TARGET DELINEATION IN HEPATOPANCREATICOBILIARY TUMORS

1. Optimal target volumes of
primary and nodal stations in
Hepato Pancreato Biliary Tumors
DR KANHU CHARAN PATRO
MD,DNB(RADIATION ONCOLOGY),MBA,FICRO,FAROI,PDCR,CEPC
HOD,RADIATION ONCOLOGY
Mahatma Gandhi Cancer Hospital And Research Institute, Visakhapatnam, India
drkcpatro@gmail.com /M+91-9160470564
1

2. Where is the Target?
2

3. PUSH AND PULL BUSINESS
OAR
TARGET
3

4. SYSTEMATIC ERROR
4

5. Delineation
• OAR
• TARGET
5

6. Settings
• Liver
– SBRT
– PVTT
• Pancreas
– NACT
• SBRT
• CONVENTIONAL
– Post-op
• Biliary
– Extrahepatic
– Intrahepatic
– Radical Gallbladder
– Post op Gallbladder
6

7. ITV
CONCEPT
• GTV- CTV- PTV
• GTV-ITV-CTV-PTV
7

8. REDUCTION IN PTV
• Custom immobilization
• Respiratory management
• Image guidance
PTV PTV
8

9. panc
D
THE VOLUME CONCEPT
9

10. Which is better?
• Which motion management system is better?
• Which phase is better?
• Empty stomach/filled stomach is better?
• DIBH/DEBH is better?
• Which immobilization is better?
• Contrast/water is better?
10

11. 11
1. Analyze the tumor in all phases of triple
phase CT
2. See the greatest resolution
3. Try to synchronization with breath hold

12. 12
ARTERIAL VENOUS DELAYED
S
T
A
R
T
S
T
A
R
T
S
T
A
R
T
BREATHHOLD SYNCHRONIZATION
0 sec 20 sec 40 sec

13. GOSSIP- WHOSE SPOUSE IS BETTER?
13

14. ANSWER
WHICH YOU ARE POSSESSING , THAT IS BETTER
BUT PLAN DATING BEFORE BATTING 14

15. IMAGING
• Plain
• Contrast
I. ORAL
II. IV
•Arterial
•Venous
•Delayed 15

16. BARIUM CONTRAST
16

17. ORAL NON-IONIC CONTRAST
17

18. 18

19. 19

20. Non contrast
20

21. 21
Arterial phase

22. Arterial phase
22

23. Portal venous phase
23

24. Portal venous phase
24

25. Delayed phase
25

26. Delayed phase
26

27. Blood supply of liver
27

28. 28

29. Liver segments by hepatic vein
30

30. 31

31. 32

32. Liver segments - clockwise
33

33. 34

34. Caudate lobe
35

35. 36

36. 37

37. 38

38. Billiary tract
39

39. 40

40. 41

41. 42

42. Common Bile Duct
• CBD contour should start at the first bifurcation or at its entry
to the portal triad inferiorly to the first portion of duodenum
• It passes posterior and medial to the duodenum and joins with
the pancreatic duct
• Irradiation of caudate lobe liver tumors may lead to high
radiation doses being received by the CBD
43

43. 44

44. 45

45. 46

46. 47

47. 48

48. 49

49. 50

50. 51

51. 52

52. 53

53. 54

54. 55

55. 56

56. 57

57. 58

58. 59

59. 60

60. 61

61. 62

62. • HCC
• ADENOCA PANCREAS
• CHOLANGIOCARCINOMA
63

63. LIVER TUMOR ANATOMY
64

64. How it looks?
• Usually, the mass enhances vividly during late arterial (~35 seconds)
• Then washes out rapidly, becoming indistinct or hypoattenuating in the portal
venous phase, compared to the rest of the liver
• Portal vein tumour thrombus can be distinguished from bland thrombus by
thrombus by demonstrating enhancement.
65

