritization

OARs

Targets



‐ Perineural

‐ Elective nodes


V Grégoire, M Evans, QT Le, J Bourhis, V Budach… - Radiotherapy and Oncology, 2018 AW Lee, WT Ng, JJ Pan, SS Poh, YC Ahn, H AlHussain… - Radiotherapy and Oncology, 2018K Jensen, J Friborg, CR Hansen, E Samsøe… - Radiotherapy and Oncology, 2020

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Primary tumor (CTVp)Larynx, Hypopharyx, Oropharynx, Oral Cavity; Nasopharynx

5 mm (70 Gy)

+5 mm

(60 Gy)

V Grégoire, M Evans, QT Le, J Bourhis, V Budach… - Radiotherapy and Oncology, 2018 18

Glottic Larynx T1bException to “5+5” rule: CTV2 is not recommended for T1 glottic SCC

Exclude thyroid cartilage


Glottic Larynx T2

Include:Anterior commissureThyroid cartilageVocal process of arytenoid

Include:SupraglottisSubglottis


Supraglottic Larynx T3

± Oropharynx (e.g. lingual surface epiglottis and vallecula)

Include post-cricoid but not posterior pharyngeal wall



Supraglottic Larynx T4a

Extend beyond strap muscles if macroscopically invaded


Hypopharynx T2

Extensive submucosal extension with HPX: consider 5+10 instead of 5+5Posteriorly include part of PCM but not pre-vertebral fascia

Caudally may extend to cervical esophagusSuperiorly may extend into oropharynx


Hypopharynx T4b

Extensive submucosal extension with HPX: consider 5+10 instead of 5+5Posteriorly include pre-vertebral fascia if invaded

Caudally extend to cervical esophagusSuperiorly extend into oropharynx


Tonsil T2

Posteriorly extend into part of PCMLaterally include parapharyngeal space but not medial pterygoid muscle



Soft Palate T1

Should not extend into non-contiguous mucosa e.g. posterior pharyngeal wall


Soft Palate T3

Extend into hard palate, parapharyngeal space


Base of Tongue T2

Laterally extend through hyoglossus muscleAnteriorly may extend into the mobile tongue and genioglossus


Vallecula T3

Extend inferiorly into pre-epiglottic fat



Posterior Pharyngeal Wall T4b

Extend through pre-vertebral fascia into longus colli and longus capitis muscles


Oral Tongue T4

Include deep extrinsic muscles of tongue

AW Lee, WT Ng, JJ Pan, SS Poh, YC Ahn, H AlHussain… - Radiotherapy and Oncology, 201831

Nasopharynx T1

Sphenoid 1/2Petrous apex

Max sinus ≥ 5 mm

Pterygoid fossaParapharyngeal

Clivus 1/3Ovale, rotundum,

lacerum

Inferior limit of nasopharynx is at caudal edge of C1

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Dose prioritization

OARs

Targets



‐ Perineural

‐ Elective nodes


J Le Guevelou, V Bastit, PY Marcy, A Lasne-Cardon… - Radiotherapy and Oncology, 2020SV Porceddu, C Daniels, SS Yom, H Liu, J Waldron… - International Journal of …, 202033

Post-op and Flaps

J Le Guevelou, V Bastit, PY Marcy, A Lasne-Cardon… - Radiotherapy and Oncology, 202034

Free FlapsStandard delineation needed to refine post-op CTV definition


Radial Forearm Free Flap


Anterolateral Thigh Free Flap



Fibula Free Flap

SV Porceddu, C Daniels, SS Yom, H Liu, J Waldron… - International Journal of …, 202038

Post-op with Free Flap

CTVp_HR (60 Gy): HRTV + minimum 5 mm, may include most of post-op bed/flap

CTVp_LR (54-56 Gy): Remaining post-op bed/flap

CTVn_LR (54-56 Gy): Undissected ipsilateral Ib, II, III, XIII (parotid), IX (bucco-facial)

CTVp_HR CTVp_LR

CTVn_LR

HRTV


Post-op Neck (DAHANCA)

