1、鼻咽癌靶区勾画建议,中山大学附属肿瘤医院 放疗科,Background,遵循原则对靶区进行定义，有助于建立共同的标准，有利多中心的交流,3,一、鼻 咽 部 MRI 所 见,4,正常解剖(信号特征）,MR：T2WI-软组织分辨率高肌肉、咽颅底筋膜：低信号粘膜和淋巴滤泡组织：偏高信号粘液：明亮的高信号咽鼓管圆枕透明软骨：高信号血管：流空效应：低信号Gd-DTPA增强：高信号致密骨：低信号松质骨：取决于骨髓成分红骨髓为主：中等信号黄骨髓为主：高信号（枕骨斜坡、颈椎椎体）,5,正常解剖及MR表现：鼻咽腔,T1WI：鼻咽腔左右不对称，左侧咽隐窝变浅T2WI：左侧咽隐窝为唾液，高信号,6,正常解剖及MR表
2、现：鼻咽腔,横断：鼻咽上部咽鼓管圆枕（软骨端、T2W）表面：粘膜覆盖前：咽鼓管咽口后：咽隐窝腭帆提肌（后外侧）腭帆张肌（前外侧）翼外肌、颞肌、咬肌椎前肌（ 头长肌、颈长肌）,7,正常解剖及MRI表现：鼻咽腔,横断（鼻咽上部）咽鼓管圆枕、咽鼓管咽口、咽隐窝腭帆张肌、腭帆提肌翼外肌、颞肌、咬肌,T2WI,T1WIC,T1WI,Gd+,8,正常解剖及MR表现：鼻咽腔,横断（鼻咽中部）咽旁间隙（腭帆提肌外侧）边界清楚，内有咽静脉翼内肌软腭、上颌骨牙槽嵴,T2WI,T1WI,T1WIC,9,正常解剖及MR表现：鼻咽腔,横断（鼻咽下部）Passavants嵴（软腭腭帆提、张肌汇合而成)咽旁间隙颊肌颈内动、
3、静脉,T2WI,T1WI,T1WIC,10,正常解剖及MR表现：鼻咽腔,冠状（鼻咽偏前部）：后鼻孔、软腭、后舌部翼内肌、翼外肌、颞肌、咬肌颅底骨、翼板、翼腭窝、眶上裂,T1WI,T1WIC,11,正常解剖及MR表现：鼻咽腔,冠状（鼻咽中部）：标志是咽鼓管圆枕圆孔NP顶的翼板下的粘膜NP侧壁为中缩肌及扁桃腺咽旁间隙（颅底颌下腺）,T1WI,T1WIC,12,正常解剖：鼻咽腔,冠状：鼻咽中部标志是咽鼓管圆枕圆孔,13,正常解剖及MR表现：鼻咽腔,冠状：海绵窦,14,正常解剖及MR表现：鼻咽腔,冠状：鼻咽偏后部 标志为腭帆提、张肌缩肌深部为腭帆提、张肌NP顶侧壁为上缩肌、淋巴组织,15,正常解剖及M
4、R表现：鼻咽腔,矢状旁正中鼻咽顶后外侧壁(粘膜.淋巴)动眼神经头长肌,T1WI,T1WIC,16,正常解剖及MR表现：咽旁间隙,咽颅底筋膜致密结缔组织膜横断面：起于：翼内板后缘向后：腭帆张肌、腭帆提肌外侧通过，至颈动脉孔前方走行：咽后壁、颈长肌前方与椎前筋膜形成潜在的咽后间隙,17,正常解剖及MR表现,咽旁间隙上方：临近咽隐窝下方：扁桃体窝相对应外侧：翼内肌、腮腺筋膜相贴内侧：咽颅底筋膜内部结构：颈外动脉和静脉丛颈动脉鞘间隙颈内、动静脉迷走神经颅神经,18,正常解剖及MR表现:咽后间隙,咽后间隙： 咽后的正中前壁为咽颅底筋膜后壁为椎前筋膜,19,鼻咽癌的MR表现,腔内病变：鼻咽粘膜局部增厚：T
5、1WI：信号稍高于周围肌肉组织 T2WI：信号高于肌肉、低于鼻甲和积液 Gd-DTPA增强T1WI：较明显强化鼻咽部肿块：鼻咽腔形态：不对称、变窄肿瘤组织的信号强度较均匀，坏死则信号强度欠均匀超腔侵犯：肿瘤穿破咽颅底筋膜，侵犯周围结构。,20,鼻咽粘膜局限性增厚,鼻咽癌的MR表现：,21,鼻咽癌的MR表现:,鼻咽粘膜局限性增厚,LN,22,鼻咽癌的MR表现：肿瘤,侵犯筋膜,Gd+T1W,T1WI,23,鼻咽肿块,鼻咽癌的MR表现：肿瘤,24,鼻咽癌的MR表现：肿瘤,鼻咽肿块,25,鼻咽癌的MR表现：肿瘤超腔侵犯 颈动脉鞘区-判断标准,MRI判断标准：有、无软组织影,26,鼻咽癌的MR表现：咽后
6、淋巴结,27,鼻咽癌超腔侵犯的MR表现：后鼻孔、头长肌,28,鼻咽癌超腔侵犯的MR表现,鼻咽癌骨质侵犯：MRI-T1、T2WI：早期骨髓浸润正常骨髓脂肪信号消失、被低信号的肿瘤组织取代信号强度与肿瘤组织相似CT：骨质破坏颅神经出颅孔道的侵犯：局部增宽、有软组织影支配肌肉的萎缩颅内侵犯：局部脑膜增厚（可能是反应性的）、强化软组织肿块、强化明显 副鼻窦侵犯注意与局部副鼻窦炎症鉴别,29,鼻咽癌超腔侵犯的MR表现： 蝶骨、枕骨斜坡,30,鼻咽癌超腔侵犯的MR表现： 蝶骨、枕骨斜坡,31,鼻咽癌超腔侵犯的MR表现：海绵窦,32,鼻咽癌超腔侵犯的MR表现：海绵窦,33,鼻咽癌超腔侵犯的MR表现：颈静脉孔
7、、枕骨,34,鼻咽癌的MR表现：破裂孔侵犯,正常破裂孔,35,鼻咽癌超腔侵犯的MR表现：圆孔,36,鼻咽癌超腔侵犯的MR表现：蝶窦,37,鼻咽癌的MR表现：淋巴结 淋巴结-判断标准,淋巴结转移大小标准：咽后淋巴结不限大小颈深上淋巴10mm淋巴链或坏死可以适当放松表现：信号与鼻咽癌组织相似增强后强化,38,鼻咽癌的MR表现：颈淋巴结,T1W Gd+T1,二、淋巴结分区指引：CTV nd (negative),DAHANCA, EORTC, GORTEC in Europe , NCIC, RTOGin North America (2003),Background,1. Two proposal
8、s: Brussels guidelines and Rotterdam guidelines. 2. To review their guidelines and derive a common set of recommendations for delineation of neck node levels.,颈部淋巴CT断层分区,The Guidelines of CTVS : 1. to translate as accurately as possible the surgical guidelines into radiologic guidelines2. based on a
