Delineation of dysphagia aspiration related structures
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Transcript of Delineation of dysphagia aspiration related structures
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Delineation of Dysphagia/Aspiration-Related Structures (DARS)
Dr Rajesh BalakrishnanMD, DNB (Radiotherapy)
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References for the Talk
• Radiotherapy and Oncology 93 (2009) 545–552• Radiotherapy and Oncology 110 (2014) 390-397
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Prerequisites
• Good Planning CT – Good Immobilistaion setup– With Contrast imaging– 3mm Slice thickness or smaller
• Suggested the center (HU) and width (HU) values (window settings) used to delineate the OARs– Brain: C35, W100– Bone: C450, W1,600– H&N: C35, W350– Parotid: C 840 , W 370
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• Temporal Lobes• Right Eye and Lens• Left eye and lens• Right Optic nerve• Left Optic nerve• Optic chiasm• Pituitary• Cochlea• Brainstem
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Organs at Risk (1)
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• Spine• Parotid Glands• Sub Mandibular Gland• Pharyngeal Constrictors• Trachea• Brachial Plexus
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Organs at Risk (2)
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OPTIC APPARATUS
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Optic/Brain – Organs at Risk
• Temporal Lobes• Right Eye and Lens• Left eye and lens• Right Optic nerve• Left Optic nerve• Optic chiasm• Pituitary• Cochlea• Brainstem
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8Radiotherapy and Oncology 110 (2014) 390–397
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9Radiotherapy and Oncology 110 (2014) 390–397
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10Radiotherapy and Oncology 110 (2014) 390–397
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11Radiotherapy and Oncology 110 (2014) 390–397
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12Radiotherapy and Oncology 110 (2014) 390–397
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13Radiotherapy and Oncology 110 (2014) 390–397
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14Radiotherapy and Oncology 110 (2014) 390–397
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15Radiotherapy and Oncology 110 (2014) 390–397
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16Radiotherapy and Oncology 110 (2014) 390–397
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17Radiotherapy and Oncology 110 (2014) 390–397
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18Radiotherapy and Oncology 110 (2014) 390–397
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19Radiotherapy and Oncology 110 (2014) 390–397
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20Radiotherapy and Oncology 110 (2014) 390–397
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21Radiotherapy and Oncology 110 (2014) 390–397
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22Radiotherapy and Oncology 110 (2014) 390–397
Odontoid Process
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SALIVARY GLANDS
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Parotid GlandBoundary Explanation
Cranial External auditory canal, mastoid process
Caudal Post. part submandibular space
AnteriorMasseter m, post. border mandibular bone, medial and lateral pterygoid m.
PosteriorAnt. belly sternocleidomastoid m, lat. side post. belly of the digastric m. (posterior-medial)
Lateral Subcutaneous fat, platysma
MedialPost. belly of the digastric m, styloid process, parapharyngeal space 24
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Submandibular GlandBoundary Explanation
Cranial Medial pterygoid m, mylohyoid m.
Caudal Fatty tissue
Anterior Lat. surface mylohyoid m, hyoglossus m.
Posterior Parapharyngeal space, sternocleidomastoid m.
LateralMed. surface medial pterygoid m, med. surface mandibular bone, platysma
MedialLat. surface mylohyoid m, hyoglossus m, superior and middle pharyngeal constrictor m, anterior belly of the digastric m. 25
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Sublingual GlandBoundary Explanation
Cranial(Mucous membrane covering the floor of the mouth), crossing lingual septum , intrinsic tongue muscles
Caudal Ant. part mylohyoid m, geniohyoid m.
Anterior Ant. part surface mandibular bone, mylohyoid m.
Posterior Hyoglossus m.
LateralAnt. part med. surface mandibular bone, mylohyoid m.
Medial Genioglossus m. 26
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Salivary Glands - Delineation
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5 Anterior belly digastric m.
6 Geniohyoid m.
10 Sternocleidomastoid m.
11 Platysma
••••• Sub Lingual Glands – Dark Blue
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Salivary Glands - Delineation
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5 Anterior belly digastric m.
