target delineation for breast and axillary nodes contouring.pptx

a detailed overview of breast and axillary nodes contouring for 3DCRT

1. How W e Contour Breast/Chest W all and R egional Nodes Dr Sadia Sadiq MBBS,FCPS SMO & Consultant Clinical Oncologist AECH,INMOL

2. Contouring Guidelines

3. ANATOMY

4. APPLIED ANATOMY OF CHEST WALL Vascular Structures Subclavian Vein Subclavian Artery Axillary Vessels Internal Thoracic Vessels Lateral Thoracic artery Internal Jugular Vein Common Carotid Artery Muscles Pectoralis Major Pectoralis Minor Lattisimus D orsi Scalene Anterior Subscapularis Sternocleidomastoid Deltoid

5. The right and left brachiocephalic veins are formed posterior to the sternoclavicular (SC) joints by the union of the internal jugular and subclavian veins . The left brachiocephalic vein is more than twice as long as the right brachiocephalic vein

6. From anterior to posterior Subclavian vein is 1 st structure arching over lung apex in coronal sections Subclavian artery follows

7. Subclavian artery artery is cranial and posterior to subclavian vein . They arch over apex of lung.

8. Just above arch of aorta(3 vessel view) L Subclavian A L CCA R Brachiocephalic Trunk

9. R Brachiocephalic trunk divides into R Subclavian and R CCA Internal Thoracic A rtery originates from R S ubclavian artery

10. Internal Thoracic vein terminates into Brachiocephalic vein

11. Internal Thoracic Vein lies medial to Internal Thoracic Artery

12. Pectoralis Major

13. Pectoralis Minor

14. Cross-sectional Anatomy Pec Major Pec Minor Lattisimus dorsi Subscapularis Teres Major

15. Bony Structures(Count from posterior to Anterior)

16. CTVp_Breast

17. CTVp_Breast In relatively obese patients the CTVp_breast is positioned more ventrally in the caudal part of the breast due to fatty tissue . Arrow points at the lateral thoracic artery. It is often possible to identify medial mammary branches of the internal thoracic artery, and the CTVp_breast is positioned lateral to these vessels.

18. CTVn_L1

19. CTVn_L2

20. Inter-pectoral Nodes Cranial Caudal Ventral Dorsal Medial Lateral Includes the cranial extent of the axillary artery (i.e. 5 mm cranial of axillary vein) Level 2’s caudal limit Major pectoral muscle Minor pectoral muscle Medial edge of minor pectoral muscle Lateral edge of minor pectoral muscle

21. CTVn_L3

22. SCFn

23. CTVn_IMN

24. Overview of CTVn_L1, CTVn_L2, the CTVn_interpectoralis , CTVn_L3, and CTVn_L4 at the midlevel of the subclavian arch (yellow arrow). Notice, in green the PRV delineated 1 cm around the humeral head to help delineation of the lateral border of CTVn_L1.

25. 3D overview of the lymph node volumes Notice, that all volumes are interconnected

26. Organs at Risk

27. CHEST WALL

28. CTVn_L 1

29. CTVn_L2

30. CTVn_L3

31. BREAST/CHEST WALL/NODAL RT : INMOL INTACT BREAST +- NODES : 40 Gy /15 # CHEST WALL +- NODES : 35 Gy /10 #..(Phase 2 Trial ongoing) Fast Forward + DIBH…still not been started