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Delineation of dysphagia aspiration related structures

Dose to the Dysphagia/Aspiration-Related Structures (DARS) is critical to ensure proper swallowing functions to the patients after IMRT to the head and neck region

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Delineation of dysphagia aspiration related structures

  1. 1. Delineation of Dysphagia/Aspiration- Related Structures (DARS) Dr Rajesh Balakrishnan MD, DNB (Radiotherapy) 1
  2. 2. References for the Talk • Radiotherapy and Oncology 93 (2009) 545–552 • Radiotherapy and Oncology 110 (2014) 390-397 2
  3. 3. 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 3
  4. 4. • Temporal Lobes • Right Eye and Lens • Left eye and lens • Right Optic nerve • Left Optic nerve • Optic chiasm • Pituitary • Cochlea • Brainstem 4 Organs at Risk (1)
  5. 5. • Spine • Parotid Glands • Sub Mandibular Gland • Pharyngeal Constrictors • Trachea • Brachial Plexus 5 Organs at Risk (2)
  6. 6. OPTIC APPARATUS 6
  7. 7. 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 7
  8. 8. 8 Radiotherapy and Oncology 110 (2014) 390–397
  9. 9. 9 Radiotherapy and Oncology 110 (2014) 390–397
  10. 10. 10 Radiotherapy and Oncology 110 (2014) 390–397
  11. 11. 11 Radiotherapy and Oncology 110 (2014) 390–397
  12. 12. 12 Radiotherapy and Oncology 110 (2014) 390–397
  13. 13. 13 Radiotherapy and Oncology 110 (2014) 390–397
  14. 14. 14 Radiotherapy and Oncology 110 (2014) 390–397
  15. 15. 15 Radiotherapy and Oncology 110 (2014) 390–397
  16. 16. 16 Radiotherapy and Oncology 110 (2014) 390–397
  17. 17. 17 Radiotherapy and Oncology 110 (2014) 390–397
  18. 18. 18 Radiotherapy and Oncology 110 (2014) 390–397
  19. 19. 19 Radiotherapy and Oncology 110 (2014) 390–397
  20. 20. 20 Radiotherapy and Oncology 110 (2014) 390–397
  21. 21. 21 Radiotherapy and Oncology 110 (2014) 390–397
  22. 22. 22 Radiotherapy and Oncology 110 (2014) 390–397 Odontoid Process
  23. 23. SALIVARY GLANDS 23
  24. 24. Parotid Gland Boundary Explanation Cranial External auditory canal, mastoid process Caudal Post. part submandibular space Anterior Masseter m, post. border mandibular bone, medial and lateral pterygoid m. Posterior Ant. belly sternocleidomastoid m, lat. side post. belly of the digastric m. (posterior-medial) Lateral Subcutaneous fat, platysma Medial Post. belly of the digastric m, styloid process, parapharyngeal space 24
  25. 25. Submandibular Gland Boundary Explanation Cranial Medial pterygoid m, mylohyoid m. Caudal Fatty tissue Anterior Lat. surface mylohyoid m, hyoglossus m. Posterior Parapharyngeal space, sternocleidomastoid m. Lateral Med. surface medial pterygoid m, med. surface mandibular bone, platysma Medial Lat. surface mylohyoid m, hyoglossus m, superior and middle pharyngeal constrictor m, anterior belly of the digastric m. 25
  26. 26. Sublingual Gland Boundary 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. Lateral Ant. part med. surface mandibular bone, mylohyoid m. Medial Genioglossus m. 26
  27. 27. Salivary Glands - Delineation 27 5 Anterior belly digastric m. 6 Geniohyoid m. 10 Sternocleidomastoid m. 11 Platysma • • • • • Sub Lingual Glands – Dark Blue
  28. 28. Salivary Glands - Delineation 28 5 Anterior belly digastric m. 6 Geniohyoid m. 9 Pharyngeal constrictor m. 10 Sternocleidomastoid m. 11 Platysma • • • • • Sub Lingual Glands – Dark Blue
  29. 29. Salivary Glands - Delineation 29 1 Genioglossus m. 2 Mylohyoid m. 3 Hyoglossus m. 10 Sternocleidomastoid m. 11 Platysma 15 Mandibular bone • • • • • Sub Lingual Glands – Dark Blue
  30. 30. Salivary Glands - Delineation 30 1 Genioglossus m. 2 Mylohyoid m. 3 Hyoglossus m. 9 Pharyngeal constrictor m. 10 Sternocleidomastoid m. 15 Mandibular bone • • • • • Sub Lingual Glands – Dark Blue
  31. 31. Salivary Glands - Delineation 31 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
  32. 32. Salivary Glands - Delineation 32 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
