中山大学附属肿瘤医院NPC靶区勾画.

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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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