IMRT planning for HN cancr:   Some clinical issues      Avraham Eisbruch     University of Michigan
Defining the targetsThe GTV:1. Clinical information: palpation,  mirror/fiberoptic exam, direct endoscopy report2. Imaging...
Nasopharynx caCT
Nasopharynx caMRI
Using FDG-PET to define the GTV• How exactly should PET be used?• If the PET-based and CT-based GTVs differ, what is the “...
Using PET-CT for GTV delineation                 CT-GTVsThe GTVs on CT and FDG-PET usually correlate well
FDG-PET may define the GTV better than CTLt BOT cancer. The GTV is blurred by CT artifact
FDG-PET may define the GTV better than CTLt tonsil cancer. CT: Retropharyngeal node was part of the CTV.                  ...
FDG-PET may be false negative: failure to detect          obvious gross diseasePrimary ca           #1      Primary ca    ...
PET may be false positive: Benign lymphatic tissue in the                     BOT accumulates FDGConsult Nuc Med to verify...
Suspicious nodes on CT, PET (-): CTVs or GTVs??                             +                      +                      ...
PET vs. other imaging modalities       vs. LN pathology              Adams et al, Eur J Nuc Med 1998
Larynx cancer: Matching the surgical specimen, CT, and PET                              Daisne, …Gregoire, Radiology 2004
Matching the surgical specimen, CT,          MRI, and PET• The GTVs according to PET were usually  slightly smaller than t...
Summary: Outlining the primary        tumor GTV• Use the PET and CT/MRI information for  composite GTV delineation• Add cl...
Summary: Outlining the nodal GTVs• Wherever a node is PET (+), include in the  GTV• If CT is highly suspicious and PET is ...
Can FDG-PET be used to define the              CTVs?• Sentinel node biopsy and neck dissection in the  clinically (-) neck...
Outlining Lymph Node CTVs• Which LN groups at at risk for each tumor  site and stage?• How should the LN be delineated on ...
Neck NodeLevels            Som et al.,            Arch.            Otolaryngol.            Head Neck            Surg.1999
Gregoire,Levendag,et al.                           WWW.RTOG.ORG                                Researchers                ...
Cranial-most extent of neck CTV• In the clinically (-) non-nasopharyngeal ca:  – The bottom of the transverse process of C...
Oral cavity lymphatics                         Rouviere, 1938
Pharyngeal lymphatics                        Rouviere, 1938
What about nasopharyngeal cancer?      Lateral retroph. n                                    Junctional n.
Nasopharynx ca                 Level II                      Level V
Should we biopsyall non-specificparotid nodules?     IJROBP 2007
Parotidean LN metastases in NPC
Eustachian Tube: Lymphatic DrainageIn addition to sub-digastric and RPN: Lymphatics to parotidean nodes                   ...
Parotidean LN metastases in NPCDue to retrograde flow when level II is heavily involved?
Tonsil ca, T3N2c      Primary Tu                   Parotidean LN met
No nasopharyngeal involvement…
…but significant ipsilateral level II nodal involvement
Parotidean metastases• Risk of retrograde lymphatic drainage when  level II is heavily involved• Suggest: omit ipsilateral...
