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    Breast Cancer Contouring

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    diya15
    This document provides guidelines for target volume delineation in radiation therapy for breast cancer. It summarizes the guidelines from RTOG and ESTRO and identifies key differences between the approaches. The ESTRO guidelines aim to standardize delineation across countries in Europe and address shortcomings in previous guidelines by better defining borders based on anatomy rather than fixed bony landmarks. The guidelines delineate clinical target volumes for the breast or chest wall (CTVp), lymph node levels in the axilla and supraclavicular fossa, and internal mammary nodes.

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    Breast Cancer Contouring

    Uploaded by

    diya15
    124 views73 pages
    This document provides guidelines for target volume delineation in radiation therapy for breast cancer. It summarizes the guidelines from RTOG and ESTRO and identifies key differences between the approaches. The ESTRO guidelines aim to standardize delineation across countries in Europe and address shortcomings in previous guidelines by better defining borders based on anatomy rather than fixed bony landmarks. The guidelines delineate clinical target volumes for the breast or chest wall (CTVp), lymph node levels in the axilla and supraclavicular fossa, and internal mammary nodes.

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    ESTRO Guideline

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    This document provides guidelines for target volume delineation in radiation therapy for breast cancer. It summarizes the guidelines from RTOG and ESTRO and identifies key differences between the approaches. The ESTRO guidelines aim to standardize delineation across countries in Europe and address shortcomings in previous guidelines by better defining borders based on anatomy rather than fixed bony landmarks. The guidelines delineate clinical target volumes for the breast or chest wall (CTVp), lymph node levels in the axilla and supraclavicular fossa, and internal mammary nodes.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    124 views73 pages

    Breast Cancer Contouring

    Uploaded by

    diya15
    This document provides guidelines for target volume delineation in radiation therapy for breast cancer. It summarizes the guidelines from RTOG and ESTRO and identifies key differences between the approaches. The ESTRO guidelines aim to standardize delineation across countries in Europe and address shortcomings in previous guidelines by better defining borders based on anatomy rather than fixed bony landmarks. The guidelines delineate clinical target volumes for the breast or chest wall (CTVp), lymph node levels in the axilla and supraclavicular fossa, and internal mammary nodes.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 73

    Target Volume Delineation

    Dr Susmita Sadhukhan
    Registrar A
    Radiation Oncology
    Another Guideline????????
    Target volume delineation : weakest part of the quality
    chain in RT.
    Large inter-observer variation
    Previous Guideline uses same fixed bony landmarks
    strong There is no reason to enlarge the
    mostly.
    radiation
    Larger treated volumes even than treated with
    conventional simulator-based RT.
    fields beyond those obtained with
    conventional simulator
    Reduce thebased treatment
    dose to the OAR set-up
    More attention paid to the vessels and less to bony
    structures
    Materials and methods

    The teachers from four countries (DK, ESP, F and NL) continued to
    work towards a European consensus on delineation guidelines.
    One of the teachers of the ESTRO course started with delineating
    relevant CTV.
    The three other teachers commented, and specific borders were
    discussed during ESTRO courses and at telephone conferences,also
    using ESTROs FALCON platform.
    Compromise between real anatomical borders and practical clinical
    borders to prevent an increase in size of the RT fields compared to
    conventional RT fields.
    Guidelines were discussed with the Belgium group , and further
    adaptations were made
    CT Simulation :
    Non-contrast-enhanced computer tomography(CT) scans in breast
    board inclined at 12.515 with both arms abducted around 120 degree.

    The head was positioned straight with the chin slightly upwards,
    avoiding skin folds at the level of the lower neck.

    Two circles of radio-opaque wires- the palpable/visible CTV breast


    (inner circle) and the provisional field borders (outer circle).

    In mastectomy patients, radio-opaque wires should be positioned


    around the imaginary original site of the breast and also
    corresponding to the mastectomy scar

    Scans were made under free breathing and with 2.5 mm thick sections
    CTVp_breast (BCS)
    RTOG
    ESTRO
    Cranial : Upper border of palpable/visible breast tissue; maximally up
    to the inferior edge of the sternoclavicular joint
    CaudalIrrespective of visible
    : Most caudal CT slice with thebreast
    position
    Ventral : 5 mm under skin surface *
    of the primary tumour bed in the
    Dorsal : Major pectoral muscle or costae and intercostal muscles
    where no muscle. breast,
    the
    MedialCTVp_breast
    : Lateral to the medialmust
    perforatingencompasses
    mammarian vessels;
    maximally to the edge of the sternal bone
    the breast
    Lateral : Lateral primary tumour
    fold; anterior bed artery
    to the lateral thoracic
    At the caudal part of the breast the dorsal border can be
    adjusted in ventro/ventrolateral direction in particular in
    obese patients with a thick subcutaneous tissue layer.
    Cranial : 2nd rib insertion caudal inferior edge of the
    sternoclavicular joint.

