RTOG放療中胸部危和器官勾畫培訓(xùn)課件

1、Outline of ContentAtlas for lung, esophagus, and spinal cord肺、食管、脊髓的勾畫Atlas for brachial plexus臂叢神經(jīng)的勾畫Atlas for proximal bronchial tree近端支氣管樹的勾畫Atlas for chest wall 胸壁的勾畫Atlas for pericardium, heart and great vessels (including normal pericardial recesses)心包、心臟、大血管（包括正常心包凹陷）的勾畫Outline of ContentAtla

2、s for luRTOG 1106 Required OARsStructureDescriptionStructure definition and contouring instructionsLungLungs 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 struct

3、ure 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.HeartHeart & PericardiumThe heart

4、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.EsophagusEsophagusThe esophagus should be contoured from the beginning at the leve

5、l 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.SpinalcordSpinal CanalThe spinal cord will be contoured based on t

6、he 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. BrachialplexBrachial PlexusThis is only required for patients

7、 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 axillar

8、y 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. RTOG 1106 Required OARsStructuRTOG 1106 Optional OARsStructure DescriptionStructure definition and contouring instructionsPericardPericar

9、diumThe 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 t

10、he heart. GreatvesAortaSVCIVCPVPAGreat vesselsAortaSuperior vena cavaInferior vena cavapulmonary veinpulmonary 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

11、 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 tu

12、mors, the aorta will be contoured. The ipsilateral PA will be delineated for tumor of either side. PbtreeProximal Bronchial TreeThis 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, th

13、e right middle lobe bronchus, the lingular bronchus, and the right and left lower lobe bronchi. CW2cmChest wall 2 cm outside of lungChest 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

14、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 ipsilat

15、eral lung (within 3 cm range of PTV).RTOG 1106 Optional OARsStructu結(jié)構(gòu)描述結(jié)構(gòu)定義和勾畫說明肺雙肺 PreGTV (composite of CT1GTV and PETMTV) 雙肺勾畫需要在肺窗勾畫.左右肺分開勾畫但作為一個器官來評價計量學(xué)。所有膨脹的、萎陷的纖維化的氣腫的均應(yīng)勾畫，肺門區(qū)的小血管應(yīng)包括在內(nèi)。然而，preGTV該結(jié)構(gòu)不應(yīng)包括肺門、氣管/大的支氣管。心臟心臟 & 心包 心臟的勾畫緊貼心包.上方即心底從肺靜脈的下緣開始越過中線延伸到心尖底部.heart. 食管 食管食管的勾畫從環(huán)狀軟骨下緣開始到進(jìn)入腹腔處的食管

16、胃連接處.在CT縱膈窗勾畫食管,以區(qū)別粘膜/粘膜下層肌層和外膜的脂肪組織。脊髓 椎管 脊髓的勾畫基于椎管的骨性限制。脊髓的勾畫從環(huán)狀軟骨下緣開始（肺尖腫瘤從顱底）依次勾畫每一張層面直至L2。椎間孔不應(yīng)包括在內(nèi)。臂叢 臂叢 臂叢的勾畫僅僅在上葉腫瘤時勾畫。僅僅同側(cè)臂叢神經(jīng)需要勾畫。范圍包括C5上緣到T2上緣從椎間孔穿出的脊神經(jīng)。不同于先前的勾畫包括鎖骨下和腋血管在內(nèi)的臂叢主干的RTOG肺癌研究，該研究要求在CT每一層面上依據(jù)解剖來勾畫。臂叢至少勾畫至PTV上3cm。結(jié)構(gòu)描述結(jié)構(gòu)定義和勾畫說明肺雙肺 PreGTV 雙肺勾畫結(jié)構(gòu)描述結(jié)構(gòu)定義與勾畫說明心包心包心包包括心包脂肪組織、部分大血管、正常凹陷

