鼻咽癌CTV勾画上课件

鼻咽癌鼻咽癌CTV勾画上文档勾画上文档ppt鼻咽癌鼻咽癌CTV勾画上文档勾画上文档ppt12010年年2月月24日日 全身全身PETCT显像示显像示鼻咽部异常增厚软组织影，代谢异常增高，考虑鼻咽鼻咽部异常增厚软组织影，代谢异常增高，考虑鼻咽癌，向上侵犯蝶窦，向前累及后鼻孔区癌，向上侵犯蝶窦，向前累及后鼻孔区左颈部淋巴结代谢异常增高，考虑转移性病变；余双左颈部淋巴结代谢异常增高，考虑转移性病变；余双侧颈部小淋巴结，部分代谢轻度增高，考虑转移性病侧颈部小淋巴结，部分代谢轻度增高，考虑转移性病变可能变可能全身其余探测部位未见明显恶性肿瘤病变及转移征象全身其余探测部位未见明显恶性肿瘤病变及转移征象 Case cont2010年年2月月24日日 全身全身PETCT显显像示像示 Case cont Case cont2010年年2月月25日日 鼻咽及颈部平扫鼻咽及颈部平扫+增强增强MR示示1.1.鼻咽顶壁及右侧壁增厚，呈等鼻咽顶壁及右侧壁增厚，呈等T1、长、长T2信号影，增强扫描病灶信号影，增强扫描病灶明显强化。病灶向前达后鼻孔水平，向上侵犯明显强化。病灶向前达后鼻孔水平，向上侵犯斜坡斜坡及右侧及右侧岩尖岩尖、海绵窦海绵窦，双侧，双侧咽旁间隙咽旁间隙存在存在2.2.双侧双侧颈动脉鞘颈动脉鞘旁可见成串珠状分布的多发大小不等的淋巴结影，旁可见成串珠状分布的多发大小不等的淋巴结影，边界清楚，增强扫描强化较均匀边界清楚，增强扫描强化较均匀 Case cont2010年年2月月25日日 鼻咽及鼻咽及颈颈部平部平扫扫+增增强强MR示示 cT4N2M0 Case contcT4N2M0 Case cont1.Background 2.Head 3.Neck lymph nodes normality involvementrecurrenceBackground normality Anatomyheadneckbackground1.1.前壁前壁是由后鼻孔及鼻中隔后缘所构成2.2.后壁后壁紧邻第一、二颈椎及颈椎旁的肌肉束3.3.上壁上壁即颅底4.4.下壁下壁其前三分之二为软腭，后三分之一则为通往口咽部之通道5.5.侧壁侧壁主要由咽鼓管的咽口所构成，病变容易造成咽鼓管机能障碍，并经由咽鼓管侵犯与鼻咽有一墙之隔的咽旁间隙咽旁间隙，其中包含重要的颈A、颈V及第九、十、十一、十二等四对颅神经侧壁及后壁相交处咽隐窝咽隐窝，为鼻咽癌最常发生部位，紧邻破裂孔、卵圆孔、颈动脉管、颞骨岩尖等Anatomyheadneckbackground前壁是由后前壁是由后MAXILLARY SINUSESZYGOMASPHENOIDSINUSCross-Sectional Anatomy 1headneckbackground蝶窦层面蝶窦层面MAXILLARY SINUSESZYGOMASPHENOIMASTOIDSNASOPHARYNXMAXILLAEXTERNALAUDITORYMEATUSheadneckbackgroundCross-Sectional Anatomy 2鼻咽层面鼻咽层面MASTOIDSNASOPHARYNXMAXILLAEXTECross-Sectional Anatomy 3headneckbackgroundMANDIBLEPAROTIDGLANDMASSETER MUSCLEPTERYGOIDMUSCLES颈颈1下缘层面下缘层面Cross-Sectional Anatomy 3headCross-Sectional Anatomy 4headneckbackgroundSUBMANDIBULARGLANDEPIGLOTTISSTERNOCLEIOMASTOIDMUSCLE颈颈2下缘层面下缘层面Cross-Sectional Anatomy 4headHYOID BONEJUGULARVEINCOMMON CAROTID ARTERIESEPIGLOTTIC VALLECULAPYRIFORM SINUSCross-Sectional Anatomy 5headneckbackground颈颈3层面层面HYOID BONEJUGULARCOMMON CAROTITHYROID CARTILAGECRICOID CARTILAGECross-Sectional Anatomy 6headneckbackground颈颈4下缘层面下缘层面THYROID CARTILAGECRICOIDCross-Cross-Sectional Anatomy 7headneckbackgroundCLAVICLETHYROID GLANDTRACHEAESOPHAGUS颈颈6下缘层面下缘层面Cross-Sectional