RADIOTHERAPY TARGET DELINEATION IN BREAST CANCER

1. RADIOTHERAPY TARGET DELINEATION
(GCP PARAMETERS) IN BREAST CANCERS
DR KANHU CHARAN PATRO
MD,DNB(Radiation Oncology),MBA,FICRO,FAROI,PDCR,CEPC
HOD,RADIATION ONCOLOGY
Mahatma Gandhi Cancer Hospital And Research Institute, Visakhapatnam, India
drkcpatro@gmail.com /M-INDIA-9160470564
1

2. Where is the Target?
2

3. PUSH AND PULL BUSINESS
OAR
TARGET
3

4. SYSTEMATIC ERROR
4

5. REDUCTION IN PTV
• Custom immobilization
• Respiratory management
• Image guidance
PTV PTV
5

6. Delineation
• OAR
• TARGET
6

7. Settings
• POST MRM
– CHEST WALL
– CHEST WALL + NODES
• BCS
– BREAST
– BREAST + NODES
– BOOST
7

8. TARGET
– CHEST WALL
– BREAST
– NODES
• AXILLARY
– LEVEL I
– LEVEL II
– LEVE III
• IMN
• SCF
– BOOST CAVITY
8

9. OAR
– LUNG
– HEART
– CORONARY VESSELS
– BRACHIAL PLEXUS
– CONTRALATERL BREAST
9

10. GUIDELINES
– EORTC
– RTOG
– TROG
– RTOG-RADCOMP
– FAST Forward
10

11. BOUNDARY GUIDELINES
– MUSKULOSKELEAL
– VSCULAR
11

12. ESTRO GUIDELINES

13. ESTRO GUIDELINES

14. RTOG GUIDELINES

15. RTOG GUIDELINES

16. RTOG GUIDELINES

17. FAST Forward GUIDELINES

22. PROCAB VASCULAR BSED GUIDELINES

23. NORMAL STRUCTURES
• MUSCLES
– PECTORALIS
• MINOR
• MAJOR
– LATISMUS
– STERNOCLEOID
– SCALENUS
– SUBSCPULARIS
– INTERCOSTAL
• VESSELS
– BRACHEOCEPALIC
– SUBCLAVIAN
– THORACIC
– INTERNAL MAMMARY
– IJV
• CARTILAGE AND BONES
– RIBS
– CLAVICLE
– STERNUM
– CRICOID
– SCAPULA
23

24. NEED OF RT
• ALL NACT MRM
• ALL NAHT MRM
• OTHER MRM
• ALL BCS
• AXILLARY NODES
– SENTINEL NODE BIOPSY ONLY
• IMN
– ALL NACT/NAHT
– MEDIAL/INNER QUADRANT
• SCF
– NODAL POSITIVE
24

25. BCS
25
The Arterial system

26. 26

27. 27

28. The venous system
28

29. 29

30. 30

31. Can you find the right and left subclavian arteries?
31

32. The right subclavian artery as it
dumps into the brachiocephalic artery.
(click to highlight)
32

33. Can you find the first 3 branches
off the aortic arch? (click for answer)
Brachiocephalic artery
Left Common Carotid artery
Left Subclavian artery
33

34. This is contrast (white) being injected into the left subclavian vein.
34

35. 35

36. 36

37. 37

38. 38

39. Can you find the left brachiocephalic vein as it dumps into the SVC?
39

40. We are at the level of the top of the aortic arch (click to highlight)
40

41. 41

42. What is the structure in blue? (click to highlight)
This is the
Superior
Vena cava
42

43. 43

44. 44

45. Can you find the azygous arch ? (where the azygous
vein comes across to dump into the SVC) (click for answer)
45

46. 46

47. Notice the bifurcation of
the trachea (corina) at this level (click to highlight)
47

48. 48

49. What is the structure in red This is the left pulmonary artery.
49

50. 50

51. 51

52. 52

53. Can you find the pulmonary trunk and right pulmonary artery?
(click for answer)
53

54. Where are the ascending (A) and descending (D) limbs of the
thoracic aorta? (click to highlight)
A
D
54

55. 55

56. We are at the level of the top of the left atrium.
Notice The pulmonary veins
dumping into it as they return from the lungs.
56