6 Geniohyoid m.
9 Pharyngeal constrictor m.
10 Sternocleidomastoid m.
11 Platysma
••••• Sub Lingual Glands – Dark Blue
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Salivary Glands - Delineation
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1 Genioglossus m.
2 Mylohyoid m.
3 Hyoglossus m.
10 Sternocleidomastoid m.
11 Platysma
15 Mandibular bone
••••• Sub Lingual Glands – Dark Blue
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Salivary Glands - Delineation
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1 Genioglossus m.
2 Mylohyoid m.
3 Hyoglossus m.
9 Pharyngeal constrictor m.
10 Sternocleidomastoid m.
15 Mandibular bone
••••• Sub Lingual Glands – Dark Blue
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Salivary Glands - Delineation
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1 Genioglossus m.
2 Mylohyoid m.
3 Hyoglossus m.
4 Posterior belly digastric m.
7 Medial pterygoid m.
10 Sternocleidomastoid m.
12 Masseter m.
13 Parapharyngeal space••••• Sub Lingual Glands – Dark Blue
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Salivary Glands - Delineation
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1 Genioglossus m.
2 Mylohyoid m.
4 Posterior belly digastric m.
7 Medial pterygoid m.
10 Sternocleidomastoid m.
12 Masseter m.
15 Mandibular bone
••••• Sub Lingual Glands – Dark Blue
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Salivary Glands - Delineation
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4 Posterior belly digastric m.
7 Medial pterygoid m.
10 Sternocleidomastoid m.
12 Masseter m.
••••• Sub Lingual Glands – Dark Blue
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Salivary Glands - Delineation
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4 Posterior belly digastric m.
7 Medial pterygoid m.
8 Lateral pterygoid m.
10 Sternocleidomastoid m.
12 Masseter m.
13 Parapharyngeal space
14 Styloid process
15 Mandibular bone••••• Sub Lingual Glands – Dark Blue
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Parotid – Axial and Coronal
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Submandibular – Sagittal and Coronal
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SubLingual – Sagittal and Coronal
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SOFT PALATE
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Soft PalateBoundary Explanation
CranialHard palate, nasopharyngeal mucosal space/air lumen
CaudalTongue base, palatine tonsils, oropharyngeal mucosal space/air lumen
AnteriorHard palate, tongue/tongue base, air present in oral cavity or pharyngeal lumen
PosteriorSuperior pharyngeal constrictor m, pharyngeal mucosal space/air lumen
Lateral
Pterygoid process, medial pterygoid plate, superior pharyngeal constrictor m, medial pterygoid m, parapharyngeal space, palatine tonsil, pharyngeal lumen 39
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SOFT PALATE – Sagittal and Axial
