Clinical Target Volumes in Conformal and Intensity Modulated Radiation Therapy: A Clinical Guide to Cancer Treatment

252 Pages·2004·12.01 MB·English

by  B. G. Lengelé MD

MEDICAL RADIOLOGY
Radiation Oncology
Editors:
L. W. Brady, Philadelphia
H.-P. Heilmann, Hamburg
M. Molls, Munich
Springer-Verlag Berlin Heidelberg GmbH
V. Gregoire· P. Scalliet . K. K. Ang (Eds.)
Clinical Target Volumes
in Conformal and Intensity
Modulated
Radiation Therapy
A Clinical Guide to Cancer Treatment
With Contributions by
A. Bosly . R. Bristow· M. Cengiz . K. S. C. Chao· E. E. Coche . G. Cosnard . T. Duprez
P. A. Gervaz . M. Gospodarowicz . V. Gregoire· 1. 1. Gunderson· M. G. Haddock· M. Hamoir
K. Haustermans . T. Haycocks· T. Herzog· M. Jewett· I. C. Kiricuta . B. G. Lengele
A. Lerut . M. Lonneux . P. Loubeyre . M. Milosevic . F. Mornex . H. Nelson· B. O'Sullivan
P. W. T. Pisters . 1. Renard· H. Reychler . P. Rocmans . P. Scalliet . B. Tombal . P. van Houtte
F. Vaylet . J. Wunder
Foreword by
1. W. Brady, H.-P. Heilmann and M. Molls
Preface by
H. Suit
With 92 Figures in 222 Separate Illustrations, 129 in Color and 73 Tables
" Springer
VINCENT GREGOIRE, MD, PhD
PIERRE SCALLIET, MD, PhD
Department of Radiation Oncology
Vniversite Catholique de Louvain
Cliniques Universitaires Saint- Luc
Avenue Hippocrate 10, VCL 10/4752
1200 Bruxelles
Belgium
K. KlAN ANG, MD, PhD
Department of Radiation Oncology
vr
MD Anderson Cancer Center
rx
Houston, 77030
VSA
MEDICAL RADIOLOGY' Diagnostic Imaging and Radiation Oncology
Series Editors: A. L. Baert· L. W. Brady· H.-P. Heilmann· M. Molls· K. Sartor
Continuation of
Handbuch der medizinischen Radiologie
Encyclopedia of Medical Radiology
ISBN 978-3-642-07463-9
Library of Congress Cataloging-in-Publication Data
Clinical target volumes in conformal and intensity modulated radiation therapy: a
clinical guide to cancer treatment I V. Gregoire, P. Scalliet, K. K. Ang (eds.); with
contributions by K. K. Ang ... let al.]; foreword by 1. W. Brady, H.-P. Heilmann, and M. Molls.
p. ; cm. --(Medical radiology)
Includes bibliographical references and index.
ISBN 978-3-642-07463-9 ISBN 978-3-662-06270-8 (eBook)
DOI 10.1007/978-3-662-06270-8
1. Cancer--Radiotherapy. I. Gregoire, V. (Vincent), 1962- II. Scalliet, P. (Pierre),
1953- III. Ang, K. K. (K. Kian) IV. Series.
[DNLM: I. Neoplasms--radiotherapy. 2. Radiotherapy Dosage. 3. Radiotherapy,
Conformal--methods. QZ 269 C6416 2002]
RC271.R3 C58 2002
616.99' 40642--dc21 2002075846
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Foreword
The advances in radiation oncology in the past 50 years are probably more dramatic than
those that occurred in the first half of the 20th century. There have been major technical
achievements associated with increased overall cure rates for cancer from 20% at 5 years
50 years ago to now nearly 60% at 5 years. The cure rates in selected tumor sites at 5 years
in 1950 and in 2000 respectively were as follows: breast, 50% and 80%; colon and rectum,
40% and 85%; lung, 5% and 15-20%; prostate, 40% and 80%; Hodgkin's disease, 50% and
more than 90%; cervix, 40% and 70-80%; uterus (endometrium), 80% and more than 90%;
bladder, 30% and 50%; head and neck, 30% and 60%; esophagus, 2% and 15%. A significant
proportion of these advancements have been due to a broader array of techniques available
in radiation oncology for treatment, as well as emphasis on combined integrated multimodal
treatment with surgery, radiation therapy, and chemotherapy.
