![Page 1: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/1.jpg)
Department of Radiation Oncology
University of Michigan
Radiation Therapy
Contouring:
Cardiac/Thoracic
Anatomy
Mary Feng, M.D.
![Page 2: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/2.jpg)
MF13 2
Why is contouring important?
• Targets: Tumors and Nodal stations
• Normal tissues:
– Reduce doses by blocking
– Choosing beam angles with greatest
separation between targets and OARs
– Understanding dose-volume-toxicity
relationships
– Reducing toxicity
![Page 3: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/3.jpg)
MF13 3
Learning Objectives
1) Understand the need for consistency in
normal tissue contouring in the thorax
2) Be able to access atlases developed by
radiation oncologists to improve contour
consistency
3) Use these atlases as a guide to
standardize contours and improve
normal tissue sparing
![Page 4: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/4.jpg)
MF13 4
OARs highlighted today
• Heart
• Brachial plexus
• Esophagus
![Page 5: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/5.jpg)
MF13 5
Radiation can cause cardiac toxicity
(Reuters Health) - The radiation that might cure a breast
cancer may also raise a woman's risk of having a heart
attack or heart disease later in life, according a new study
that looked back at the cases of 2,168 women in Sweden
and Denmark
![Page 6: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/6.jpg)
MF13 6 Darby, et al, NEJM, 2013.
Radiation can cause cardiac toxicity
![Page 7: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/7.jpg)
MF13 7
Dose effect on the heart
Darby, et al, NEJM, 2013.
No threshold
![Page 8: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/8.jpg)
MF13 8
Dose effect on the heart
10 Gy
3 Gy
Darby, et al, NEJM, 2013.
![Page 9: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/9.jpg)
MF13 9
How was dosimetry analyzed?
• Virtual simulation and planning based on CT
or manual planning “were used to reconstruct
each radiotherapy regimen on the CT scan of
a woman with typical anatomy”
• (Virtual) Radiation doses to the structures of
interest were then estimated
• In manual planning, the (virtual) doses were
estimated on the basis of charts on which
isodose curves had been drawn
Darby, et al, NEJM, 2013.
![Page 10: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/10.jpg)
MF13 10
• Dose-volume histograms for the whole heart
and for the left anterior descending coronary
artery were obtained
• Mean doses were calculated
Darby, et al, NEJM, 2013.
How was dosimetry analyzed?
![Page 11: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/11.jpg)
MF13 11
Are these results believable?
• In general? Probably
• Specifically? No
– Reconstructed, hypothesized cardiac
doses
– Not based on reality
![Page 12: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/12.jpg)
MF13 12
What do we know about cardiac toxicity?
The time-course and extent of cardiac
damage depends on dose
– In the past, Hodgkin’s survivors were
diagnosed with heart disease 1-2 years
after radiotherapy (30 Gy+)
– Latency greater for lower doses of RT
![Page 13: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/13.jpg)
MF13 13
Cardiac toxicity after breast RT
Darby, et al. Lancet Oncology 2005
SEER study of 300,000 women with breast cancer
![Page 14: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/14.jpg)
MF13 14
Rationale for heart avoidance
![Page 15: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/15.jpg)
MF13 15
Mechanisms of RT cardiac effects
Lancelloti, et al. Euro Heart J– Cardio Imaging, 2013.
![Page 16: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/16.jpg)
MF13 16
Dose-volume-toxicity data in other organs
Kwa et al, IJROBP 1998 Dijkema et al, IJROBP 2010
Pneumonitis Xerostomia
![Page 17: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/17.jpg)
MF13 17
Rectal Toxicity Gastric Bleed
Tucker, et al, IJROBP 2012 Feng, et al, IJROBP 2012
Dose-volume-toxicity data in other organs
![Page 18: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/18.jpg)
MF13 18
• In the pre-CT era, we could not accurately define the heart
• There is little agreement on how to define the heart
• Additionally, substructures of the heart may have specific importance
Why haven’t we had similar plots for
cardiac damage?
Mean LAD dose
Ris
k o
f is
ch
em
ic e
ve
nt
Mean heart dose
Ris
k o
f is
ch
em
ic e
ve
nt
![Page 19: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/19.jpg)
MF13 19
The data is hypothesized
Gagliardi, et al, QUANTEC, IJROBP 2010.
![Page 20: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/20.jpg)
MF13 20
Hypothesized curves
Gagliardi, et al, QUANTEC, IJROBP 2010.
![Page 21: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/21.jpg)
MF13 21
How can we move forward?