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SOFT PALATE
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1 Tongue
2 Medial pterygoid m.
3 Superior pharyngeal constrictor m.
4 Uvula
5 Hard palate
6 Medial pterygoid plate
7 Pharyngeal lumen
8 Parapharyngeal space
9 Pterygoid process
10 Level of the palatine tonsil.
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SOFT PALATE
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1 Tongue
2 Medial pterygoid m.
3 Superior pharyngeal constrictor m.
4 Uvula
5 Hard palate
6 Medial pterygoid plate
7 Pharyngeal lumen
8 Parapharyngeal space
9 Pterygoid process
10 Level of the palatine tonsil.
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SOFT PALATE
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1 Tongue
2 Medial pterygoid m.
3 Superior pharyngeal constrictor m.
4 Uvula
5 Hard palate
6 Medial pterygoid plate
7 Pharyngeal lumen
8 Parapharyngeal space
9 Pterygoid process
10 Level of the palatine tonsil.
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SOFT PALATE
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1 Tongue
2 Medial pterygoid m.
3 Superior pharyngeal constrictor m.
4 Uvula
5 Hard palate
6 Medial pterygoid plate
7 Pharyngeal lumen
8 Parapharyngeal space
9 Pterygoid process
10 Level of the palatine tonsil.
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SOFT PALATE
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1 Tongue
2 Medial pterygoid m.
3 Superior pharyngeal constrictor m.
4 Uvula
5 Hard palate
6 Medial pterygoid plate
7 Pharyngeal lumen
8 Parapharyngeal space
9 Pterygoid process
10 Level of the palatine tonsil.
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SOFT PALATE
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1 Tongue
2 Medial pterygoid m.
3 Superior pharyngeal constrictor m.
4 Uvula
5 Hard palate
6 Medial pterygoid plate
7 Pharyngeal lumen
8 Parapharyngeal space
9 Pterygoid process
10 Level of the palatine tonsil.
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LIPS AND BUCCAL MUCOSA
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Inner Surface Upper LipsBoundary Explanation
CranialHard palate (lateral), anterior nasal spine (at the midline)
Caudal Lower edge upper lip
Anterior Orbicularis oris m, subcutaneous tissue/fatty skin
Posterior Teeth, maxillary bone, hard palate, tongue
Lateral Depressor anguli oris m, buccinator m, levator anguli oris m./risorius m.
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Inner Surface Lower LipsBoundary Explanation
Cranial Upper edge lower lip
CaudalLower edge teeth sockets, cranial edge mandibular body
Anterior Orbicularis oris m, subcutaneous tissue/fatty skin
Posterior Mandibular body, teeth, tongue, air (if present)
Lateral Depressor anguli oris m, buccinator m.
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Inner Surface CheeksBoundary Explanation
CranialTransition between maxillary sinus and alveolar process maxilla
Caudal Alveolar process mandible
Anterior Orbicularis oris m.
Posterior Post. edge mandibular body, post. edge maxilla
Lateral Buccinator muscle, fatty tissue
Medial Mandibular body, teeth, tongue50
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1 Orbicularis oris
2 Tongue
3 Fatty tissue
4 Hard palate
5 Mandibular body
6 Maxillary bone
7 Anterior nasal spine
8 Buccinator m
9 Levator anguli oris/risorius m
10 Alveolar process maxilla
11 Maxillary sinus
12 Depressor anguli oris m
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1 Orbicularis oris
2 Tongue
3 Fatty tissue
4 Hard palate
5 Mandibular body
6 Maxillary bone
7 Anterior nasal spine
8 Buccinator m
9 Levator anguli oris/risorius m
10 Alveolar process maxilla
11 Maxillary sinus
12 Depressor anguli oris m
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54
1 Orbicularis oris
2 Tongue
3 Fatty tissue
4 Hard palate
5 Mandibular body
6 Maxillary bone
7 Anterior nasal spine
8 Buccinator m
9 Levator anguli oris/risorius m
10 Alveolar process maxilla
11 Maxillary sinus
12 Depressor anguli oris m
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55
1 Orbicularis oris
2 Tongue
3 Fatty tissue
4 Hard palate
5 Mandibular body
6 Maxillary bone
7 Anterior nasal spine
8 Buccinator m
9 Levator anguli oris/risorius m
10 Alveolar process maxilla
11 Maxillary sinus
12 Depressor anguli oris m
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56
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57
1 Orbicularis oris
2 Tongue
3 Fatty tissue
4 Hard palate
5 Mandibular body