Anatomy 7headCTV DelineationheadneckbackgroundCTV Delineationheadneckbackgro Base of skull枕骨颈静脉结节（舌下神经管顶）CTV DelineationBilateral levels IV and VBCase contLyon,France:IARC Press;2005.Inferior petrosal sinus;transverse sinus,meningeal branches from occipital and ascending pharyngeal arteriesaBased on magnetic resonance imaging of 308 patients from Pamela Youde Nethersole Eastern Hospital,Hong Kong.Modified from Chan J,Bray F,McCarron P,et al.510 mm from mucosal surface of nasopharynxAnterior:Junction with nasal choanaLateral:Medial border of parapharyngeal spaceCaudal:Caudal border of C1 vertebrainvolvementRetropharyngeal and Parapharyngeal Space contCross-Sectional Anatomy 1Internal auditory artery下翼腭管腭大、小孔口腔Foramen/FissureWorld Health Classfication of Tumors.Neck lymph nodesOptic foramen与垂体、脑干、第38对脑神经、颈静脉球及海绵窦等重要结构关系密切pCTV1：为GTVnx外扩510 mm,包括整个鼻咽粘膜pCTV2：鼻咽肿瘤极易侵犯的结构，包括鼻咽、颅底、咽旁间隙、咽后间隙、翼颚窝、蝶窦下部、鼻腔及上颌窦后1/3，以及 GTVnd及其所在和需预防照射的淋巴引流区CTV Delineation Wuhanheadneckbackground Base of skullCTV1：为为GTVnx外外扩扩5StructuresAnatomicBoundariesCTV_70GTV+510mmmargin(2mmifabutneurologicalstructures)Wholenasopharynx510mmfrommucosalsurfaceofnasopharynxAnterior:JunctionwithnasalchoanaLateral:MedialborderofparapharyngealspaceCaudal:CaudalborderofC1vertebraCTV_61.25CTV_70+5mmmargin(2mmifabutneurologicorbonystructures)PosteriornasalcavityAnterior:PosteriorthirdofnasalcavityPosteriormaxillarysinusesAnterior:PosteriorthirdofmaxillarysinusesLowersphenoidsinusCranial:LowerhalfofsphenoidsinusPterygoidfossaeParapharyngealspacesLateral:LateralborderofstyloidprocessesBaseofskullPosterior:Anteriorhalfofclivusifnogrossinvasion,wholeclivusifinvasiondetectedLateral:LateralborderofforamenovaleElectivenodallevelsAll:Bilateralretropharyngeal,levelII,III,VAIfnode-positive:AddlevelIBCTV_52.5Uppersphenoidsinus(ifsphenoidinvolved)PartofsphenoidsinusatandabovethelevelofopticchiasmaElectivenodallevelsBilaterallevelsIVandVBBased on guideline currently used at Pamela Youde Nethersole Eastern