• We must first understand the relationship
between dose and volume of heart (or cardiac
substructures) and toxicity
• We can then incorporate these into treatment
planning to minimize the risk of cardiac
complications
![Page 22: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/22.jpg)
MF13 22
Standardizing cardiac contours
Motivated by the lack of consistency in
cardiac delineation, we
– Developed an atlas of cardiac substructure
anatomy through a collaboration with
cardiology and cardiac radiology
– Validated this atlas using a pre- and post-
test study of 7 radiation oncologists
![Page 23: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/23.jpg)
MF13 23
Cardiac atlas
Feng, et al. IJROBP, 2011
Non-contrast CT
Heart begins just inferior to
L pulmonary artery
![Page 24: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/24.jpg)
MF13 24
Cardiac atlas
Non-contrast CT
Feng, et al. IJROBP, 2011
![Page 25: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/25.jpg)
MF13 25
Cardiac atlas
Non-contrast CT
Feng, et al. IJROBP, 2011
![Page 26: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/26.jpg)
MF13 26
Cardiac atlas
Non-contrast CT
Feng, et al. IJROBP, 2011
![Page 27: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/27.jpg)
MF13 27
Cardiac atlas
Non-contrast CT
Feng, et al. IJROBP, 2011
![Page 28: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/28.jpg)
MF13 28
Cardiac atlas
Contrast CT
Feng, et al. IJROBP, 2011
![Page 29: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/29.jpg)
MF13 29
Cardiac atlas
Contrast CT
Pulmonic valve
Feng, et al. IJROBP, 2011
![Page 30: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/30.jpg)
MF13 30
Cardiac atlas
Contrast CT
RV LAD
Feng, et al. IJROBP, 2011
![Page 31: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/31.jpg)
MF13 31
Cardiac atlas
Contrast CT
RV
LV
RV
LV
Feng, et al. IJROBP, 2011
![Page 32: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/32.jpg)
MF13 32
Cardiac atlas
Contrast CT
RV
LV
RV
LV
Feng, et al. IJROBP, 2011
![Page 33: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/33.jpg)
MF13 33
Cardiac atlas
Contrast CT RV LV
Feng, et al. IJROBP, 2011
![Page 34: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/34.jpg)
MF13 34
Quiz
Which of these structures is the LAD?
A
B
C
D
![Page 35: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/35.jpg)
MF13 35
Cardiac atlas
Multi-observer pre-test and post-test study
Pre-test Post-test Feng, et al. IJROBP, 2011
![Page 36: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/36.jpg)
MF13 36
Cardiac atlas
Pre-test Post-test Feng, et al. IJROBP, 2011
![Page 37: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/37.jpg)
MF13 37
Percent overlap of observer and gold
standard contours
Structure Pre-atlas
(mean
±SD)
Post-atlas
(mean
±SD)
p-value
Heart 79 ± 13 91 ± 4 <0.001
L main 10 ± 22 22 ± 20 <0.001
LAD 35 ± 21 62 ± 16 <0.001
R coronary 11 ± 14 24 ± 18 0.002
Left
ventricle
87 ± 11 92 ± 6 0.06
Right
ventricle
65 ± 10 74 ± 8 0.003 Feng, et al. IJROBP, 2011
![Page 38: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/38.jpg)
MF13 38
Concordance index
Structure Pre-atlas
(mean
±SD)
Post-atlas
(mean
±SD)
p-value
Heart 0.76 ± 0.11 0.89 ± 0.03 <0.001
L main 0.05 ± 0.12 0.18 ± 0.16 <0.001
LAD 0.19 ± 0.11 0.34 ± 0.07 <0.001
R coronary 0.08 ± 0.10 0.18 ± 0.08 <0.001
Left
ventricle
0.75 ± 0.06 0.79 ± 0.05 0.04
Right
ventricle
0.55 ± 0.08 0.65 ± 0.08 <0.001 Feng, et al. IJROBP, 2011
![Page 39: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/39.jpg)
MF13 39
Mean absolute value dose difference (Gy)
Structure Pre-atlas
(mean
±SD)
Post-atlas
(mean
±SD)
p-value
Heart 0.88 0.15 0.14 0.14 <0.001
L main 1.68 1.53 0.88 1.56 0.005
LAD 3.90 2.80 2.56 3.31 <0.001
R coronary 1.15 1.07 0.61 0.39 0.001
Left
ventricle
0.25 0.20 0.15 0.14 0.13
Right
ventricle
1.06 0.73 0.46 0.37 0.008 Feng, et al. IJROBP, 2011
![Page 40: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/40.jpg)
MF13 40
Cardiac summary
• Breast RT may increase the risk of cardiac
death many years after treatment
• Unlike other structures such as the
parotid gland, lung, and rectum, the
heart’s dose-volume-toxicity profile is not
well-understood
• With a validated, detailed cardiac atlas, we
can begin to collect information to
elucidate the effect of RT on heart
structures
![Page 41: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/41.jpg)
MF13 41
OARs highlighted today
• Heart
• Brachial plexus
• Esophagus
![Page 42: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/42.jpg)
MF13 42
OARs highlighted today
• Heart
• Brachial plexus
• Esophagus
