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TARGET DELINEATION IN HEPATOPANCREATICOBILIARY TUMORS

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TARGET DELINEATION IN HEPATOPANCREATICOBILIARY TUMORS

  1. 1. Optimal target volumes of primary and nodal stations in Hepato Pancreato Biliary Tumors 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+91-9160470564 1
  2. 2. Where is the Target? 2
  3. 3. PUSH AND PULL BUSINESS OAR TARGET 3
  4. 4. SYSTEMATIC ERROR 4
  5. 5. Delineation • OAR • TARGET 5
  6. 6. Settings • Liver – SBRT – PVTT • Pancreas – NACT • SBRT • CONVENTIONAL – Post-op • Biliary – Extrahepatic – Intrahepatic – Radical Gallbladder – Post op Gallbladder 6
  7. 7. ITV CONCEPT • GTV- CTV- PTV • GTV-ITV-CTV-PTV 7
  8. 8. REDUCTION IN PTV • Custom immobilization • Respiratory management • Image guidance PTV PTV 8
  9. 9. panc D THE VOLUME CONCEPT 9
  10. 10. Which is better? • Which motion management system is better? • Which phase is better? • Empty stomach/filled stomach is better? • DIBH/DEBH is better? • Which immobilization is better? • Contrast/water is better? 10
  11. 11. 11 1. Analyze the tumor in all phases of triple phase CT 2. See the greatest resolution 3. Try to synchronization with breath hold
  12. 12. 12 ARTERIAL VENOUS DELAYED S T A R T S T A R T S T A R T BREATHHOLD SYNCHRONIZATION 0 sec 20 sec 40 sec
  13. 13. GOSSIP- WHOSE SPOUSE IS BETTER? 13
  14. 14. ANSWER WHICH YOU ARE POSSESSING , THAT IS BETTER BUT PLAN DATING BEFORE BATTING 14
  15. 15. IMAGING • Plain • Contrast I. ORAL II. IV •Arterial •Venous •Delayed 15
  16. 16. BARIUM CONTRAST 16
  17. 17. ORAL NON-IONIC CONTRAST 17
  18. 18. 18
  19. 19. 19
  20. 20. Non contrast 20
  21. 21. 21 Arterial phase
  22. 22. Arterial phase 22
  23. 23. Portal venous phase 23
  24. 24. Portal venous phase 24
  25. 25. Delayed phase 25
  26. 26. Delayed phase 26
  27. 27. Blood supply of liver 27
  28. 28. 28
  29. 29. Liver segments by hepatic vein 30
  30. 30. 31
  31. 31. 32
  32. 32. Liver segments - clockwise 33
  33. 33. 34
  34. 34. Caudate lobe 35
  35. 35. 36
  36. 36. 37
  37. 37. 38
  38. 38. Billiary tract 39
  39. 39. 40
  40. 40. 41
  41. 41. 42
  42. 42. Common Bile Duct • CBD contour should start at the first bifurcation or at its entry to the portal triad inferiorly to the first portion of duodenum • It passes posterior and medial to the duodenum and joins with the pancreatic duct • Irradiation of caudate lobe liver tumors may lead to high radiation doses being received by the CBD 43
  43. 43. 44
  44. 44. 45
  45. 45. 46
  46. 46. 47
  47. 47. 48
  48. 48. 49
  49. 49. 50
  50. 50. 51
  51. 51. 52
  52. 52. 53
  53. 53. 54
  54. 54. 55
  55. 55. 56
  56. 56. 57
  57. 57. 58
  58. 58. 59
  59. 59. 60
  60. 60. 61
  61. 61. 62
  62. 62. • HCC • ADENOCA PANCREAS • CHOLANGIOCARCINOMA 63
  63. 63. LIVER TUMOR ANATOMY 64
  64. 64. How it looks? • Usually, the mass enhances vividly during late arterial (~35 seconds) • Then washes out rapidly, becoming indistinct or hypoattenuating in the portal venous phase, compared to the rest of the liver • Portal vein tumour thrombus can be distinguished from bland thrombus by thrombus by demonstrating enhancement. 65
  65. 65. 66 DELAYED PHASEMORE WASHOUT VENOUS PHASE_ WASHOUT ARTERIAL ENHANCMENNT CAPSULE/PSEUDO CAPSULE NON CONTRAST
  66. 66. 67 ARTERIAL PHASE_ ENHANCED
  67. 67. 68 VENOU PHASE_ WASHOUT
  68. 68. 69 DELAYED PHASE_ MORE WASHOUT
  69. 69. 70 Massive mass with thrombus
  70. 70. 71 Portal vein thrombus