Can we improve outcome by GTV         dose escalation?• Escalate doses to the whole GTV• Escalate the doses to the parts o...
Escalate/accelerate doses to the             whole GTV• Baylor: “SMART”: 60 Gy/2.4 Gy/fraction  – BED2Gy 70 Gy, over 5 wee...
Escalate/accelerate doses to the              whole GTV• Nasopharynx ca: 64.8/2.4/fr. Over 5.5 weeks conc.  with cisplatin...
High fraction doses: Oropharyngeal ca• RTOG 00-22: 66 Gy/30 fractions, no chemo   – Few long-term complications      • 6% ...
Moderately high fraction doses:           laryngeal/hypopharyngeal ca• MSKCC: 70 Gy/32-33 fractions (2.12 Gy/fraction) con...
Escalate the dose to part of the GTV• The FDG-PET avid part of the GTV tumor• Hypoxic regions within the GTV
CTV• Outlining the CTV  – Anatomically: taking into account the    compartments at risk  – Uniformly, arbitrary margins: 1...
CTV Doses and their BED(2 Gy)       (assuming alpha/beta 10 Gy and loss of 0.7 Gy/day of                       extending t...
Considerations• Conc chemo:  – Adds 12 Gy/ 2 Gy fractions (Kasibhatla et al,    IJROBP 2007)  – Adds 7 Gy/2 (Fowler JF, IJ...
How should we treat the low         neck?
NTCP: Glottic edema grade 2+Extensive neck RT for non-laryngeal cancer, mostly no conc. chemo                             ...
No effort to spare the larynx/esophagus: High rates of dysphagiaafter whole-neck IMRT compared with split-field.          ...
split field vs whole neck IMRT                        Head Neck 2004
Amdur et al, Head Neck 2004
Laryngeal shield: do not extend caudallybecause jugular vein and nodes become more medial                         Mendenha...
Extend the midline blockto shield also inferior constrictor and esophagus                               Caudell JJ IJROBP ...
Whole neck IMRT                           or        upper neck IMRT + abutted AP low neck field• Abutting AP low neck fiel...
Whole-neck IMRT in cases of low neck involvement or high risk
Higher weight to targets or organs• PTV doses: 99%-107% presc. doses• Larynx/constr./esophagus: reduce mean dose as much a...
PTVs (yellow/purple) weigh lower than larynx/inf. constrictor
PTVs (yellow) weigh higher than esophagus
The low neck• Split-field technique is simpler, faster, less  monitor units, likely less skin toxicity• Whole-field IMRT a...
Rosenthal et al, IJROBP 2008
Rosenthal et al, IJROBP 2008
Oral cavityNot included in the cost function
Oral cavity Included
Lt tonsillar cancer
After 23 fractions (GTV dose 46 Gy)           concurrent with carboplatin+taxolEstimated lip mucositis site dose 30 Gy/1.3...
Mucosal point doses vs. length of time of mucositis                        Narayan et al, IJROBP 2008;72:756
Lt tonsillar ca, chemo-RT: oral cavity outside the PTVs spared
Induction chemotherapy for HN cancer                  Response to induction chemo:    CR 17%, PR 55%                      ...
Neoadjuvant chemo: Its tumor effect may be trivial even if                clinical CR is achieved.                        ...
After induction chemotherapy• Use the pre-chemo targets• It is essential to examine the patient, have  adequate imaging st...
Acknowledgements• UM Rad-Onc residents,        • Speech pathology  students & fellows              – Teresa Lyden   –   Fe...
Upcoming SlideShare
Loading in …5
×