9、xial CT sections. All the landmarks used to delineate the various node levels during a neck dissection were located on axial CT slices.,推 荐 的 边 界,Retropharyngeal nodes (RP)咽后淋巴结,头：颅底 足：舌骨上缘 前：腭帆张肌 后：椎前肌 内：中线 外：血管鞘内缘,44,45,46,47,Level I a,头：下颌骨下缘 足：舌骨体 前：下颌骨内缘、皮肤 后：口底、舌骨体 内：中线 外：下颌骨内缘,Level I b,头：下颌骨
10、支中部或口底 足：舌骨体 前：下颌骨内缘、颈阔肌、皮肤 后：二腹肌、翼内肌、颌下腺 内：二腹肌 外缘 外：下颌骨内缘、颈阔肌、皮肤,50,51,Level II a,头：C1 足：舌骨体下缘 前：颌下腺后缘 后：II b 内：颈动脉鞘内缘 外：胸锁乳突肌内缘,Level II b,头：C1 足：舌骨体下缘 前：II a 后：胸锁乳突肌后缘 内：颈动脉鞘内缘 外：胸锁乳突肌内缘,Level II,1. Robbins originally described the cranial limit of Level II as the base of skull. 2. Brussels guide
11、lines used the bottom 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,颈内静脉后缘是 II a / II b 分界线,57,58,Level II,下颌下腺是 I b / II a 分区界线,60,61,Level III,头：舌骨体下缘 足：环状软骨 前：胸锁乳突肌前缘 后：胸锁乳突肌后缘 内：颈动脉鞘内缘、椎旁肌 外：胸锁乳突肌内缘,63,64,Level I
12、V,头：环状软骨下缘 足：胸锁关节上缘上2cm 前：胸锁乳突肌前缘 后：胸锁乳突肌后缘 内：颈动脉鞘内缘、甲状腺外缘 外：胸锁乳突肌内缘,66,Level 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 IV 2 cm abov
13、e the cranial edge of the sternoclavicular joint.,68,Level Va,头：舌骨上缘 足：环状软骨下缘 前：胸锁乳突肌后缘 后：斜方肌前缘 内：椎旁肌 外：颈阔肌、皮肤,The cranial limit of level V,* commonly questioned. 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
14、view, a horizontal plane crossing the cranial edge of the body of the hyoid bone appears 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 part
15、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 skin tumor.,72,Level IV,胸锁乳突肌和前斜角肌后缘分 III, / ,74,75,Level V b,头：环状软骨下缘 足：颈横血管 前：胸锁乳突肌
16、、前斜角肌后缘 后：斜方肌前缘 内：椎旁肌 外：颈阔肌、皮肤,The caudal limit of level V,CT slices of transverse vessels Hos triangle include the fatty planes below and around the clavicle down to the trapezius muscle.,78,Level VI,头：舌骨体 足：胸骨切迹 前：皮肤 后：椎体 内：气管、食管 外：颈动脉鞘内缘、甲状腺,Level VI,Anterior neck compartment nodes Contains the l
17、ymph nodes located in the viscerasl space: the pre- and paratracheal nodes , precrinoid node and the perithyroid nodes.,81,82,S c I N,头：锁骨上缘 足：第一肋骨上缘 前：胸锁乳突肌后缘 后：前斜角肌、胸膜顶 内：颈血管鞘外缘 外：与锁骨下静脉伴行,84,85,PTV,The levels delineated correspond to the CTV, and thus do not include any security margin.,Why use s
18、urgical guidelines as basic frame of radiotherapy guidelines?,1. Achievements in head and neck 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 guideli
19、nes 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 node-negative neck without post-operative radiotherapy.,Why use surgical guide
