中山大學附屬腫瘤醫(yī)院npc靶區(qū)勾畫

1、鼻咽癌靶區(qū)勾畫建議,中山大學附屬腫瘤醫(yī)院 放療科,Background,遵循原則對靶區(qū)進行定義，有助于建立共同的標準，有利多中心的交流,3,一、鼻 咽 部 MRI 所 見,4,正常解剖(信號特征）,MR：T2WI-軟組織分辨率高肌肉、咽顱底筋膜：低信號粘膜和淋巴濾泡組織：偏高信號粘液：明亮的高信號咽鼓管圓枕透明軟骨：高信號血管：流空效應：低信號Gd-DTPA增強：高信號致密骨：低信號松質(zhì)骨：取決于骨髓成分紅骨髓為

2、主：中等信號黃骨髓為主：高信號（枕骨斜坡、頸椎椎體）,5,正常解剖及MR表現(xiàn)：鼻咽腔,T1WI：鼻咽腔左右不對稱，左側咽隱窩變淺T2WI：左側咽隱窩為唾液，高信號,6,,正常解剖及MR表現(xiàn)：鼻咽腔,橫斷：鼻咽上部咽鼓管圓枕（軟骨端、T2W↑）表面：粘膜覆蓋前：咽鼓管咽口后：咽隱窩腭帆提?。ê笸鈧龋╇穹珡埣。ㄇ巴鈧龋┮硗饧?、顳肌、咬肌椎前?。?頭長肌、頸長?。?7,正常解剖及MRI表現(xiàn)：鼻咽腔,橫斷（鼻咽上部）咽鼓

3、管圓枕、咽鼓管咽口、咽隱窩腭帆張肌、腭帆提肌翼外肌、顳肌、咬肌,T2WI,T1WI＋C,T1WI,Gd+,8,正常解剖及MR表現(xiàn)：鼻咽腔,橫斷（鼻咽中部）咽旁間隙（腭帆提肌外側）邊界清楚，內(nèi)有咽靜脈翼內(nèi)肌軟腭、上頜骨牙槽嵴,T2WI,T1WI,T1WI＋C,9,正常解剖及MR表現(xiàn)：鼻咽腔,橫斷（鼻咽下部）Passavant’s嵴（軟腭．腭帆提、張肌匯合而成)咽旁間隙頰肌頸內(nèi)動、靜脈,T2WI,T1WI,T1WI＋C,

4、10,正常解剖及MR表現(xiàn)：鼻咽腔,冠狀（鼻咽偏前部）：后鼻孔、軟腭、后舌部翼內(nèi)肌、翼外肌、顳肌、咬肌顱底骨、翼板、翼腭窩、眶上裂,T1WI,T1WI＋C,11,正常解剖及MR表現(xiàn)：鼻咽腔,冠狀（鼻咽中部）：標志是咽鼓管圓枕圓孔NP頂?shù)囊戆逑碌恼衬P側壁為中縮肌及扁桃腺咽旁間隙（顱底－頜下腺）,T1WI,T1WI＋C,,,12,正常解剖：鼻咽腔,冠狀：鼻咽中部標志是咽鼓管圓枕圓孔,,13,正常解剖及MR表現(xiàn)：鼻咽腔

5、,冠狀：海綿竇,14,正常解剖及MR表現(xiàn)：鼻咽腔,冠狀：鼻咽偏后部 標志為腭帆提、張肌縮肌深部為腭帆提、張肌NP頂側壁為上縮肌、淋巴組織,15,正常解剖及MR表現(xiàn)：鼻咽腔,矢狀旁正中鼻咽頂后外側壁(粘膜.淋巴)動眼神經(jīng)頭長肌,T1WI,T1WI＋C,16,,正常解剖及MR表現(xiàn)：咽旁間隙,咽顱底筋膜致密結締組織膜橫斷面：起于：翼內(nèi)板后緣向后：腭帆張肌、腭帆提肌外側通過，至頸動脈孔前方走行：咽后壁、頸長肌前方

