This document discusses various problems and considerations for delineating nodal volumes and organs at risk (OARs) in head and neck radiotherapy planning. It addresses 30 specific problems or questions regarding delineation of nodal volumes, lymph node levels, high/low risk nodal areas, OARs like parotid glands and dysphagia structures, and other challenges like extracapsular extension and unknown primary tumors. The document provides detailed guidelines and proposed solutions for each delineation problem.

1. DELINEATION OF NODAL VOLUMES AND OARS
A PROBLEM BASED APPROACH
Dr Kanhu Charan Patro
ICRO, PUNE
1
THE ENCROACHMENT

2. MY REGARDS

3. THE ENCROACHMENT
&
THE TRESPASS
THE NODAL AREA & OAR
3

4. 4

5. 5

6. 6

7. NODAL AREA ENCROACHING OAR
• TOXICITY
7

8. OAR ENCROACHING NODAL AREA
• RECURRENCE
8

9. OAR
TARGET
9
PUSHING BACKWARD AND FORWARD AT A TIME
DIFFICULT BUT NOT IMPOSSIBLE

10. CONTOURING ERROR
THE SYSTEMATIC ERROR
• INTRAOBSERVOR
• INTEROBSERVOR
10

11. 11

12. 12

13. 13

14. 14

15. 15

16. 16

17. PROBLEM-1
REFINING
DEFINING THE LEVEL
17

18. 18

19. 19

20. 20

21. 21

22. 22

23. 23

24. PROBLEM-2
IDENTYFYING
24

25. HOW TO INDENTIFY?
MUSCLES DAIGASTRIC
MYLOHYOID
TRAPIZEUS
STERNOCELIDOMASTOID
VESSELs CAROTIDS
IJV
BONES MANDIBLE
HYOID
CRICOID
CLAVICLE
25

26. 1A
CRANIAL MYLOHYOID
CAUDAL PLATYSMA
MEDIAL NA
LATERAL MEDIAL BORDER ANT DIGASTRIC
ANTERIOR SYMPHYSIS MENTI
POSTERIOR HYOID BODY
MYLOHYOID
SITES 1. ANTERIOR TONGUE
2. FOM
3. ANT ALVEOLUS
4. LOWER LIP
26

27. 1B
CRANIAL CRANIAL EDGE SUBMANDIBULAR
GLAND
CAUDAL CAUDAL EDGE SUBMANDIBULAR
GLAND
CAUDAL EDGE MANDIBLE
CAUDAL EDGE OF HYOID BONE
MEDIAL BOTH BELLIES OF DIGASTRIC MUSCLE
LATERAL PLATYSMA
MANDIBLE
ANTERIOR SYMPHYSIS MENTI
POSTERIOR POSTERIOR EDGE OF
SUBMANDIBULAR GLAND
SITES 1. ORAL CAVITY
2. MID FACE
3. NASAL CAVITY
4. SUBMANDIBULAR GLAND 27

28. IIA
CRANIAL Caudal edge of the lateral Process of C1
CAUDAL Caudal edge of the body of the hyoid
ANTERIOR 1. Posterior edge of the submandibular
gland/
2. posterior edge of posterior belly of
digastric m.
POSTERIOR Posterior edge of sternocleidomastoid
LATERAL 1. Deep (medial) surface of SCM
/platysma m.
2. /parotid gland
3. /posterior belly of digastric m.
MEDIAL Medial edge of internal carotid Artery
and /scalenius m.
SITES 1. Nasal cavity, oral cavity,
2. Nasopharynx,
3. Oropharynx,
4. Hypopharynx,
5. Larynx,
6. Major salivary glands 28

29. IIA - IIB
29

30. III
CRANIAL Caudal edge of the body of the hyoid
CAUDAL Caudal edge of the CRICOID
ANTERIOR Anterior edge of Sternocleidomast oid m.
/posterior third of thyro-hyoid m
POSTERIOR Posterior edge of sternocleidomastoid
MEDIAL Medial edge of common carotid Artery
/scalenius mm.
LATERAL Deep (medial) surface of sternocleidomast
oid m.
SITES 1. oral cavity,
2. nasopharynx,
3. oropharynx,
4. hypopharynx
5. larynx.
30