  33. 33. Salivary Glands - Delineation 33 4 Posterior belly digastric m. 7 Medial pterygoid m. 10 Sternocleidomastoid m. 12 Masseter m. • • • • • Sub Lingual Glands – Dark Blue
  34. 34. Salivary Glands - Delineation 34 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
  35. 35. Parotid – Axial and Coronal 35
  36. 36. Submandibular – Sagittal and Coronal 36
  37. 37. SubLingual – Sagittal and Coronal 37
  38. 38. SOFT PALATE 38
  39. 39. Soft Palate Boundary Explanation Cranial Hard palate, nasopharyngeal mucosal space/air lumen Caudal Tongue base, palatine tonsils, oropharyngeal mucosal space/air lumen Anterior Hard palate, tongue/tongue base, air present in oral cavity or pharyngeal lumen Posterior Superior 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
  40. 40. SOFT PALATE – Sagittal and Axial 40
  41. 41. SOFT PALATE 41 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.
  42. 42. SOFT PALATE 42 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.
  43. 43. SOFT PALATE 43 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.
  44. 44. SOFT PALATE 44 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.
  45. 45. SOFT PALATE 45 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.
  46. 46. SOFT PALATE 46 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.
  47. 47. LIPS AND BUCCAL MUCOSA 47
  48. 48. Inner Surface Upper Lips Boundary Explanation Cranial Hard 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
  49. 49. Inner Surface Lower Lips Boundary Explanation Cranial Upper edge lower lip Caudal Lower 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
  50. 50. Inner Surface Cheeks Boundary Explanation Cranial Transition 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, tongue 50
  51. 51. 51
  52. 52. 52 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
  53. 53. 53 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
  54. 54. 54 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
  55. 55. 55 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
  56. 56. 56
  57. 57. 57 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
  58. 58. 58 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
  59. 59. 59 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
  60. 60. 60 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
  61. 61. PHARYNGEAL CONSTRICTORS 61
  62. 62. Superior Constrictor Muscle Boundary 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 62
  63. 63. 63 Radiotherapy and Oncology 110 (2014) 390–397
  64. 64. 64 Radiotherapy and Oncology 110 (2014) 390–397
  65. 65. 65 Radiotherapy and Oncology 110 (2014) 390–397
  66. 66. 66 Radiotherapy and Oncology 110 (2014) 390–397
  67. 67. Middle Constrictor Muscle Boundary 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 67
  68. 68. 68 Radiotherapy and Oncology 110 (2014) 390–397
  69. 69. 69 Radiotherapy and Oncology 110 (2014) 390–397
  70. 70. 70 Radiotherapy and Oncology 110 (2014) 390–397
  71. 71. Inferior Constrictor Muscle Boundary 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 71
  72. 72. 72 Radiotherapy and Oncology 110 (2014) 390–397
  73. 73. 73 Radiotherapy and Oncology 110 (2014) 390–397
  74. 74. 74 Radiotherapy and Oncology 110 (2014) 390–397
  75. 75. 75 Radiotherapy and Oncology 110 (2014) 390–397
  76. 76. 76 Radiotherapy and Oncology 110 (2014) 390–397
  77. 77. 77 Radiotherapy and Oncology 110 (2014) 390–397
  78. 78. Dose Constraints Constrictors Mean Dose < 50 Gy QUANTEC Lips Mean Dose <20 Gy For parotid tumor: Max < 30Gy For 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 78
  79. 79. 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 <50Gy Mean < 45 Gy RTOG 1016 QUANTEC 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 Gy V59Gy < 1-10cc QUANTEC Spinal cord Max 50 Gy QUANTEC 79
  80. 80. Conclusion • Correct Contouring of OARs is as important to contouring of Target. • Whenever in doubt please refer to atlases available online. 80

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