delineation of dysphagia aspiration related structures
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Delineation of Dysphagia/Aspiration-Related Structures (DARS)
Dr Rajesh BalakrishnanMD, DNB (Radiotherapy)
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References for the Talk
• Radiotherapy and Oncology 93 (2009) 545–552• Radiotherapy and Oncology 110 (2014) 390-397
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Prerequisites
• Good Planning CT – Good Immobilistaion setup– With Contrast imaging– 3mm Slice thickness or smaller
• Suggested the center (HU) and width (HU) values (window settings) used to delineate the OARs– Brain: C35, W100– Bone: C450, W1,600– H&N: C35, W350– Parotid: C 840 , W 370
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• Temporal Lobes• Right Eye and Lens• Left eye and lens• Right Optic nerve• Left Optic nerve• Optic chiasm• Pituitary• Cochlea• Brainstem
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Organs at Risk (1)
• Spine• Parotid Glands• Sub Mandibular Gland• Pharyngeal Constrictors• Trachea• Brachial Plexus
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Organs at Risk (2)
OPTIC APPARATUS
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Optic/Brain – Organs at Risk
• Temporal Lobes• Right Eye and Lens• Left eye and lens• Right Optic nerve• Left Optic nerve• Optic chiasm• Pituitary• Cochlea• Brainstem
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8Radiotherapy and Oncology 110 (2014) 390–397
9Radiotherapy and Oncology 110 (2014) 390–397
10Radiotherapy and Oncology 110 (2014) 390–397
11Radiotherapy and Oncology 110 (2014) 390–397
12Radiotherapy and Oncology 110 (2014) 390–397
13Radiotherapy and Oncology 110 (2014) 390–397
14Radiotherapy and Oncology 110 (2014) 390–397
15Radiotherapy and Oncology 110 (2014) 390–397
16Radiotherapy and Oncology 110 (2014) 390–397
17Radiotherapy and Oncology 110 (2014) 390–397
18Radiotherapy and Oncology 110 (2014) 390–397
19Radiotherapy and Oncology 110 (2014) 390–397
20Radiotherapy and Oncology 110 (2014) 390–397
21Radiotherapy and Oncology 110 (2014) 390–397
22Radiotherapy and Oncology 110 (2014) 390–397
Odontoid Process
SALIVARY GLANDS
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Parotid GlandBoundary Explanation
Cranial External auditory canal, mastoid process
Caudal Post. part submandibular space
AnteriorMasseter m, post. border mandibular bone, medial and lateral pterygoid m.
PosteriorAnt. belly sternocleidomastoid m, lat. side post. belly of the digastric m. (posterior-medial)
Lateral Subcutaneous fat, platysma
MedialPost. belly of the digastric m, styloid process, parapharyngeal space 24
Submandibular GlandBoundary Explanation
Cranial Medial pterygoid m, mylohyoid m.
Caudal Fatty tissue
Anterior Lat. surface mylohyoid m, hyoglossus m.
Posterior Parapharyngeal space, sternocleidomastoid m.
LateralMed. surface medial pterygoid m, med. surface mandibular bone, platysma
MedialLat. surface mylohyoid m, hyoglossus m, superior and middle pharyngeal constrictor m, anterior belly of the digastric m. 25
Sublingual GlandBoundary Explanation
Cranial(Mucous membrane covering the floor of the mouth), crossing lingual septum , intrinsic tongue muscles
Caudal Ant. part mylohyoid m, geniohyoid m.
Anterior Ant. part surface mandibular bone, mylohyoid m.
Posterior Hyoglossus m.
LateralAnt. part med. surface mandibular bone, mylohyoid m.
Medial Genioglossus m. 26
Salivary Glands - Delineation
27
5 Anterior belly digastric m.
6 Geniohyoid m.
10 Sternocleidomastoid m.
11 Platysma
••••• Sub Lingual Glands – Dark Blue
Salivary Glands - Delineation
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5 Anterior belly digastric m.