17、、心包積液（如果有的話）和心室腔。心包從主動脈弓上緣開始到膈上心尖的最后一層結(jié)束。心包包括心臟。 大血管（主動脈上腔靜脈下腔靜脈肺靜脈肺動脈）大血管（主動脈、上腔靜脈、下腔靜脈、肺靜脈、肺動脈）大血管應(yīng)與心臟分開勾畫在，在縱隔窗將血管壁和肌層與外膜脂肪組織（對比劑增強后的血管壁外5mm）區(qū)別。大血管勾畫至少從PTV上3cm開始，依次勾畫直至PTV下3cm。對于右側(cè)的腫瘤上腔靜脈需要勾畫，左側(cè)腫瘤主動脈需要勾畫，任意一側(cè)的腫瘤，肺動脈均需勾畫。 近端支氣管樹近端支氣管樹該結(jié)構(gòu)包括氣管遠(yuǎn)端2cm、隆突、雙側(cè)主支氣管、左右上葉支氣管、中間葉支氣管、右中葉支氣管、舌葉支氣管、左右下葉支氣管。 胸壁2c

18、m 肺外胸壁2cm 胸壁可以自動從同側(cè)肺向外、前、后擴2cm來勾畫。前內(nèi)界為胸骨邊緣。后內(nèi)界為椎體邊緣包括脊神經(jīng)根穿出處。 2cm的胸壁包括肋間肌肉、神經(jīng)，不包括椎體、胸骨、皮膚?？梢酝ㄟ^同側(cè)肺自動外擴來完成（PTV3cm范圍內(nèi)）結(jié)構(gòu)描述結(jié)構(gòu)定義與勾畫說明心包心包心包包括心包脂肪組織、部分Atlas of lung, esophagus, and spinal cord 肺、食管、脊髓勾畫 Int J Radiat Oncol Biol Phys. 2011 81(5):1442-57Atlas of lung, esophagus, and RTOG放療中胸部危和器官勾畫培訓(xùn)課件Esopha

19、gus starts at the level of cricoidLung is visible now of the left apex食管從環(huán)狀軟骨開始，此時左側(cè)肺尖可見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.脊髓亦應(yīng)從環(huán)狀軟骨下一層開始，或從顱底C1脊髓可見時開始，尤其是當(dāng)腫瘤侵犯頸部和肺尖時。

20、LungEsophagus starts at the level The structure of spinal cord should include the entire spinal canal to decrease contouring variations .脊髓應(yīng)該包括整個椎管，且向下勾畫的輪廓在變化Esophagus and lung continue食管和肺繼續(xù)向下勾畫Spinal cord The structure of spinal cord Esophagus, lung and cord continueGreat vessels delineation is r

21、ecommended, but not mandated.大血管、近端支氣管推薦勾畫但不強求SVC=superior vena cavaProximal bronchial tree delineation is recommended, but not mandated.Proximal Bronchial TreeEsophagus, lung and cord contiEsophagus, lung and cord continueSVC=superior vena cavagreat vessels start from the level of aortic arch大血管從主動

22、脈弓層面開始Proximal bronchial tree starts at 2 cm above carina近端支氣管樹從隆突上2cm開始 Esophagus, lung and cord contiEsophagus, lung and cord continueand great vessels, proximal bronchial treeAA=ascending aorta升主動脈, PA=pulmonary artery肺動脈, DA=descending aorta降主動脈, SVC=superior vena cava上腔靜脈Esophagus, lung and cor

23、d contiEsophagus, lung, cord, great vessels and proximal bronchial treeAA=ascending aorta, PA=pulmonary artery, DA=descending aorta, SVC=superior vena cavaEsophagus, lung, cord, great vEsophagus, lung, cord, great vessels and proximal bronchial treeAA=ascending aorta, PA=pulmonary artery, DA=descend

24、ing aorta, SVC=superior vena cavaEsophagus, lung, cord, great vEsophagus, lung, cord, great vessels and proximal bronchial tree continueAA=ascending aorta, PA=pulmonary artery, DA=descending aorta, SVC=superior vena cavaEsophagus, lung, cord, great vAA=ascending aorta, PA=pulmonary artery, DA=descen

25、ding aorta, SVC=superior vena cavaEsophagus, lung, cord, great vessels and proximal bronchial tree AA=ascending aorta, PA=pulmonaEsophagus, lung, cord continueDA=descending aortaEsophagus, lung, cord continueEsophagus ends at gastric-esophageal junction,Lung and cord continue IVC=inferior vena cava下