The volume by Gregoire, Scalliet and Ang identifies a new technique with regard to confor
mal radiation therapy that allows for appropriate selection and delineation of clinical target
volumes for different tumor sites. Included within that definition is the knowledge of lymph
node areas with potential microscopic involvement, addressing the issues of those areas that
must be included in the target volumes.
The volume makes significant and important data available relative to clinical, radiol
ogical, and pathological examiniation for surgical specimens as well as the patterns of
local regional relapse to influence the recommendations for the selection of clinical target
volumes. Three-dimensional reconstructed treatment planning and three-dimensional
reconstructed treatment delivery to the identified primary tumor as well as the potentially
involved regional lymph node involvement would be associated with improvement in the
ultimate outcome. These basic, data allow for decisions that are important in selection and
delineation of the target volume, emphasizing the appropriate radiation therapy techniques.
This information is crucial with regard to the maximization of tumor control and the mini
mization of complications from the treatment regimen.
Without question, these data are important in making more appropriate and proper use of
the radiation therapy technology. These advances, based on major clinical information from
surgical and pathologic studies along with clever and careful biologic research, form the foun
dation for conformal treatment and its ultimate contribution to the care of the cancer patient.
Philadelphia LUTHER W. BRADY
Hamburg HANS-PETER HEILMANN
Munich MICHAEL MOLLS
Preface
This book deals comprehensively with the critically important requirement for radiation
oncologists to integrate knowledge of the anatomy and the new imaging techniques for plan
ning and delivery of radiation treatment. The remarkable and rapid gains in the technical
ability of the physicists and engineers to deliver radiation dose to any defined target volumes
in patients with an uncertainty of only a few millimeters has resulted in much more intense
emphasis on defining the target and the secure knowledge of the position of the entirety of
the target relative to the beam throughout each treatment session.
Currently, high-technology radiation treatments include three-dimensional conformal,
intensity-modulated radiation treatment planning/delivery and high-resolution online
portal imaging. Thus, there is the requirement for accurate knowledge in the individual
patient of the exact position of the primary and secondary targets. This book places heavy
and appropriate emphasis on defining the location of lymph node chains in each patient.
That is, the treatment volume should not be based on the volumes of tissues in which a par
ticular nodal chain is found in a patient population, but rather on the location of the node
chain of concern in the particular patient whose treatment is being planned. In parallel, it
is necessary to define the extent and pattern of subclinical tumor. Further, the distinction
between edema and inflammatory changes owing to tumor infiltration is essential. These
considerations apply similarly to radiation therapy and surgery, as the target volumes are, of
course, exactly the same for the two modalities. These imaging techniques include very thin
section CT, MRI, MRS, ultrasound and PET. Advances in both the precision and the accuracy
of these techniques are in development for specific sites, e.g., paramagnetic iron oxide as the
contrast agent for visualization of lymph nodes.
A central theme in this book is the detailed presentation of the anatomy of the lymph node
chains and the likelihood of nodal involvement for tumors at different body sites. The open
ing chapter is an extensive and scholarly description of the anatomy of the lymph vessels and
nodes at various parts of the human body. This is followed by analysis of imaging of lymph
nodes using CT, MRI and PET.
The ensuing chapters are valuable contributions on the anatomy and treatment plan
ning at specific sites: head and neck, lung, esophagus, breast, prostate, bladder, gynecologic
tumors, rectum/anus, sarcoma of soft tissues and lymphomas. In most of these, there is con
sideration of identification of the number, size and anatomic distribution of lymph nodes
and the probability of their involvement by metastatic tumor.