20、lines as basic frame of radiotherapy guidelines?,2. This observation confirmed that the locations of the lymphatic areas at risk for microscopic infiltration often are well-defined. That is as an effective prophylactic irradiation .,Why use surgical guidelines as basic frame of radiotherapy guidelin
21、es?,3. Selection of the target volumes for head and neck radiotherapy 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 surgical reference system” guideline was
22、 more appropriate than a translation of 2D irradiation techniques into 3D volumes.,NPC淋巴引流途径,内膜毛细淋巴管外周淋巴网集合导管注入第一站引流淋巴结 锁骨下静脉或胸导管（左）、颈静脉（右）,The first echelon lymph nodes of NPC,1. Retropharyngeal nodes (RP)2. Internal jugular nodes (IJNu)3. Spinal accessory nodes (SAN),Guidelines of CTV nd,The guide
23、lines do not intend to give any recommendation for the optimal treatment for node-negative patients with a head and neck primary .,Node - positive,The risk of extracapsular extension (ECE) is portional to the size of the lymph node: 2040% for nodes 75% for bulky nodes 3 cm . Node 3 cm, additional ad
24、jacent 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 CTV, or only a portion of it in the vicinity of the node, is unknown.,Node - positive,For th
25、e node-positive neck:1. whether the cranial limit and caudal limit of the CTV should be enlarged? 2. Infiltration of the upper 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,定义 CTVnd 时，更倾向于 勾画
26、一宽的连续的区域，而不断断续续地勾画。 一些与放射治疗很少相关的淋巴结如肌肉间淋巴结不标记 。,Guidelines of CTV nd,鼻咽癌不同T-N-分期应选择那一淋巴引流区作为CTV，取决于此区的淋巴结的受侵的几率和危险度，以及相邻敏感器官的NTCP。研究方法主要有几种形式： 1） 临床治疗结果；2）治疗失败的分析；3）尸检报告；4）有价值的外科的报道,100,Suggested guidelines for the treatment of the neck of patients with head and neck squamous cell carcinomas (AJCC 1
27、997) Appropriate node levels to be treated N0 N1 N2b Nasopharynx II, III, IV, V, II, III, IV, V, and RP and RP,ENI,建立 勾画 CTVnd 的 Guidelines 十分重要，目的是选择需预防的高危阴性淋巴引流区，减少不必要的扩大照射。在此研究基础上相应改进放疗技术，保护唾液腺、咽、喉等正常结构, 有利提高治疗获得比。,三、靶区勾画演示,结合MRI进行靶区勾画,103,鼻咽癌分期: T4N1M0 MRI T1+C,咽旁、翼内肌、 口咽软腭受侵,T1+C: 蝶窦底壁,104,鼻咽癌分
28、期: T4N1M0 MRI T1,+C: 海绵窦、园孔,C: 岩尖破坏,105,鼻咽癌分期: T4N1M0 SAGITAL,T1-C:斜坡破坏,T1+C :病灶强化,106,扫描范围：头顶露空至锁骨头下缘2cm方式：螺旋扫描 Slice width: 3mm增强扫描计划设计：网络转送至Pinnacle工作站,CT sim扫描技术,107,将鼻咽和颈部GTV分开，分别为 GTVnx 和GTV nd 。 GTVnx为 CT/MRI 所显示的鼻咽原发肿瘤区。GTVnd 为 CT/MRI 所显示的直径1cm的淋巴结。,靶区定义,108,CTV1 : 包括GTV及其周围的亚临床病灶区（GTV外扩0.75
29、1cm）,可根据周围组织情况作适当的修改。还必须包括完整鼻咽腔的全壁，正常的鼻咽粘膜下0.81.0cm的软组织。,靶区定义,109,CTV2: 包括CTV1及其周围易受侵犯的区域，可设定为CTV1外0.51cm范围，根据周围组织情况作适当的修改 。 鼻咽、口咽、咽后淋巴引流区和颈部阴性淋巴引流区设置于同一CTV2内。,靶区定义,110,PTV：计划靶体积，PTVnx、PTVnd、PTV1、PTV2分别为GTVnx、GTVnd、CTV1、CTV2及其外扩一定范围； 计算机根据数据自动生成，以保证外扩 的三维径线的准确性。,靶区定义,111,CTV2: 深蓝色,112,CTV2: 深蓝色CTV1-
