Basics of Head and Neck IMRT Planning and Anatomy

Kenneth H Hu, M M.D. D Beth Israel Medical Center, NY Assoc. Professor Albert Einstein College of Medicine

No Disclosures

Learning Objectives
To review basic anatomy and nodal target delineation To understand dosimetric parameters associated with improved functional/QOL outcomes xerostomia swallowing outcomesxerostomia, swallowing, dental morbidity and neurologic function To T review i pathways th of f perineural i l spread d

Basics of Contouring
GTV by imaging/physical exam/endoscopy
CT neck standard for nodal and primary PET/CT to guide equivocal MRI for NPC, paranasal cavity tumors to evaluate intracranial spread, mucus, RP nodes, parapharyngeal, clivus, perineural

CTV margin 5mm PTV Margins 3-5mm trim based on skin, air and bone along with compartments

References for Lymph Node Delineation

CT-Based Delineation of Lymph y p Node Levels and Related CTV in Node Negative Neck Dahanca, EORTC, GORTEC,NCIC,RTOG
G Gregoire, i et t al. l Radiotherapy R di th and dO Oncology, l 65 2003 2003, 227-236

Proposal for the delineation of the nodal CTV in Node-positve and the post-operative neck
Gregoire, et al. Radiotherapy and Oncology, 79 2006, 15 20 15-20

RTOG Website www.rtog.org

Percentage Incidence and Distribution of P th l i ll I Pathologically Involved l dN Nodes d i in a Clinical Cli i l Node Negative Neck After Elective Radical N k Di Neck Dissection ti
I Oropharynx n=48 Hypopharynx n=24 Larynx n=79 Oral Cavity N 192 N=192 2 0 5 20 II 25 13 19 17 III 19 13 20 9 IV 8 0 9 3 V 2 0 25 2.5 0.5

Shah, J.P et al. The patterns of cervical lymph node metastases from squamous carcinoma of the oral cavity. Cancer, 1990. 66(1): p. 109-13

Percentage g Incidence and Distribution of Pathologically Involved Nodes in a Clinical p Radical Node Positive after Therapeutic Neck Dissection
I Oropharynx n=165 Larynx n=183 Hypopharynx yp p y n=104 Oral Cavity n=324 14 7 10 46 II 71 57 76 43 III 42 59 73 33 IV 28 29 46 15 V 9 4 11 3

Shah, J.P., Patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract. Am J Surg, 1990. 160(4): p. 405-9.

Image-Based Neck Node Level Classification

Som et al, AJR, 2000

Nodal LN in LNLN vs LN+

Pt with an unknown primary with T0N2bM0 involving the right neck

ICA IJV ICA,

CTV of LN+ J foramen

Sparing of parotid in LNp

Sup constrictor spared on L L Lat RP LN

Upper Ib,II,Va

C1 TVP

Ib,IIa/b

Submandib gl

IIa/b

Ia LN spared Lx, SMG, mid constrictors

L III/Va LN, Lx, inf constrictors

L IV,Vb LN, Lx, cricopharyngeus

L IV,SCL LN, trachea, cervical esoph

L IV,SCL LN, L IV, cervical esoph

Coverage of Nodal Volumes

Retropharyngeal Nodes
Skull Base down to hyoid bone Lateral L t l RP LN i involved l d fi first t( (spare constrictors) ti t ) Medial RP LN if lateral RP LN+

Cervical Nodal
LN- Inferior margin of C1 Transverse and selective nodal

jugular foramen if LN+ and comprehensive nodal treatment Level VI (pre-tracheal/delphian) (pre tracheal/delphian) for subglottic tumor/hypopharynx/thyroid IV, Level VII (superior mediastinum) with level IV thyroid, cervical esophagus

IMRT Improved Xerostomia: PASSPORT Trial

94 pts with OP/HP cancer randomized to IMRT vs 3DRT Whole contralateral p parotid < 24Gy y
Lent SOMA Score EORTC Dry Mouth Subscale

Nutting CM et al, Lancet Oncol 2011, 12:127

Submandibular Gland Sparing

36 pts OPX ( (n=28) 28) NPX treated d with i h RT Case matched18pts with SMG sparing and d 18 without. ith t SMG spared had lower N stage (no N2b3) vs SMG non-spared d group (59% N2b N2b-3) 3)
Saarilahti et al Radiotherapy and Oncology78 (2006) 27075.