![Page 43: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/43.jpg)
MF13 43
Importance of the brachial plexus
• Brachial plexus damage could lead to arm
weakness or pain
• Commonly used dose limits range from 50
to 60 Gy
• Hot spots in treatment plans can be
located in the brachial plexus if careful
planning is not used
![Page 44: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/44.jpg)
MF13 44
Brachial plexus anatomy
![Page 45: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/45.jpg)
MF13 45
Brachial plexus on MRI
www.healthcare.siemens.com
![Page 46: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/46.jpg)
MF13 46
Brachial plexus on CT
AS = anterior scalene MS = middle scalene BP = brachial plexus
Hall, et al. IJROBP 2008 and at http://www.rtog.org
![Page 47: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/47.jpg)
MF13 47
Brachial plexus on CT
Hall, et al. IJROBP 2008 and at http://www.rtog.org
AS = anterior scalene MS = middle scalene BP = brachial plexus
![Page 48: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/48.jpg)
MF13 48
Brachial plexus on CT
Hall, et al. IJROBP 2008 and at http://www.rtog.org
AS = anterior scalene MS = middle scalene BP = brachial plexus
![Page 49: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/49.jpg)
MF13 49
Brachial plexus on CT
Hall, et al. IJROBP 2008 and at http://www.rtog.org
AS = anterior scalene MS = middle scalene BP = brachial plexus
![Page 50: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/50.jpg)
MF13 50
Brachial plexus
Hall, et al. IJROBP 2008 and at http://www.rtog.org
![Page 51: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/51.jpg)
MF13 51
Quiz
Which of these structures
Is the brachial plexus?
A
B
C
D
![Page 52: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/52.jpg)
MF13 52
Brachial plexopathy from RT
Eblan, et al, IJROBP 2012
![Page 53: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/53.jpg)
MF13 53
Brachial plexopathy from RT
Eblan, et al, IJROBP 2012
![Page 54: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/54.jpg)
MF13 54
OARs highlighted today
• Heart
• Brachial plexus
• Esophagus
![Page 55: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/55.jpg)
MF13 55
OARs highlighted today
• Heart
• Brachial plexus
• Esophagus
![Page 56: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/56.jpg)
MF13 56
Esophagitis
• Can be a significant side effect of RT,
especially if combined with chemotherapy
for lung cancer
• Pain affects quality of life and causes
patients to lose weight, which reduces the
ability to tolerate treatment
• Multiple dose-volume limits have been
proposed to minimize esophagitis
![Page 57: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/57.jpg)
MF13 57
Esophageal contours
• RTOG recommends contouring from the
cricoid to the GE junction
• Esophageal diameter, shape, and position
are variable
• Pay attention for accurate contours
![Page 58: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/58.jpg)
MF13 58
OAR Atlas for RTOG 1106
The esophagus starts at the level of cricoid
Lung
Kong, et al
![Page 59: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/59.jpg)
MF13 59
Esophageal contours
Usually it quickly becomes round
Kong, et al
![Page 60: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/60.jpg)
MF13 60
Esophageal contours
Then it can take a turn to the side
Kong, et al
![Page 61: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/61.jpg)
MF13 61
Esophageal contours
…and flatten out more…
Kong, et al
![Page 62: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/62.jpg)
MF13 62
Esophageal contours
…before it rounds out again and joins the stomach.
Kong, et al
![Page 63: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/63.jpg)
MF13 63
Esophagitis from RT
Kwint, et al, IJROBP 2012
![Page 64: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/64.jpg)
MF13 64
Variability in esophageal contours
Kong, et al, IJROBP 2011
![Page 65: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/65.jpg)
MF13 65
Summary
• Accurate OAR contouring is important for
treatment planning
• Atlases have been created to improve
consistency
• As centers create more uniform OAR
contours, data can be compiled to build
more realistic models to estimate and
minimize toxicity risk
![Page 66: Radiation Therapy Contouring: Cardiac/Thoracic Anatomyamos3.aapm.org/abstracts/pdf/77-22550-313436-91101.pdf · Radiation Therapy Contouring: Cardiac/Thoracic Anatomy ... The radiation](https://reader031.vdocuments.us/reader031/viewer/2022022505/5abb48ee7f8b9ab1118cd47e/html5/thumbnails/66.jpg)
MF13 66
Thanks for your attention