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Contouring and Treatment Planning ConsensusGuidelines for Head and Neck and Skin Cancers
Jason Chan, MDUCSF Radiation OncologyAssistant Professor
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Disclosures
None
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ObjectivesBecome familiar with recent consensus guidelines on the following topics
Dose prioritization
OARs
Targets
‐ Primary tumor (CTVp) for OC, OPX, LX, HPX; NPC
‐ Post-op and flaps
‐ Perineural
‐ Elective nodes
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ObjectivesBecome familiar with recent consensus guidelines on the following topics
Dose prioritization
OARs
Targets
‐ Primary tumor (CTVp) for OC, OPX, LX, HPX; NPC
‐ Post-op and flaps
‐ Perineural
‐ Elective nodes
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AW Lee, WT Ng, JJ Pan, CL Chiang, SS Poh, HC Choi… - International Journal of …, 2019K Jensen, J Friborg, CR Hansen, E Samsøe… - Radiotherapy and Oncology, 20205
Dose Prioritization
AW Lee, WT Ng, JJ Pan, CL Chiang, SS Poh, HC Choi… - International Journal of …, 20196
NPC Dose PrioritizationGenerally prioritize tumor coverage over most OARs
Three PTV levels all priority 2
AW Lee, WT Ng, JJ Pan, CL Chiang, SS Poh, HC Choi… - International Journal of …, 2019K Jensen, J Friborg, CR Hansen, E Samsøe… - Radiotherapy and Oncology, 20207
PTV1 ObjectivesNot meeting these parameters are considered major deviations
PTV1 Dose Ref.
0.03 cc 117% HN004
0.03 cc 115% HN005
1.8 cc 110% DAHANCA
10% 107% NPC
20% 105% NPC
PTV1 Dose Ref.
D100% 90% DAHANCA
D99% 90% HN005
D95% 95% DAHANCA
GTV Dose (Gy) Ref.
D100% 95% (66.5) NPC
AW Lee, WT Ng, JJ Pan, CL Chiang, SS Poh, HC Choi… - International Journal of …, 2019K Jensen, J Friborg, CR Hansen, E Samsøe… - Radiotherapy and Oncology, 2020W De Neve, Y Wu, G Ezzell - Image-guided IMRT, 2006
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PTV2 and 3 ObjectivesMuch fewer QA parameters
No hot spot constraints PTV2/3 Dose Ref.
D95% 95% HN004/5
CTV2/3 Dose (Gy) Ref.
D95% 95% DAHANCA
Overlapping PTVs are optimized as the higher dose level
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K Jensen, J Friborg, CR Hansen, E Samsøe… - Radiotherapy and Oncology, 20209
DAHANCA Dose PrioritizationDifferent priorities for PTV1 and elective targets PTV2 and PTV3
1. Critical OARS, potentially lethal complicationSpinalCordBrainStem
2. TargetsGTVCTV1
3. Critical serial OARsEyeFront and EyeBackChiasm
4. TargetsPTV1CTV2 and CTV3PTV2 and PTV3
5. Remaining OARs…LarynxSGLarynx GOralCavityBuccalMucPCM…
6. Avoid overdosage of PTV2 and PTV3
Which other OARs should be higher priority than PTV2 and PTV3?