6、與椎前筋膜形成潛在的咽后間隙,17,,正常解剖及MR表現(xiàn),咽旁間隙上方：臨近咽隱窩下方：扁桃體窩相對應外側：翼內(nèi)肌、腮腺筋膜相貼內(nèi)側：咽顱底筋膜內(nèi)部結構：頸外動脈和靜脈叢頸動脈鞘間隙頸內(nèi)、動靜脈迷走神經(jīng)Ⅸ~Ⅻ顱神經(jīng),18,,正常解剖及MR表現(xiàn):咽后間隙,咽后間隙： 咽后的正中前壁為咽顱底筋膜后壁為椎前筋膜,19,,鼻咽癌的MR表現(xiàn),腔內(nèi)病變：鼻咽粘膜局部增厚：T1WI：信號稍高于周圍肌肉組織

7、 T2WI：信號高于肌肉、低于鼻甲和積液 Gd-DTPA增強T1WI：較明顯強化鼻咽部腫塊：鼻咽腔形態(tài)：不對稱、變窄腫瘤組織的信號強度較均勻，壞死則信號強度欠均勻超腔侵犯：腫瘤穿破咽顱底筋膜，侵犯周圍結構。,√√,20,鼻咽粘膜局限性增厚,鼻咽癌的MR表現(xiàn)：,21,鼻咽癌的MR表現(xiàn):,鼻咽粘膜局限性增厚,,LN,22,鼻咽癌的MR表現(xiàn)：腫瘤,侵犯筋膜,Gd+T1W,T1WI,23,鼻咽腫塊,,,,鼻咽癌的M

8、R表現(xiàn)：腫瘤,24,鼻咽癌的MR表現(xiàn)：腫瘤,鼻咽腫塊,25,鼻咽癌的MR表現(xiàn)：腫瘤超腔侵犯 頸動脈鞘區(qū)----判斷標準,MRI判斷標準：有、無軟組織影,,26,鼻咽癌的MR表現(xiàn)：咽后淋巴結,,,,,27,鼻咽癌超腔侵犯的MR表現(xiàn)：后鼻孔、頭長肌,28,,鼻咽癌超腔侵犯的MR表現(xiàn),鼻咽癌骨質(zhì)侵犯：MRI-T1、T2WI：早期骨髓浸潤正常骨髓脂肪信號消失、被低信號的腫瘤組織取代信號強度與腫瘤組織相似CT：骨質(zhì)破壞顱神經(jīng)

9、出顱孔道的侵犯：局部增寬、有軟組織影支配肌肉的萎縮顱內(nèi)侵犯：局部腦膜增厚（可能是反應性的）、強化軟組織腫塊、強化明顯 副鼻竇侵犯注意與局部副鼻竇炎癥鑒別,29,鼻咽癌超腔侵犯的MR表現(xiàn)： 蝶骨、枕骨斜坡,30,鼻咽癌超腔侵犯的MR表現(xiàn)： 蝶骨、枕骨斜坡,31,鼻咽癌超腔侵犯的MR表現(xiàn)：海綿竇,32,鼻咽癌超腔侵犯的MR表現(xiàn)：海綿竇,,33,鼻咽癌超腔侵犯的MR表現(xiàn)：頸靜脈孔、

10、枕骨,34,鼻咽癌的MR表現(xiàn)：破裂孔侵犯,,正常破裂孔,35,鼻咽癌超腔侵犯的MR表現(xiàn)：圓孔,36,鼻咽癌超腔侵犯的MR表現(xiàn)：蝶竇,,,,37,,鼻咽癌的MR表現(xiàn)：淋巴結 淋巴結----判斷標準,淋巴結轉移大小標準：咽后淋巴結不限大小頸深上淋巴≥10mm淋巴鏈或壞死可以適當放松表現(xiàn)：信號與鼻咽癌組織相似增強后強化,38,鼻咽癌的MR表現(xiàn)：頸淋巴結,,,T1W

11、 Gd+T1,二、淋巴結分區(qū)指引：CTV nd (negative),DAHANCA, EORTC, GORTEC in Europe , NCIC, RTOGin North America (2003),Background,1. Two proposals: Brussels guidelines and Rotterdam guidelines. 2. To review t

12、heir guidelines and derive a common set of recommendations for delineation of neck node levels.,頸部淋巴CT斷層分區(qū),The Guidelines of CTVS : 1. to translate as accurately as possible the surgical guidelines into radiologic gui