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Dose prioritization

OARs

Targets



‐ Perineural

‐ Elective nodes


RL Bakst, CM Glastonbury, U Parvathaneni, N Katabi… - International Journal of …, 2019J Biau, V Dunet, M Lapeyre, C Simon, M Ozsahin… - Radiotherapy and Oncology, 201941

Perineural Invasion and Spread

RL Bakst, CM Glastonbury, U Parvathaneni, N Katabi… - International Journal of …, 201942

PNI/PNTS Recommendations


Extensive PNIElective V3 coverage to foramen ovale





PNTS along V3 ATN and VIITympanic segment

ATN

CN VII

Posterior genu

Canalicular segment

70 GyElective



RL Bakst, CM Glastonbury, U Parvathaneni, N Katabi… - International Journal of …, 2019J Biau, V Dunet, M Lapeyre, C Simon, M Ozsahin… - Radiotherapy and Oncology, 201947

PNTS along V2 with Anterograde

PPF

GSPN

Ovale

Cochlea

Rotundum

Meckel’sCave

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Dose prioritization

OARs

Targets



‐ Perineural

‐ Elective nodes


J Biau, M Lapeyre, I Troussier, W Budach, J Giralt… - Radiotherapy and Oncology, 201949

Elective NodesLevel Group

Ia Submental

Ib Submandibular

II Upper Jugular

III Middle Jugular

IVa Lower Jugular

Va and Vb Upper and Lower Posterior Triangle

Vc Lateral SCV

VIa Anterior Jugular

VIb Pre-laryngeal, pre-tracheal, para-tracheal

VIIa Retropharyngeal

VIIb Retro-styloid

VIII Parotid

IX Bucco-facial

Xa Retroauricular and subauricular

Xb Occipital

J Biau, M Lapeyre, I Troussier, W Budach, J Giralt… - Radiotherapy and Oncology, 2019CJ Tsai, TJ Galloway, DN Margalit, RL Bakst… - Head & neck, 202150

Elective Nodes

Oral Cavity Oropharynx

Contralateral neck may be omitted as per Tsai et al.


Elective Nodes

Hypopharynx Larynx


Elective Nodes

Nasopharynx Paranasal Sinus



Elective Nodes (DAHANCA)Much more selective than Biau et al.

I II III IV Va Vb VIVIIa(RP)

VIIb(Retrostyloid)

Other

All N+Extend elective regions ≥ 2 cm CC of GTV-N

If ENE to muscle, include entire muscle ≥ 2 cm CC of GTV-N

Oral Cavity N0 X X X

Oral Cavity N+ X X X

Nasopharynx N0 X X X X X

Nasopharynx N+ X* X X X X X X X *Ib included if invasion of SMG, OC, anterior NC

Oropharynx N0 X* X X X**Ib included if OC involvement

*RP included if posterior pharyngeal wall involvement

Oropharynx N+ X* X X X*

Hypopharynx N0 X* X X X**The cranial part of level II can be excluded after individual

consideration*Level VI if subglottic/esophageal involvement

Hypopharynx N+ X X X X* *Level VI if subglottic/esophageal involvement

Supraglottic / Glottic (≥ T3)

X X X*X*

*Level IV on side of nodal involvement or bilateral if hypopharynx involved

*Level VI if subglottic/esophageal involvement

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SummaryRecent consensus guidelines

Dose prioritization: NPC, DAHANCA prioritize PTV1 over most OARs

OARs: contour individual swallowing OARs (SMPCM and IPCM per DARS)

Targets

‐ Primary tumor (CTVp) for OC, OPX, LX, HPX; NPC: “5+5” rule, consider larger for HPX

‐ Post-op and flaps: entire flap should be part of post-op target; follow free flap atlas

‐ Perineural: coverage for elective nerve pathway, interconnections, anterograde spread

‐ Elective nodes: Biau et al. and DAHANCA for recommendations by primary tumor

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25 chan contouring treatment - ucsf cme · 2021. 4. 22. · contouring and treatment planning...

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