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ObjectivesBecome familiar with recent consensus guidelines on the following topics
Dose prioritization
OARs
Targets
‐ Primary tumor (CTVp) for OC, OPX, LX, HPX; NPC
‐ Post-op and flaps
‐ Perineural
‐ Elective nodes
R Mir, SM Kelly, Y Xiao, A Moore, CH Clark… - Radiotherapy and Oncology, 2020CL Brouwer, RJHM Steenbakkers, J Bourhis… - Radiotherapy and Oncology, 2015
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OARsAccurate OAR contouring is just as important as target delineation
MEMC Christianen, JA Langendijk, HE Westerlaan… - Radiotherapy and Oncology, 201112
OARs Involved in Swallowing
Superior and middle PCM should be contoured separately
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econtour.org13
Superior/Middle (SMPCM)
Cricopharyngeus muscle
Inferior (IPCM)
EIM (first 1 cm) and cervical esophagus
OARS involved in SwallowingPterygoid plates
Hyoid bone
1st slice caudal to hyoid bone
Arytenoids
1st slice caudal to arytenoids
1st slice caudal to cricoid cartilage
Cricoid cartilageThoracic inlet
I Petkar, K Rooney, JWG Roe, JM Patterson… - BMC cancer, 201614
CRUK/14/014 (DARS)Phase III IMRT ± Dysphagia Optimization
Dmean < 50 Gy SMPCM outside CTV_6500
Dmean < 20 Gy (OP) or < 40 Gy (HPX) IPCM outside CTV_6500
Do not spare overlap within PTV_6500 margin
Dose prioritization: critical OARS (spinal cord and brainstem); PTV_6500; constrictors; PTV_5400; other OARs
C Nutting, K Rooney, B Foran, L Pettit, M Beasley… - ASCO 202015
CRUK/14/014 (DARS)Phase III IMRT ± Dysphagia Optimization
112 patients. T1-4 N0-3 M0 OP (97%)/HPX cancer. 84% CCRT
Standard vs. Dysphagia-optimized IMRT
Median mean S/MPC 57 vs. 50 Gy; IPC 50 vs. 28 Gy
Median mean 1y MDADI 70 vs. 78
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ObjectivesBecome familiar with recent consensus guidelines on the following topics
Dose prioritization
OARs
Targets
‐ Primary tumor (CTVp) for OC, OPX, LX, HPX; NPC
‐ Post-op and flaps
‐ Perineural
‐ Elective nodes
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V Grégoire, M Evans, QT Le, J Bourhis, V Budach… - Radiotherapy and Oncology, 2018 AW Lee, WT Ng, JJ Pan, SS Poh, YC Ahn, H AlHussain… - Radiotherapy and Oncology, 2018K Jensen, J Friborg, CR Hansen, E Samsøe… - Radiotherapy and Oncology, 2020
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Primary tumor (CTVp)Larynx, Hypopharyx, Oropharynx, Oral Cavity; Nasopharynx
5 mm (70 Gy)
+5 mm
(60 Gy)
V Grégoire, M Evans, QT Le, J Bourhis, V Budach… - Radiotherapy and Oncology, 2018 18
Glottic Larynx T1bException to “5+5” rule: CTV2 is not recommended for T1 glottic SCC
Exclude thyroid cartilage
V Grégoire, M Evans, QT Le, J Bourhis, V Budach… - Radiotherapy and Oncology, 2018 19
Glottic Larynx T2
Include:Anterior commissureThyroid cartilageVocal process of arytenoid
Include:SupraglottisSubglottis
V Grégoire, M Evans, QT Le, J Bourhis, V Budach… - Radiotherapy and Oncology, 2018 20
Supraglottic Larynx T3
± Oropharynx (e.g. lingual surface epiglottis and vallecula)
Include post-cricoid but not posterior pharyngeal wall
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V Grégoire, M Evans, QT Le, J Bourhis, V Budach… - Radiotherapy and Oncology, 2018 21
Supraglottic Larynx T4a
Extend beyond strap muscles if macroscopically invaded
V Grégoire, M Evans, QT Le, J Bourhis, V Budach… - Radiotherapy and Oncology, 2018 22
Hypopharynx T2
Extensive submucosal extension with HPX: consider 5+10 instead of 5+5Posteriorly include part of PCM but not pre-vertebral fascia
Caudally may extend to cervical esophagusSuperiorly may extend into oropharynx
V Grégoire, M Evans, QT Le, J Bourhis, V Budach… - Radiotherapy and Oncology, 2018 23
Hypopharynx T4b