13、delines2. based on axial CT sections. All the landmarks used to delineate the various node levels during a neck dissection were located on axial CT slices.,推 薦 的 邊 界,,Retropharyngeal nodes (RP)咽后淋巴結,頭：顱底

14、 足：舌骨上緣 前：腭帆張肌 后：椎前肌 內(nèi)：中線 外：血管鞘內(nèi)緣,44,45,46,47,Level I a,頭：下頜骨下緣 足：舌骨體 前：下頜骨內(nèi)緣、皮膚 后：口底、舌骨體 內(nèi)：中線 外：下頜骨內(nèi)緣,Level I b,頭：下頜骨支中部或口底

15、 足：舌骨體 前：下頜骨內(nèi)緣、頸闊肌、皮膚 后：二腹肌、翼內(nèi)肌、頜下腺 內(nèi)：二腹肌 外緣 外：下頜骨內(nèi)緣、頸闊肌、皮膚,50,51,Level II a,頭：C1 足：舌骨體下緣 前：頜下腺后緣 后：II b 內(nèi)：頸動脈鞘內(nèi)緣 外：胸鎖乳突肌內(nèi)緣,Level I

16、I b,頭：C1 足：舌骨體下緣 前：II a 后：胸鎖乳突肌后緣 內(nèi)：頸動脈鞘內(nèi)緣 外：胸鎖乳突肌內(nèi)緣,Level II,1. Robbins originally described the cranial limit of Level II as the base of skull. 2. Brussels guidelines used the bo

17、ttom edge of the body of C1.3. Surgeons used the insertion of the posterior belly of the digastric muscle to the mastoid .,55,Level II,頸內(nèi)靜脈后緣是 II a / II b 分界線,57,58,Level II,下頜下腺是 I b / II a 分區(qū)界線,60,61,Level III,

18、頭：舌骨體下緣 足：環(huán)狀軟骨 前：胸鎖乳突肌前緣 后：胸鎖乳突肌后緣 內(nèi)：頸動脈鞘內(nèi)緣、椎旁肌 外：胸鎖乳突肌內(nèi)緣,63,64,Level IV,頭：環(huán)狀軟骨下緣 足：胸鎖關節(jié)上緣上2cm 前：胸鎖乳突肌前緣 后：胸鎖乳突肌后緣 內(nèi)：頸動脈鞘內(nèi)緣、甲狀腺外緣 外：胸鎖乳突肌內(nèi)緣,66,Le

19、vel IV,Critical surgical dissection of level IV does not go down to the Clavicle and never reaches the medial potion of the clavicle at the level of sternoclavicular joint. It was agreed to set the caudal limit of

20、 IV 2 cm above the cranial edge of the sternoclavicular joint.,68,Level Va,頭：舌骨上緣 足：環(huán)狀軟骨下緣 前：胸鎖乳突肌后緣 后：斜方肌前緣 內(nèi)：椎旁肌 外：頸闊肌、皮膚,The cranial limit of level V,* commonly questioned.

21、Hamoir et al. has recently proposed to use the lower two-thirds of the SAN as the cranial limit of level V. From a radiological point of view, a horizontal plane crossing the cranial edge of the body of the hyoid bone a

22、ppears as reliable landmark for the cranial limit of level V.,Level V,Robbins: A few lymph nodes lying along the upper third of the SAN may be found. These nodes are actually included in level II b. The uppermost p

23、art of level V contains superficial occipital lymph nodes. which collect lymphatics from the occipital scalp, and the post-auricular regions etc. They are not involved in the drainage of head and neck cancers except of

24、skin tumor.,72,Level IV,,胸鎖乳突肌和前斜角肌后緣分 III, Ⅳ / Ⅴ,74,75,Level V b,頭：環(huán)狀軟骨下緣 足：頸橫血管 前：胸鎖乳突肌、前斜角肌后緣 后：斜方肌前緣 內(nèi)：椎旁肌 外：頸闊肌、皮膚,The caudal limit of level V,CT slices of transverse vessels Ho’s t

25、riangle include the fatty planes below and around the clavicle down to the trapezius muscle.,78,Level VI,頭：舌骨體 足：胸骨切跡 前：皮膚 后：椎體 內(nèi)：氣管、食管 外：頸動脈鞘內(nèi)緣、甲狀腺,Level VI,Anterior neck compartment node

