Review of Head and Neck Anatomy

Vipul Thakkar, MD AAMD Annual Meeting June 11, 2012

Objectives

Identify the landmarks in the H/N region. Use this information to critically evaluate
target and organ at risk structures.

Obtain practical information to integrate

immediately into clinical practice.

Outline

I. Background II. Intracranial Structures

chiasm, orbits, brainstem, cochlea

III. III.

Head / Neck Structures

cord, oral cavity, mandible, parotids,

pharynx submandibular, larynx, esophagus, plexus

Miscellaneous Topics / QA

Importance of XRT

High dose radiation is a mainstay of

treatment for many H/N cancers.

Dose limiting structures carry significant

morbidity.

Head and Neck region has complex,

intimidating anatomy.

Resources

A number of newer resources are

available Netter / Gray Published Papers RTOG Protocols & Atlases Web resources

Format

Head to Toe RTOG definitions Netters Atlas & CT data from actual patients

CT data
Target / OAR delineation are directly related to CT data quality GE Lightspeed RT16 multi slice, wide bore 2.5 mm slices without contrast Retrospective reconstructions for H/N planning

Concepts
OAR PRV Organ at Risk Planning Organs at Risk Volume

MRI / PET Allows better delineation of target volume. Fusions ** CT sim data is KING ** Volume Effect Contouring Papers Evaluate the volume of OAR receiving a dose in addition to absolute / max dose. Lots of variability in contouring

Optic Chiasm
Disease Prescription Dose 54-60 Gy OAR max

05-39

Meningioma

54 - 56 Gy

09-13

GBM

60 Gy

56 Gy

Optic Chiasm
Visual data travels from the retina to the chiasm through the optic nerves.

Image from Grays Anatomy

Photo from Atlas of Human Anatomy

Optic Chiasm

Optic Chiasm

Optic Chiasm

Optic Chiasm

Optic Chiasm
Landmarks: Sella Tursica and Optic Nerves

Image from Grays Anatomy

Optic Structures
Disease OAR max 7 Gy Lens 50 Gy Retina 55 Gy Nerves 7 Gy Lens 50 Gy Retina 55 Gy Nerves

05-39

Meningioma

09-13

GBM

Optic Structures

Images from Atlas of Human Anatomy

Optic Structures

Brainstem
Control Center Cranial Nerves Midbrain, Pons, Medulla

Brainstem
Disease OAR max

05-39

Meningioma

55-60 Gy

09-13

GBM

60 Gy

** Less for H/N protocols ~52 Gy **

Photo from Atlas of Human Anatomy

Brainstem

Brainstem

Brainstem

Brainstem

Landmarks: Clivus C1

Brainstem

Landmarks: Sella CSF

Inner Ear / Cochlea

Disease 10-08 06-15 Post-op Salivary Gland Nasopharynx Prescription Dose 60-66 70 Gy OAR max 50 Gy 55 Gy / 5%

Inner Ear / Cochlea

Images from Atlas of Human Anatomy

Inner Ear / Cochlea

Inner Ear / Cochlea

Landmarks: Mastoid Air cells External Acoustic Meatus IAC
Pan et al. IJROBP 2005 Volume 61, Issue 5 , p 1393-1402

Spinal Cord
Disease 10-16 p16+ Oropharynx Post op Salivary Gland Prescription Dose 52-70 Gy OAR max 48 Gy 0.03 PRV 45 Gy 0.03 PRV 48 Gy 0.01 PRV

10-08

60-66 Gy

Spinal Cord
Brainstem vs. Cord? Top of C1 Cord ends around L1-L2

Images from Atlas of Human Anatomy

Spinal Cord

Spinal Cord

Spinal Cord
Landmarks: C1 Vertebral Body Spinous process L1-2

Oral Cavity and Lips

Anterior 1/2 to 2/3 of the oral tongue, floor of mouth, buccal mucosa, and palate

Disease 10-16 10-08 p16+ Oropharynx Post-op Salivary Gland

OAR max <30 Gy Mean <30 Gy Mean

Lip dose should be much lower than OC

Oral Cavity

Images from Atlas of Human Anatomy

Oral Cavity

Mandible
Entire bony structure of the mandible from TMJ through the symphysis. Prescription Dose 50-70 Gy 60-66 Gy

Disease 10-16 10-08 p16+ Oropharynx Post op Salivary Gland

OAR max <66 Gy <64 - 70 Gy

Mandible

Images from Atlas of Human Anatomy

Mandible

Parotid
Major producer of saliva for stimulated state

Disease

OAR max

10-16

10-08

contralateral <26 Gy p16+ mean Oropharynx ~20% complication rate contralateral <26 Gy Post op Salivary mean Gland 50% of 1 gland <30 Gy 20 cc <20 Gy

Image from Atlas of Human Anatomy

Parotid

Parotid

Image from Atlas of Human Anatomy

Parotid

Parotid
Landmarks: Mandible Styoid Masseter Window / Level Deep lobe

Submandibular Gland
Major producer of saliva in unstimulated state Marks border of level Ib and II nodes

Disease 10-16 10-08 p16+ Oropharynx Post op Salivary

OAR <39 Gy mean contralateral N/A

Submandibular Gland

Larynx
Triangular shaped starting below hyoid and extending to the cricoid cartilage from anterior commisure to arytenoids. Prescription Dose 50-70 Gy

Disease 10-16 p16+ Oropharynx Post op Salivary GLand

OAR Mean <20 Gy Mean <35 Gy

10-08

60-66 Gy

Image from Atlas of Human Anatomy

Larynx

Larynx

Larynx
Landmarks: C4-C6 Hyoid bone Thyroid cartilage vertebral body Cricoid cartilage

Pharynx
Posterior pharyngeal wall plus adjacent constrictor muscles. from the superior constrictor region -- inferior pterygoid plates to the cricopharyngeal inlet -- posterior cricoid cartilage level.

Some recommended (but not mandatory) goals include: 1) No more than 33% exceeds 50 Gy 2) Mean dose < 40 Gy 3) No more than 10% of the OARpharynx exceeds 60 Gy.

Pharynx

Pharynx

Cervical Esophagus

Reduce the dose as much as possible. Recommended (but not mandatory) goals include: 1) No more than 30% of the esophagus exceeds 45 Gy 2) Mean dose < 35 Gy 3) No more than 10% of the esophagus exceeds 54 Gy

Image from Atlas of Human Anatomy

Esophagus

Esophagus
Starts below OAR pharynx and extends to thoracic inlet Landmarks: Larynx / cricoid vertebral body

Brachial Plexus
Bundle of nerves from C5-T1 that provides sensory and motor innervation to the upper extremity

Disease 10-16 10-08 p16+ Oropharynx Post-op Salivary Gland

OAR Not specified 60 Gy - low neck nodes 66 Gy + low neck nodes

Image from Atlas of Human Anatomy

Brachial Plexus

Brachial Plexus

Hall et al. IJROBP 2008 Volume 72, Issue 5 , p 1362-1367

Lymph Node CTV

Landmarks: Vascular structures Fat planes SCM Inferior C1 Cartilages

Summary
OAR contouring in the H/N is a critical but highly variable endeavor Numerous resources exist to assist the XRT team Knowledge of anatomic landmarks and relationships with high quality CT data quality will allow accurate & efficient contouring of OAR.

Resources
Atlas of Human Anatomy, Frank Netter MD Red Journal papers (inner ear, brachial plexus) RTOG protocols RTOG contouring atlases Web resources: IMAIOS e-Anatomy

THANK YOU ! vthakkar@sero.net