The authors are well recognized for their expertise in their respective fields. The infor
mation contained in this book will serve as a valuable resource for daily practice for both
the clinician and the physicist. Significantly, this book constitutes a highly useful aid in the
education of young doctors.
HERMAN SUIT
Andres Sorian Distinguished Professor of Radiation Oncology,
Harvard Medical School/Radiation Oncologist,
Massachusetts General Hospital, Boston, Massachusetts, USA
Introduction
Radiation oncology is a relatively young medical speciality that focuses on the treatment of
neoplastic diseases using ionizing radiation. The fascination for using ionizing radiation in
medical treatment started right after the discovery of X-rays by Wilhelm Conrad Rontgen
in 1895 and isolation of radium by Marie and Pierre Curie in 1898. Among the first docu
mented medical uses of radiation was that in 1896, when a Viennese dermatologist, Leopold
Freund, treated the hairy nevus utilizing the very low dose rate X-rate tube available at that
time. However, without rudimentary understanding of how radiation affected living tissues,
radiation was mostly used by dermatologists and surgeons during the first two decades of
the twentieth century as a form of cautery. High single radiation doses were generally admin
istered that caused tissue sloughing, which led to morbid sequelae. Such casual applications
of radiation resulted in a general skepticism about its usefulness as a therapeutic modality
during the first two decades of the twentieth century, but the specialty has come a long way
since then.
More systematic applications and investigations of radiation for medical treatments began
around 1920. This was characterized by a swing toward fractionated treatment in Paris,
Zurich, and Vienna, based on the pioneering clinical work of Regaud, Coutard, Schwarz, Hol
zknecht and others complemented by experimental findings on the sterilization of testicles in
the grasshopper and rabbit. The field of radiation oncology then evolved gradually, starting
in Europe, at first in combination with diagnostic radiology but subsequently growing to a
separate speciality at varying speeds in different countries. "Fractionation in Radiotherapy",
edited by Thames and Hendry and published by Taylor and Francis in 1987, is an excellent
reference for readers interested in the history of the specialty.
Radiation oncology has experienced a number of "quantum leaps" brought about by com
binations of advances in equipment engineering and better insight into biological processes
governing cellular and tissue responses to ionizing radiation. The advent of telecobalt units
followed by invention of accelerators producing both high-energy photons and electrons, for
instance, made it possible to deliver potentially tumoricidal radiation doses even to deep
seated neoplasms without exceeding the tolerance of the skin and subcutaneous tissues. The
development of technology for portal shaping (e.g., lead collimation or Cerrobend block)
and beam intensity modulation (e.g., wedges and missing tissue compensator) along with
computerized treatment-planning systems gradually improved the flexibility and precision
of radiation dose delivery.
Simultaneous with gradual refinement of radiotherapy techniques, conceptions of basic
biological principles had an important impact on radiation therapy. The idea of decreasing
"density of clonogenic infestation" with increasing distance from the tumor epicenter, for
example, led to the conception and validation of the "shrinking field" technique and laid the
foundation for combining surgery and radiotherapy. More recently critical scrutiny of clini
cal and experimental data on the effects of radiation dose fractionation resulted in the design
of biologically rational altered fractionation regimes, i.e., hyperfractionation and accelerated
fractionation. The collective data of many phase III trials designed to test these biologically
sound regimes indeed validated the superiority of some of the altered frationation regimens
in yielding local-regional tumor control.
Advances in the knowledge of drug-radiation interaction have also generated enthusiasm
for combining radiation with cytotoxic agents to improve therapy outcome. Numerous
radiation-chemotherapy regimens, particularly when given concurrently, have been found
in phase III studies to be better than radiation alone in obtaining local-regional control and
survival of patients with a variety of cancers, but, unfortunately, too often at the cost of
increased late normal tissues toxicity. Roaring progress in molecular and tumor biology is
beginning, forming the foundation for development of a new generation of therapies target
ing specific molecules or signaling pathways to selectively enhance the response of tumors
with distinct molecular make-up.