Extensive submucosal extension with HPX: consider 5+10 instead of 5+5Posteriorly include pre-vertebral fascia if invaded
Caudally extend to cervical esophagusSuperiorly extend into oropharynx
V Grégoire, M Evans, QT Le, J Bourhis, V Budach… - Radiotherapy and Oncology, 2018 24
Tonsil T2
Posteriorly extend into part of PCMLaterally include parapharyngeal space but not medial pterygoid muscle
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V Grégoire, M Evans, QT Le, J Bourhis, V Budach… - Radiotherapy and Oncology, 2018 25
Soft Palate T1
Should not extend into non-contiguous mucosa e.g. posterior pharyngeal wall
V Grégoire, M Evans, QT Le, J Bourhis, V Budach… - Radiotherapy and Oncology, 2018 26
Soft Palate T3
Extend into hard palate, parapharyngeal space
V Grégoire, M Evans, QT Le, J Bourhis, V Budach… - Radiotherapy and Oncology, 2018 27
Base of Tongue T2
Laterally extend through hyoglossus muscleAnteriorly may extend into the mobile tongue and genioglossus
V Grégoire, M Evans, QT Le, J Bourhis, V Budach… - Radiotherapy and Oncology, 2018 28
Vallecula T3
Extend inferiorly into pre-epiglottic fat
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V Grégoire, M Evans, QT Le, J Bourhis, V Budach… - Radiotherapy and Oncology, 2018 29
Posterior Pharyngeal Wall T4b
Extend through pre-vertebral fascia into longus colli and longus capitis muscles
V Grégoire, M Evans, QT Le, J Bourhis, V Budach… - Radiotherapy and Oncology, 2018 30
Oral Tongue T4
Include deep extrinsic muscles of tongue
AW Lee, WT Ng, JJ Pan, SS Poh, YC Ahn, H AlHussain… - Radiotherapy and Oncology, 201831
Nasopharynx T1
Sphenoid 1/2Petrous apex
Max sinus ≥ 5 mm
Pterygoid fossaParapharyngeal
Clivus 1/3Ovale, rotundum,
lacerum
Inferior limit of nasopharynx is at caudal edge of C1
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ObjectivesBecome familiar with recent consensus guidelines on the following topics
Dose prioritization
OARs
Targets
‐ Primary tumor (CTVp) for OC, OPX, LX, HPX; NPC
‐ Post-op and flaps
‐ Perineural
‐ Elective nodes
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J Le Guevelou, V Bastit, PY Marcy, A Lasne-Cardon… - Radiotherapy and Oncology, 2020SV Porceddu, C Daniels, SS Yom, H Liu, J Waldron… - International Journal of …, 202033
Post-op and Flaps
J Le Guevelou, V Bastit, PY Marcy, A Lasne-Cardon… - Radiotherapy and Oncology, 202034
Free FlapsStandard delineation needed to refine post-op CTV definition
J Le Guevelou, V Bastit, PY Marcy, A Lasne-Cardon… - Radiotherapy and Oncology, 202035
Radial Forearm Free Flap
J Le Guevelou, V Bastit, PY Marcy, A Lasne-Cardon… - Radiotherapy and Oncology, 202036
Anterolateral Thigh Free Flap
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J Le Guevelou, V Bastit, PY Marcy, A Lasne-Cardon… - Radiotherapy and Oncology, 202037
Fibula Free Flap
SV Porceddu, C Daniels, SS Yom, H Liu, J Waldron… - International Journal of …, 202038
Post-op with Free Flap
CTVp_HR (60 Gy): HRTV + minimum 5 mm, may include most of post-op bed/flap
CTVp_LR (54-56 Gy): Remaining post-op bed/flap
CTVn_LR (54-56 Gy): Undissected ipsilateral Ib, II, III, XIII (parotid), IX (bucco-facial)
CTVp_HR CTVp_LR
CTVn_LR
HRTV
K Jensen, J Friborg, CR Hansen, E Samsøe… - Radiotherapy and Oncology, 202039
Post-op Neck (DAHANCA)
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ObjectivesBecome familiar with recent consensus guidelines on the following topics
Dose prioritization
OARs
Targets
‐ Primary tumor (CTVp) for OC, OPX, LX, HPX; NPC
‐ Post-op and flaps
‐ Perineural
‐ Elective nodes
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RL Bakst, CM Glastonbury, U Parvathaneni, N Katabi… - International Journal of …, 2019J Biau, V Dunet, M Lapeyre, C Simon, M Ozsahin… - Radiotherapy and Oncology, 201941
Perineural Invasion and Spread