    Anterior : Skin 5mm beneath skin

    Medial : Sternal-rib junction lateral to the medial


    perforating mammarian vessels

    Lateral : Mid axillary line anterior to the lateral


    thoracic artery
    CTVp_thoracic wall
    RTOG
    ESTRO
    Cranial : Guided by palpable/visible signs; contralateral breast;
    maximally up to the inferior edge of the sterno-clavicular joint.
    Caudal : Guided by palpable/visible signs; contralateral breast
    Ventral : 5 mm under skin surface
    Mostly Clinical Based on
    Dorsal : Major pectoral muscle or costae and intercostal muscles
    where no muscle
    Medial : Opposite Breast
    Guided by palpable/visible signs; contralateral breast
    Lateral : Guided by palpable/visible signs; contralateral breast.
    Usually anterior to the mid-axillary line
    Exclude P. muscles and ribs from chest wall unless
    invasion
    What we need to change
    ?????
    Use bolus in case of thin chest wall and skin
    involvement
    Axilla Level I
    RTOG
    Cranial
    Medial: 5 mm cranial to the axillary vein
    Lateral: max up to 1 cm below the edge of the humeral head,5 mm around
    the axillary vein
    Caudal
    To the level of rib 4 5, taking also into account the visible effects of the
    sentinel lymph node biopsy.
    Ventral
    Pectoralis major &minor muscles
    Dorsal
    Cranially up to the thoraco-dorsal vessels, and more caudally up to an
    imaginary line between the anterior edge of the latissimus dorsi muscle
    and the intercostal muscles.
    Medial:
    Level 2, the interpectoral level and the thoracic wall more caudally

    Surgical scarring after ALND or


    Lateral :
    sentinel
    Cranially : an imaginary linelymph
    between thenode biopsy
    major pectoral and deltoid
    muscles
    Caudalusually should
    : a line between be
    the major included
    pectoral indorsi
    and latissimus themuscles
    CTVn_L1.
    RTOG
    ESTRO
    Cranial : includes the cranial extent of the axillary artery (i.e. 5 mm
    cranial of axillary vein
    Caudal : The caudal border of the minor pectoral muscle. The caudal
    border may therefore in these cases be modified to exclude the surgical
    bed from the Level 2 volume.
    Ventral : Minor pectoral muscle
    Dorsal : Up to 5 mm dorsal of axillary vein or to costae and intercostal
    muscles
    Medial : Medial edge of minor pectoral muscle
    Lateral : Lateral edge of minor pectoral muscle
    Axilla Level III RTOG
    ESTRO
    Cranial : Includes the cranial extent of the subclavian artery(i.e. 5 mm
    cranial of subclavian vein)
    Caudal : 5 mm caudal to the subclavian vein.
    Ventral : Major pectoral muscle
    Dorsal : Up to 5 mm dorsal of subclavian vein or to costae and
    intercostal muscles
    Medial : clavicle & Junction of subclavian and internal jugular veins
    Lateral : Medial side of the minor pectoral muscle
    Lymph node level 4: CTVn_L4
    ESTRO
    Cranial : Includes the cranial extent of the subclavian artery(i.e. 5 mm
    cranial of subclavian vein) *
    Caudal : Includes the subclavian vein with 5 mm margin, thus
    connecting to the cranial border of CTVn_IMN
    Ventral : Sternocleidomastoid muscle, dorsal edge of the clavicle
    Dorsal : Pleura
    Medial : Including the jugular vein without margin; excluding the
    thyroid gland and the common carotid artery
    Lateral : Includes the anterior scalene muscles and connects to the
    medial border of CTVn_L3
    ESTRO SCF
    RTOG
    Internal Mammary lymph nodes: encompass the
    internal mammary/ thoracic vessels

    Cranial : Superior aspect of the medial 1st rib.

    Caudal : Cranial aspect of the 4th rib


    ESTRO CTVn_IMN

    Cranial : Caudal limit of CTVn_L4


    Caudal : Cranial side of the 4th rib (in selected cases 5th rib)
    Ventral : Ventral limit of the vascular area
    Dorsal : Pleura
    Medial : 5 mm from the internal mammary vein (artery in
    cranial part up to and including first intercostal space) or the
    sternum, whatever is closest.
    Lateral : Same as medial border
    The interpectoral lymph nodes

    These lymph nodes are also known as the Rotter lymph


    nodes,
    Located ventral to the minor pectoral muscle and dorsal to
    the major pectoral muscle
    Other limits largely reflect the limits of CTVn_L2.
    Major changes ??
    Ribs and P. muscles are not included in CTV in case of chest
    wall contouring.
    Anterior border is 5mm beneath skin.
    The dorsal border of CTVn_L1 and CTVn_L2, which to a large
    extent defines the depth of the target volumes.(Lung dose)
    P. minor muscle is no more included in CTVn_L2.(dorsal to
    that )
    Exclude carotid artery from Supraclavicular volume.
    Cranial border of SCF much reduced.
    CTVn_IMN dorsal to the sterno-clavicular joint- cause much
    increase in the dose to the ipsilateral lung . Not included in a
    most previous guidelines.
    Lateral border of CTVn_IMN : The definition of CTVn_IMN is
    modified to include both the internal mammary vein and artery with 5
    mm margin.

    Dose to CTVn_L1 ???: May compromise on dose coverage of the


    lateral part of CTVn_L1 and sometimes also of CTVn_L2.

    Lateral border of CTVp_breast : In patients with clearly visible


    glandular breast tissue, it is recommended to include the glandular
    tissue and not necessarily extend the volume lateral upto the thoracic
    vessels.

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