Finally, the explosive growth in computer hardware and software along with improved
design of medical linear accelerators has begun to revolutionize radiotherapy. The availabil
ity of computer-operated multi-leaf collimators offers the flexibility not only to dynamically
shape the radiation portal but also to vary the beam intensity across the portal. This capacity,
along with improvements in the accuracy of tumor delineation through progress in diagnos
tic imaging methodology, has introduced an unprecedented era of high-precision radiation
therapy. This relatively new technology will improve physical targeting of tumors, i.e., deliver
high radiation doses to three-dimensional volumes that conform to the shapes of tumors
and involved nodes, thereby reducing the dose administered to normal tissues. In general
terms, such high-precision radiation delivery is, therefore, referred to as three-dimensional
conformal radiotherapy (3-D CRT) or simply conformal radiotherapy.
Proper application of conformal radiotherapy, however, demands greater familiarity
with tumor and normal tissue anatomy and better knowledge of the patterns of contigu
ous and lymphatic spread to minimize the risk of geographically missing tumors or their
potential microscopic extension. Therefore, this volume attempts to provide general intro
ductory guidelines for delineation of the gross target volume and clinical target volume for
a number of common neoplasms as a practical day-to-day reference for novices in the field.
We are grateful that many radiation oncologists who pioneered the clinical use of conformal
radiotherapy have contributed to this project. It is important to keep in mind in using this
handbook that general guidelines cannot address all possible clinical permutations, so that
it may be prudent to apply rational clinical judgement or consult more experienced col
leagues in unusual cases. We also anticipate that these general guidelines will require further
refinement based on emerging clinical experience. Therefore, we will appreciate feedback,
remarks, and advice.
Bruxelles VINCENT GREGOIRE
Houston K.KIAN ANG
Bruxelles PIERRE SCALLIET
Contents
1 The Lymphatic System
B. G. LENGELE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Imaging the Lymph Nodes: CT, MRI, and PET
E. E. COCHE, T. DUPREz, and M. LONNEUX .................................... 37
3 Selection and Delineation of Lymph Node Target Volumes in Head
and Neck Conformal and Intensity Modulated Radiation Therapy
V. GREGOIRE, E. E. COCHE, G. COSNARD, M. HAMOIR, and H. REYCHLER .......... 69
4 Lung Cancer
P. VAN HOUTTE, F. MORNEX, P. ROCMANs, P. LOUBEYRE, and F. VAYLET . . . . . . . . . . .. 91
5 Esophageal Tumors
K. HAuSTERMANS and A. LERUT ............................................. 107
6 Target Volume Selection and Delineation in Breast Cancer Conformal
Radiotherapy
I. C. KIRICUTA ............................................................. 121
7 CTV for Lymphatics in Prostate Adenocarcinoma, an Anatomical Description
and a Clinical Discussion
P. SCALLIET, 1. RENARD, B. G. LENGELE, and B. TOMBAL ......................... 145
8 Intensity-Modulated Radiation Therapy (IMRT) for Lymph Node Metastases
in Bladder Cancer
M. MILOSEVIC, M. GOSPODAROWICZ, M. JEWETT, R. BRISTOW, and T. HAYCOCKS ... 157
9 Gynecologic Tumors
K. S. C. CHAO, M. CENGIZ, and T. HERzoG ..................................... 171
10 Rectal and Anal Cancers in Conformal Radiotherapy Planning: Selection
and Delineation of Lymph Node Areas Tumors
1. 1. GUNDERSON, M. G. HADDOCK, P. A. GERVAZ, and H. NELsoN ................ 187
11 Target Description for Radiotherapy of Soft Tissue Sarcoma
B. O'SULLIVAN, J. WUNDER, and P. W. T. PISTERS ............................... 205
12 Role of Radiotherapy in Lymphomas
A. BOSLY .................................................................. 229
Subject Index ................................................................ 241
