放疗中胸部危及器官勾画ppt课件.ppt

AtlasesforOrgansatRisk(OARs)inThoracicRadiationTherapy放疗中胸部危机器官勾画,Feng-Ming(Spring)KongMDPhDLeslieQuintMDMitchellMachtayMDJeffreyBradleyMD,1,OutlineofContent,Atlasforlung,esophagus,andspinalcord肺、食管、脊髓的勾画Atlasforbrachialplexus臂丛神经的勾画Atlasforproximalbronchialtree近端支气管树的勾画Atlasforchestwall胸壁的勾画Atlasforpericardium,heartandgreatvessels(includingnormalpericardialrecesses)心包、心脏、大血管（包括正常心包凹陷）的勾画,2,RTOG1106RequiredOARs,3,RTOG1106OptionalOARs,4,5,6,Atlasoflung,esophagus,andspinalcord肺、食管、脊髓勾画,IntJRadiatOncolBiolPhys.201181(5):1442-57,7,8,EsophagusstartsatthelevelofcricoidLungisvisiblenowoftheleftapex食管从环状软骨开始，此时左侧肺尖可见,SpinalcordshouldalsostartatthisleveljustbelowthecricordorfromthebaseofskullC1ifscanisavailable,particularlywhenthetumorsinvolveneckorapex.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,Thestructureofspinalcordshouldincludetheentirespinalcanaltodecreasecontouringvariations.脊髓应该包括整个椎管，且向下勾画的轮廓在变化,Esophagusandlungcontinue食管和肺继续向下勾画,Spinalcord,10,Esophagus,lungandcordcontinue,Greatvesselsdelineationisrecommended,butnotmandated.大血管、近端支气管推荐勾画但不强求,SVC=superiorvenacava,Proximalbronchialtreedelineationisrecommended,butnotmandated.,ProximalBronchialTree,11,Esophagus,lungandcordcontinue,SVC=superiorvenacava,greatvesselsstartfromthelevelofaorticarch大血管从主动脉弓层面开始,Proximalbronchialtreestartsat2cmabovecarina近端支气管树从隆突上2cm开始,12,Esophagus,lungandcordcontinue,andgreatvessels,proximalbronchialtree,AA=ascendingaorta升主动脉,PA=pulmonaryartery肺动脉,DA=descendingaorta降主动脉,SVC=superiorvenacava上腔静脉,13,Esophagus,lung,cord,greatvesselsandproximalbronchialtree,AA=ascendingaorta,PA=pulmonaryartery,DA=descendingaorta,SVC=superiorvenacava,14,Esophagus,lung,cord,greatvesselsandproximalbronchialtree,AA=ascendingaorta,PA=pulmonaryartery,DA=descendingaorta,SVC=superiorvenacava,15,Esophagus,lung,cord,greatvesselsandproximalbronchialtreecontinue,AA=ascendingaorta,PA=pulmonaryartery,DA=descendingaorta,SVC=superiorvenacava,16,AA=ascendingaorta,PA=pulmonaryartery,DA=descendingaorta,SVC=superiorvenacava,Esophagus,lung,cord,greatvesselsandproximalbronchialtree,17,Esophagus,lung,cordcontinue,DA=descendingaorta,18,Esophagusendsatgastric-esophagealjunction,Lungandcordcontinue,IVC=inferiorvenacava下腔静脉,DA=descendingaorta,19,Lungends,cordcontinuesuntilthebottomofL2Vertebralbody肺结束，脊髓继续直到L2椎体,IVC=inferiorvenacava,DA=descendingaorta,20,AtlasforBrachialPlexus臂丛勾画,21,LocatingtheBrachialPlexus定位臂丛,Vein,artery,andnerve(VAN,anteriortoposterior)willgooverthe1stribandundertheclavicle静脉、动脉、神经（VAN，后前位）从第1肋和锁骨间经过Usingcoronalimages,findtheplanewherevascular/nervestructures(tubesandwires)passbetweenthe1stribandclavicle用冠