Download PHP, 8 December 2012

Target Volume Delineation: the Lymph Node
Areas
Philip Poortmans, MD, PhD
Tilburg
Conflict of interest: none
PHP, 8 December 2012
TV Delineation: LN areas.
1. Introduction: background
2. The axilla
3. Supraclavicular
4. Internal mammary
5. Margins
6. Summary
PHP, 8 December 2012
Target Volume Delineation.
Background
Effect of PMRT
nN0
Courtesy of Sarah Darby
pN1-3
Preliminary results. Subject to revision
pN4+
EBCTCG Fifth Cycle
Target Volume Delineation.
Background
Discussion about:
• Thoracic wall
• Axilla:
• Posterior border
• Rotter LN
PHP, 8 December 2012
PHP, 8 December 2012
PHP, 8 December 2012
Target Volume Delineation.
Background
• LN supraclavicular
• LN infraclavicular/level III
• LN Rotter
• LN axilla /level I and II
• LN internal mammary
Courtesy Youlia Kirova et al, Institut Curie, Paris
PHP, 8 December 2012
TV Delineation: LN areas.
1. Introduction: background
2. The axilla
Level 1
Level 2
Rotter
Level 3
3. Supraclavicular
4. Internal mammary
PHP, 8 December 2012
TV Delineation: Axilla.
Traditionally  subdivided into 3 subregions:
- level 1 caudally from lower border of major pectoral muscle
- level 2 posterior to minor pectoral muscle
- level 3 located cranially from the pectoral muscles
+ Rotter located between minor and major pectoral muscle
Courtesy of DBCG 2012. Manuscript in preparation
PHP, 8 December 2012
TV Delineation: Axilla.
Axillary surgery  in general level 1 & (part of) level 2.
Remark: no consensus on including posterior part (
Courtesy of DBCG 2012. Manuscript in preparation
).
PHP, 8 December 2012
TV Delineation: Axilla.
Level 1
Inferior border: around the level of ribs 4 – 5
Lateral border: up to the superficial part of
the muscles
Medial border: level II and thoracic wall
Anterior border: pectoralis major & minor muscles
Posterior border: up to the posterior blood vessel
Superior border: inferior limit level II/Rotter; up to 1 cm below
and following the edge of the caput humeri, use surgical
effects to guide.
PHP, 8 December 2012
Lateral border: up to the superficial part of the muscles (line)
Medial border: level II and thoracic wall
Anterior border: pectoralis major & minor muscles
Posterior border: up to the posterior blood vessel (arrow)
PHP, 8 December 2012
TV Delineation: Axilla.
Level 2
Behind minor pectoral muscle and includes the axillary
vessels with 5 mm margin in posterior direction
Level II
PHP, 8 December 2012
TV Delineation: Axilla.
Rotter
Between: pectoralis major and pectoralis minor muscles
At the level of the 2nd intercostal space
PHP, 8 December 2012
TV Delineation: Axilla.
Level 3 (infraclavicular)
Superior border: pectoralis minor muscle
Inferior border: sterno-clavicular articulation
Lateral border: medial side of the pectoralis
minor muscle
Medial border: clavicle
Anterior border: pectoralis major muscle
Posterior border: up to 5 mm posterior to the axillary vessels
PHP, 8 December 2012
Superior border: pectoralis minor muscle
TV Delineation: Axilla.
Inferior border: sterno-clavicular articulation
Level 3 (infraclavicular)
Lateral border: medial side of the pectoralis minor muscle
Medial border: clavicle
Anterior border: pectoralis major muscle
Posterior border: up to 5 mm posterior to the axillary vessels
PHP, 8 December 2012
TV Delineation: LN areas.
1. Introduction: background
2. The axilla
3. Supraclavicular
4. Internal mammary
5. Margins
6. Summary
PHP, 8 December 2012
TV Delineation: Supraclavicular.
Superior border: cricoid cartilage
Inferior border: clavicular head
Medial border: trachea, gld thyroidea
Postero-lateral border: anterior scalene muscle
Postero-medial border: carotid artery
PHP, 8 December 2012
Superior border: cricoid cartilage
Inferior border: clavicular head
Medial border: trachea, gld thyroidea
Postero-lateral border: anterior scalene muscle
Postero-medial border: carotid artery
PHP, 8 December 2012
Medial border: trachea, gld thyroidea
Postero-medial border: carotid artery
 discussion: vessels to be included?
PHP, 8 December 2012
TV Delineation: LN areas.
1. Introduction: background
2. The axilla
3. Supraclavicular
4. Internal mammary
5. Margins
6. Summary
PHP, 8 December 2012
TV Delineation: Internal mammary.