6 Maxillary bone
7 Anterior nasal spine
8 Buccinator m
9 Levator anguli oris/risorius m
10 Alveolar process maxilla
11 Maxillary sinus
12 Depressor anguli oris m
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58
1 Orbicularis oris
2 Tongue
3 Fatty tissue
4 Hard palate
5 Mandibular body
6 Maxillary bone
7 Anterior nasal spine
8 Buccinator m
9 Levator anguli oris/risorius m
10 Alveolar process maxilla
11 Maxillary sinus
12 Depressor anguli oris m
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59
1 Orbicularis oris
2 Tongue
3 Fatty tissue
4 Hard palate
5 Mandibular body
6 Maxillary bone
7 Anterior nasal spine
8 Buccinator m
9 Levator anguli oris/risorius m
10 Alveolar process maxilla
11 Maxillary sinus
12 Depressor anguli oris m
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60
1 Orbicularis oris
2 Tongue
3 Fatty tissue
4 Hard palate
5 Mandibular body
6 Maxillary bone
7 Anterior nasal spine
8 Buccinator m
9 Levator anguli oris/risorius m
10 Alveolar process maxilla
11 Maxillary sinus
12 Depressor anguli oris m
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PHARYNGEAL CONSTRICTORS
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Superior Constrictor MuscleBoundary Explanation
Cranial Occipital condyle
Caudal Superior Edge of Hyoid Bone
Anterior Anterior edge of pterygoid muscle
Posterior Longus Capitis muscle
Lateral Palatine Tonsil or Parapharyngeal space
Medial Pharynx
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63Radiotherapy and Oncology 110 (2014) 390–397
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64Radiotherapy and Oncology 110 (2014) 390–397
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65Radiotherapy and Oncology 110 (2014) 390–397
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66Radiotherapy and Oncology 110 (2014) 390–397
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Middle Constrictor MuscleBoundary Explanation
Cranial 0.5 cm Above Hyoid bone
Caudal Inferior Edge of Hyoid Bone
Anterior Oropharynx, Lateral edge of Hyoid bone
Posterior Longus Capitis muscle
Lateral Palatine Tonsil or Parapharyngeal space
Medial Pharynx
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68Radiotherapy and Oncology 110 (2014) 390–397
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69Radiotherapy and Oncology 110 (2014) 390–397
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70Radiotherapy and Oncology 110 (2014) 390–397
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Inferior Constrictor MuscleBoundary Explanation
Cranial Inferior edge of Hyoid bone
Caudal Esophagus
Anterior Arytenoid, First Tracheal ring
Posterior Longus Capitis muscle, Anterior Vertebral body
Lateral Parapharyngeal space, Lateral edge of Thyroid
Medial Pharynx
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72Radiotherapy and Oncology 110 (2014) 390–397
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73Radiotherapy and Oncology 110 (2014) 390–397
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74Radiotherapy and Oncology 110 (2014) 390–397
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75Radiotherapy and Oncology 110 (2014) 390–397
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76Radiotherapy and Oncology 110 (2014) 390–397
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77Radiotherapy and Oncology 110 (2014) 390–397
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Dose ConstraintsConstrictors Mean Dose < 50 Gy QUANTEC
Lips Mean Dose <20 GyFor parotid tumor: Max < 30GyFor SM tumor : Max < 45 Gy
RTOG 1008
Oral Cavity (Non OC tumor) Mean < 30 Gy ; No hot spots > 60 Gy
RTOG 0920
Oral Cavity (OC tumor) Mean < 50 Gy ; V55 < 1 %Max dose -65 Gy
RTOG 0920
TMJ / Mandible Max 70 Gy RTOG 0615
Larynx Mean < 44 Gy ; V50 < 33 %Max dose - 63 -66Gy
QUANTEC
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Dose Constraints
Parotid Glands Mean < 25 Gy (Both glands)Mean < 20 Gy (Single gland)
QUANTEC
Submandibular Glands Mean < 35 Gy QUANTEC
Thyroid V26 < 20 % JHH guidelines
Cochlea Ipsilateral Max <50GyMean < 45 Gy
RTOG 1016QUANTEC
Eyes Max <30 Gy RTOG 1008
Lens Max : < 2.5 Gy RTOG 1008
Optic nerve/ Chiasm Max < 30 Gy RTOG 1008
Brainstem Entire Brainstem – < 54 GyV59Gy < 1-10cc
QUANTEC
Spinal cord Max 50 Gy QUANTEC
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Conclusion
• Correct Contouring of OARs is as important to contouring of Target.
• Whenever in doubt please refer to atlases available online.
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