30、浅蓝色,113,PTV-深蓝色CTV-浅蓝色,CTV2: 深蓝色CTV1-浅蓝色,114,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,115,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,116,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,117,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,同上层骨窗,118,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,119,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,120,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,121,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,122,CTV2: 深蓝色CTV1-浅蓝色
31、GTVnx红色,同上层软组织窗,123,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,124,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,同上层骨窗,125,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,126,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,同上层骨窗,127,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,128,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,129,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,130,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,131,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,132,CTV2: 深
32、蓝色CTV1-浅蓝色GTVnx红色,133,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,134,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,Level 2,135,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,136,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,137,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,138,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,139,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,140,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,141,CTV2: 深蓝色CTV1-浅蓝色GTVnx红色,142,CTV2: 深蓝色
33、CTV1-浅蓝色GTVnd粉红色,143,CTV2: 深蓝色CTV1-浅蓝色GTVnd粉红色,144,CTV2: 深蓝色GTVnd粉红色,Nodes of Ia,Ib,145,CTV2: 深蓝色GTVnd粉红色,146,CTV2: 深蓝色GTVnd粉红色,147,CTV2: 深蓝色GTVnd粉红色,148,CTV2: 深蓝色GTVnd粉红色,Level II / Va,149,CTV2: 深蓝色GTVnd粉红色,150,CTV2: 深蓝色GTVnd粉红色,151,CTV2: 深蓝色GTVnd粉红色,152,CTV2: 深蓝色GTVnd粉红色,153,CTV2: 深蓝色GTVnd粉红色,154,
34、CTV2: 深蓝色GTVnd粉红色,155,CTV2: 深蓝色GTVnd粉红色,Level III / Va,156,CTV2: 深蓝色GTVnd粉红色,157,CTV2: 深蓝色,158,CTV2: 深蓝色,159,CTV2: 深蓝色,160,CTV2: 深蓝色,161,CTV2: 深蓝色,162,CTV2: 深蓝色,163,CTV2: 深蓝色,164,CTV2: 深蓝色,165,CTV2: 深蓝色,Level IV / Vb,166,CTV2: 深蓝色,167,CTV2: 深蓝色,168,CTV2: 深蓝色,169,CTV2: 深蓝色,170,CTV2: 深蓝色,171,CTV2: 深蓝色,172,CTV2: 深蓝色,Level IV,173,CTV2: 深蓝色,174,CTV2: 深蓝色,175,CTV2: 深蓝色,176,CTV2: 深蓝色,177,CTV2: 深蓝色,178,CTV2: 深蓝色,179,