Mean SMG<35Gy

 78 pts III/IV Opx prospectively followed after IMRT designed to spare bilateral parotids oral cavity, parotids, cavity contralateral SMG Pt and observer reported xerostomia surveys and salivary collection up to 2yrs

Little et al, Little, al IJROBP In press

Mean Oral Cavity<40Gy

Mean SMG <50Gy

Dysphagia
RTOG 0129 Cisplatin + RT RTOG-0129 PEG dependence 1yr 30% Measures of dysphagia: Feeding tube dependence py aspiration p videofluoroscopy/silent dysphagia qol surveys

Pharyngeal Constrictors

Superior Mid Inferior

Werbrouch J et al, IJROBP 2009, 73:1187

Courtesy Dr. Eisbruch/Le

Levendag PC, et al. Radiother Oncol. 2007

.4

.5

.6

Probability Swallowing Problems

Cyberknife (3x + 4x) .3 . y py implant p Brachytherapy No BT / No Cyberknife .2

.1

4x 3x

10

20

30

40

50

60

70

80

Dose superior constrictor muscle (Gy)

Levendag PC, et al. Radiother Oncol. 2007

Constrictors Mean Dose <55Gy

Mean Larynx Dose <40Gy

73 III/IV Opx 70Gy/7wks + taxol/carbo/wk Med F/U 36mo 3yr LRC 96% DFS 88%

Feng JCO 2010

PEG dependence 1.4% at 1yr Dysphagia related to dose to PC PC,Lx, Lx Esoph Neck dissection/smoking/t-stage

5 pts t with ith strictures ti t 8 pts with pneumoniaall silent aspirators

Mean Tolerance Doses and Swallowing Complications

PEGdepend Eisbruch
(IJROBP,2011) ( , )

Aspiration Lx<40Gy PC<56Gy Lx<41Gy

Stricture Esoph<48Gy SPC V65<1/3 MPC V65<3/4

Caudell
(IJROBP 2010) (IJROBP,2010)

LX<50Gy

IPC<50Gy

Caglar
(IJROBP,2008)

Lx<48Gy Esoph<40Gy IPC<54Gy IPC<54Gy

Li
(Rad Oncol 2009)

Caveats- Other Causes of CaveatsDysphagia

T-Stage Tumor Location

Neck Dissection

Machtay M et al, JCO 26:3582

Courtesy Dr. Le

Dosimetric Factors For Dental Events

Mandible

MSKCC, N=168 pts Med f/u 37mos

Dental caries 9% Dental Extraction 12%

ORN 1% (2/168pts)

Decreased if Decreased if

Mean p parotid dose < 26Gy y Mean mandible < 38Gy or Max Mandible < 68Gy

Gomez IJROBP 81, No. 4, pp. e20713, 2011

Brachial plexus

Truong, Radiographics,RSNA 2010

Temporal Lobe Necrosis

V55 <1 mL V40 < 5 ml l V30 <10 mL V25 <20 mL V15 <40 mL

Hara Wet al, ASTRO 2010

Courtesy Dr. Le

Cochlea
Tolerance <48Gy with CDDP

Chen et al., Cancer,2006 106 (4)820-9

Perineural Invasion
Noncontiguous spread along the nerve endoneurium d i f from a t tumor Skin cancers, Parotid (adenoid cystic), Nasopharynx

Caldemeyer, Radiographics 1998

Relation of CN VII and V

GLUCK et al. IJROBP Vol. 74, No. 1, pp. 3846, 2009

Neuroforamina of CN V
VC F. Ovale SOF

F. Ovale

F R t d Rotundum VC

Caldemeyer, Radiographics 1998

CN 7 pathway
G. Ganglion g Horizontal CN 7

DescendingCN 7

Caldemeyer, Radiographics 1998

Skin Cancer and PNI

T4 Adenoid Cystic Ca of L Parotid

Deep lobe Pterygoid mm Auriculotemporal nn

Desc CN 7 IAC

Desc CN 7