26、腔靜脈, DA=descending aortaEsophagus ends at gastric-esopLung ends, cord continues until the bottom of L2 Vertebral body肺結(jié)束，脊髓繼續(xù)直到L2椎體IVC=inferior vena cava, DA=descending aortaLung ends, cord continues untiAtlas for Brachial Plexus臂叢勾畫Atlas for Brachial Plexus臂叢勾畫Locating the Brachial Plexus定位臂叢Vein,

27、artery, and nerve (VAN, anterior to posterior) will go over the 1st rib and under the clavicle靜脈、動脈、神經(jīng)（VAN，后前位）從第1肋和鎖骨間經(jīng)過Using coronal images, find the plane where vascular/nerve structures (tubes and wires) pass between the 1st rib and clavicle用冠狀位圖像，找到血管神經(jīng)穿過第1肋和鎖骨處的層面Roughly contour these neuro-va

28、scular tissues in this coronal plane (as shown in yellow)在冠狀位上粗步勾畫這些神經(jīng)血管組織You will use these rough contours in the next step下一步要用到粗步勾畫的輪廓1st ribclavicleTimmermans Trick-1Locating the Brachial Plexus定Locating the Brachial Plexus Project coronal contours onto axial images (yellow points shown on axial

29、 image)將冠狀位勾畫的輪廓投影到軸位In the region between the projected points, identify the VAN on either side. Contour the “N” as the root(s) of the brachial plexus將所投影的點之間的區(qū)域內(nèi)在每一層內(nèi)找到血管神經(jīng)，勾畫出神經(jīng)作為臂叢的神經(jīng)根Note: Finding the brachial plexus on the uninvolved side will help in finding it on the involved side找到不涉及臂叢的層面有

30、助于找到臂叢Note: IV contrast greatly facilitates this task (see contrast in artery)靜脈用對比劑用利于勾畫VANTimmermans Trick-1Locating the Brachial Plexus PBrachial plexus starts between C4 C5臂叢從C4C5開始Brachial plexus starts betweenRTOG放療中胸部危和器官勾畫培訓(xùn)課件RTOG放療中胸部危和器官勾畫培訓(xùn)課件RTOG放療中胸部危和器官勾畫培訓(xùn)課件RTOG放療中胸部危和器官勾畫培訓(xùn)課件RTOG放療中胸部

31、危和器官勾畫培訓(xùn)課件RTOG放療中胸部危和器官勾畫培訓(xùn)課件RTOG放療中胸部危和器官勾畫培訓(xùn)課件VeinArteryNerveVeinArteryNerveBrachial plexus not visible any moreBrachial plexus not visible anPBT 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 b

32、ronchus, 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應(yīng)該包括器官遠(yuǎn)端2cm、隆突、左右主支氣管、左右上葉支氣管、中間支氣管、右中葉支氣管、舌葉支氣管、和左右下葉支氣管。Proximal Bronchial Tree (PBT)近端支氣管樹PBT can be contoured by autosegmenting the airspace of the cen

33、tral airway with 3 mm expansion (2 mm for lobar bronchus, 3 mm for main bronchus, 4 mm for trachea) PBT should include the distal Proximal Bronchial TreeThe proximal bronchial tree can be contoured using mediastinal windows on the CT scan to correspond to the mucosal, submucosa, and cartilage rings

34、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掃描的縱隔窗勾畫，可以顯示粘膜、粘膜下

35、、軟骨環(huán)、氣道及相關(guān)結(jié)構(gòu)。作為一個結(jié)構(gòu)來勾畫，包括氣管最遠(yuǎn)端2層cm和雙側(cè)臨近氣道。葉支氣管的勾畫應(yīng)該在段支氣管分叉處結(jié)束。Recommendation based on Timmerman et al for RTOG 0236 and RTOG 0618, Bezjak et al for RTOG 0813 Proximal Bronchial TreeThe proPBT starts at 2 cm above carinaPBT從隆突上2cm開始PBT starts at 2 cm above carinProximal Bronchus Tree continuesProxima

36、l Bronchus Tree continu Proximal Bronchus Tree continues Proximal Bronchus Tree continProximal Bronchus Tree ContinuesProximal Bronchus Tree ContinuProximal Bronchus Tree continuesProximal Bronchus Tree continuRTOG放療中胸部危和器官勾畫培訓(xùn)課件RTOG放療中胸部危和器官勾畫培訓(xùn)課件RTOG放療中胸部危和器官勾畫培訓(xùn)課件RTOG放療中胸部危和器官勾畫培訓(xùn)課件RTOG放療中胸部危和器官勾