Hospital(Hong Kong)CTV Delineation Hong KongheadneckbackgroundStructuresAnatomic BoundariesCCTV DelineationheadneckbackgroundCTV Delineationheadneckbackgro1.Background2.Head3.Neck lymph nodesnormality involvementrecurrenceBackgroundnormality StructuresInvolvedFrequency(%)AdjacentsofttissueNasalcavity87Parapharyngealspace68Pterygoidmuscle(medial,lateral)48Prevertebralmuscle19Bonyerosion/paranasalsinusClivus41Sphenoidbone,foraminalacerum,ovale,rotundum38Pterygoidplates,pterygomaxillaryfissure,pterygopalatinefossa27Petrousbone,petro-occipitalfissure19Ethmoidsinus6Maxillaryantrum4Jugularforamen,hypoglossalcanal4Pituitaryfossa/gland3Structures InvolvedbackgroundneckheadStructures InvolvedFrequency(StructuresInvolvedFrequency(%)Extensive/intracranialextensionCavernoussinus16Infratemporalfossa9Orbit,orbitalfissure(s)4Cerebrum,meninges,cisterns4Hypopharynx2aBasedonmagneticresonanceimagingof308patientsfromPamelaYoudeNethersoleEasternHospital,HongKong.ModifiedfromChanJ,BrayF,McCarronP,etal.Nasopharyngealcarcinoma.In:Pathology and Genetics of Head and Neck Tumours.WorldHealthOrganizationClassificationofTumours.Lyon,France:IARCPress;2005.backgroundneckheadStructures Involved contStructures InvolvedFrequency(backgroundneckheadSkull Base颅底孔道有许多重要的神经血管经过，一旦受到侵犯，可能出现相关症状backgroundneckheadSkull Base颅颅底底Foramen/FissureCranialNerveOtherStructuresCribriformplateOlfactorynerve(I)AnteriorethmoidalnerveOpticforamenOpticnerve(II)OphthalmicarterySuperiororbitalfissureOculomotor(III),trochlear(IV),ophthalmicdivisionoftrigeminal(V1)nerve,abducent(VI)nervesOphthalmicvein,orbitalbranchofmiddlemeningealandrecurrentbranchoflacrimalarteries,sympatheticplexus,filamentsfromcarotidplexusForamenrotundumMaxillarydivisionoftrigeminal(V2)nerveForamenovaleMandibulardivisionoftrigeminal(V3)nerveAccessorymeningealartery,lessersuperficialpetrosalnerveForamenlacerumInternalcarotid,sympatheticcarotidplexus;vidiannerve,meningealbranchofascendingpharyngealartery,emissaryveinForamenspinosumRecurrentbranchofV3nerveMiddlemeningealarteryandveinStylomastoidforamenFacial(VII)nerveInternalacousticmeatusAuditory(VIII)nerveInternalauditoryarteryJugularforamenGlossopharyngeal(IX),vagus(X),spinalaccessory(XI)nervesInferiorpetrosalsinus;transversesinus,meningealbranchesfromoccipitalandascendingpharyngealarteriesHypoglossalcanalHypoglossal(XII)nerveMeningealbranchofascendingpharyngealarteryForamenmagnumSpinalcord,spinalaccessorynerve,vertebralvessels,anteriorandposteriorspinalvesselsbackgroundneckheadSkull Base contForamen/FissureCranial NerveOt翼腭窝位于颞下窝内侧、眶尖后下方的狭小骨性间隙，上部较宽广翼腭窝位于颞下窝内侧、眶尖后下方的狭小骨性间隙，上部较宽广,下部逐渐狭窄下部逐渐狭窄,移行于翼腭管移行于翼腭管通连通连 经经7 7个通道与周围相交通个通道与周围相交通前眶下裂眼眶前眶下裂眼眶外翼上颌裂颞下窝外翼上颌裂颞下窝内蝶腭孔鼻腔内蝶腭孔鼻腔后上圆孔颅中窝后上圆孔颅中窝后下腭咽管鼻咽后下腭咽管鼻咽后内翼管破裂孔后内翼管破裂孔下翼腭管腭大、小孔口腔下翼腭管腭大、小孔口腔backgroundneckheadPterygopalatine Fossa翼腭翼腭窝窝位于位于颞颞下下窝窝内内侧侧、眶尖后下方的狭小骨性、眶尖后下方的狭小骨性间间隙，上部隙，上部较宽较宽广广,翼腭窝位于颞下窝内侧、眶尖后下方的狭小骨性间隙，上部较宽广翼腭窝位于颞下窝内侧、眶尖后下方的狭小骨性间隙，上部较宽广,下部逐渐狭窄下部逐渐狭窄,移行于翼腭管移行于翼腭管通连通连 经经7 7个通道与周围相交通个通道与周围相交通前眶下裂眼眶前眶下裂眼眶外翼上颌裂颞下窝外翼上颌裂颞下窝内蝶腭孔鼻腔内蝶腭孔鼻腔后上圆孔颅中窝后上圆孔颅中窝后下腭咽管鼻咽后下腭咽管鼻咽后内翼管破裂孔后内翼管破裂孔下翼腭管腭大、小孔口腔下翼腭管腭大、小孔口腔backgroundneckheadPterygopalatine Fossa1234765翼腭翼腭窝窝位于位于颞颞下下窝窝内内侧侧、眶尖后下方的狭小骨性、眶尖后下方的狭小骨性间间隙，上部隙，上部较宽较宽广广,耳蜗（含外半规管）耳蜗（含外半规管）Image 1 眶上裂（眶上裂（III,IV,V1,VI）内听道内听道(VIII)中耳中耳backgroundneckheadSkull Base and Pterygopalatine Fossa耳耳蜗蜗（含外半（含外半规规管）管）Image 1 眶上裂（眶上裂（III,IV,圆孔（圆孔（V2）颈动脉管颈动脉管下颌窝顶下颌窝顶Image 2 中耳中耳backgroundneckhead眶下裂眶下裂 Skull Base and Pterygopalatine Fossa cont圆圆孔（孔（V2）颈动颈动脉管下脉管下颌窝顶颌窝顶Image 2 中耳中耳backg卵圆孔（卵圆孔（V3）枕骨颈静脉结节（舌下神经管顶）枕骨颈静脉结节（舌下神经管顶）翼腭窝翼腭窝 蝶骨大翼蝶骨大翼 棘孔（棘孔（V3）眶下裂眶下裂 颈动脉管颈动脉管破裂孔（颈内动脉）破裂孔（颈内动脉）Image 3 backgroundneckheadSkull Base and Pterygopalatine Fossa cont斜坡由枕骨基底部和蝶骨体共同构成，向前上约呈45角倾斜上界为鞍背，下界为枕骨大孔前缘，两侧毗邻破裂孔、颈静脉孔、舌下神经管内口等结构与垂体、脑干、第38对脑神经、颈静脉球及海绵窦等重要结构关系密切斜坡斜坡卵卵圆圆孔（孔（V3）枕骨枕骨颈颈静脉静脉结节结节（舌下神（舌下神经经管管顶顶）翼腭翼腭窝窝 蝶骨蝶骨Structures InvolvedForamen ovaleinvolvementSkull Base and Pterygopalatine Fossa cont Base of skull Base of skullIX,2;X,5.Posterior nasal