65. 66
DELAYED PHASEMORE WASHOUT
VENOUS PHASE_ WASHOUT
ARTERIAL ENHANCMENNT
CAPSULE/PSEUDO CAPSULE
NON CONTRAST

66. 67
ARTERIAL PHASE_ ENHANCED

67. 68
VENOU PHASE_ WASHOUT

68. 69
DELAYED PHASE_ MORE WASHOUT

69. 70
Massive mass with thrombus

70. 71
Portal vein thrombus

71. RT. PORTAL VEIN THROMBOSIS
72

72. Collaterals
73

73. METASTSIS
• HYPOVASCULAR
• HYPERVASCULAR
74

74. 75

75. 76

76. 77

77. 78

78. 79

79. Target volume for HCC
80

80. Liver SBRT
81

81. 82
Pancreatic Tumor Anatomy

82. 83

83. 84

84. 85

85. 1. Size of the tumor
2. Involvement of critical vascular structures as defined by the NCCN or DPCG
criteria
3. Invasion of nearby structures like transverse mesocolon, root of the
mesentery and perineural invasion
4. Lymph node involvement locoregional or extraregional
86

86. ADENOCARCINOMA
87

87. ENDOSCOPIC ULTARSOUND
88

88. EXOPHYTIC TUMORS OF PANCREAS
89

89. Tumour vessel interface
90

90. 91

91. ABUTMENT AND ENCASEMENT
92

92. 93

93. Ishikawa classification system
94

94. Ishikawa classification system
95

95. 96

96. 1. There seems to be just limited contact with the portal vein (arrow).
97

97. oval or round to a teardrop
98

98. 99

99. 100
CELIAC ARTERY ENCASEMENT

100. 101

101. 102

102. 103

103. 104

104. FULL VS EMPTY STOMACH
105

105. 106

106. 107

107. HANDLING STOMACH FILLING
1. Variations in gastric filling may lead to significant intrafraction
differences dose to normal stomach.
2. To mitigate this most panelists recommended keeping patients
NPO for 2-3 hours before simulation and each treatment.
3. However, treating patients at a consistent interval after meals
also appears to result in reproducible gastric positioning, and
may be more comfortable for some patients
108

108. WATER RATHER THAN CONTRAST
109

109. Applied radiology
110

110. IMAGING PROTOCOL- NEGATIVE/NEUTRAL CONTRAST
111

111. 1. Use water rather than contrast
2. Pancreatic phase instead of the arterial phase.
Pancreatic phase refers to the late arterial
phase (typically 40-45 sec after contrast
injection) during IV contrast.
Pancreatic Protocol
112

112. 113

113. A CT REQUSITION
• High-resolution dual-phase (arterial and portal)
contrast material–enhanced CT is the established
technique for evaluating pancreatic adenocarcinoma.
• LATE Arterial phase imaging (per-formed 20–40
seconds after contrast agent injection) allows optimal
visualization of the tumor and peripancreatic arteries.
• Portal phase imaging (performed 50–70 seconds after
injection) is optimal for detecting metastatic disease to
the liver and for assessing the peripancreatic veins
114

114. TRIPLE PHASE PET CT- NON ENHANCE/ART/VENOUS
115

115. TRIPLE FUSION-EXCLUDES CONFUSION
116

116. 117

117. 118

118. Red-no, Orange-chemo alone
Green- CTRT
119

119. ANASTOMOSIS
120

120. Whipples surgery
121

121. 122

122. PANCREATICO-JEJUNOSTOMY
123

123. Remnant
Pancreas
Pancreaticojejuno
stomy
124

124. Pancreaticogastro
stomy
Residual
Pancreas
125

125. Hepatico jejunostomy
126

126. Pancreatico jejunostomy
127

127. 128

128. CTV- Post op
pancreas
129

129. 130

130. GCP
• Post op bed
• Nodal volume
• Stomas
131

131. 132

132. Target delineation
133
1. Delineate ROI’s:
1. Portal vein (PV: starts at confluence of SMV and splenic vein)
2. Pancreaticojejunostomy (PJ)
3. Celiac artery (proximal 1-1.5cm)
4. SMA (proximal 2.5-3cm)
5. Aorta (superiorly to most cephalad of CA, PV, or PJ contours; inferiorly to bottom
L2, or as low as L3 to cover pre-op GTV)
6. Hepaticojejunostomy (HJ)
7. Tumor bed (based on review of pre-op imaging, pathology report, surgical clips)
2. Expansion 1: 1.0cm on PV, PJ, CA, SMA
3. Expansion 2: all on Aorta --> 2.5-3cm on R, 1cm on L, 2-2.5cm anteriorly,
0.2cm posteriorly
4. CTV Boolean Expansions 1 + 2, confirm that tumor bed (including clips) and HJ (if
present) are encompassed
5. PTV = CTV + 0.5cm