01 planning for hn india feb 2013 (cancer ci 2013) avraham eisbruch

1,408 views

Published on

0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,408
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
21
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide

01 planning for hn india feb 2013 (cancer ci 2013) avraham eisbruch

  1. 1. IMRT planning for HN cancr: Some clinical issues Avraham Eisbruch University of Michigan
  2. 2. Defining the targetsThe GTV:1. Clinical information: palpation, mirror/fiberoptic exam, direct endoscopy report2. Imaging: Planning CT (contrast-enhanced) • Register with MRI / PET
  3. 3. Nasopharynx caCT
  4. 4. Nasopharynx caMRI
  5. 5. Using FDG-PET to define the GTV• How exactly should PET be used?• If the PET-based and CT-based GTVs differ, what is the “truth”?
  6. 6. Using PET-CT for GTV delineation CT-GTVsThe GTVs on CT and FDG-PET usually correlate well
  7. 7. FDG-PET may define the GTV better than CTLt BOT cancer. The GTV is blurred by CT artifact
  8. 8. FDG-PET may define the GTV better than CTLt tonsil cancer. CT: Retropharyngeal node was part of the CTV. PET: it should be a GTV.
  9. 9. FDG-PET may be false negative: failure to detect obvious gross diseasePrimary ca #1 Primary ca #1 #2 LN #2: extensive necrosis; not detected by PET
  10. 10. PET may be false positive: Benign lymphatic tissue in the BOT accumulates FDGConsult Nuc Med to verify that the signal intensity/SUV are right
  11. 11. Suspicious nodes on CT, PET (-): CTVs or GTVs?? + + ? Use clinical judgement
  12. 12. PET vs. other imaging modalities vs. LN pathology Adams et al, Eur J Nuc Med 1998
  13. 13. Larynx cancer: Matching the surgical specimen, CT, and PET Daisne, …Gregoire, Radiology 2004
  14. 14. Matching the surgical specimen, CT, MRI, and PET• The GTVs according to PET were usually slightly smaller than the CT/MRI volumes• No modality showed the extent of the primary with complete accuracy – evaluation of submucosal tumor extension was deficient by all modalities. Daisne, …Gregoire, Radiology 2004
  15. 15. Summary: Outlining the primary tumor GTV• Use the PET and CT/MRI information for composite GTV delineation• Add clinical examination results, especially for the mucosal extent of the gross disease
  16. 16. Summary: Outlining the nodal GTVs• Wherever a node is PET (+), include in the GTV• If CT is highly suspicious and PET is (-), include in the GTV.• In borderline cases of (+) CT and (-) PET, use clinical judgement to define as GTV or CTV.
  17. 17. Can FDG-PET be used to define the CTVs?• Sentinel node biopsy and neck dissection in the clinically (-) neck: nodes were examined by the pathologists at 2 mm slices• Occult metastases (size 1.2-1.5 mm): in 5/12 patients;• FDG PET correctly identified only one (sensitivity of 25%).• We cannot rely on PET for outlying the CTV. Stoeckli et al, Head Neck 2002
  18. 18. Outlining Lymph Node CTVs• Which LN groups at at risk for each tumor site and stage?• How should the LN be delineated on the planning CT?
  19. 19. Neck NodeLevels Som et al., Arch. Otolaryngol. Head Neck Surg.1999
  20. 20. Gregoire,Levendag,et al. WWW.RTOG.ORG Researchers HN Atlaswww.rtog.org/hnatlas/main.htm
  21. 21. Cranial-most extent of neck CTV• In the clinically (-) non-nasopharyngeal ca: – The bottom of the transverse process of C1 • Gregoire et alThis will ensure coverage of the JD (sub- digastric) nodes
  22. 22. Oral cavity lymphatics Rouviere, 1938
  23. 23. Pharyngeal lymphatics Rouviere, 1938
  24. 24. What about nasopharyngeal cancer? Lateral retroph. n Junctional n.
  25. 25. Nasopharynx ca Level II Level V
  26. 26. Should we biopsyall non-specificparotid nodules? IJROBP 2007
  27. 27. Parotidean LN metastases in NPC
  28. 28. Eustachian Tube: Lymphatic DrainageIn addition to sub-digastric and RPN: Lymphatics to parotidean nodes H. Rouviere, 1932
  29. 29. Parotidean LN metastases in NPCDue to retrograde flow when level II is heavily involved?
  30. 30. Tonsil ca, T3N2c Primary Tu Parotidean LN met
  31. 31. No nasopharyngeal involvement…
  32. 32. …but significant ipsilateral level II nodal involvement
  33. 33. Parotidean metastases• Risk of retrograde lymphatic drainage when level II is heavily involved• Suggest: omit ipsilateral parotid sparing if ipsilateral level II is heavily involved.
  34. 34. Can we improve outcome by GTV dose escalation?• Escalate doses to the whole GTV• Escalate the doses to the parts of the GTV judged to be at highest risk
  35. 35. Escalate/accelerate doses to the whole GTV• Baylor: “SMART”: 60 Gy/2.4 Gy/fraction – BED2Gy 70 Gy, over 5 weeks – Concurrent with chemotherapy: not tolerable due to acute mucositis • Amosson, ASTRO 2003