cavity与垂体、脑干、第38对脑神经、颈静脉球及海绵窦等重要结构关系密切翼腭窝位于颞下窝内侧、眶尖后下方的狭小骨性间隙，上部较宽广,下部逐渐狭窄,移行于翼腭管枕骨颈静脉结节（舌下神经管顶）Cross-Sectional Anatomy 3Foramen ovaleNasopharynx.Base of skullStructures InvolvedEthmoid sinus与垂体、脑干、第38对脑神经、基底动脉、颈静脉球及海绵窦等重要结构关系密切Nasopharyngeal carcinoma.aBased on magnetic resonance imaging of 308 patients from Pamela Youde Nethersole Eastern Hospital,Hong Kong.Based on guideline currently used at Pamela Youde Nethersole Eastern Hospital(Hong Kong)斜坡（枕骨段）斜坡（枕骨段）卵圆孔（卵圆孔（V3）舌下神经管（舌下神经管（XII）翼腭窝翼腭窝 蝶腭孔蝶腭孔 棘孔（棘孔（V3）颈动脉管外口颈动脉管外口破裂孔破裂孔（颈内动脉）（颈内动脉）Image 4 翼管翼管蝶骨体蝶骨体 鳞部岩部鼓部backgroundneckheadSkull Base and Pterygopalatine Fossa cont颈静脉孔（颈静脉孔（IX,X,XI）Structures Involved斜坡（枕骨段）斜坡（枕骨段）卵卵圆圆孔孔茎突基底部茎突基底部 枕骨基底部（后斜坡）枕骨基底部（后斜坡）翼突翼突 舌下神经管舌下神经管 翼腭窝翼腭窝 Image 5 backgroundneckheadSkull Base and Pterygopalatine Fossa cont茎突基底部茎突基底部 枕骨基底部（后斜坡）枕骨基底部（后斜坡）翼突翼突 舌下神舌下神经经管管 翼腭翼腭窝窝 下颌骨冠突下颌骨冠突 下颌骨下颌骨髁突颈部髁突颈部 翼上颌裂翼上颌裂 翼腭窝翼腭窝 翼板翼板 茎突茎突 Image 6backgroundneckheadSkull Base and Pterygopalatine Fossa cont下下颌颌骨冠突骨冠突 下下颌颌骨髁突骨髁突颈颈部部 翼上翼上颌颌裂裂 翼腭翼腭窝窝 翼板翼板 茎突茎突 I1咽后间隙（咽后间隙（retropharyngeal space）位于椎前筋膜与颊咽筋膜之间，上起颅底枕骨部，下达第一、二胸椎平面，鼻、鼻窦及咽部的淋巴都汇入其中2咽旁间隙（咽旁间隙（parapharyngeal space）位于咽后间隙两侧，左右各一，呈三角形漏斗状上界为颅底下达舌骨大角处后壁为椎前筋膜内壁为颊咽筋膜、咽上缩肌，与扁桃体窝相隔外侧壁为上颌骨升支内壁及其附着的翼内肌与腮腺包囊茎突茎突及其附着肌肉将此间隙分为茎突前隙和茎突后隙两部茎突前间隙较小，内侧与扁桃体窝仅隔咽上缩肌，茎突后间隙（亦称颈动脉鞘区颈动脉鞘区）较大，其内有颈内动脉、颈内静脉、舌咽神经、迷走神经、副神经、舌下神经及交感神经等穿过，还有颈深淋巴结上群backgroundneckheadRetropharyngeal and Parapharyngeal Space1咽后咽后间间隙（隙（retropharyngeal space）T1加权:鼻咽癌向后侵犯，咽后及椎前间隙弥漫受侵T1加权:鼻咽肿瘤强化，明显粘膜下侵润，并侵犯高信号的咽旁间隙，右侧咽旁间隙正常backgroundneckheadRetropharyngeal and Parapharyngeal Space contT1加加权权:T1加加权权:backgroundneckheadRe斜坡由枕骨基底部和蝶骨体共同构成，向前上约呈45角倾斜上界为鞍背，下界为枕骨大孔前缘，两侧毗邻破裂孔、颈静脉孔、舌下神经管内口等结构与垂体、脑干、第38对脑神经、基底动脉、颈静脉球及海绵窦等重要结构关系密切backgroundneckheadClivus斜坡由枕骨基底部和蝶骨体共同构成，向前上斜坡由枕骨基底部和蝶骨体共同构成，向前上约约呈呈45角角倾倾斜斜ba（外）卵圆孔（外）卵圆孔（外）（外）棘孔棘孔（外）颈动脉管外口（外）颈动脉管外口（内）破裂孔（内）破裂孔（外）颈静脉孔（外）颈静脉孔（后）岩枕裂（后）岩枕裂（前）岩蝶裂（前）岩蝶裂岩尖综合征（Gradenigo 综合征）：颞部岩骨尖端病变损伤外展神经和三叉神经所致的综合征，表现为眼球内斜视，同侧眼支区域及面部疼痛或麻木backgroundneckheadPetrous Apex（外）卵（外）卵圆圆孔孔（外）棘孔（外）（外）棘孔（外）颈动颈动脉管外口（内）破裂孔（外）脉管外口（内）破裂孔（外）p海绵窦（海绵窦（Cavernous