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

AtlasesforOrgansatRisk OARs inThoracicRadiationTherapy放疗中胸部危机器官勾画 Feng Ming Spring KongMDPhDLeslieQuintMDMitchellMachtayMDJeffreyBradleyMD 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 RTOG1106RequiredOARs RTOG1106OptionalOARs Atlasoflung esophagus andspinalcord肺 食管 脊髓勾画 IntJRadiatOncolBiolPhys 201181 5 1442 57 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 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 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 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 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 Esophagus lung cord greatvesselsandproximalbronchialtree AA ascendingaorta PA pulmonaryartery DA descendingaorta SVC superiorvenacava Esophagus lung cord greatvesselsandproximalbronchialtree AA ascendingaorta PA pulmonaryartery DA descendingaorta SVC superiorvenacava Esophagus lung cord greatvesselsandproximalbronchialtreecontinue AA ascendingaorta PA pulmonaryartery DA descendingaorta SVC superiorvenacava AA ascendingaorta PA pulmonaryartery DA descendingaorta SVC superiorvenacava Esophagus lung cord greatvesselsandproximalbronchialtree Esophagus lung cordcontinue DA descendingaorta Esophagusendsatgastric esophagealjunction Lungandcordcontinue IVC inferiorvenacava下腔静脉 DA descendingaorta Lungends cordcontinuesuntilthebottomofL2Vertebralbody肺结束 脊髓继续直到L2椎体 IVC inferiorvenacava DA descendingaorta AtlasforBrachialPlexus臂丛勾画 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 Timmerman sTrick 1 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 Timmerman sTrick 1 BrachialplexusstartsbetweenC4C5臂丛从C4C5开始 Vein Artery Nerve Brachialplexusnotvisibleanymore 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 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 PBTstartsat2cmabovecarinaPBT从隆突上2cm开始 ProximalBronchusTreecontinues ProximalBronchusTreecontinues ProximalBronchusTreeContinues ProximalBronchusTreecontinues ProximalBronchusTreeEndsattheleveloflobarbronchusbifurcatingintosegmentalbronchus 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 Epubaheadofprint Supportedby CW2cmconsistentlyenabledbetterpredictionofCWtoxicitythanCW3cm inMutteretal IntJRadiatOncolBiolPhys 2011Aug23 Epubaheadofprint 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 ChestWall ThesuperiorendofPTV PTV CWreferstoCW2cmwhichincludeintercostalmuscles nervesexcludevertebralbodies sternumandskin ChestWall ThesuperiorendofGTV GTV PTV CWreferstoCW2cmwhichincludeintercostalmuscles nervesexcludevertebralbodies sternumandskin ChestWall CWreferstoCW2cmwhichincludeintercostalmuscles nervesexcludevertebralbodies sternumandskin ChestwallcontoursaroundGTV ChestWall TheinferiorendofPTV 3cmbelowPTV CWreferstoCW2cmwhichincludeintercostalmuscles nervesexcludevertebralbodies sternumandskin CWendsat3cmfromtheinferioredgeofPTV 胸壁在PTV下3cm结束 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 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 AnatomyofPericardium Pericardialsacandnormalrecesses PericardialNormalRecesses Groelletal Radiology 1999 Veselyetal 1986 AA AA ascendingaorta SVC superiorvenacava SVC AA Posteriorsuperioranteriorrecesses pSAR AA ascendingaorta V superiorvenacava SVC SVC AA DA AA ascendingaorta DA descendingaorta SVC superiorvenacava AA V DA Anteriorsuperioraortarecess aSAR AA ascendingaorta DA descendingaorta SVC superiorvenacava Posteriorsuperioraortarecess pSAR Pericardium AA DA AA SVC PA AA ascendingaorta DA descendingaorta SVC superiorvenacava PA pulmonaryartery Pericardium Anteriorsuperioraortarecess aSAR Posteriorsuperioraortarecess pSAR MPA DA AA AA ascendingaorta DA descendingaorta MPA mainpulmonaryartery Pericardium Pericardium Pericardium DA AA SVC PA LA Leftpulmonicrecess LPR Rightsuperioraorticrecess rSAR AA ascendingaorta DA descendingaorta V superiorvenacava PA mainpulmonaryartery PA rightpulmonaryartery LA leftatrium Pericardium Pericardium 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 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 RV LV LA RA rightatrium RV rightventricle LV leftventricle LA Leftatrium AA AscendingAorta RA AA Pericardiumeffusion PEFF RV LV DA LA RA RA rightatrium RV rightventricle LV leftventricle LA Leftatrium AA aorticarch DA LA RA RV E LV Pericardium Pericardium Pericardium Pericardialeffusion PEFF RA rightatrium RV rightventricle LV leftventricle LA Leftatrium LIVER Pericardialeffusion PEFF Pericardium Pericardium LV AtlasforHeartandPericardium心脏心包图解Pericardium basedonanatomyHeart basedonconsensuscontoursofmostRTOGcenters previoustrials actuallyincludingpartofpericardium 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 Pericardiumcontinues Pericardium Pericardium AorticArch AorticArch SVC SVC SVC superiorvenacava Pericardiumcontinues Pericardium Pericardium SVC SVC AorticArch AorticArch SVC superiorvenacava Pericardiumcontinues Pericardium AA Pericardium DA SVC SVC AorticArch SVC superiorvenacava Pericardiumcontinues Pericardium AA DA Pericardium AA DA SVC SVC SVC superiorvenacavaAA AscendingaortaDA Descendingaorta Pericardiumcontinues Pericardium AA DA PA Pericardium AA DA PA SVC SVC SVC superiorvenacavaPA PulmonaryarteryAA AscendingaortaDA Descendingaorta Pericardium AA DA PA Pericardium AA DA PA SVC SVC SVC SuperiorvenacavaPA PulmonaryarteryAA AscendingaortaDA Descendingaorta PericardiumContinues Pericardium AA DA PA Pericardium AA DA PA SVC SVC SVC SuperiorvenacavaPA PulmonaryarteryAA AscendingaortaDA Descendingaorta PericardiumContinues Pericardium AA DA PA Pericardium AA DA PA SVC PA PA SVC SVC superiorvenacavaPA PulmonaryarteryAA AscendingaortaDA Descendingaorta CT GTV PericardiumContinues Pericardium AA DA PA Pericardium AA DA PA SVC PA PA SVC SVC SuperiorvenacavaPA PulmonaryarteryAA AscendingaortaDA Descendingaorta CT GTV CT GTV PericardiumContinues Pericardium AA DA PA Pericardium AA DA PA SVC PA SVC0 CT GTV CT GTV PV PV SVC SuperiorvenacavaPA PulmonaryarteryAA AscendingaortaDA Descendingaorta Pericardiumcontinues Heartcontourstartsatthislevel 1slicebelowpulmonaryarterytrunkpassingthemidline Heartandpericardiumaretobeoverlapped Pericardium AA DA PA Pericardium AA DA PA SVC SVC PA PA CT GTV CT GTV PV PV Heart Heart PV PV 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 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 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 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 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 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 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 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 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 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 Heartandpericardiumcontinue Pericardium DA Pericardium DA RA LV Heart Heart LV IVC IVC IVC inferiorvenacavaRA rightventricleLV leftventricleDA descendingaorta Heartandpericardiumcontinue Pericardium DA Pericardium DA LV Heart Heart LV IVC IVC IVC inferiorvenacavaLV leftventricleDA descendingaorta 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 ChestWallContours Chestwallcanbeautosegmented