  36. 36. Escalate/accelerate doses to the whole GTV• Nasopharynx ca: 64.8/2.4/fr. Over 5.5 weeks conc. with cisplatin – “modest increase in toxicities” • WS Koom, Head Neck 2008• Larynx/hypopharynx ca: 67.2 Gy/2.4 conc. with cisplatin – “acceptable acute toxicity”. • Guerrero-Urbano , Radiother Oncol 2007
  37. 37. High fraction doses: Oropharyngeal ca• RTOG 00-22: 66 Gy/30 fractions, no chemo – Few long-term complications • 6% ORN • Eisbruch et al, IJROBP 2009• Stanford: 66 Gy/30 fractions, conc. chemo – Few long-term complications • Orocutaneous fistula, tracheal stenosis, ORN • Daly ME et al, IJROBP 2009
  38. 38. Moderately high fraction doses: laryngeal/hypopharyngeal ca• MSKCC: 70 Gy/32-33 fractions (2.12 Gy/fraction) conc with chemo – Late complications: • 20% PEG dependency at 2 years • Laryngeal necrosis, necrotizing skin fascitis • Lee NY, IJROBP 2007
  39. 39. Escalate the dose to part of the GTV• The FDG-PET avid part of the GTV tumor• Hypoxic regions within the GTV
  40. 40. CTV• Outlining the CTV – Anatomically: taking into account the compartments at risk – Uniformly, arbitrary margins: 1-2.5 cm
  41. 41. CTV Doses and their BED(2 Gy) (assuming alpha/beta 10 Gy and loss of 0.7 Gy/day of extending treatment)Total dose (Gy) Dose /fraction (Gy) BED2 (Gy)63 1.8 6059 1.7 5456 1.6 4952 1.5 42
  42. 42. Considerations• Conc chemo: – Adds 12 Gy/ 2 Gy fractions (Kasibhatla et al, IJROBP 2007) – Adds 7 Gy/2 (Fowler JF, IJROBP• Very good prognosis patients, such as HPV- related oropharyngeal ca, may require quite low doses
  43. 43. How should we treat the low neck?
  44. 44. NTCP: Glottic edema grade 2+Extensive neck RT for non-laryngeal cancer, mostly no conc. chemo Rancati T, IJROBP 2009
  45. 45. No effort to spare the larynx/esophagus: High rates of dysphagiaafter whole-neck IMRT compared with split-field. Fua et al, 2007
  46. 46. split field vs whole neck IMRT Head Neck 2004
  47. 47. Amdur et al, Head Neck 2004
  48. 48. Laryngeal shield: do not extend caudallybecause jugular vein and nodes become more medial Mendenhall, Amdur, Million, 1992
  49. 49. Extend the midline blockto shield also inferior constrictor and esophagus Caudell JJ IJROBP 2009
  50. 50. Whole neck IMRT or upper neck IMRT + abutted AP low neck field• Abutting AP low neck field: 30% of the recurrences were in the low neck – Chao et al IJROBP 2003
  51. 51. Whole-neck IMRT in cases of low neck involvement or high risk
  52. 52. Higher weight to targets or organs• PTV doses: 99%-107% presc. doses• Larynx/constr./esophagus: reduce mean dose as much as possible (<20 Gy) – Targets weigh higer than organs – Organs weigh higher than targets
  53. 53. PTVs (yellow/purple) weigh lower than larynx/inf. constrictor
  54. 54. PTVs (yellow) weigh higher than esophagus
  55. 55. The low neck• Split-field technique is simpler, faster, less monitor units, likely less skin toxicity• Whole-field IMRT allows better certainty in target coverage – may be preferable in cases of gross low neck involvement or when the low neck is at high risk
  56. 56. Rosenthal et al, IJROBP 2008
  57. 57. Rosenthal et al, IJROBP 2008
  58. 58. Oral cavityNot included in the cost function
  59. 59. Oral cavity Included
  60. 60. Lt tonsillar cancer
  61. 61. After 23 fractions (GTV dose 46 Gy) concurrent with carboplatin+taxolEstimated lip mucositis site dose 30 Gy/1.3 Gy/fraction
  62. 62. Mucosal point doses vs. length of time of mucositis Narayan et al, IJROBP 2008;72:756
  63. 63. Lt tonsillar ca, chemo-RT: oral cavity outside the PTVs spared
  64. 64. Induction chemotherapy for HN cancer Response to induction chemo: CR 17%, PR 55% CR 9%, PR 59%Patients proceed to chemo-RT after most tumors shrink by induction. GTVs: the pre-chemo or the post-chemo volumes?
  65. 65. Neoadjuvant chemo: Its tumor effect may be trivial even if clinical CR is achieved. Ian Tannock
  66. 66. After induction chemotherapy• Use the pre-chemo targets• It is essential to examine the patient, have adequate imaging studies, and preferably simulate the patient before chemo starts.• Re-simulate after induction chemo and register the pre-chemo GTVs to the new planning CT.• Same principle: do not reduce the GTV as tumor shrinks during RT. Salama et al, IJROBP 2009
  67. 67. Acknowledgements• UM Rad-Onc residents, • Speech pathology students & fellows – Teresa Lyden – Felix Feng – Marc Haxer – Mary Feng • Dentistry – Alex Lin – Carol-Anne Murdoch-Kinch – Siavash Jabbari – Jonathan Ship – Laura Dawson • Rad-Onc Physics – Aron Popovtzer – Randall Ten Haken – Iris Gluck – Karen Vineberg• Otolaryngol-HN Surgery – Dick Fraas – Doug Chepeha • NKI, Amsterdam – Ted Teknos – Marco Schwartz – Carol Bradford – Coen Rasch – Gregory WolfSupported by NCI grants PO1 59827 and HN SPORE P50 CA/DE97248

×