26、s Contains the lymph nodes located in the viscerasl space: the pre- and paratracheal nodes , precrinoid node and the perithyroid nodes.,81,82,S c I N,頭：鎖骨上緣 足：第一肋骨上緣 前：胸鎖乳突肌后緣 后：前斜角肌、胸膜頂 內(nèi)：頸血管鞘外緣

27、 外：與鎖骨下靜脈伴行,84,85,PTV,The levels delineated correspond to the CTV, and thus do not include any security margin.,Why use surgical guidelines as basic frame of radiotherapy guidelines?,1. Achievements in head and n

28、eck oncology have resulted from interactions of surgery and radiotherapy. This us to advocate for the use of a similar language to that already used by surgeons for more than a decade.,Why use surgical guidelines

29、as basic frame of radiotherapy guidelines?,2. Neck node dissection performed according to standardized procedures, removing only selected nodal levels, has produced high rates of control in the pathologically assessed n

30、ode-negative neck without post-operative radiotherapy.,Why use surgical guidelines as basic frame of radiotherapy guidelines?,2. This observation confirmed that the locations of the lymphatic areas at risk for microsco

31、pic infiltration often are well-defined. That is as an effective prophylactic irradiation .,Why use surgical guidelines as basic frame of radiotherapy guidelines?,3. Selection of the target volumes for head and neck r

32、adiotherapy more by technical limitations than by patient anatomy. Lead to unnecessary irradiation of normal tissues bearing little or no risk of tumor cell infiltration .,Guideline of ENI,The use of a ‘su

33、rgical reference system” guideline was more appropriate than a translation of 2D irradiation techniques into 3D volumes.,NPC淋巴引流途徑,內(nèi)膜毛細淋巴管→外周淋巴網(wǎng)→集合導管→注入第一站引流淋巴結 →鎖骨下靜脈或胸導管（左）、頸靜脈（右）,The first echelon lymph nodes of NPC,

34、1. Retropharyngeal nodes (RP)2. Internal jugular nodes (IJNu)3. Spinal accessory nodes (SAN),Guidelines of CTV nd,The guidelines do not intend to give any recommendation for the optimal treatment for node-negative p

35、atients with a head and neck primary .,Node - positive,The risk of extracapsular extension (ECE) is portional to the size of the lymph node: 20~40% for nodes 75% for bulky nodes > 3 cm . Node > 3 cm, addit

36、ional adjacent structures at risk of tumor Infiltration should be included in the CTV.,Node - positive,When the fascia has been disrupted, the whole muscle is at risk. Whether the entire muscle should be included in

37、CTV, or only a portion of it in the vicinity of the node, is unknown.,Node - positive,For the node-positive neck:1. whether the cranial limit and caudal limit of the CTV should be enlarged? 2. Infiltration of the upp

38、er part of level II , to include the jugular fossa in the CTV? or to include the supraclavicular area in case of lower neck infiltration?,Guidelines of CTVnd,定義 CTVnd 時，更傾向于 勾畫一寬的連續(xù)的區(qū)域，而不斷斷續(xù)續(xù)地勾畫。 一些與放射治療很少相關的淋巴結如肌肉間淋巴結不

39、標記 。,Guidelines of CTV nd,鼻咽癌不同T-N-分期應選擇那一淋巴引流區(qū)作為CTV，取決于此區(qū)的淋巴結的受侵的幾率和危險度，以及相鄰敏感器官的NTCP。研究方法主要有幾種形式： 1） 臨床治療結果；2）治療失敗的分析；3）尸檢報告；4）有價值的外科的報道,100,Suggested guidelines for the treatment of the neck of patients with head and

40、neck squamous cell carcinomas (AJCC 1997) Appropriate node levels to be treated N0 –N1 N2b Nasopharynx II, III, IV, V,

41、II, III, IV, V, and RP and RP,ENI,建立 勾畫 CTVnd 的 Guidelines 十分重要，目的是選擇需預防的高危陰性淋巴引流區(qū)，減少不必要的擴大照射。在此研究基礎上相應改進放療技術，保護唾液腺、咽、喉等正常結構, 有利提高治療獲得比。,三、靶區(qū)勾畫演示,結合MRI進行靶區(qū)勾畫,103,鼻