状位图像，找到血管神经穿过第1肋和锁骨处的层面Roughlycontourtheseneuro-vasculartissuesinthiscoronalplane(asshowninyellow)在冠状位上粗步勾画这些神经血管组织Youwillusetheseroughcontoursinthenextstep下一步要用到粗步勾画的轮廓,1strib,clavicle,TimmermansTrick-1,22,LocatingtheBrachialPlexus,Projectcoronalcontoursontoaxialimages(yellowpointsshownonaxialimage)将冠状位勾画的轮廓投影到轴位Intheregionbetweentheprojectedpoints,identifytheVANoneitherside.Contourthe“N”astheroot(s)ofthebrachialplexus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:Findingthebrachialplexusontheuninvolvedsidewillhelpinfindingitontheinvolvedside找到不涉及臂丛的层面有助于找到臂丛Note:IVcontrastgreatlyfacilitatesthistask(seecontrastinartery)静脉用对比剂用利于勾画,TimmermansTrick-1,23,BrachialplexusstartsbetweenC4C5臂丛从C4C5开始,24,25,26,27,28,29,30,31,Vein,Artery,Nerve,32,Brachialplexusnotvisibleanymore,33,PBTshouldincludethedistal2cmofthetrachea,thecarina,therightandleftmainstembronchi,therightandleftupperlobebronchi,theintermediusbronchus,therightmiddlelobebronchus,thelingularbronchus,andtherightandleftlowerlobebronchi(a,b,c,d,e,f,ginthefigure)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。,ProximalBronchialTree(PBT)近端支气管树,PBTcanbecontouredbyautosegmentingtheairspaceofthecentralairwaywith3mmexpansion(2mmforlobarbronchus,3mmformainbronchus,4mmfortrachea),34,ProximalBronchialTree,TheproximalbronchialtreecanbecontouredusingmediastinalwindowsontheCTscantocorrespondtothemucosal,submucosa,andcartilageringsandairwaychannelsassociatedwiththesestructures.Itcanbecontouredasonestructure,includingthemostinferior2cmofdistaltracheaandtheproximalairwaysofbothsides.Contouringthelobarbronchishouldendimmediatelyatthelevelofasegmentalbifurcation.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。,RecommendationbasedonTimmermanetalforRTOG0236andRTOG0618,BezjaketalforRTOG0813,35,PBTstartsat2cmabovecarinaPBT从隆突上2cm开始,36,ProximalBronchusTreecontinues,37,ProximalBronchusTreecontinues,38,ProximalBronchusTreeContinues,39,ProximalBronchusTreecontinues,40,41,42,43,44,45,46,47,48,49,50,51,ProximalBronchusTreeEndsattheleveloflobarbronchusbifurcatingintosegmentalbronchus,52,ChestWallContours,Chestwallcanbeautosegmentedfromtheipsilaterallungwitha2-cmexpansioninthelateral,anterior,andposteriordirections.Anteriorlyandmedially,itendsattheedgeofthesternum.Posteriorlyandmedially,itstopsattheedgeofthevertebralbodywithinclusionofthespinalnerverootexitsite.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。