sinus）位于蝶窦、蝶鞍、垂体两旁，是眼眶到蝶骨细长神）位于蝶窦、蝶鞍、垂体两旁，是眼眶到蝶骨细长神经轴硬膜外结构局部扩张的一段经轴硬膜外结构局部扩张的一段p海绵窦以其特殊性、复杂性和重要性而倍受重视，自1734年Winslou 对其命名以来，一直是解剖学、颅底外科学重点研究的部位，Parkinson 称其为“解剖学的珠宝箱”p近年也有学者主张其应被称作鞍旁结构（Laterna sellar compartmen,LSC）backgroundneckheadCavernous Sinus海海绵窦绵窦（Cavernous sinus）位于蝶）位于蝶窦窦、蝶鞍、垂体、蝶鞍、垂体内部结构动脉颈内动脉是海绵窦内的重要结构静脉静脉丛颅神经在前床突根部平面，动眼神经、滑车神经、外展神经、三叉神经眼支、上颌支backgroundneckheadCavernous Sinus cont 内部内部结结构构backgroundneckheadCaverp文献报道，鼻咽癌颅神经受累率为文献报道，鼻咽癌颅神经受累率为20.757.4%p严洁华等对全国严洁华等对全国4971例鼻咽癌患者总结显示例鼻咽癌患者总结显示,第第5，6和和12对颅神经受累对颅神经受累率分别为率分别为26.8%、17.6%和和13.1%,占据颅神经受累的前三位占据颅神经受累的前三位p鼻咽癌好发于鼻咽顶前壁或侧壁，肿瘤向上外侧侵袭可通过破裂孔到达鼻咽癌好发于鼻咽顶前壁或侧壁，肿瘤向上外侧侵袭可通过破裂孔到达鞍旁海绵窦区鞍旁海绵窦区，在此行程中易累及三叉神经眼支及上颌支损害，其次也，在此行程中易累及三叉神经眼支及上颌支损害，其次也易累及展神经、动眼神经和滑车神经等易累及展神经、动眼神经和滑车神经等p鼻咽癌也易通过直接浸润或淋巴结转移累及鼻咽癌也易通过直接浸润或淋巴结转移累及咽旁间隙咽旁间隙,损伤第损伤第912对颅对颅神经神经backgroundneckheadCranial Nerve文献文献报报道，鼻咽癌道，鼻咽癌颅颅神神经经受累率受累率为为20.757.4%backgCranialNerveChaoandPereza(N=164)(%)Leeetal.b(N=722)(%)III1.30.8III3.51.3IV2.40.6V7.8V1,3.5;V2,5.8%;V3,3.9VI13.35.1VII3.60.1VIII4.8IXXIIIX,2;X,5.4;XI,1.3;XII,4.82.4aChaoKS,PerezCA.Nasopharynx.Principles and Practice of Radiation Oncology,4th ed.Philadelphia:LippincottWilliams&Wilkins,1997:918961.bChanJ,BrayF,McCarronP,etal.Nasopharyngealcarcinoma.In:Pathology and Genetics of Head and Neck Tumors.World Health Classfication of Tumors.IARCPress,Lyon,France,2005:85-97backgroundneckheadCranial Nerve contCranial NerveChao and Pereza(Internal auditory arteryInferior petrosal sinus;transverse sinus,meningeal branches from occipital and ascending pharyngeal arteries外侧壁为上颌骨升支内壁及其附着的翼内肌与腮腺包囊Jugular foramen,hypoglossal canalFacial(VII)nerve下壁其前三分之二为软腭，后三分之一则为通往口咽部之通道Middle meningeal artery and veinWorld Health Classfication of Tumors.Skull Base contSkull Base contCribriform plateinvolvementSkull Base and Pterygopalatine Fossa contSkull Base and Pterygopalatine Fossa2010年2月24日 全身PETCT显像示Ethmoid sinusCTV DelineationEPIGLOTTIC VALLECULA谢谢观看！谢谢观看！谢谢观看！谢谢观看！Internal auditory artery谢谢观谢谢观看！看！