31. CRANIAL Caudal edge of cricoid cartilage
CAUDAL 2 cm cranial to sternal manubrium
ANTERIOR Anterior edge of SCM (cranially)
/body of SCM. (caudally
POSTERIOR Posterior edge of SCM
/scalenius mm. (caudally)
LATERAL Deep (medial) surface of SCM (cranially)
/lateral edge of Sternocleidomast oid m.
(caudally)
medial Medial edge of common carotid Artery
/lateral edge of thyroid gland
/scalenius mm. (cranially)
/medial edge of SCM
SITES 1. Hypopharynx
2. Larynx,
3. Thyroid And
4. Cervical Esophagus.
IVA
31

32. IVB
32

33. VA/VB/VC
33

34. VIA/VIB
34

35. VIIA/VIIB
35

36. VIII
36

37. IX
37

38. LEVEL-XA/XB
38

39. WHERE TO KEEP UPPER BORDER?
LEVEL-II
39
PROBLEM-3

40. 40

41. MARGIN FOR ENLARGED NODE
41
PROBLEM-4

42. Moreover, expansion from GTVn to
CTVn does not imply that the
whole level would be part of CTVn.
Some authors would add 5mm
10 mm around the GTV of lymph
nodes to account for potential
subclinical (extracapsular) spread.
42

43. GTVn TO CTVn EXPANSION 0.5CM
43

44. GTVn TO CTVn EXPANSION ?ECE 1CM
44

45. DOSE FOR SUBCLINICAL NODAL AREA
LOW RISK CTV NODE?
45
PROBLEM-5

46. RISK LEVELS
PROBLEM-6
46

47. • HIGH RISK NODAL AREA
• INTERMEDIATE RISK NODAL AREA
• LOWRISK NODAL AREA
47

48. HIGH RISK NODAL AREA
• APPLICABLE FOR GORSS NODAL AREA
• 5 MM MARGIN FOR NO ECE
• 1CM MRAGIN IF ECE SUSPECTED
• ATLEAST 70 Gy
48

49. INTERMEDIATE RISK NODAL AREA
• APPLICABLE FOR ADJACENT GORSS NODAL
AREA
• INVOLVED LN LEVELS PLUS ONE LEVEL ABOVE
AND BELOW
• THE NODAL SPACES TO BE CONTOURED
• ATLEAST 54 TO 63Gy
49

50. LOW RISK NODAL AREA
• APPLICABLE FOR OTHER NODAL AREAS
• THE NODAL SPACES TO BE CONTOURED
• ATLEAST 50Gy
• LOW RISK NODAL AREAS (MOST OFTEN IB, V,
and RP)
50

51. PROBLEM-7
• WINDOWING
51

52. 52
HORIZONTAL SCROLL/WIDTH/CONTRAST /OBJECTS INSIDE THE IMAGE
VERTICALSCROLL/LEVEL/BRIGHTNESS/IMAGE

53. Brightness- window level Contrast- window width
53

54. PROBLEM-8
IDENTYFYING HIDDEN NODE
THE MAGIC
54

55. 55

56. SCREEN THE SCAN
56

57. 57

58. CLINICAL EXAMINATION
58

59. 59

60. CONTRALATERALITY
60

61. CONTRAST ENHANCEMENT
61

62. CYSTIC
62

63. CONTOUR
63

64. CAPSULAR BREACH
64

65. CENTRAL HILUM
65

66. 66

67. CONTINUITY
67

68. CONGLOMERATION
68

69. CIRCULAR
69

70. CLOT-THROMBOTIC VEIN
70

71. CRITERIA-SIZE
71

72. PROBLEM-9
SUSPECTING AND RESPECTING THE
EXTRACAPSULAR EXTENSION
72

73. 73

74. CLASSIFICATION
74

75. CLASSIFICATION
75

76. 76

77. MRI SIGNS
1. FLARE SIGN
2. SHAGGY SIGN
3. VANISHING BORDER SIGN
77

78. SIGNS OF ECE
78

79. SHAGGY
MARGIN
79
AN IRREGULAR NODAL MARGIN ON GADOLINIUM-ENHANCED T1-
WEIGHTED IMAGES (“SHAGGY MARGIN”)

80. Vanishing
Border sign
80
Obliterated fat spaces between the metastatic node and adjacent
tissues, such as the muscles and skin on T1-weighted images
(“vanishing border” sign)

81. “FLARE” SIGN
81
The presence of high-intensity signals in the interstitial tissues around
and extending from a metastatic node on fat-suppressed T2-weighte
(“flare” sign);