  71. 71. RT. PORTAL VEIN THROMBOSIS 72
  72. 72. Collaterals 73
  73. 73. METASTSIS • HYPOVASCULAR • HYPERVASCULAR 74
  74. 74. 75
  75. 75. 76
  76. 76. 77
  77. 77. 78
  78. 78. 79
  79. 79. Target volume for HCC 80
  80. 80. Liver SBRT 81
  81. 81. 82 Pancreatic Tumor Anatomy
  82. 82. 83
  83. 83. 84
  84. 84. 85
  85. 85. 1. Size of the tumor 2. Involvement of critical vascular structures as defined by the NCCN or DPCG criteria 3. Invasion of nearby structures like transverse mesocolon, root of the mesentery and perineural invasion 4. Lymph node involvement locoregional or extraregional 86
  86. 86. ADENOCARCINOMA 87
  87. 87. ENDOSCOPIC ULTARSOUND 88
  88. 88. EXOPHYTIC TUMORS OF PANCREAS 89
  89. 89. Tumour vessel interface 90
  90. 90. 91
  91. 91. ABUTMENT AND ENCASEMENT 92
  92. 92. 93
  93. 93. Ishikawa classification system 94
  94. 94. Ishikawa classification system 95
  95. 95. 96
  96. 96. 1. There seems to be just limited contact with the portal vein (arrow). 97
  97. 97. oval or round to a teardrop 98
  98. 98. 99
  99. 99. 100 CELIAC ARTERY ENCASEMENT
  100. 100. 101
  101. 101. 102
  102. 102. 103
  103. 103. 104
  104. 104. FULL VS EMPTY STOMACH 105
  105. 105. 106
  106. 106. 107
  107. 107. HANDLING STOMACH FILLING 1. Variations in gastric filling may lead to significant intrafraction differences dose to normal stomach. 2. To mitigate this most panelists recommended keeping patients NPO for 2-3 hours before simulation and each treatment. 3. However, treating patients at a consistent interval after meals also appears to result in reproducible gastric positioning, and may be more comfortable for some patients 108
  108. 108. WATER RATHER THAN CONTRAST 109
  109. 109. Applied radiology 110
  110. 110. IMAGING PROTOCOL- NEGATIVE/NEUTRAL CONTRAST 111
  111. 111. 1. Use water rather than contrast 2. Pancreatic phase instead of the arterial phase. Pancreatic phase refers to the late arterial phase (typically 40-45 sec after contrast injection) during IV contrast. Pancreatic Protocol 112
  112. 112. 113
  113. 113. A CT REQUSITION • High-resolution dual-phase (arterial and portal) contrast material–enhanced CT is the established technique for evaluating pancreatic adenocarcinoma. • LATE Arterial phase imaging (per-formed 20–40 seconds after contrast agent injection) allows optimal visualization of the tumor and peripancreatic arteries. • Portal phase imaging (performed 50–70 seconds after injection) is optimal for detecting metastatic disease to the liver and for assessing the peripancreatic veins 114
  114. 114. TRIPLE PHASE PET CT- NON ENHANCE/ART/VENOUS 115
  115. 115. TRIPLE FUSION-EXCLUDES CONFUSION 116
  116. 116. 117
  117. 117. 118
  118. 118. Red-no, Orange-chemo alone Green- CTRT 119
  119. 119. ANASTOMOSIS 120
  120. 120. Whipples surgery 121
  121. 121. 122
  122. 122. PANCREATICO-JEJUNOSTOMY 123
  123. 123. Remnant Pancreas Pancreaticojejuno stomy 124
  124. 124. Pancreaticogastro stomy Residual Pancreas 125
  125. 125. Hepatico jejunostomy 126
  126. 126. Pancreatico jejunostomy 127
  127. 127. 128
  128. 128. CTV- Post op pancreas 129
  129. 129. 130
  130. 130. GCP • Post op bed • Nodal volume • Stomas 131
  131. 131. 132