Superior border: inferior limit of supraclavicular area
Inferior border: superior side of the 4th rib
Lateral border: external limit of the vascular area or 2 cm
lateral to the edge of the sternal bone (whatever is most
lateral)
Medial border: up to the edge of the sternal bone
Anterior border: anterior limit of the vascular area
Posterior border: the pleura
PHP, 8 December 2012
Lateral border: external limit of the vascular area or 2
cm lateral to the edge of the sternal bone (whatever is
most lateral)
Medial border: up to the edge of the sternal bone
Anterior border: anterior limit of the vascular area
Posterior border: the pleura
PHP, 8 December 2012
Superior border: inferior limit of supraclavicular area
Critical area just
behind the
sternoclavicular
junction
Kirova et al Br J Rad 2010
PHP, 8 December 2012
TV Delineation: LN areas.
1. Introduction: background
2. The axilla
3. Supraclavicular
4. Internal mammary
5. Margins
6. Summary
PHP, 8 December 2012
TV Delineation: margins.
CTV  PTV margins:
 Ideally: dependent on your own measurements!!!
 Mind increasing treated volumes!!!
 Most often: 5 mm
PHP, 8 December 2012
TV Delineation: LN areas.
1. Introduction: background
2. The axilla
3. Supraclavicular
4. Internal mammary
5. Margins
6. Summary
PHP, 8 December 2012
TV Delineation for LN: examples.
Supraclavicular
BVO green, PHP blue
PHP, 8 December 2012
TV Delineation for LN: examples.
Supraclavicular
BVO green, PHP blue
PHP, 8 December 2012
TV Delineation for LN: examples.
Supraclavicular, level 3
Delineations made by students attending ESTRO´s breast teaching course
PHP, 8 December 2012
TV Delineation for LN: examples.
Supraclavicular, level 3
BVO green, PHP blue
PHP, 8 December 2012
TV Delineation for LN: examples.
Supraclavicular, Rotter, axilla level 1-3
Delineations made by students attending ESTRO´s breast teaching course
PHP, 8 December 2012
TV Delineation for LN: examples.
Supraclav, Rotter, level 1-3
BVO green and red, PHP blue and yellow
PHP, 8 December 2012
TV Delineation for LN: examples.
IMC, Rotter and axilla level 1-3
Delineations made by students attending ESTRO´s breast teaching course
PHP, 8 December 2012
TV Delineation for LN: examples.
Rotter, level 1 & 2, IMC
BVO green and red, PHP blue and yellow
PHP, 8 December 2012
TV Delineation for LN: examples.
Breast, level 1&2, IMC
Delineations made by students attending ESTRO´s breast teaching course
PHP, 8 December 2012
TV Delineation for LN: examples.
Breast, level 1, IMC
BVO green and red, PHP blue and yellow
PHP, 8 December 2012
TV Delineation for LN: examples.
Breast, level 1, IMC
BVO green and red, PHP blue and yellow
PHP, 8 December 2012
TV Delineation for LN: examples.
Breast, level 1, IMC
BVO green and red, PHP blue and yellow
PHP, 8 December 2012
TV Delineation: summary.
General:
We have no clinical argument to increase the field size
compared to the old standard fields;
Consider making a CT-scan in treatment position preceding
systemic therapy/surgery for later image fusion.
PHP, 8 December 2012
TV Delineation: summary.
General:
The LN volumes should all interconnect (= touch each other at
the edges)  horse-shoe like LN chain surrounding the breast.
PHP, 8 December 2012
TV Delineation: summary.
General:
Always individualise in relation to the risk of LRR, e.g:
If pathological lymph nodes have been left behind (e.g. in level
III) consider to give a boost in that area. Optimally the surgeon
has placed a clip where the pathological LN was felt. A limited
boost volume may be treated to 60-62 Gy (2 Gy per fr), but be
aware of the vessels and the plexus brachialis.
PHP, 8 December 2012
TV Delineation: summary.
Co morbidity:
Always individualise in relation to the risk of late morbidity:
Patient factors: heart disease; hypertension; obesity; diabetes;
smoking (QUIT THIS!); connective tissue disease; previous
RT to the region; specific anatomy, e.g. pectus excavatum or
carinatum.
Treatment factors: complications after the surgery (infection;
delayed wound healing; shoulder mobility); systemic therapy
(chemotherapy with anthracyclines, taxanes, endocrine
therapy, trastuzumab and other new drugs).
PHP, 8 December 2012
TV Delineation: summary.
Advices:
Balance benefit and cost for the patient while
evaluating the treatment plan.
Consider techniques such as gating; prone
position; ”modified” IMRT; mastectomy; …
PHP, 8 December 2012
TV Delineation: summary.
Advices:
Train in TV delineation; use as much information as possible.
Use proper imaging techniques.
Individualise the CTV  PTV margins but mind increasing the
field size!
PHP, 8 December 2012
Acknowledgements:
- Birgitte Offersen
- Youlia Kirova
- Liesbeth Boersma
- Albert Biete Sola
- Sandra Hol
- And many others!
PHP, 8 December 2012
Thank you very much for your attention!
PHP, 8 December 2012