82. 82

83. 83

84. 84

85. ECE INCREASED WITH SIZE
85

86. 86

87. FINDINGS
1. The incidence and extension of ECE are associated
with larger LN size
2. The mean ECE extensions were 1.7 and 2.0 mm for
LN of #10 mm and LN of >10 mm
3. The incidence of ECE is associated with larger LN
size.
4. However, ECE is found in a substantial number of LN
with a diameter of < 10 mm
5. Recommended the use of 10-mm CTV margins
around the GTV to account for ECE in patients with
N1 or <3mm N2b or N2c HNSCC
87

88. PROBLEM-10
HANDLING LOWER NECK- NASOPHARYNX
88

89. 89

90. PROBLEM-11
PAROTID VESSEL INTERFACE
90

91. THAT DIAGASTRIC MUSCLE
91

92. 92

93. 93

94. 94

95. PROBLEM -12
NODE WITH SKIN
INFILTRATION/ULCERATION
95

96. 96

97. SOLUTIONS
1. BOLUS
2. VIRTUAL BOLUS
3. DIFFERENTIAL PTV
4. SURFACE DOSE
5. FLASH
97

98. 98

99. 99

100. 100

101. 101

102. 102

103. PROBLEM-13
RETROSTYLOID NODAL DELINEATION
103

104. 104

105. In case of involvement of upper level II
(IIa or IIb) with one or more lymph nodes,
it is Recommended to extend the upper
border of level II to include the
retrostyloid space up to the base of skull
105

106. 106

107. 107

108. PROBLEM-14
In case of involvement of level IV or Vb
with one or more lymph nodes
108

109. In case of involvement of level IV or Vb with
one or more lymph nodes, it is Recommended
to extend the lower border to include the
supraclavicular fossa in the CTV
109

110. 110

111. PROBLEM-15
involved lymph node abuts a muscle
111

112. When an involved lymph node abuts a muscle
(e.g.sterno-cleido-mastoid or para-spinal) and/or
show clearradiological indication of muscular
infiltration, it isrecommended to include this
muscle at the vicinity of the node in the CTV, at
least for the entire invaded level and at least with
a 1 cm margins in all directions
112

113. 113

114. MUSCLE ABUTTING/INVOLVEMENT
114

115. lymph node is located at the
boundary with another leveL
PROBLEM-16
115

116. 116

117. 1. When an involved lymph node is located at the
boundary with another level, which was not
intended to be part of the CTV, it is recommended
to extend the CTV to include this adjacent level
2. This recommendation will only apply to patients
with a single lymph node (N1), and for whom a
selective treatment may be advocated,
3. e.g. an oropharyngeal SCC with a N1 node in level
II at the boundary with level Ib;
4. An oral cavity tumor with a N1 node in level III at
the boundary with level IV.
117

118. PROBLEM-17
HANDLING RETROPHARYNGEAL NODES
118

119. SPARING CONSTRICTORS
• In case of pharyngeal tumors with pathological lymph
node involvement, retropharyngeal lymph nodes
delineated according to the published guidelines
should be included in the CTV
• Considering the rare involvement of the medial
retropharyngeal nodes, it may be reasonable to only
outline the lateral retropharyngeal nodes alone (i.e.
medial to the carotid arteries)
• This may enable partial sparing of the pharyngeal
Constrictor muscles, whose dysfunction following
intensive chemo-RT may be a major cause of late
dysphagia
119

120. THIS IMPACT
1. There is a high incidence of RPLN metastasis
in patients with tumors of the oropharynx,
hypopharynx, and supraglottic larynx.
2. However, metastasis to the RPLN group does
not impact disease control or survival in
patients with advanced non-nasopharyngeal
SCCHN treated with multimodality therapy
120