Thisrecommendationwas:basedonKongetal,IntJRadiatOncolBiolPhys.2010Oct7.EpubaheadofprintSupportedby“CW2cmconsistentlyenabledbetterpredictionofCWtoxicitythanCW3cm”inMutteretal,IntJRadiatOncolBiolPhys.2011Aug23.Epubaheadofprint,53,ChestWall(CW),Chestwall,CWcontouringstartsat3cmabovethePTV胸壁从PTV上3cm开始勾画,CWreferstoCW2cmwhichincludeintercostalmuscles,nervesexcludevertebralbodies,sternumandskin.Thiscanbeaccomplishedthroughauto-expansionoftheipsilaterallung(within3cmrangeofPTV).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,ChestWall,ThesuperiorendofPTV,PTV,CWreferstoCW2cmwhichincludeintercostalmuscles,nervesexcludevertebralbodies,sternumandskin.,55,ChestWall,ThesuperiorendofGTV,GTV,PTV,CWreferstoCW2cmwhichincludeintercostalmuscles,nervesexcludevertebralbodies,sternumandskin.,56,ChestWall,CWreferstoCW2cmwhichincludeintercostalmuscles,nervesexcludevertebralbodies,sternumandskin.,ChestwallcontoursaroundGTV.,57,ChestWall,TheinferiorendofPTV,3cmbelowPTV,CWreferstoCW2cmwhichincludeintercostalmuscles,nervesexcludevertebralbodies,sternumandskin.,CWendsat3cmfromtheinferioredgeofPTV.胸壁在PTV下3cm结束。,58,Pericardium/Heart,GreatVessels,HeartChambers,andNormalPericardialRecesses心包/心脏、大血管、心腔、正常心包凹陷,Feng-Ming(Spring)Kong(RTOG),LeslieQuint(ACRIN),JeffreyBradley(RTOG),SureshSenan(EORTC),RitsukoKomaki(RTOG),LaurieGaspar(SWOG),LuyingXu(UM),ChengboHan(UM),JunLiu(UM),WeiliWang(UM),RobinMarsh(UM),RandallTenHaken(UM),CharlesThomas(SWOG),JeffreyBogart(CALGB),MitchellMachtay(RTOG),59,Pericardium,normalrecessesandheartchambers心包、正常凹陷和心腔,Thestructureofpericardiumincludespericardialfattytissue,partofgreatvessels,normalrecesses,pericardialeffusion(ifapplicable)andheartchambers.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,AnatomyofPericardium,Pericardialsacandnormalrecesses,61,PericardialNormalRecesses,Groelletal,Radiology,1999,Veselyetal,1986,62,AA,AA=ascendingaorta,SVC=superiorvenacava,SVC,63,AA,Posteriorsuperioranteriorrecesses(pSAR),AA=ascendingaorta,V=superiorvenacava,SVC,64,SVC,AA,DA,AA=ascendingaorta,DA=descendingaorta,SVC=superiorvenacava,65,AA,V,DA,Anteriorsuperioraortarecess(aSAR),AA=ascendingaorta,DA=descendingaorta,SVC=superiorvenacava,Posteriorsuperioraortarecess(pSAR),Pericardium,66,AA,DA,AA,SVC,PA,AA=ascendingaorta,DA=descendingaorta,SVC=superiorvenacava,PA=pulmonaryartery,Pericardium,Anteriorsuperioraortarecess(aSAR),Posteriorsuperioraortarecess(pSAR),67,MPA,DA,AA,AA=ascendingaorta,DA=descendingaorta,MPA=mainpulmonaryartery,Pericardium,Pericardium,Pericardium,68,DA,AA,SVC,PA,LA,Leftpulmonicrecess(LPR),Rightsuperioraorticrecess(rSAR),AA=ascendingaorta,DA=descendingaorta,V=superiorvenacava,PA=mainpulmonaryartery,PA=rightpulmonaryartery,LA=leftatrium,Pericardium,Pericardium,69,DA,AA,SVC,LA,RA,MPA,E,Pericardium,PosteriorPericardialrecess(PPR),Pericardium,Pericardium,Rightpulmonicrecess(RPR),RA=rightatrium心房,AA=aorticarch,LV=leftventricle,LA=Leftatrium,MPA=mainpulmonaryartery,DA=descendingaorta,E=esophagus,70,DA,AA,LA,RA,RV,E,LV,Pericardium,Pericardium,Pericardium,Obliquesinus(OS),RA=rightatrium,RV=rightventricle心室,LV=leftventricle,LA=Leftatrium,AA=aorticarch,DA=descendingaorta,E=esophagus,71,RV,LV,LA,RA=rightatrium,RV=rightventricle,LV=leftventricle,LA=Leftatrium,AA=AscendingAorta,RA,AA,72,Pericardiumeffusion(PEFF),RV,LV,DA,LA,RA,RA=rightatrium,RV=rightventricle,LV=leftventricle,LA=Leftatrium,AA=aorticarch,73,DA,LA,RA,RV,E,LV,Pericardium,Pericardium,Pericardium,Pericardialeffusion(PEFF),RA=rightatrium,RV=rightventricle,LV=leftventricle,LA=Leftatrium,74,LIVER,Pericardialeffusion(PEFF),Pericardium,Pericardium,LV,75,AtlasforHeartandPericardium心脏心包图解Pericardium:basedonanatomyHeart:basedonconsensuscontoursofmostRTOGcenters/previoustrials,actuallyincludingpartofpericardium,76,Pericardiumstarts,Pericardium,A,Pericardiumstartsat1-2slices(5-6mm)abovethesuperiorendoftheaorticarch心包的勾画从主动脉弓上表面上1-2层（5-6mm）开始。,Pericardium,Brachiocephalicvein,Leftcarotidartery,Innominateartery,Subclavianartery,77,Pericardiumcontinues,Pericardium,Pericardium,AorticArch,AorticArch,SVC,SVC,SVC=superiorvenacava,78,Pericardiumcontinues,Pericardium,Pericardium,SVC,SVC,AorticArch,AorticArch,SVC=superiorvenacava,79,Pericardiumcontinues,Pericardium,AA,Pericardium,DA,SVC,SVC,AorticArch,SVC=superiorvenacava,80,Pericardiumcontinues,Pericardium,AA,DA,Pericardium,AA,DA,SVC,SVC,SVC=superiorvenacavaAA=AscendingaortaDA=Descendingaorta,81,Pericardiumcontinues,Pericardium,AA,DA,PA,Pericardium,AA,DA,PA,SVC,SVC,SVC=superiorvenacavaPA=PulmonaryarteryAA=AscendingaortaDA=Descendingaorta,82,Pericardium,AA,DA,PA,Pericardium,AA,DA,PA,SVC,SVC,SVC=SuperiorvenacavaPA=PulmonaryarteryAA=AscendingaortaDA=Descendingaorta,83,PericardiumContinues,Pericardium,AA,DA,PA,Pericardium,AA,DA,PA,SVC,SVC,SVC=SuperiorvenacavaPA=PulmonaryarteryAA=AscendingaortaDA=Descendingaorta,84,PericardiumContinues,Pericardium,AA,DA,PA,Pericardium,AA,DA,PA,SVC,PA,PA,SVC,SVC=superiorvenacavaPA=PulmonaryarteryAA=AscendingaortaDA=Descendingaorta,CT-GTV,85,PericardiumContinues,Pericardium,AA,DA,PA,Pericardium,AA,DA,PA,SVC,PA,PA,SVC,SVC=SuperiorvenacavaPA=PulmonaryarteryAA=AscendingaortaDA=Descendingaorta,CT-GTV,CT-GTV,86,PericardiumContinues,Pericardium,AA,DA,PA,Pericardium,AA,DA,PA,SVC,PA,SVC0,CT-GTV,CT-GTV,PV,PV,SVC=SuperiorvenacavaPA=PulmonaryarteryAA=AscendingaortaDA=Descendingaorta,87,PericardiumcontinuesHeartcontourstartsatthislevel,1slicebelowpulmonaryarterytrunkpassingthemidline,Heartandpericardiumaretobeoverlapped.,Pericardium,AA,DA,PA,Pericardium,AA,DA,PA,SVC,SVC,PA,PA,CT-GTV,CT-GTV,PV,PV,Heart,