  132. 132. Target delineation 133 1. Delineate ROI’s: 1. Portal vein (PV: starts at confluence of SMV and splenic vein) 2. Pancreaticojejunostomy (PJ) 3. Celiac artery (proximal 1-1.5cm) 4. SMA (proximal 2.5-3cm) 5. Aorta (superiorly to most cephalad of CA, PV, or PJ contours; inferiorly to bottom L2, or as low as L3 to cover pre-op GTV) 6. Hepaticojejunostomy (HJ) 7. Tumor bed (based on review of pre-op imaging, pathology report, surgical clips) 2. Expansion 1: 1.0cm on PV, PJ, CA, SMA 3. Expansion 2: all on Aorta --> 2.5-3cm on R, 1cm on L, 2-2.5cm anteriorly, 0.2cm posteriorly 4. CTV Boolean Expansions 1 + 2, confirm that tumor bed (including clips) and HJ (if present) are encompassed 5. PTV = CTV + 0.5cm
  133. 133. Tumor bed with clips 134
  134. 134. PV,CA,AORTA 135
  135. 135. Celiac artery branches 136
  136. 136. 137
  137. 137. SMA 138
  138. 138. 139
  139. 139. 140 AORTA OTHER VESSELS POST OP
  140. 140. 141
  141. 141. SBRT PANCREAS 142
  142. 142. Steps pancreatic SBRT 14 3 • Delineate vessels – CA - Celiac artery – CHA - Common hepatic artery – LGA - Left gastric artery – PV - Portal vein – SMV - Superior mesenteric vein – SV- Splenic vein – AORTA • Delineate GTV TOTAL – GTV PRIMARY {GTVp} – GTV VESSEL EXAPANSION- GTVp + 0.5 mm • Delineate TVI – The entire circumference of involved or proximal vessels are contoured to form tumor vessel interface • CTV – GTV + TVI • PTV – CTV + 0.5mm
  143. 143. What is GTV in pancreas? • MRI • PET • ENDOSCOPY- Duodenal involvement • CT – The GTVp should include fibrotic areas near vessels based on experienced radiologist review. This is identified as poorly defined or thickened vessel edges. – It is now known that pancreatic stellate cells and the desmoplastic reaction around tumor edges is a key contributor to pancreatic cell cancer biology, including regional progression and distant metastasis. – As such, this poorly defined area around the tumor should be included in the GTVp. – If it is unclear whether a vessel is involved, it should be included in the GTVp 144
  144. 144. DOSING PATTERN 145
  145. 145. Vessel invasion 146
  146. 146. The TVI • We define the TVI as the area where the GTVp is involving or within 5 mm of the major vessels in the upper abdomen, including celiac artery, superior mesenteric artery, common hepatic artery, left gastric artery, superior mesenteric vein, portal vein, splenic vein, or aorta. • If GTVp is within 5 mm of these structures, then a TVI is defined as above and incorporated into a clinical target volume of 40. • In principle, any major vessel within 5 mm of the tumor should be contoured from 5 mm proximal to 5 mm distal of the GTVp (Fig 2). • This region should be defined in 3 dimensions (eg, using axial, sagittal, and coronal planes Whole vessel circumference should be included. • In the case of aorta and portal vein, only the proximal half may need to be contoured as part of the TVI as these vessels have a much larger circumference 147
  147. 147. GTVp 148
  148. 148. GTV VESSEL EXPANSION 149
  149. 149. TVI- BLUE 150
  150. 150. CTV 151
  151. 151. PTV- CTV + 0.5mm 152
  152. 152. Handling the PTV • In general, a 5-mm margin is recommended. • When a PTV of 40 crosses into or near a hollow viscous PRV, compromises need to be made to dose coverage in this area to Preserve hollow viscous dose constraints 153
  153. 153. PRV • We recommend the duodenal, stomach, small bowel, and large bowel PRV be a minimum 3-mm expansion. • However, if treating during free breathing or organ movement is seen to be large on multiple end expiratory breath hold scans or 4D-CT, a greater PRV margin is required. • Concessions to large bowel maximum dose (D0.5 cm3 and D5 cm3) may be considered to meet coverage goals 154
  154. 154. The ITV CONCEPT • ITV40 creation using motion information from multiple end-expiratory breath hold scans and/or 4D-CT 155