List of Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 245
1 The Lymphatic System
Anatomical Bases for Radiological Delineation of Lymph Node Areas
B. G. LENGELE
CONTENTS 1.8.3 Delineation of Lymph Node Areas 34
1.9 Conclusions 35
1.1 Introduction References 36
1.2 Main Collecting Ducts 2
1.2.1 The Thoracic Duct 2
1.2.2 The Right Lymphatic Duct 2
1.3 Lymphatics of the Head and Neck 3 1.1
1.3.1 Lymph Node Groups of the Pericervical Circle 5 Introduction
1.3.2 Descending Cervical Chains 6
1.3.2.1 The Deep Lateral Cervical Chain 6
The lymphatic system is constituted of numerous
1.3.2.2 The Deep Posterior Cervical Chain 7
1.3.2.3 The Superficial Lateral Cervical Chain 7 fine vessels which traverse several groups of nodes
1.3.2.4 The Anterior Cervical Chains 7 and transport the lymph into the venous system.
1.3.3 Functional Drainage Pathways 8 The capillaries of origin have closed extremities
1.3.4 Delineation of Lymph Node Areas 10 which are disseminated within the connective tis
1.4 Lymphatics of the Upper Limbs 10
sues beyond the epithelial lining, and which through
1.4.1 Axillary Lymph Nodes 11
several interconnecting anastomoses form primary
1.4.2 Superficial Lymph Nodes 11
1.4.3 Functional Drainage Pathways 11 networks which drain the lymphatic fluid into the
1.4.4 Delineation of Lymph Node Areas 14 first collecting ducts. Passing through the successive
1.5 Lymphatics of the Thorax 14 groups of lymph nodes, these ducts again divide into
1.5.1 Parietal Vessels and Nodes 15
capillaries and then finally give rise to the larger col
1.5.2 Visceral Vessels and Nodes 15
lecting vessels which are usually two in number: the
1.5.3 Functional Drainage Pathways 17
1.5.4 Delineation of Lymph Node Areas 17 thoracic duct and right lymphatic duct, which join
1.6 Lymphatics of the Abdomen 18 the left and right brachiocephalic veins respectively.
1.6.1 Parietal Vessels and Nodes 18 The lymphatic vessels have very thin endothelial
1.6.2 Visceral Vessels and Nodes 18
walls, are filled with a clear colourless fluid, and are
1.6.2.1 The Pre-aortic Group of Nodes
usually not visible in living tissue so that various stain
and Their Digestive Affluents 19
1.6.2.2 The Lateral Aortic Lymph Nodes ing or radio-opaque substances have to be injected
and Their Urogenital Affiuents 21 before their distribution and general pathways can
1.6.3 Functional Drainage Pathways 22 be studied. In the small intestine, however, they have
1.6.4 Delineation of Lymph Node Areas 22
a milk-white appearance during the immediate post
1.7 Lymphatics of the Pelvis 23
prandial period, which explains their original name
1.7.1 Parietal Lymph Vessels and Nodes 23
1.7.2 Visceral Vessels and Nodes 23 of lacteal veins. They possess numerous valves which
1.7.2.1 Juxtavisceral Nodes 23 result in a characteristic moniliform appearance and
1.7.2.2 External Iliac Nodes 25 are present in all tissues of the human body except for
1.7.2.3 Internal Iliac Lymph Nodes 26
avascular structures such as the epidermis, the cornea
1.7.2.4 Common Iliac Lymph Nodes 26
and the cartilage. They are also absent in the brain,
1.7.3 Functional Drainage Pathways 27
1.7.4 Delineation of Pelvic Lymph Node Areas 28 spinal cord, and bone marrow.
1.8 Lymphatics of the Lower Limbs 31 According to their location, the lymphatic vessels
1.8.1 Lymph Node Groups 31
branch into two networks located respectively above
1.8.2 Functional Drainage Pathways 32
and below the deep fasciae. The superficial lymph ves
sels drain the skin and the subcutaneous tissue and
B. G. LENGELE, MD, PhD, FCCP
tend to run alongside the superficial veins, though
Professor and Head of the Human Anatomy Department,
Universite Catholique de Louvain, Avenue E. Mounier 52.40, some may be independently situated. Vessels of the
1200 Brussels, Belgium deep subfascial network similarly course alongside the