Heart,PV,PV,88,Heartandpericardiumcontinue,Pericardium,AA,DA,PA,Pericardium,AA,DA,LA,SVC,PA,LA,SVC,PA,CT-GTV,CT-GTV,PA,PV,PV,PV,PA,Heart,Heart,LV,AA=AscendingAorta,PA=pulmonaryartery,RA=rightatrium,RV=rightventricle,LV=leftventricle,LA=Leftatrium,PV=pulmonaryvein,DA=descendingaorta,SVC=superiorvenacava,89,PericardiumandHeartcontinue,Pericardium,AA,DA,PA,Pericardium,AA,DA,PA,RA,LA,RA,LV,PA,CT-GTV,CT-GTV,LA,Heart,Heart,LV,PV,RA=rightatrium,RV=rightventricleLV=leftventricle,LA=LeftatriumDA=descendingaorta,90,PericardiumandHeartcontinue,Pericardium,DA,RV,Pericardium,AA,DA,PA,RA,PA,LA,RA,LV,CT-GTV,CT-GTV,LA,Heart,Heart,LV,PV,PV,AA=AscendingAorta,PA=pulmonaryartery,RA=rightatrium,RV=rightventricleLV=leftventricle,LA=Leftatrium,PV=pulmonaryvein,DA=descendingaorta,91,Heartandpericardiumcontinue,Pericardium,DA,RV,Pericardium,DA,RV,RA,PV,LA,RA,LV,CT-GTV,CT-GTV,LA,Heart,Heart,LV,PV,RA=rightatrium,RV=rightventricleLV=leftventricle,LA=LeftatriumDA=descendingaorta,92,Heartandpericardiumcontinue,Pericardium,DA,RV,Pericardium,DA,RV,RA,LA,RA,LV,CT-GTV,CT-GTV,LA,Heart,Heart,LV,PV,RA=rightatrium,RV=rightventricleLV=leftventricle,LA=LeftatriumDA=descendingaorta,93,Heartandpericardiumcontinue,Pericardium,DA,RV,Pericardium,DA,RV,RA,LA,RA,LV,CT-GTV,CT-GTV,LA,Heart,Heart,LV,RA=rightatrium,RV=rightventricleLV=leftventricle,LA=LeftatriumDA=descendingaorta,94,Heartandpericardiumcontinue,Pericardium,DA,RV,Pericardium,DA,RV,RA,RA,LV,CT-GTV,CT-GTV,LA,Heart,Heart,LV,RA=rightatrium,RV=rightventricleLV=leftventricle,LA=leftatriumDA=descendingaorta,95,Heartandpericardiumcontinue,Pericardium,DA,RV,Pericardium,DA,RV,RA,RA,LV,CT-GTV,CT-GTV,Heart,Heart,LV,IVC,IVC=inferiorvenacavaRA=rightatrium,RV=rightventricleLV=leftventricleDA=descendingaorta,96,Heartandpericardiumcontinue,Pericardium,DA,RV,Pericardium,DA,RV,RA,RA,LV,CT-GTV,CT-GTV,Heart,Heart,LV,IVC,IVC,IVC=inferiorvenacavaRA=rightatrium,RV=rightventricleLV=leftventricleDA=descendingaorta,97,Heartandpericardiumcontinue,Pericardium,DA,RV,Pericardium,DA,RV,RA,RA,LV,CT-GTV,CT-GTV,Heart,Heart,LV,IVC,IVC,IVC=inferiorvenacavaRA=rightatrium,RV=rightventricleLV=leftventricleDA=descendingaorta,98,Heartandpericardiumcontinue,Pericardium,DA,Pericardium,DA,RA,LV,Heart,Heart,LV,IVC,IVC,IVC=inferiorvenacavaRA=rightventricleLV=leftventricleDA=descendingaorta,99,Heartandpericardiumcontinue,Pericardium,DA,Pericardium,DA,LV,Heart,Heart,LV,IVC,IVC,IVC=inferiorvenacavaLV=leftventricleDA=descendingaorta,100,Heartandpericardiumendatdiaphragm心脏和心包的勾画在横隔层面结束,DA,Pericardium,DA,Heart,LV,IVC,IVC,IVC=inferiorvenacavaLV=leftventricleDA=descendingaorta,101,ChestWallContours,Chestwallcanbeautosegmented