121. PROBLEM-18
POST OP NODAL VOLUME
121

122. 122

123. 123

124. 124

125. WHERE TO KEEP MEDIAL BORDER?
125
PROBLEM-19

126. 126

127. 127

128. PROBLEM-20
WHERE NOT TO SPARE PAROTID IN
NASOPHARYNX?
128

129. 129

130. PROBLEM-21
SUSPICIOUS NODE
130

131. WHEN THINGS ARE SUSPICIOUS
PET CT IS AUSPICIOUS
131

132. 132

133. PROBLEM-22
SPARING OF SUBMANDIBULAR
GLAND
133

134. 134

135. PROBLEM-23
Dysphagia structures
135

136. DELINEATION GUIDELINES FOR DARS AS OAR
136

137. 137

138. 138

139. 139

140. 140

141. 141

142. 142

143. 143

144. CAN WE DARE TO SPARE DARS?
CAN THEY BE SPARED BY IMRT?
144

145. 145

146. 146

147. Dose constraint for DARS
Sparing these structures could prevent late dysphagia. (#)
No clear dose or volume constraints available
Mean dose to DARS: < 50 Gy.
Beyond 50–60 Gy : Occurrence of late dysphagia.(*,**)
Best approach: Keep RT dose to these structures as low as
possible.(##)
*Feng FY, et al. IIMRT of head and neck cancer aiming to reduce dysphagia: early-dose eff ect relationships for the swallowing structures. Int J Radi2007;
68: 1289–98.
** Levendag PC, et al. Dysphagia disorders in patients with cancer of the oropharynx are signifi cantly aff ected by the radiation therapy dose to the
superior and middle constrictor muscle: a dose-eff ect relationship. Radiother Oncol 2007; 85: 64–73.
# Jensen K, et al. Late swallowing dysfunction and dysphagia after radiotherapy for pharynx cancer: frequency, intensity and correlation with dose and
volume parameters. Radiother Oncol 2007; 85: 74–82.
## Teguh DN et al. Treatment techniques and site considerations regarding dysphagia-related QOL in cancer of the oropharynx and nasopharynx. Int J
Radiat 2008; 72: 1119–27.
147

148. PROBLEM-24
• Unknown primary
148

149. 149

150. 150

151. PROBLEM-25
Cord brainstem interface
151

152. 152

153. SPINAL CORD INSULT-CONVENTIONAL VS IMRT
2nd DECEMBER 2017/RE-RTJUST CALCULATE
WITH
CONVENTIONAL
PLANNING CORD
GETS 2Gy/# TILL 22#
BED =88Gy2
WITH IMRT SUPPOSE
CORD IS GETTING
35Gy IN 50Gy/ 25#
MEANS 1.4Gy/#
SO BED =59.9Gy2
IT IS A GOOD THING
FOR REIRRADIATION
AND SPINAL CORD
RECOVERY ALSO
ALWAYS
CHOOSE
ADVANCED
TECHNIQUE
WITH IMRT, SPINAL CORD
NOT ONLY GETTING THE LESS
DOSE BUT ALSO BED IS VERY
LESS COMPARED TO
CONVENTIONAL RT.
LESS INSULT WITH IMRT
[BED CALCULATOR]EQD2.COM
conventionalIMRT
α/β for cervical and thoracic cord is
2 and lumbar cord is 4

155. PROBLEM-26
DELINEATING OPTIC NERVE
155

156. 156

157. PROBLEM-27
DELINEATING OPTIC CHIASM
157

158. 158

159. 159

160. PROBLEM-28
DELINEATING MASTICATOR SPACE
160

161. 161

162. PROBLEM-29
DELINEATING LARYNX
162

163. WHITE CAT

164. CAT STRACTURES FOR LARYNX
•Cricoid
•Aretynoid
•Thyroid

165. v

167. Midline block

168. PROBLEM-30
DELINEATING THYROID
168

169. 169

170. 170

171. PROBLEM-31
171

172. 172

173. 173

174. PROBLEM-32
DELINEATING PAROTID
174

175. 175

176. PROBLEM-33
DELINEATING COCHLEA
176

177. 177

178. AUTO SKIN MODE
178

179. PROBLEM-34
DELINEATING BRACHIAL PLEXUS
179

180. 180

181. 181

182. 182

183. 183

184. PROBLEM-35
HANDLING TONGUE
184

185. 185

186. 186

187. PROBLEM-36
HANDLING ERRORS
187

188. 188

189. 189

190. PROBLEM-37
REMAINING VOLUME AT RISK
190

191. 191

192. 192

193. PROBLEM-38
THE MOIST STRACTURES
193

194. THE MOIST STRACTURE
194

195. 195

196. 196

197. 197

198. PROBLEM-39
THE PTV AND OAR OVERLAP
198

199. 199

200. 200

201. 201

202. PROBLEM-40
CONSTRAINTS
202

203. 203

207. A-ANALYZE
B -BROWSE
C -COMMUNICATE
D-DELIVER
E-EXTRA CARE

209. econtour.org
209

210. THANKS AUDIENCE
THANKS AROI
THANKS ICRO
210