RL Bakst, CM Glastonbury, U Parvathaneni, N Katabi… - International Journal of …, 201942
PNI/PNTS Recommendations
RL Bakst, CM Glastonbury, U Parvathaneni, N Katabi… - International Journal of …, 201943
Extensive PNIElective V3 coverage to foramen ovale
RL Bakst, CM Glastonbury, U Parvathaneni, N Katabi… - International Journal of …, 201944
PNI/PNTS Recommendations
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RL Bakst, CM Glastonbury, U Parvathaneni, N Katabi… - International Journal of …, 201945
PNTS along V3 ATN and VIITympanic segment
ATN
CN VII
Posterior genu
Canalicular segment
70 GyElective
RL Bakst, CM Glastonbury, U Parvathaneni, N Katabi… - International Journal of …, 201946
PNI/PNTS Recommendations
RL Bakst, CM Glastonbury, U Parvathaneni, N Katabi… - International Journal of …, 2019J Biau, V Dunet, M Lapeyre, C Simon, M Ozsahin… - Radiotherapy and Oncology, 201947
PNTS along V2 with Anterograde
PPF
GSPN
Ovale
Cochlea
Rotundum
Meckel’sCave
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ObjectivesBecome familiar with recent consensus guidelines on the following topics
Dose prioritization
OARs
Targets
‐ Primary tumor (CTVp) for OC, OPX, LX, HPX; NPC
‐ Post-op and flaps
‐ Perineural
‐ Elective nodes
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J Biau, M Lapeyre, I Troussier, W Budach, J Giralt… - Radiotherapy and Oncology, 201949
Elective NodesLevel Group
Ia Submental
Ib Submandibular
II Upper Jugular
III Middle Jugular
IVa Lower Jugular
Va and Vb Upper and Lower Posterior Triangle
Vc Lateral SCV
VIa Anterior Jugular
VIb Pre-laryngeal, pre-tracheal, para-tracheal
VIIa Retropharyngeal
VIIb Retro-styloid
VIII Parotid
IX Bucco-facial
Xa Retroauricular and subauricular
Xb Occipital
J Biau, M Lapeyre, I Troussier, W Budach, J Giralt… - Radiotherapy and Oncology, 2019CJ Tsai, TJ Galloway, DN Margalit, RL Bakst… - Head & neck, 202150
Elective Nodes
Oral Cavity Oropharynx
Contralateral neck may be omitted as per Tsai et al.
J Biau, M Lapeyre, I Troussier, W Budach, J Giralt… - Radiotherapy and Oncology, 201951
Elective Nodes
Hypopharynx Larynx
J Biau, M Lapeyre, I Troussier, W Budach, J Giralt… - Radiotherapy and Oncology, 201952
Elective Nodes
Nasopharynx Paranasal Sinus
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K Jensen, J Friborg, CR Hansen, E Samsøe… - Radiotherapy and Oncology, 202053
Elective Nodes (DAHANCA)Much more selective than Biau et al.
I II III IV Va Vb VIVIIa(RP)
VIIb(Retrostyloid)
Other
All N+Extend elective regions ≥ 2 cm CC of GTV-N
If ENE to muscle, include entire muscle ≥ 2 cm CC of GTV-N
Oral Cavity N0 X X X
Oral Cavity N+ X X X
Nasopharynx N0 X X X X X
Nasopharynx N+ X* X X X X X X X *Ib included if invasion of SMG, OC, anterior NC
Oropharynx N0 X* X X X**Ib included if OC involvement
*RP included if posterior pharyngeal wall involvement
Oropharynx N+ X* X X X*
Hypopharynx N0 X* X X X**The cranial part of level II can be excluded after individual
consideration*Level VI if subglottic/esophageal involvement
Hypopharynx N+ X X X X* *Level VI if subglottic/esophageal involvement
Supraglottic / Glottic (≥ T3)
X X X*X*
*Level IV on side of nodal involvement or bilateral if hypopharynx involved
*Level VI if subglottic/esophageal involvement
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SummaryRecent consensus guidelines
Dose prioritization: NPC, DAHANCA prioritize PTV1 over most OARs
OARs: contour individual swallowing OARs (SMPCM and IPCM per DARS)
Targets
‐ Primary tumor (CTVp) for OC, OPX, LX, HPX; NPC: “5+5” rule, consider larger for HPX
‐ Post-op and flaps: entire flap should be part of post-op target; follow free flap atlas
‐ Perineural: coverage for elective nerve pathway, interconnections, anterograde spread
‐ Elective nodes: Biau et al. and DAHANCA for recommendations by primary tumor