57. Can you find the left main coronary artery
coming off the aorta? (click for answer)
57

58. The left coronary branch into the Circumflex artery and the LAD artery
58

59. 59

60. Positioning of heart chambers
60
RA
RV
LA
LV

61. Here is a good image of the
aortic semi-lunar valve leaflets. Can
you find them? (click for answer)
61

62. 62

63. Here is a good image of the left atrium dumping
Into the left ventricle. Can you find it? (click to highlight)
63

64. 64

65. You can clearly see the left ventricular wall and septum
with the projecting papillary wall muscles attaching
to the mitral valve leaflets. (click to highlight)
65

66. 66

67. 67

68. Contrast filling the right ventricle
68

69. 69

70. Can you find the pericardial sac here
It is relatively easy to
see because there is a
fat layer around the
heart
and around the
pericardium making the
soft tissue more visible
70

71. 71

72. 72

73. 73
Medial mammary branches of
the internal thoracic artery
Lateral thoracic artery.

74. Thoracic muscles
74

75. Can you find the right pectoralis major and minor? (click for answer)
75

76. 76

77. 77

78. Axilla boundary
78

79. 79

80. 80

81. 81

82. 82

83. 83

84. 84

85. 85

86. 86

87. 87

88. PECTORLIS MAJOR AND MINOR MUSCLE
88

89. 89

90. 90

91. 91

92. 92

93. 93

94. 94

95. 95

96. 96

97. 97

98. CONTOUR THE FAT SPACE AROUND MUSCLES
98

99. 99

100. LEVEL I
100

101. Axilla level I
ESTRO RTOG RTOG-RADCOMP TROG
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
Axillary vessels cross
lateral edge of
pectoralis minor m
Axillary vv at lateral edge
pectoralis minor & below
humeral head
Tendon of latissimus dorsi,
generally not above superior
aspect of coracoid process
CAUDAL To the level of rib 4 and 5, taking also
into account the visible effects of the
sentinel lymph node biopsy
Pectoralis major insert
onto ribs
Pectoralis major inserts
into ribs (around fourth
and fifth rib
Superior to visible breast
tissue, wherever vessels can
be seen laterally in the space
between the lateral aspect of
pectoralis major & teres
muscles
MEDIAL Axilla level II, the interpectoral level and
the thoracic wall
Lateral border
pectoralis minor
Lateral border pectoralis
minor/level II axilla
Pectoralis mm, CW, and the
level II axilla
LATERAL Cranially up to an imaginary line
between the major pectoral and deltoid
muscles & caudal up to a line between
the major pectoral and latissimus dorsi
muscles
Medial border of
latissimus dorsi
Latissimus dorsi, at line
connecting latissimus
dorsi and deltoid or up to
skin
Teres major, subscapularis
and skin
ANTERIOR Pectoralis major and minor mm Plane defined by
anterior surface of
pectoralis major and
lat dorsi
Posterior pectoralis major
or skin
Skin
POSTERIO
R
Cranially up to the thoracodorsal
vessels, and caudally up to an
imaginary line between the anterior
edge of the latissimus dorsi mm &
intercostal mm
Anterior surface
subscapularis muscle
Anterior border
subscapularis and
latissimus dorsi
Post border of axillary
vessels, subscapularis and
teres mm