6 Geniohyoid m.
9 Pharyngeal constrictor m.
10 Sternocleidomastoid m.
11 Platysma
••••• Sub Lingual Glands – Dark Blue
Salivary Glands - Delineation
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1 Genioglossus m.
2 Mylohyoid m.
3 Hyoglossus m.
10 Sternocleidomastoid m.
11 Platysma
15 Mandibular bone
••••• Sub Lingual Glands – Dark Blue
Salivary Glands - Delineation
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1 Genioglossus m.
2 Mylohyoid m.
3 Hyoglossus m.
9 Pharyngeal constrictor m.
10 Sternocleidomastoid m.
15 Mandibular bone
••••• Sub Lingual Glands – Dark Blue
Salivary Glands - Delineation
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1 Genioglossus m.
2 Mylohyoid m.
3 Hyoglossus m.
4 Posterior belly digastric m.
7 Medial pterygoid m.
10 Sternocleidomastoid m.
12 Masseter m.
13 Parapharyngeal space••••• Sub Lingual Glands – Dark Blue
Salivary Glands - Delineation
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1 Genioglossus m.
2 Mylohyoid m.
4 Posterior belly digastric m.
7 Medial pterygoid m.
10 Sternocleidomastoid m.
12 Masseter m.
15 Mandibular bone
••••• Sub Lingual Glands – Dark Blue
Salivary Glands - Delineation
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4 Posterior belly digastric m.
7 Medial pterygoid m.
10 Sternocleidomastoid m.
12 Masseter m.
••••• Sub Lingual Glands – Dark Blue
Salivary Glands - Delineation
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4 Posterior belly digastric m.
7 Medial pterygoid m.
8 Lateral pterygoid m.
10 Sternocleidomastoid m.
12 Masseter m.
13 Parapharyngeal space
14 Styloid process
15 Mandibular bone••••• Sub Lingual Glands – Dark Blue
Parotid – Axial and Coronal
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Submandibular – Sagittal and Coronal
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SubLingual – Sagittal and Coronal
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SOFT PALATE
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Soft PalateBoundary Explanation
CranialHard palate, nasopharyngeal mucosal space/air lumen
CaudalTongue base, palatine tonsils, oropharyngeal mucosal space/air lumen
AnteriorHard palate, tongue/tongue base, air present in oral cavity or pharyngeal lumen
PosteriorSuperior pharyngeal constrictor m, pharyngeal mucosal space/air lumen
Lateral
Pterygoid process, medial pterygoid plate, superior pharyngeal constrictor m, medial pterygoid m, parapharyngeal space, palatine tonsil, pharyngeal lumen 39
