鼻咽癌靶区勾画 罗伟

鼻咽癌靶区勾画建议中山大学附属肿瘤医院放疗科Background遵循原则对靶区进行定义，有助于建立共同的标准，有利多中心的交流3一、鼻咽部MRI所见4正常解剖(信号特征）MR：T2WI-软组织分辨率高肌肉、咽颅底筋膜：低信号粘膜和淋巴滤泡组织：偏高信号粘液：明亮的高信号咽鼓管圆枕透明软骨：高信号血管：流空效应：低信号Gd-DTPA增强：高信号致密骨：低信号松质骨：取决于骨髓成分红骨髓为主：中等信号黄骨髓为主：高信号（枕骨斜坡、颈椎椎体）5正常解剖及MR表现：鼻咽腔T1WI：鼻咽腔左右不对称，左侧咽隐窝变浅T2WI：左侧咽隐窝为唾液，高信号6正常解剖及MR表现：鼻咽腔横断：鼻咽上部咽鼓管圆枕（软骨端、T2W↑）表面：粘膜覆盖前：咽鼓管咽口后：咽隐窝腭帆提肌（后外侧）腭帆张肌（前外侧）翼外肌、颞肌、咬肌椎前肌（头长肌、颈长肌）7正常解剖及MRI表现：鼻咽腔横断（鼻咽上部）咽鼓管圆枕、咽鼓管咽口、咽隐窝腭帆张肌、腭帆提肌翼外肌、颞肌、咬肌T2WIT1WI＋CT1WIGd+8正常解剖及MR表现：鼻咽腔横断（鼻咽中部）咽旁间隙（腭帆提肌外侧）边界清楚，内有咽静脉翼内肌软腭、上颌骨牙槽嵴T2WIT1WIT1WI＋C9正常解剖及MR表现：鼻咽腔横断（鼻咽下部）Passavant’s嵴（软腭．腭帆提、张肌汇合而成)咽旁间隙颊肌颈内动、静脉T2WIT1WIT1WI＋C10正常解剖及MR表现：鼻咽腔冠状（鼻咽偏前部）：后鼻孔、软腭、后舌部翼内肌、翼外肌、颞肌、咬肌颅底骨、翼板、翼腭窝、眶上裂T1WIT1WI＋C11正常解剖及MR表现：鼻咽腔冠状（鼻咽中部）：标志是咽鼓管圆枕圆孔NP顶的翼板下的粘膜NP侧壁为中缩肌及扁桃腺咽旁间隙（颅底－颌下腺）T1WIT1WI＋C12正常解剖：鼻咽腔冠状：鼻咽中部标志是咽鼓管圆枕圆孔视交叉颈内V垂体柄蝶窦圆孔上颌N胼胝体侧脑室13正常解剖及MR表现：鼻咽腔视交叉颈内V垂体柄蝶窦圆孔上颌N胼胝体侧脑室冠状：海绵窦14正常解剖及MR表现：鼻咽腔冠状：鼻咽偏后部标志为腭帆提、张肌缩肌深部为腭帆提、张肌NP顶侧壁为上缩肌、淋巴组织T1WIT1WI＋C15正常解剖及MR表现：鼻咽腔矢状旁正中鼻咽顶后外侧壁(粘膜.淋巴)动眼神经头长肌T1WIT1WI＋C16正常解剖及MR表现：咽旁间隙咽颅底筋膜致密结缔组织膜横断面：起于：翼内板后缘向后：腭帆张肌、腭帆提肌外侧通过，至颈动脉孔前方走行：咽后壁、颈长肌前方与椎前筋膜形成潜在的咽后间隙17正常解剖及MR表现咽旁间隙上方：临近咽隐窝下方：扁桃体窝相对应外侧：翼内肌、腮腺筋膜相贴内侧：咽颅底筋膜内部结构：颈外动脉和静脉丛颈动脉鞘间隙颈内、动静脉迷走神经Ⅸ~Ⅻ颅神经18正常解剖及MR表现:咽后间隙咽后间隙：咽后的正中前壁为咽颅底筋膜后壁为椎前筋膜19鼻咽癌的MR表现腔内病变：鼻咽粘膜局部增厚：T1WI：信号稍高于周围肌肉组织T2WI：信号高于肌肉、低于鼻甲和积液Gd-DTPA增强T1WI：较明显强化鼻咽部肿块：鼻咽腔形态：不对称、变窄肿瘤组织的信号强度较均匀，坏死则信号强度欠均匀超腔侵犯：肿瘤穿破咽颅底筋膜，侵犯周围结构。√√20鼻咽粘膜局限性增厚鼻咽癌的MR表现：21鼻咽癌的MR表现:鼻咽粘膜局限性增厚T1WIT1WIT2WICTLN22鼻咽癌的MR表现：肿瘤侵犯筋膜Gd+T1WT1WI23•鼻咽肿块鼻咽癌的MR表现：肿瘤24鼻咽癌的MR表现：肿瘤•鼻咽肿块25鼻咽癌的MR表现：肿瘤超腔侵犯颈动脉鞘区----判断标准MRI判断标准：有、无软组织影26鼻咽癌的MR表现：咽后淋巴结27鼻咽癌超腔侵犯的MR表现：后鼻孔、头长肌28鼻咽癌超腔侵犯的MR表现鼻咽癌骨质侵犯：MRI-T1、T2WI：早期骨髓浸润正常骨髓脂肪信号消失、被低信号的肿瘤组织取代信号强度与肿瘤组织相似CT：骨质破坏颅神经出颅孔道的侵犯：局部增宽、有软组织影支配肌肉的萎缩颅内侵