102. AXILLARY I
102

103. 103
SUPERIOR
AXILLARY VESSELS AS THEY EXIT PEC MINOR

104. 104
LATERAL
LATERAL EDGE OF LATISMUS DORSI

105. 105
MEDIAL
LATERAL EDGE PECTORALIS MINOR

106. 106
POSTERIOR
ANTERIOR MARGIN OF SUBSCAPULARIS

107. 107

108. 108

109. 109

110. 110

111. 111

112. 112

113. 113

114. 114
INFERIOR
LATERAL EDGE OF FIRST SLICE OF MAJOR AND 4TH RIB

115. LEVEL II
115

116. Axilla level II
ESTRO RTOG RTOG-RADCOMP TROG
CRANIAL Cranial extent of the axillary
artery (i.e. 5 mm cranial of
axillary vein)
Axillary vessels cross
medial edge of pectoralis
minor m
At or below pectoralis
minor insertion on
coracoid
Superior slice of the
axillary vessels posterior
or deep to pectoralis
minor
CAUDAL Caudal border of pectoralis
minor mm, (or top of ALND)
Axillary vessels cross
lateral edge of pectoralis
minor m
Obliteration of fat space
between pectoralis
major and pectoralis
minor or CW (may
include pectoralis minor
mm for ease of
contouring
Last slice where
pectoralis minor has not
attached to CW
MEDIAL Medial border pectoralis minor Medial border pectoralis
minor
Medial border pectoralis
minor/level III axilla
Medial border pectoralis
minor/level III axilla
LATERAL Lateral border pectoralis minor Lateral border pectoralis
minor
Lateral border pectoralis
minor/level I
Lateral border pectoralis
minor/level I axilla
ANTERIOR Pectoralis minor Anterior surface pectoralis
minor
Posterior pectoralis
major
Posterior pectoralis
major
POSTERIOR Up to 5 mm dorsal of axillary
vein or to costae and intercostal
muscles
Ribs and intercostal mm CW 5 mm margin on
posterior border of
axillary vessels; or CW
(no margin)

117. AXILLARY II
117

118. 118
SUPERIOR
UPPER BOARDER OF PECTORALIS MINOR

119. 119
MEDIAL
MEDIAL EDGE OF PECTORALIS MINOR

120. 120
LATERAL
LATERAL EDGE OF PECTORALIS MINOR

121. 121
POSTERIOR
RIB AND INTERCOSTAL SPACE

122. 122
ANTERIOR
POSTERIOR MARGIN OF PECTORALIS MAJOR

123. 123

124. 124
INFERIOR
LOSS OF FAT SPACE BETWEEN RIB & MINOR

125. 125
INFERIOR
LOSS OF FAT SPACE BETWEEN RIB & MAJOR

126. LEVEL III-GRREN
126

127. Axilla level III
ESTRO RTOG RTOG-RADCOMP TROG
CRANIAL Cranial extent of the subclavian
artery (i.e. 5 mm cranial of
subclavian vein
Pectoralis minor insert on
cricoid
At or below pectoralis
minor insertion on
coracoid
Inferior to infraclavicular
volume
CAUDAL 5 mm caudal to subclavian vein
(or top ALND
Axillary vessels cross-
medial edge of pectoralis
minor
Obliteration of fat space
between pectoralis
major and CW
Inferior CT slice of the
axillary vessels
MEDIAL Junction of subclavian and
internal jugular veins –> level 4
Thoracic inlet Obliteration of fat space
and supraclavicular
volume
Clavicle, rib, and the
lateral aspect of the
jugulo-subclavian
junction
LATERAL Medial side of the minor
pectoral muscle
Medial border of pectoralis
minor
Level 2/medial border
pectoralis minor
Medial border pectoralis
minor
ANTERIOR Pectoralis major Posterior surface pectoralis
major
Posterior pectoralis
major
Posterior surface
pectoralis major
POSTERIOR Up to 5 mm dorsal of subclavian
vein or to costae and intercostal
muscles
Ribs and intercostal mm CW Ribs and axillary
vessels

128. AXILLARY III
128

129. SUPERIOR
UPPER BOARDER OF PECTORALIS MINOR
129

130. 130
LATERAL
MEDIAL BOARDER OF PECTORALIS MINOR

131. 131
MEDIAL
CLAVICALE AND 1ST RIB JUNCTION

132. 132

133. 133

134. 134

135. 135

136. 136
INFERIOR
LOSS OF FAT SPACE BETWEEN RIB & MAJOR

137. 137

138. SUPRACLAVICULAR
138

139. Supraclavicular Fossa
ESTRO RTOG RTOG-RADCOMP
CRANIAL Whole of subclavian vein and artery
(or 1–2 cm sup to involved LN)
Caudal to cricoid cartilage Below the cricoid
CAUDAL Subclavian vein with a 5 mm margin
(connecting to IMN)
Junction of brachiocephalic-
axillary veins/caudal edge
clavicle head (superior border of
breast/CW field)
Connect to IMN (include
subclavian vein)
MEDIAL Jugular vein without margin; exclude
thyroid and common carotid artery
Exclude thyroid and trachea Medial edge carotid artery
LATERAL Anterior scalene mm and connects to
medial border level 3
Cranial: lat edge SCM; caudal:
junction first rib-clavicle
Lateral edge SCM, clavicle
and connecting to axilla level
III
ANTERIOR SCM, posterior edge clavicle SCM Dorsal surface of SCM,
clavicle or strap mm
POSTERIOR Pleura Anterior aspect scalene mm Scalenus (ant and med),
levator scapulae

140. SCF
140

141. 141

142. 142

143. 143
SUPERIOR
LOWER BORDER OF CRICOID

144. 144
ANTERIOR
POSTERIOR SURFACE SCM

145. POSTEROIR
ANTERIOR SURFACE SCALANAE ANTERIOR
145

146. 146
MEDIAL
MEDIAL EDGE OF CAROTID

147. 147

148. 148
LATERAL
MEDIAL EDGE OF SUBCLAVIAN VESSELS

149. 149
LATERAL
LOWER EDGE OF CLAVICULAR HEAD

150. INTERNAL MAMMRY NODE
LEMON GREEN
150

151. Internal mammary chain
ESTRO RTOG RTOG-RADCOMP TROG
CRANIAL Caudal limit of SCF
(CTVn_L4)
Superior aspect medial
first rib
Inferior supraclav
volume or caudal to
head of clavicle
Internal mammary artery
and vein are used as
surrogates
CAUDAL Cranial side of fourth rib (fifth
rib in select cases)
Cranial aspect of fourth
rib
Cranial border fourth
rib
MEDIAL 5 mm margin on internal
mammary vein and artery
Encompass internal
mammary/thoracic
vessels
Sternum
LATERAL 5 mm margin on internal
mammary vein and artery
Include any visible fat
ANTERIOR Anterior limit of vascular area Posterior chest wall
POSTERIO
R
Pleura To pleura (include fat
but no lung)

152. IMN
152

153. 1st RIB
153

154. 154

155. 155

156. 156

157. 157

158. 158

159. 159

160. 160

161. 161

162. 162

163. 4th RIB
163

164. GCP PARAMETERS MRM
• CTV
• PTV
• PTV DVH/EVALUATION
164

165. GCP PARAMETERS
WHLOE BREAST
16
5
PRIMARY
• CTV
• PTV
• PTV DVH/EVALUATION
BOOST
• CAVITY
• CTV CAVITY
• PTV
• PTV BOOST DVH/EVALUATION

