中山大学附属肿瘤医院NPC靶区勾画课件.ppt

鼻咽癌靶区勾画建议,中山大学附属肿瘤医院放疗科,Background,遵循原则对靶区进行定义，有助于建立共同的标准，有利多中心的交流,3,一、鼻咽部MRI所见,4,正常解剖(信号特征）,MR：T2WI-软组织分辨率高肌肉、咽颅底筋膜：低信号粘膜和淋巴滤泡组织：偏高信号粘液：明亮的高信号咽鼓管圆枕透明软骨：高信号血管：流空效应：低信号Gd-DTPA增强：高信号致密骨：低信号松质骨：取决于骨髓成分红骨髓为主：中等信号黄骨髓为主：高信号（枕骨斜坡、颈椎椎体）,5,正常解剖及MR表现：鼻咽腔,T1WI：鼻咽腔左右不对称，左侧咽隐窝变浅T2WI：左侧咽隐窝为唾液，高信号,6,正常解剖及MR表现：鼻咽腔,横断：鼻咽上部咽鼓管圆枕（软骨端、T2W）表面：粘膜覆盖前：咽鼓管咽口后：咽隐窝腭帆提肌（后外侧）腭帆张肌（前外侧）翼外肌、颞肌、咬肌椎前肌（头长肌、颈长肌）,7,正常解剖及MRI表现：鼻咽腔,横断（鼻咽上部）咽鼓管圆枕、咽鼓管咽口、咽隐窝腭帆张肌、腭帆提肌翼外肌、颞肌、咬肌,T2WI,T1WIC,T1WI,Gd+,8,正常解剖及MR表现：鼻咽腔,横断（鼻咽中部）咽旁间隙（腭帆提肌外侧）边界清楚，内有咽静脉翼内肌软腭、上颌骨牙槽嵴,T2WI,T1WI,T1WIC,9,正常解剖及MR表现：鼻咽腔,横断（鼻咽下部）Passavants嵴（软腭腭帆提、张肌汇合而成)咽旁间隙颊肌颈内动、静脉,T2WI,T1WI,T1WIC,10,正常解剖及MR表现：鼻咽腔,冠状（鼻咽偏前部）：后鼻孔、软腭、后舌部翼内肌、翼外肌、颞肌、咬肌颅底骨、翼板、翼腭窝、眶上裂,T1WI,T1WIC,11,正常解剖及MR表现：鼻咽腔,冠状（鼻咽中部）：标志是咽鼓管圆枕圆孔NP顶的翼板下的粘膜NP侧壁为中缩肌及扁桃腺咽旁间隙（颅底颌下腺）,T1WI,T1WIC,12,正常解剖：鼻咽腔,冠状：鼻咽中部标志是咽鼓管圆枕圆孔,13,正常解剖及MR表现：鼻咽腔,冠状：海绵窦,14,正常解剖及MR表现：鼻咽腔,冠状：鼻咽偏后部标志为腭帆提、张肌缩肌深部为腭帆提、张肌NP顶侧壁为上缩肌、淋巴组织,15,正常解剖及MR表现：鼻咽腔,矢状旁正中鼻咽顶后外侧壁(粘膜.淋巴)动眼神经头长肌,T1WI,T1WIC,16,正常解剖及MR表现：咽旁间隙,咽颅底筋膜致密结缔组织膜横断面：起于：翼内板后缘向后：腭帆张肌、腭帆提肌外侧通过，至颈动脉孔前方走行：咽后壁、颈长肌前方与椎前筋膜形成潜在的咽后间隙,17,咽旁间隙上方：临近咽隐窝下方：扁桃体窝相对应外侧：翼内肌、腮腺筋膜相贴内侧：咽颅底筋膜内部结构：颈外动脉和静脉丛颈动脉鞘间隙颈内、动静脉迷走神经颅神经,18,正常解剖及MR表现:咽后间隙,咽后间隙：咽后的正中前壁为咽颅底筋膜后壁为椎前筋膜,19,鼻咽癌的MR表现,腔内病变：鼻咽粘膜局部增厚：T1WI：信号稍高于周围肌肉组织T2WI：信号高于肌肉、低于鼻甲和积液Gd-DTPA增强T1WI：较明显强化鼻咽部肿块：鼻咽腔形态：不对称、变窄肿瘤组织的信号强度较均匀，坏死则信号强度欠均匀超腔侵犯：肿瘤穿破咽颅底筋膜，侵犯周围结构。,20,鼻咽粘膜局限性增厚,鼻咽癌的MR表现：,21,鼻咽癌的MR表现:,鼻咽粘膜局限性增厚,LN,22,鼻咽癌的MR表现：肿瘤,侵犯筋膜,Gd+T1W,T1WI,23,鼻咽肿块,鼻咽癌的MR表现：肿瘤,24,鼻咽癌的MR表现：肿瘤,鼻咽肿块,25,鼻咽癌的MR表现：肿瘤超腔侵犯颈动脉鞘区-判断标准,MRI判断标准：有、无软组织影,26,鼻咽癌的MR表现：咽后淋巴结,27,鼻咽癌超腔侵犯的MR表现：后鼻孔、头长肌,28,鼻咽癌超腔侵犯的MR表现,鼻咽癌骨质侵犯：MRI-T1、T2WI：早期骨髓浸润正常骨髓脂肪信号消失、被低信号的肿瘤组织取代信号强度与肿瘤组织相似CT：骨质破坏颅神经出颅孔道的侵犯：局部增宽、有软组织影支配肌肉的萎缩颅内侵犯：局部脑膜增厚（可能是反应性的）、强化软组织肿块、强化明显副鼻窦侵犯注意与局部副鼻窦炎症鉴别,29,鼻咽癌超腔侵犯的MR表现：蝶骨、枕骨斜坡,30,鼻咽癌超腔侵犯的MR表现：蝶骨、枕骨斜坡,31,鼻咽癌超腔侵犯的MR表现：海绵窦,32,鼻咽癌超腔侵犯的MR表现：海绵窦,33,鼻咽癌超腔侵犯的MR表现：颈静脉孔、枕骨,34,鼻咽癌的MR表现：破裂孔侵犯,正常破裂孔,35,鼻咽癌超腔侵犯的MR表现：圆孔,36,鼻咽癌超腔侵犯的MR表现：蝶窦,37,鼻咽癌的MR表现：淋巴结淋巴结-判断标准,淋巴结转移大小标准：咽后淋巴结不限大小颈深上淋巴10mm淋巴链或坏死可以适当放松表现：信号与鼻咽癌组织相似增强后强化,38,鼻咽癌的MR表现：颈淋巴结,T1WGd+T1,二、淋巴结分区指引：CTVnd(negative),DAHANCA,EORTC,GORTECinEurope,NCIC,RTOGinNorthAmerica(2003),Background,1.Twoproposals:BrusselsguidelinesandRotterdamguidelines.2.Toreviewtheirguidelinesandderiveacommonsetofrecommendationsfordelineationofnecknodelevels.,颈部淋巴CT断层分区,TheGuidelinesofCTVS:1.totranslateasaccuratelyaspossiblethesurgicalguidelinesintoradiologicguidelines2.basedonaxialCTsections.AllthelandmarksusedtodelineatethevariousnodelevelsduringaneckdissectionwerelocatedonaxialCTslices.,推荐的边界,Retropharyngealnodes(RP)咽后淋巴结,头：颅底足：舌骨上缘前：腭帆张肌后：椎前肌内：中线外：血管鞘内缘,44,45,46,47,LevelIa,头：下颌骨下缘足：舌骨体前：下颌骨内缘、皮肤后：口底、舌骨体内：中线外：下颌骨内缘,LevelIb,头：下颌骨支中部或口底足：舌骨体前：下颌骨内缘、颈阔肌、皮肤后：二腹肌、翼内肌、颌下腺内：二腹肌外缘外：下颌骨内缘、颈阔肌、皮肤,50,51,LevelIIa,头：C1足：舌骨体下缘前：颌下腺后缘后：IIb内：颈动脉鞘内缘外：胸锁乳突肌内缘,LevelIIb,头：C1足：舌骨体下缘前：IIa后：胸锁乳突肌后缘内：颈动脉鞘内缘外：胸锁乳突肌内缘,LevelII,1.RobbinsoriginallydescribedthecraniallimitofLevelIIasthebaseofskull.2.BrusselsguidelinesusedthebottomedgeofthebodyofC1.3.Surgeonsusedtheinsertionoftheposteriorbellyofthedigastricmuscletothemastoid.,55,LevelII,颈内静脉后缘是IIa/IIb分界线,57,58,LevelII,下颌下腺是Ib/IIa分区界线,60,61,LevelIII,头：舌骨体下缘足：环状软骨前：胸锁乳突肌前缘后：胸锁乳突肌后缘内：颈动脉鞘内缘、椎旁肌外：胸锁乳突肌内缘,63,64,LevelIV,头：环状软骨下缘足：胸锁关节上缘上2cm前：胸锁乳突肌前缘后：胸锁乳突肌后缘内：颈动脉鞘内缘、甲状腺外缘外：胸锁乳突肌内缘,66,LevelIV,CriticalsurgicaldissectionoflevelIVdoesnotgodowntotheClavicleandneverreachesthemedialpotionoftheclavicleatthelevelofsternoclavicularjoint.ItwasagreedtosetthecaudallimitofIV2cmabovethecranialedgeofthesternoclavicularjoint.,68,LevelVa,头：舌骨上缘足：环状软骨下缘前：胸锁乳突肌后缘后：斜方肌前缘内：椎旁肌外：颈阔肌、皮肤,ThecraniallimitoflevelV,*commonlyquestioned.Hamoiretal.hasrecentlyproposedtousethelowertwo-thirdsoftheSANasthecraniallimitoflevelV.Fromaradiologicalpointofview,ahorizontalplanecrossingthecranialedgeofthebodyofthehyoidboneappearsasreliablelandmarkforthecraniallimitoflevelV.,LevelV,Robbins:AfewlymphnodeslyingalongtheupperthirdoftheSANmaybefound.ThesenodesareactuallyincludedinlevelIIb.TheuppermostpartoflevelVcontainssuperficialoccipitallymphnodes.whichcollectlymphaticsfromtheoccipitalscalp,andthepost-auricularregionsetc.Theyarenotinvolvedinthedrainageofheadandneckcancersexceptofskintumor.,72,LevelIV,胸锁乳突肌和前斜角肌后缘分III,/,74,75,LevelVb,头：环状软骨下缘足：颈横血管前：胸锁乳突肌、前斜角肌后缘后：斜方肌前缘内：椎旁肌外：颈阔肌、皮肤,ThecaudallimitoflevelV,CTslicesoftransversevesselsHostriangleincludethefattyplanesbelowandaroundtheclavicledowntothetrapeziusmuscle.,78,LevelVI,头：舌骨体足：胸骨切迹前：皮肤后：椎体内：气管、食管外：颈动脉鞘内缘、甲状腺,LevelVI,AnteriorneckcompartmentnodesContainsthelymphnodeslocatedinthevisceraslspace:thepre-andparatrachealnodes,precrinoidnodeandtheperithyroidnodes.,81,82,ScIN,头：锁骨上缘足：第一肋骨上缘前：胸锁乳突肌后缘后：前斜角肌、胸膜顶内：颈血管鞘外缘外：与锁骨下静脉伴行,84,85,PTV,ThelevelsdelineatedcorrespondtotheCTV,andthusdonotincludeanysecuritymargin.,Whyusesurgicalguidelinesasbasicframeofradiotherapyguidelines?,1.Achievementsinheadandneckoncologyhaveresultedfrominteractionsofsurgeryandradiotherapy.Thisustoadvocatefortheuseofasimilarlanguagetothatalreadyusedbysurgeonsformorethanadecade.,Whyusesurgicalguidelinesasbasicframeofradiotherapyguidelines?,2.Necknodedissectionperformedaccordingtostandardizedprocedures,removingonlyselectednodallevels,hasproducedhighratesofcontrolinthepathologicallyassessednode-negativeneckwithoutpost-operativeradiotherapy.,Whyusesurgicalguidelinesasbasicframeofradiotherapyguidelines?,2.Thisobservationconfirmedthatthelocationsofthelymphaticareasatriskformicroscopicinfiltrationoftenarewell-defined.Thatisasaneffectiveprophylacticirradiation.,Whyusesurgicalguidelinesasbasicframeofradiotherapyguidelines?,3.Selectionofthetargetvolumesforheadandneckradiotherapymorebytechnicallimitationsthanbypatientanatomy.Leadtounnecessaryirradiationofnormaltissuesbearinglittleornoriskoftumorcellinfiltration.,2019/12/15,91,可编辑,GuidelineofENI,Theuseofasurgicalreferencesystem”guidelinewasmoreappropriatethanatranslationof2Dirradiationtechniquesinto3Dvolumes.,NPC淋巴引流途径,内膜毛细淋巴管外周淋巴网集合导管注入第一站引流淋巴结锁骨下静脉或胸导管（左）、颈静脉（右）,ThefirstechelonlymphnodesofNPC,1.Retropharyngealnodes(RP)2.Internaljugularnodes(IJNu)3.Spinalaccessorynodes(SAN),GuidelinesofCTVnd,Theguidelinesdonotintendtogiveanyrecommendationfortheoptimaltreatmentfornode-negativepatientswithaheadandneckprimary.,Node-positive,Theriskofextracapsularextension(ECE)isportionaltothesizeofthelymphnode:2040%fornodes75%forbulkynodes3cm.Node3cm,additionaladjacentstructuresatriskoftumorInfiltrationshouldbeincludedintheCTV.,Node-positive,Whenthefasciahasbeendisrupted,thewholemuscleisatrisk.WhethertheentiremuscleshouldbeincludedinCTV,oronlyaportionofitinthevicinityofthenode,isunknown.,Node-positive,Forthenode-positiveneck:1.whetherthecraniallimitandcaudallimitoftheCTVshouldbeenlarged?2.InfiltrationoftheupperpartoflevelII,toincludethejugularfossaintheCTV?ortoincludethesupraclavicularareaincaseoflowerneckinfiltration?,GuidelinesofCTVnd,定义CTVnd时，更倾向于勾画一宽的连续的区域，而不断断续续地勾画。一些与放射治疗很少相关的淋巴结如肌肉间淋巴结不标记。,GuidelinesofCTVnd,鼻咽癌不同T-N-分期应选择那一淋巴引流区作为CTV，取决于此区的淋巴结的受侵的几率和危险度，以及相邻敏感器官的NTCP。研究方法主要有几种形式：1）临床治疗结果；2）治疗失败的分析；3）尸检报告；4）有价值的外科的报道,101,Suggestedguidelinesforthetreatmentoftheneckofpatientswithheadandnecksquamouscellcarcinomas(AJCC1997)AppropriatenodelevelstobetreatedN0N1N2bNasopharynxII,III,IV,V,II,III,IV,V,andRPandRP,ENI,建立勾画CTVnd的Guidelines十分重要，目的是选择需预防的高危阴性淋巴引流区，减少不必要的扩大照射。在此研究基础上相应改进放疗技术，保护唾液腺、咽、喉等正常结构,有利提高治疗获得比。,三、靶区勾画演示,结合MRI进行靶区勾画,104,鼻咽癌分期:T4N1M0MRIT1+C,咽旁、翼内肌、口咽软腭受侵,T1+C:蝶窦底壁,105,鼻咽癌分期:T4N1M0MRIT1,+C:海绵窦、园孔,C:岩尖破坏,106,鼻咽癌分期:T4N1M0SAGITAL,T1-C:斜坡破坏,T1+C:病灶强化,107,扫描范围：头顶露空至锁骨头下缘2cm方式：螺旋扫描Slicewidth:3mm增强扫描计划设计：网络转送至Pinnacle工作站,CTsim扫描技术,108,将鼻咽和颈部GTV分开，分别为GTVnx和GTVnd。GTVnx为CT/MRI所显示的鼻咽原发肿瘤区。GTVnd为CT/MRI所显示的直径1cm的淋巴结。,靶区定义,109,CTV1:包括GTV及其周围的亚临床病灶区（GTV外扩0.751cm）,可根据周围组织情况作适当的修改。还必须包括完整鼻咽腔的全壁，正常的鼻咽粘膜下0.81.0cm的软组织。,靶区定义,110,CTV2:包括CTV1及其周围易受侵犯的区域，可设定为CTV1外0.51cm范围，根据周围组织情况作适当的修改。鼻咽、口咽、咽后淋巴引流区和颈部阴性淋巴引流区设置于同一CTV2内。,靶区定义,111,PTV：计划靶体积，PTVnx、PTVnd、PTV1、PTV2分别为GTVnx、GTVnd、CTV1、CTV2及其外扩一定范围；计算机根据数据自动生成，以保证外扩的三维径线的准确性。,靶区定义,112,CTV2:深蓝色,113,CTV2:深蓝色CTV1-浅蓝色,114,PTV-深蓝色CTV-浅蓝色,CTV2:深蓝色CTV1-浅蓝色,115,CTV2:深蓝色CTV1-浅蓝色GTVnx红色,116,CTV2:深蓝色CTV1-浅蓝色GTVnx红色,117,CTV2:深蓝色CTV1-浅蓝色GTVnx红色,118,CTV2:深蓝色CTV1-浅蓝色GTVnx红色,同上层骨窗,119,CTV2:深蓝色CTV1-浅蓝色GTVnx红色,120,CTV2:深蓝色CTV1-浅蓝色GTVnx红色,121,CTV2:深蓝色CTV1-浅蓝色GTVnx红色,122,CTV2:深蓝色CTV1-浅蓝色GTVnx红色,123,CTV2:深蓝色CTV1-浅蓝色GTVnx红色,同上层软组织窗,124,CTV2:深蓝色CTV1-浅蓝色GTVnx红色,125,CTV2:深蓝色CTV1-浅蓝色GTVnx红色,同上层骨窗,126,CTV2:深蓝色CTV1-浅蓝色GTVnx红色,127,CTV2:深蓝色CTV1-浅蓝色GTVnx红色,同上层骨窗,128,CTV2:深蓝色CTV1-浅蓝色GTVnx红色,129,CTV2:深蓝色CTV1-浅蓝色GTVnx红色,130,CTV2:深蓝色CTV1-浅蓝色GTVnx红色,131,CTV2:深蓝色CTV1-浅蓝色GTVnx红色,132,CTV2:深蓝色CTV1-浅蓝色GTVnx红色,133,CTV2:深蓝色CTV1-浅蓝色GTVnx红色,134,CTV2:深蓝色CTV1-浅蓝色