42、咽癌分期: T4N1M0 MRI T1+C,,咽旁、翼內(nèi)肌、 口咽軟腭受侵,T1+C: 蝶竇底壁,104,鼻咽癌分期: T4N1M0 MRI T1,,+C: 海綿竇、園孔,－C: 巖尖破壞,105,鼻咽癌分期: T4N1M0 SAGITAL,,T1-C:斜坡破壞,T1+C :病灶強化,106,掃描范圍：頭頂露空至鎖骨頭下緣2cm方式：螺旋掃描 Slice width: 3mm增強掃描計劃設計：網(wǎng)絡轉送至Pinn

43、acle工作站,CT sim掃描技術,107,將鼻咽和頸部GTV分開，分別為 GTVnx 和GTV nd 。 GTVnx為 CT/MRI 所顯示的鼻咽原發(fā)腫瘤區(qū)。GTVnd 為 CT/MRI 所顯示的直徑〉1cm的淋巴結。,靶區(qū)定義,108,CTV1 : 包括GTV及其周圍的亞臨床病灶區(qū)（GTV外擴0.75~1cm）,可根據(jù)周圍組織情況作適當?shù)男薷?。還必須包括完整鼻咽腔的全壁，正常的鼻咽粘膜下0.8～1.0cm的軟組織。,靶區(qū)定義,1

44、09,CTV2: 包括CTV1及其周圍易受侵犯的區(qū)域，可設定為CTV1外0.5~1cm范圍，根據(jù)周圍組織情況作適當?shù)男薷?。 鼻咽、口咽、咽后淋巴引流區(qū)和頸部陰性淋巴引流區(qū)設置于同一CTV2內(nèi)。,靶區(qū)定義,110,PTV：計劃靶體積，PTVnx、PTVnd、PTV1、PTV2分別為GTVnx、GTVnd、CTV1、CTV2及其外擴一定范圍； 計算機根據(jù)數(shù)據(jù)自動生成，以保證外擴 的三維徑線的準確性。,靶區(qū)定義,111,CTV2: 深藍

45、色,112,,CTV2: 深藍色CTV1-淺藍色,113,PTV-深藍色CTV-淺藍色,CTV2: 深藍色CTV1-淺藍色,114,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,115,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,116,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,117,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,同上層骨窗,118,CTV2: 深藍色CTV1-淺藍色GT

46、Vnx紅色,119,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,120,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,121,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,122,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,同上層軟組織窗,123,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,124,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,同上層骨窗,125,CTV2: 深藍色

47、CTV1-淺藍色GTVnx紅色,126,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,同上層骨窗,127,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,128,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,129,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,130,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,131,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,132,CTV2: 深

48、藍色CTV1-淺藍色GTVnx紅色,133,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,134,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,Level 2,135,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,136,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,137,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,138,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,139,CT

49、V2: 深藍色CTV1-淺藍色GTVnx紅色,140,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,141,CTV2: 深藍色CTV1-淺藍色GTVnx紅色,142,CTV2: 深藍色CTV1-淺藍色GTVnd－粉紅色,143,CTV2: 深藍色CTV1-淺藍色GTVnd－粉紅色,144,CTV2: 深藍色GTVnd－粉紅色,Nodes of Ia,Ib,145,CTV2: 深藍色GTVnd－粉紅色,146

50、,CTV2: 深藍色GTVnd－粉紅色,147,CTV2: 深藍色GTVnd－粉紅色,148,CTV2: 深藍色GTVnd－粉紅色,Level II / Va,149,CTV2: 深藍色GTVnd－粉紅色,150,CTV2: 深藍色GTVnd－粉紅色,151,CTV2: 深藍色GTVnd－粉紅色,152,CTV2: 深藍色GTVnd－粉紅色,153,CTV2: 深藍色GTVnd－粉紅色,154,CTV2: 深藍色GT

51、Vnd－粉紅色,155,CTV2: 深藍色GTVnd－粉紅色,Level III / Va,156,CTV2: 深藍色GTVnd－粉紅色,157,CTV2: 深藍色,158,CTV2: 深藍色,159,CTV2: 深藍色,160,CTV2: 深藍色,161,CTV2: 深藍色,162,CTV2: 深藍色,163,CTV2: 深藍色,164,CTV2: 深藍色,165,CTV2: 深藍色,,Level IV / Vb,166,CTV