SOFT PALATE – Sagittal and Axial
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SOFT PALATE
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1 Tongue
2 Medial pterygoid m.
3 Superior pharyngeal constrictor m.
4 Uvula
5 Hard palate
6 Medial pterygoid plate
7 Pharyngeal lumen
8 Parapharyngeal space
9 Pterygoid process
10 Level of the palatine tonsil.
SOFT PALATE
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1 Tongue
2 Medial pterygoid m.
3 Superior pharyngeal constrictor m.
4 Uvula
5 Hard palate
6 Medial pterygoid plate
7 Pharyngeal lumen
8 Parapharyngeal space
9 Pterygoid process
10 Level of the palatine tonsil.
SOFT PALATE
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1 Tongue
2 Medial pterygoid m.
3 Superior pharyngeal constrictor m.
4 Uvula
5 Hard palate
6 Medial pterygoid plate
7 Pharyngeal lumen
8 Parapharyngeal space
9 Pterygoid process
10 Level of the palatine tonsil.
SOFT PALATE
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1 Tongue
2 Medial pterygoid m.
3 Superior pharyngeal constrictor m.
4 Uvula
5 Hard palate
6 Medial pterygoid plate
7 Pharyngeal lumen
8 Parapharyngeal space
9 Pterygoid process
10 Level of the palatine tonsil.
SOFT PALATE
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1 Tongue
2 Medial pterygoid m.
3 Superior pharyngeal constrictor m.
4 Uvula
5 Hard palate
6 Medial pterygoid plate
7 Pharyngeal lumen
8 Parapharyngeal space
9 Pterygoid process
10 Level of the palatine tonsil.
SOFT PALATE
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1 Tongue
2 Medial pterygoid m.
3 Superior pharyngeal constrictor m.
4 Uvula
5 Hard palate
6 Medial pterygoid plate
7 Pharyngeal lumen
8 Parapharyngeal space
9 Pterygoid process
10 Level of the palatine tonsil.
LIPS AND BUCCAL MUCOSA
47
Inner Surface Upper LipsBoundary Explanation
CranialHard palate (lateral), anterior nasal spine (at the midline)
Caudal Lower edge upper lip
Anterior Orbicularis oris m, subcutaneous tissue/fatty skin
Posterior Teeth, maxillary bone, hard palate, tongue
Lateral Depressor anguli oris m, buccinator m, levator anguli oris m./risorius m.
48
Inner Surface Lower LipsBoundary Explanation
Cranial Upper edge lower lip
CaudalLower edge teeth sockets, cranial edge mandibular body
Anterior Orbicularis oris m, subcutaneous tissue/fatty skin
Posterior Mandibular body, teeth, tongue, air (if present)
Lateral Depressor anguli oris m, buccinator m.
49
Inner Surface CheeksBoundary Explanation
CranialTransition between maxillary sinus and alveolar process maxilla
Caudal Alveolar process mandible
Anterior Orbicularis oris m.
Posterior Post. edge mandibular body, post. edge maxilla
Lateral Buccinator muscle, fatty tissue
Medial Mandibular body, teeth, tongue50
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1 Orbicularis oris
2 Tongue
3 Fatty tissue
4 Hard palate
5 Mandibular body
6 Maxillary bone
7 Anterior nasal spine
8 Buccinator m
9 Levator anguli oris/risorius m
10 Alveolar process maxilla
11 Maxillary sinus
12 Depressor anguli oris m
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1 Orbicularis oris
2 Tongue
3 Fatty tissue
4 Hard palate
5 Mandibular body
6 Maxillary bone
7 Anterior nasal spine
8 Buccinator m
9 Levator anguli oris/risorius m
10 Alveolar process maxilla
11 Maxillary sinus
12 Depressor anguli oris m
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1 Orbicularis oris
2 Tongue
3 Fatty tissue
4 Hard palate
5 Mandibular body
6 Maxillary bone
7 Anterior nasal spine
8 Buccinator m
9 Levator anguli oris/risorius m
10 Alveolar process maxilla
11 Maxillary sinus
12 Depressor anguli oris m
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1 Orbicularis oris
2 Tongue
3 Fatty tissue
4 Hard palate
5 Mandibular body
6 Maxillary bone
7 Anterior nasal spine
8 Buccinator m
9 Levator anguli oris/risorius m
10 Alveolar process maxilla