37、畫培訓(xùn)課件RTOG放療中胸部危和器官勾畫培訓(xùn)課件RTOG放療中胸部危和器官勾畫培訓(xùn)課件RTOG放療中胸部危和器官勾畫培訓(xùn)課件RTOG放療中胸部危和器官勾畫培訓(xùn)課件RTOG放療中胸部危和器官勾畫培訓(xùn)課件RTOG放療中胸部危和器官勾畫培訓(xùn)課件Proximal Bronchus Tree Ends at the level of lobar bronchus bifurcatinginto segmental bronchusProximal Bronchus Tree Ends Chest Wall ContoursChest wall can be autosegmented from the

38、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.胸壁可以自動從同側(cè)肺向外、前、后擴2cm來勾畫。前內(nèi)界為胸

39、骨邊緣。后內(nèi)界為椎體邊緣包括脊神經(jīng)根穿出處。This recommendation was:based on Kong et al, Int J Radiat Oncol Biol Phys. 2010 Oct 7. Epub ahead of printSupported 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 printChest W

40、all ContoursChest wall Chest Wall (CW)Chest wallCW contouring starts at 3 cm above the PTV胸壁從PTV上3cm開始勾畫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

41、of PTV).2cm的胸壁包括肋間肌肉、神經(jīng)，不包括椎體、胸骨、皮膚?？梢酝ㄟ^同側(cè)肺自動外擴來完成。Chest Wall (CW)Chest wallCW coChest Wall The superior end of PTVPTVCW refers to CW2cm which include intercostal muscles, nerves exclude vertebral bodies, sternum and skin. Chest Wall The superior end ofChest WallThe superior end of GTVGTVPTVCW refer

42、s to CW2cm which include intercostal muscles, nerves exclude vertebral bodies, sternum and skin. Chest WallThe superior end of Chest WallCW refers to CW2cm which include intercostal muscles, nerves exclude vertebral bodies, sternum and skin. Chest wall contours around GTV.Chest WallCW refers to CW2c

43、m wChest WallThe inferior end of PTV3 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結(jié)束。Chest WallThe inferior end of Pericardium/Heart, Great Vessels, Heart Chambers, and No

44、rmal Pericardial Recesses心包/心臟、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), Cha

45、rles Thomas (SWOG), Jeffrey Bogart (CALGB), Mitchell Machtay (RTOG)Pericardium/Heart, Great VessePericardium, 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 h

46、eart chambers. 心包的結(jié)構(gòu)包括心包脂肪組織、部分大血管 、正常凹陷、心包積液和心腔。Pericardium, normal recesses aAnatomy of PericardiumPericardial sac and normal recessesAnatomy of PericardiumPericardPericardial Normal Recesses Groell et al, Radiology, 1999Vesely et al, 1986Pericardial Normal Recesses GrAAAA=ascending aorta, SVC=sup

47、erior vena cavaSVCAAAA=ascending aorta, SVC=supeAAPosterior superior anterior recesses (pSAR)AA=ascending aorta, V=superior vena cavaSVCAAPosterior superior anterior SVCAADAAA=ascending aorta, DA=descending aorta, SVC=superior vena cavaSVCAADAAA=ascending aorta, DA=AAVDAAnterior superior aorta reces

48、s (aSAR) AA=ascending aorta, DA=descending aorta, SVC=superior vena cavaPosterior superior aorta recess (pSAR) PericardiumAAVDAAnterior superior aorta rAADAAASVCPAAA=ascending aorta, DA=descending aorta, SVC=superior vena cava, PA= pulmonary arteryPericardiumAnterior superior aorta recess (aSAR) Pos

49、terior superior aorta recess (pSAR) AADAAASVCPAAA=ascending aorta,MPADAAAAA=ascending aorta, DA=descending aorta, MPA=main pulmonary arteryPericardiumPericardiumPericardiumMPADAAAAA=ascending aorta, DA=DAAASVCPALALeft pulmonic recess (LPR)Right superior aortic recess (rSAR)AA=ascending aorta, DA=des

50、cending aorta, V=superior vena cava, PA=main pulmonary artery, PA=right pulmonary artery, LA=left atriumPericardiumPericardiumDAAASVCPALALeft pulmonic recesDAAASVCLARAMPAEPericardiumPosterior Pericardial recess (PPR)PericardiumPericardiumRight pulmonic recess (RPR)RA=right atrium心房, AA=aortic arch,

51、LV=left ventricle, LA=Left atrium, MPA=main pulmonary artery, DA=descending aorta, E=esophagusDAAASVCLARAMPAEPericardiumPostDAAALARARVELVPericardiumPericardiumPericardiumOblique sinus (OS)RA=right atrium, RV=right ventricle心室, LV=left ventricle, LA=Left atrium, AA=aortic arch, DA=descending aorta, E

52、=esophagusDAAALARARVELVPericardiumPericaPericardiumPericardiumRVLVLARA=right atrium, RV=right ventricle, LV=left ventricle, LA=Left atrium, AA=Ascending AortaRAAAPericardiumPericardiumRVLVLARAPericardiumPericardiumPericardium effusion (PEFF)RVLVDALARARA=right atrium, RV=right ventricle, LV=left vent

53、ricle, LA=Left atrium, AA=aortic archPericardiumPericardiumPericardDALARARVELVPericardiumPericardiumPericardiumPericardial effusion (PEFF)RA=right atrium, RV=right ventricle, LV=left ventricle, LA=Left atriumDALARARVELVPericardiumPericardLIVERPericardial effusion (PEFF)PericardiumPericardiumLVLIVERP

54、ericardial effusion (PEFAtlas for Heart and Pericardium心臟心包圖解Pericardium: based on anatomyHeart: based on consensus contours of most RTOG centers/previous trials, actually including part of pericardium Atlas for Heart and PericardiuPericardium startsPericardiumAPericardium starts at 1-2 slices (5-6

55、mm) above the superior end of the aortic arch心包的勾畫從主動脈弓上表面上1-2層（5-6mm）開始。PericardiumBrachiocephalic veinLeft carotid arteryInnominate arterySubclavian arteryPericardium startsPericardiumAPericardium continuesPericardiumPericardiumAortic ArchAortic ArchSVCSVCSVC=superior vena cavaPericardium continue

56、sPericardPericardium continuesPericardiumPericardiumSVCSVCAortic ArchAortic ArchSVC=superior vena cavaPericardium continuesPericardPericardium continuesPericardiumAAPericardiumDASVCSVCAortic ArchSVC=superior vena cavaPericardium continuesPericardPericardium continuesPericardiumAADAPericardiumAADASVC

57、SVCSVC=superior vena cavaAA=Ascending aortaDA=Descending aortaPericardium continuesPericardPericardium continuesPericardiumAADAPAPericardiumAADAPASVCSVCSVC=superior vena cavaPA=Pulmonary arteryAA=Ascending aortaDA=Descending aortaPericardium continuesPericardPericardiumAADAPAPericardiumAADAPASVCSVCS

58、VC=Superior vena cavaPA=Pulmonary arteryAA=Ascending aortaDA=Descending aortaPericardiumAADAPAPericardiumAAPericardium ContinuesPericardiumAADAPAPericardiumAADAPASVCSVCSVC=Superior vena cavaPA=Pulmonary arteryAA=Ascending aortaDA=Descending aortaPericardium ContinuesPericardPericardium ContinuesPeri

59、cardiumAADAPAPericardiumAADAPASVCPAPASVCSVC=superior vena cavaPA=Pulmonary arteryAA=Ascending aortaDA=Descending aortaCT-GTVPericardium ContinuesPericardPericardium ContinuesPericardiumAADAPAPericardiumAADAPASVCPAPASVCSVC=Superior vena cavaPA=Pulmonary arteryAA=Ascending aortaDA=Descending aortaCT-G

60、TVCT-GTVPericardium ContinuesPericardPericardium ContinuesPericardiumAADAPAPericardiumAADAPASVCPASVC0CT-GTVCT-GTVPVPVSVC=Superior vena cavaPA=Pulmonary arteryAA=Ascending aortaDA=Descending aortaPericardium ContinuesPericardPericardium continuesHeart contour starts at this level, 1 slice below pulmo