RTOG_乳腺癌靶区勾画共识.pdf

1Breast Cancer Atlas for Radiation Therapy Planning: Consensus Definitions22CollaboratorsJulia White1, An Tai1, Douglas Arthur2, Thomas Buchholz3, Shannon MacDonald4, Lawrence Marks5, Lori Pierce6, Abraham Recht7, Rachel Rabinovitch8, Alphonse Taghian4, Frank Vicini9, Wendy Woodward3, X. Allen Li11Medical College of Wisconsin, 2Virginia Commonwealth University, 3M.D. Anderson Cancer Center, 4Massachusetts General Hospital, 5University of North Carolina, 6University of Michigan, 7Beth Israel Deaconess Medical Center Hospital, 8University of Colorado, 9 William Beaumont Hospital3Content→ Overlying principles: slides 4 - 6→Consensus definitions of anatomical boundaries: slides 7 - 12→Illustrative cases:– A: Stage I intact post-lumpectomy left breast(slides 13 - 30)– B: Stage III post-mastectomy left breast(slides 32 - 51)– C: Stage III intact post-lumpectomy right breast (slides 54 - 71)4Overlying principles: Breast ContourBreast CTV:– Considers referenced clinical breast at time of CT– Includes the apparent CT glandular breast tissue– Incorporates consensus definitions of anatomical borders (see table)– Includes the lumpectomy CTVLumpectomy GTV: Includes seroma and surgical clips when present45Overlying principles: Chestwall ContourChestwall CTV:– Considers referenced clinical chestwall at time of CT– Incorporates consensus definitions of anatomical borders (see table)– Includes the mastectomy scar (may not be feasible for occasional cases where the scar extends beyond the typical borders of the chestwall)6Overlying principles: Nodal volumesRegional nodal CTV:– Nodal volumes contoured for targeting will depend on the specific clinical case– Considers consensus definitions of anatomical borders (see table)– The three levels of the axilla can overlap caudal to cranial– “Axillary apex” was considered level III of the axilla67Breast and Chestwall Contour: Anatomical BoundariesCranial Caudal Anterior Posterior Lateral MedialBreast1Clinical Reference+ Second rib insertionaClinical reference + loss of CT apparent breastSkinExcludes pectoralis muscles, chestwall muscles, ribsClinical Reference +mid axillary line typically, excludes latissimus (Lat.) dorsi m. bSternal-rib junction cBreast + Chestwall2Same Same SameIncludes pectoralis muscles, chestwall muscles, ribsSame SameChestwall3Caudal border of the clavicle headClinical reference+ loss of CT apparent contralateral breastSkinRib-pleural interface.(Includes pectoralis muscles, chestwall muscles, ribs)Clinical Reference/mid axillary line typically, excludes lattismus dorsi m aSternal-rib junction b78Contouring Comments: Breast and Chestwall1. Breast: After appropriate lumpectomy for breast only treatmenta. Cranial border is highly variable depending on breast size and patient position. The lateral aspect can be more cranial then the medial aspect depending on breast shape and patient position. b. Lateral border is highly variable depending on breast size and amount of ptosis.c.Medial border is highly variable depending on breast size and amount of ptosis. Clinical reference needs to be taken into account. Should not cross midline. 9Contouring Comments: Breast and Chestwall2. Breast-Chestwall: CTV after appropriate lumpectomy for more locally advanced cases includes those:– With clinical stage IIb, III who receive neoadjuvant chemotherapy and lumpectomy– Who have sufficient risk disease to require post-mastectomy radiation had mastectomy done3. Chestwall: CTV after appropriate mastectomy:a. Lateral border meant to estimate the lateral border of the previous breast. Typically extends beyond the lateral edge of the pectoralis muscles but excluded the latissimus dorsi muscleb.Clinical reference marks need to be taken into account. The chestwall typically should not cross midline. Medial extent of mastectomy scar should typically be included Regional Nodal Contours: Anatomical BoundariesCranial Caudal Anterior Posterior Lateral MedialSupra-clavicularCaudal to the cricoid cartilageJunction of brachioceph.-axillary vns./ caudal edge clavicle headaSternocleidomastoid (SCM) muscle (m.)Anterior aspect of the scalene m.Cranial: lateral edge of SCM m.Caudal:junction 1strib-clavicleExcludes thyroid and tracheaAxilla-Level IAxillary vessels cross lateral edge of Pec. Minor m.Pectoralis (Pec.) major muscle insert into ribs bPlane defined by: anterior surface of Pec. Maj. m. and Lat. Dorsi m.Anterior surface of subscapularis m.Medial border of lat. dorsi m.Lateral border of Pec. minor m.Axilla-level IIAxillary vessels cross medial edge of Pec. Minor m.Axillary vessels cross lateral edge of Pec. Minor m. cAnterior surface Pec. Minor m.Ribs and intercostal muscles Lateral border of Pec. Minor m.Medial border of Pec. Minor m.Axilla-level IIIPec. Minor m. insert on cricoidAxillary vessels cross medial edge of Pec. Minor m. d.Posterior surface Pec. Major m.Ribs and intercostal musclesMedial border of Pec. Minor m.Thoracic inle。