11 Maxillary sinus
12 Depressor anguli oris m
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1 Orbicularis oris
2 Tongue
3 Fatty tissue
4 Hard palate
5 Mandibular body
6 Maxillary bone
7 Anterior nasal spine
8 Buccinator m
9 Levator anguli oris/risorius m
10 Alveolar process maxilla
11 Maxillary sinus
12 Depressor anguli oris m
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1 Orbicularis oris
2 Tongue
3 Fatty tissue
4 Hard palate
5 Mandibular body
6 Maxillary bone
7 Anterior nasal spine
8 Buccinator m
9 Levator anguli oris/risorius m
10 Alveolar process maxilla
11 Maxillary sinus
12 Depressor anguli oris m
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1 Orbicularis oris
2 Tongue
3 Fatty tissue
4 Hard palate
5 Mandibular body
6 Maxillary bone
7 Anterior nasal spine
8 Buccinator m
9 Levator anguli oris/risorius m
10 Alveolar process maxilla
11 Maxillary sinus
12 Depressor anguli oris m
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1 Orbicularis oris
2 Tongue
3 Fatty tissue
4 Hard palate
5 Mandibular body
6 Maxillary bone
7 Anterior nasal spine
8 Buccinator m
9 Levator anguli oris/risorius m
10 Alveolar process maxilla
11 Maxillary sinus
12 Depressor anguli oris m
PHARYNGEAL CONSTRICTORS
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Superior Constrictor MuscleBoundary Explanation
Cranial Occipital condyle
Caudal Superior Edge of Hyoid Bone
Anterior Anterior edge of pterygoid muscle
Posterior Longus Capitis muscle
Lateral Palatine Tonsil or Parapharyngeal space
Medial Pharynx
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63Radiotherapy and Oncology 110 (2014) 390–397
64Radiotherapy and Oncology 110 (2014) 390–397
65Radiotherapy and Oncology 110 (2014) 390–397
66Radiotherapy and Oncology 110 (2014) 390–397
Middle Constrictor MuscleBoundary Explanation
Cranial 0.5 cm Above Hyoid bone
Caudal Inferior Edge of Hyoid Bone
Anterior Oropharynx, Lateral edge of Hyoid bone
Posterior Longus Capitis muscle
Lateral Palatine Tonsil or Parapharyngeal space
Medial Pharynx
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69Radiotherapy and Oncology 110 (2014) 390–397
70Radiotherapy and Oncology 110 (2014) 390–397
Inferior Constrictor MuscleBoundary Explanation
Cranial Inferior edge of Hyoid bone
Caudal Esophagus
Anterior Arytenoid, First Tracheal ring
Posterior Longus Capitis muscle, Anterior Vertebral body
Lateral Parapharyngeal space, Lateral edge of Thyroid
Medial Pharynx
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73Radiotherapy and Oncology 110 (2014) 390–397
74Radiotherapy and Oncology 110 (2014) 390–397
75Radiotherapy and Oncology 110 (2014) 390–397
76Radiotherapy and Oncology 110 (2014) 390–397
77Radiotherapy and Oncology 110 (2014) 390–397
Dose ConstraintsConstrictors Mean Dose < 50 Gy QUANTEC
Lips Mean Dose <20 GyFor parotid tumor: Max < 30GyFor SM tumor : Max < 45 Gy
RTOG 1008
Oral Cavity (Non OC tumor) Mean < 30 Gy ; No hot spots > 60 Gy
RTOG 0920
Oral Cavity (OC tumor) Mean < 50 Gy ; V55 < 1 %Max dose -65 Gy
RTOG 0920
TMJ / Mandible Max 70 Gy RTOG 0615
Larynx Mean < 44 Gy ; V50 < 33 %Max dose - 63 -66Gy
QUANTEC
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Dose Constraints
Parotid Glands Mean < 25 Gy (Both glands)Mean < 20 Gy (Single gland)
QUANTEC
Submandibular Glands Mean < 35 Gy QUANTEC
Thyroid V26 < 20 % JHH guidelines
Cochlea Ipsilateral Max <50GyMean < 45 Gy
RTOG 1016QUANTEC
Eyes Max <30 Gy RTOG 1008
Lens Max : < 2.5 Gy RTOG 1008
Optic nerve/ Chiasm Max < 30 Gy RTOG 1008
Brainstem Entire Brainstem – < 54 GyV59Gy < 1-10cc
QUANTEC
Spinal cord Max 50 Gy QUANTEC
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Conclusion
• Correct Contouring of OARs is as important to contouring of Target.
• Whenever in doubt please refer to atlases available online.
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