  155. 155. PTV COVERAGE 156
  156. 156. OAR constraints PANCREATIC SBRT 157
  157. 157. Cholangiocarcinoma 158
  158. 158. 15 9
  159. 159. 160
  160. 160. 161
  161. 161. Imaging pictures • The lesion has the following characteristics: • The lesion is hypodense in the arterial and portal venous phase with some peripheral enhancement. • The lesion is hyperdense in the equilibrium phase indicating dens fibrous tissue. • The lesion causes retraction of the liver capsule • The finding of an infiltrating mass with capsular retraction and delayed persistent enhancement is very typical for a cholangiocarcinoma. 163
  162. 162. Delayed phase enhancement • Small cholangiocarcinoma not visible in portal venous phase (left) but seen as relative hyperdense lesion in the delayed phase (right). 164
  163. 163. 165
  164. 164. 166
  165. 165. 167
  166. 166. Cholangiocarcinoma With glandular stroma
  167. 167. 169 INTRAHEPATIC CHOLANGIO CA
  168. 168. EXTRAHEPATIC CHOLANGIO CA 170
  169. 169. 171 HILAR CHOLANGIO CA
  170. 170. GCP volume – Biliary tract 176
  171. 171. NODAL VOLUME- Biliary tract 177
  172. 172. Target lymph node for biliary tract cancer 178
  173. 173. CTV - intrahepatic cholangiocarcinoma 179
  174. 174. Intrahepatic cholangiocarcinoma 180
  175. 175. CTV - extrahepatic cholangiocarcinoma 181
  176. 176. Extrahepatic cholangiocarcinoma 182
  177. 177. CTV – Gallbladder carcinoma 183
  178. 178. Gall bladder 184
  179. 179. 185
  180. 180. 186
  181. 181. Japanese lymph node stations 187
  182. 182. LYMPH NODE NAMINGS 188
  183. 183. CTV N0 • In this CTV-N delineation, a 10 mm margin of soft tissue around vessels, ligament and ducts was suggested, based on several literature data, without overlap with radiosensitive structures (duodenum, liver, small bowel, stomach). • Only for para-cardials nodes and lesser gastric curvature nodes, the suggested target was defined without any further expansion to preserve the surrounding OARs 189
  184. 184. See the continuity See the contour See the location Follow the vessel 0.7 to 2.5 cm margin to vessel 190
  185. 185. DIFFERENTIATING NODE FROM VESSEL 8 C • CLINICAL • CONTRAST • CONTINUITY • CONTUR • CONTRALATERALITY • CONGLOMERATION • CYSTIC COMPONENET • CIRCULAR 191
  186. 186. 192 Black-gastro esophageal
  187. 187. 193
  188. 188. 194
  189. 189. 195
  190. 190. 196 CRURAL GROUP MIDDLE COLIC
  191. 191. 197 GASTRO ESOPHAGEAL ANTERIOR DIAPHRAGMATIC
  192. 192. 198 LT GASTRIC GREATER CURVATURE PHRENIC
  193. 193. 199 HEPATIC ARTERY GROUP
  194. 194. 200 PYLORIC
  195. 195. 201 COFLIC GROUP
  196. 196. 202 SUPERIOR MASENTRIC GASTRO DUODENAL
  197. 197. 203 SUPERIOR MASENTRIC
  198. 198. 204 PERIPORTAL
  199. 199. 205 PANCREATICO DUODENAL
  200. 200. 206 RENAL HILAR
  201. 201. 207 AORTOCAVAL
  202. 202. 208 RENAL HILAR
  203. 203. 209 PARAAORITC
  204. 204. 210 PARAAORITC
  205. 205. 211 INFERIOR MASENTRIC
  206. 206. 212
  207. 207. 213
  208. 208. 214
  209. 209. 215
  210. 210. 216
  211. 211. OAR 217
  212. 212. BOWEL BAG VS INDIVIDUAL BOWEL LOOP 218
  213. 213. 219
  214. 214. 220
  215. 215. For liver contouring • Gallbladder should be excluded • IVC should be excluded when it is discrete from the liver • Portal vein (PV) should be included in the liver contour when Segment (Seg) I (caudate lobe) is seen to the left of PV 221
  216. 216. 222
  217. 217. 223
  218. 218. Thank You. 224

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