166. CHEST WALL
• SKIN
• SUBCUT TISSUE
• RIB
• INTERCOSTAL MUSCLE
166

167. CTV CHEST WALL
167

168. PTV CHEST WALL
168

169. PTV CHEST WALL DVH
169

170. Chest wall
ESTRO RTOG RTOG-RADCOMP FAST FORWARD
CRANIAL Palpable/visible signs, guided
by contralateral breast; max up
to the inferior edge of the
sternoclavicular joint
Caudal border clavicle
head
Interior to head of
clavicle
Encompasses the skin
flaps and includes the
soft tissues down to
the deep fascia
excluding the
underlying muscle and
rib cage
CAUDAL Palpable/visible signs, guided
by contralateral breast
Clinical reference + loss
of CT apparent
contralateral breast
1-2 cm below breast
tissue (or prior breast
tissue
MEDIAL Palpable/visible signs, guided
by contralateral breast
Sternal–rib junction To sternum
LATERAL Palpable/visible signs, guided
by contralateral breast, anterior
to the midaxillary line
Midaxillary line, typically
excludes latissimus dorsi
mm
To midaxillary line (or if
not including level 1&2,
may extend more
posterior)
ANTERIOR 5mm under skin surface Skin Skin
POSTERIOR Pectoralis major or
costal/intercostal mm where no
muscle
Includes pectoralis mm,
CW mm, ribs
Up to but not including
ribs

171. 171
ESTRO RTOG

172. WHOLE BREAST
• GLANDULAR BREAST TISSUE
• SKIN
• SUBCUT TISSUE
• RIB
• INTERCOSTAL MUSCLE
172

173. CTV Whole Breast
ESTRO RTOG FAST FORWARD
CRANIAL Upper border of palpable/visible breast
tissue; maximally up to the inferior edge
of the sternoclavicular joint
Clinical reference + second rib
insertion
Should not extend beyond
the edges of the
visible/palpable breast
CAUDAL Most caudal slice with visible breast Clinical reference + loss of CT
apparent breast
Should not extend beyond
the edges of the
visible/palpable breast
MEDIAL Lateral to the medial perforating
mammary vessels; maximally to the
edge of the sternal bone
Sternal–rib junction Should not extend beyond
the edges of the
visible/palpable breast
LATERAL Lateral breast fold; anterior to the lateral
thoracic artery
Clinical reference and
midaxillary line, typically
excludes latissimus dorsi mm
Should not extend beyond
the edges of the
visible/palpable breast
ANTERIOR 5mm under skin surface Skin 5 mm below the skin surface
POSTERIOR Pectoralis major or costal/intercostal
mm where no muscle
Excludes pectoralis mm, CW
mm, ribs
Should not extend beyond
the deep fascia (unless
clearly breached by the
tumor)

174. BREAST
174

175. CTV BREAST
175

176. PTV BREAST
176

177. PTV BREAST DVH
177

178. 178

179. BOOST
179

181. 181

182. 182

183. BOOST- SCAR
• SCAR
• CAVITY
• CLIP
• CLINICAL
• ARCHITECTURE
• RADIOLOGY
– CT
– PET
– MRI
– MAMMO
183

184. SCAR
184

185. CLINICAL EXAMINATION
185

186. CLIPS
186

187. CAVITY
187

188. ARCHITECTURE
188

189. RADIOLOGY
189

190. GTV BOOST
190

191. CTV BOOST- 1-1.5 CM
191

192. PTV BOOST 1 CM
192

193. 193
PTV BOOST EVALUATION- PTV BOOST DVH
CROP 0.5 CM FROM SKIN

194. Changes
• Ribs are not included in CTV in case of chest wall contouring.
• The dorsal border of CTVn_L1 and CTVn_L2, which to a large extent
defines the depth of the target volumes.
• P. minor muscle is no more included in CTVn_L2.(dorsal to that )
• Exclude carotid artery from Supraclavicular volume.
• 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.

195. Changes
195

196. Conclusion
• Understand the anatomy
• Follow guidelines
• Vascular guidelines looks better
• Follo clinical findings
• Follow imaging
– Pre chemo
– Pre op
– Pathology
– Mammo
196

197. MONACO
1. POST BCS- UMR8 1788- ARATI NAYAYK- KCP 2023
2. POST MRM- UMR 84962 BADE MOGADARAMMA- KCP 2023
3. FAST Forward- UMR 74301 PRAVATI DAS- KCP2022
197

198. Thank You.
198