犯：局部脑膜增厚（可能是反应性的）、强化软组织肿块、强化明显副鼻窦侵犯注意与局部副鼻窦炎症鉴别29鼻咽癌超腔侵犯的MR表现：蝶骨、枕骨斜坡30鼻咽癌超腔侵犯的MR表现：蝶骨、枕骨斜坡斜坡CT正常，MRI显示明显骨质侵犯和局部脑膜增厚31鼻咽癌超腔侵犯的MR表现：海绵窦32鼻咽癌超腔侵犯的MR表现：海绵窦33鼻咽癌超腔侵犯的MR表现：颈静脉孔、枕骨颈静脉孔枕骨斜坡舌肌萎缩34鼻咽癌的MR表现：破裂孔侵犯正常破裂孔35鼻咽癌超腔侵犯的MR表现：圆孔三叉神经上颌支36鼻咽癌超腔侵犯的MR表现：蝶窦37鼻咽癌的MR表现：淋巴结淋巴结----判断标准淋巴结转移大小标准：咽后淋巴结不限大小颈深上淋巴≥10mm淋巴链或坏死可以适当放松表现：信号与鼻咽癌组织相似增强后强化38鼻咽癌的MR表现：颈淋巴结T1WGd+T1二、淋巴结分区指引：CTVnd(negative)DAHANCA,EORTC,GORTECinEurope,NCIC,RTOGinNorthAmerica(2003)Background1.Twoproposals:BrusselsguidelinesandRotterdamguidelines.2.Toreviewtheirguidelinesandderiveacommonsetofrecommendationsfordelineationofnecknodelevels.颈部淋巴CT断层分区TheGuidelinesofCTVS:1.totranslateasaccuratelyaspossiblethesurgicalguidelinesintoradiologicguidelines2.basedonaxialCTsections.AllthelandmarksusedtodelineatethevariousnodelevelsduringaneckdissectionwerelocatedonaxialCTslices.推荐的边界Retropharyngealnodes(RP)咽后淋巴结头：颅底足：舌骨上缘前：腭帆张肌后：椎前肌内：中线外：血管鞘内缘44454647LevelIa头：下颌骨下缘足：舌骨体前：下颌骨内缘、皮肤后：口底、舌骨体内：中线外：下颌骨内缘LevelIb头：下颌骨支中部或口底足：舌骨体前：下颌骨内缘、颈阔肌、皮肤后：二腹肌、翼内肌、颌下腺内：二腹肌外缘外：下颌骨内缘、颈阔肌、皮肤5051LevelIIa头：C1足：舌骨体下缘前：颌下腺后缘后：IIb内：颈动脉鞘内缘外：胸锁乳突肌内缘LevelIIb头：C1足：舌骨体下缘前：IIa后：胸锁乳突肌后缘内：颈动脉鞘内缘外：胸锁乳突肌内缘LevelII1.RobbinsoriginallydescribedthecraniallimitofLevelIIasthebaseofskull.2.BrusselsguidelinesusedthebottomedgeofthebodyofC1.3.Surgeonsusedtheinsertionoftheposteriorbellyofthedigastricmuscletothemastoid.55LevelII颈内静脉后缘是IIa/IIb分界线5758LevelII下颌下腺是Ib/IIa分区界线6061LevelIII头：舌骨体下缘足：环状软骨前：胸锁乳突肌前缘后：胸锁乳突肌后缘内：颈动脉鞘内缘、椎旁肌外：胸锁乳突肌内缘6364LevelIV头：环状软骨下缘足：胸锁关节上缘上2cm前：胸锁乳突肌前缘后：胸锁乳突肌后缘内：颈动脉鞘内缘、甲状腺外缘外：胸锁乳突肌内缘66LevelIVCriticalsurgicaldissectionoflevelIVdoesnotgodowntotheClavicleandneverreachesthemedialpotionoftheclavicleatthelevelofsternoclavicularjoint.ItwasagreedtosetthecaudallimitofIV2cmabovethecranialedgeofthesternoclavicularjoint.68LevelVa头：舌骨上缘足：环状软骨下缘前：胸锁乳突肌后缘后：斜方肌前缘内：椎旁肌外：颈阔肌、皮肤ThecraniallimitoflevelV*commonlyquestioned.Hamoiretal.hasrecentlyproposedtousethelowertwo-thirdsoftheSANasthecraniallimitoflevelV.Fromaradiologicalpointofview,ahorizontalplanecrossingthecranialedgeofthebodyofthehyoidboneappearsasreliablelandmarkforthecraniallimitoflevelV.LevelVRobbins:AfewlymphnodeslyingalongtheupperthirdoftheSANmaybefound.ThesenodesareactuallyincludedinlevelIIb.TheuppermostpartoflevelVcontainssuperficialoccipitallymphnodes.whichcollectlymphaticsfromtheoccipitalscalp,andthepost-auricularregionsetc.Theyarenotinvolvedinthedrainageofheadandneckcancersexceptofskintumor.72LevelIV胸锁乳突肌和前斜角肌后缘分III,Ⅳ/Ⅴ7475LevelVb头：环状软骨下缘足：颈横血管前：胸锁乳突肌、前斜角肌后缘后：斜方肌前缘内：椎旁肌外：颈阔肌、皮肤ThecaudallimitoflevelVCTslicesoftransversevesselsHo’striangleincludethefattyplanesbelowandaroundtheclavicledowntothetrapeziusmuscle.78LevelVI头：舌骨体足：胸骨切迹前：皮肤后：椎体内：气管、食管外：颈动脉鞘内缘、甲状腺LevelVIAnteriorneckcompartmentnodesContainsthelymphnodeslocatedinthevisceraslspace:thepre-andparatrachealnodes,precrinoidnodeandtheperithyroidnodes.8182ScIN头：锁骨上缘足：第一肋骨上缘前：胸锁乳突肌后缘后：前斜角肌、胸膜顶内：颈血管鞘外缘外：与锁骨下静脉伴行8485PTVThelevelsdelineatedcorrespondtotheCTV,andthusdonotincludeanysecuritymargin.Whyusesurgicalguidelinesasbasicframeofradiotherapyguidelines?1.Achievementsinheadandneckoncologyhaveresultedfrominteractionsofsurgeryandradiotherapy.Thisustoadvocatefortheuseofasimilarlanguagetothatalreadyusedbysurgeonsformorethanadecade.Whyusesurgicalguidelinesasbasicframeofradiotherapyguidelines?2.Necknodedissection