133. Tumor bed with clips
134

134. PV,CA,AORTA
135

135. Celiac artery branches
136

136. 137

137. SMA
138

138. 139

139. 140
AORTA
OTHER
VESSELS
POST OP

140. 141

141. SBRT PANCREAS
142

142. Steps
pancreatic
SBRT
14
3
• Delineate vessels
– CA - Celiac artery
– CHA - Common hepatic artery
– LGA - Left gastric artery
– PV - Portal vein
– SMV - Superior mesenteric vein
– SV- Splenic vein
– AORTA
• Delineate GTV TOTAL
– GTV PRIMARY {GTVp}
– GTV VESSEL EXAPANSION- GTVp + 0.5 mm
• Delineate TVI
– The entire circumference of involved or
proximal vessels are contoured to form
tumor vessel interface
• CTV
– GTV + TVI
• PTV
– CTV + 0.5mm

143. What is GTV in pancreas?
• MRI
• PET
• ENDOSCOPY- Duodenal involvement
• CT
– The GTVp should include fibrotic areas near vessels based on experienced radiologist
review. This is identified as poorly defined or thickened vessel edges.
– It is now known that pancreatic stellate cells and the desmoplastic reaction around tumor
edges is a key contributor to pancreatic cell cancer biology, including regional progression
and distant metastasis.
– As such, this poorly defined area around the tumor should be included in the GTVp.
– If it is unclear whether a vessel is involved, it should be included in the GTVp
144

144. DOSING PATTERN
145

145. Vessel invasion
146

146. The TVI
• We define the TVI as the area where the GTVp is involving or within
5 mm of the major vessels in the upper abdomen, including celiac
artery, superior mesenteric artery, common hepatic artery, left gastric
artery, superior mesenteric vein, portal vein, splenic vein, or aorta.
• If GTVp is within 5 mm of these structures, then a TVI is defined as
above and incorporated into a clinical target volume of 40.
• In principle, any major vessel within 5 mm of the tumor should be
contoured from 5 mm proximal to 5 mm distal of the GTVp (Fig
2).
• This region should be defined in 3 dimensions (eg, using axial,
sagittal, and coronal planes Whole vessel circumference should be
included.
• In the case of aorta and portal vein, only the proximal half may
need to be contoured as part of the TVI as these vessels have a
much larger circumference
147

147. GTVp
148

148. GTV VESSEL EXPANSION
149

149. TVI- BLUE
150

150. CTV
151

151. PTV- CTV + 0.5mm
152

152. Handling the PTV
• In general, a 5-mm margin is
recommended.
• When a PTV of 40 crosses into or near a
hollow viscous PRV, compromises need to
be made to dose coverage in this area to
Preserve hollow viscous dose constraints
153

153. PRV
• We recommend the duodenal, stomach, small bowel,
and large bowel PRV be a minimum 3-mm expansion.
• However, if treating during free breathing or organ
movement is seen to be large on multiple end expiratory
breath hold scans or 4D-CT, a greater PRV margin is
required.
• Concessions to large bowel maximum dose (D0.5
cm3 and D5 cm3) may be considered to meet coverage
goals
154

154. The ITV CONCEPT
• ITV40 creation using motion information
from multiple end-expiratory breath hold
scans and/or 4D-CT
155

155. PTV COVERAGE
156

156. OAR constraints PANCREATIC SBRT
157

157. Cholangiocarcinoma
158

158. 15
9

159. 160

160. 161

161. Imaging pictures
• The lesion has the following characteristics:
• The lesion is hypodense in the arterial and portal venous phase with
some peripheral enhancement.
• The lesion is hyperdense in the equilibrium phase indicating dens
fibrous tissue.
• The lesion causes retraction of the liver capsule
• The finding of an infiltrating mass with capsular retraction and
delayed persistent enhancement is very typical for a
cholangiocarcinoma.
163

162. Delayed phase enhancement
• Small cholangiocarcinoma not visible in portal
venous phase (left) but seen as relative hyperdense
lesion in the delayed phase (right).
164

163. 165

164. 166

165. 167

166. Cholangiocarcinoma
With glandular stroma

167. 169
INTRAHEPATIC CHOLANGIO CA

168. EXTRAHEPATIC CHOLANGIO CA
170

169. 171
HILAR CHOLANGIO CA

170. GCP volume – Biliary tract
176

171. NODAL VOLUME- Biliary tract
177

172. Target lymph node for biliary tract
cancer
178

173. CTV - intrahepatic cholangiocarcinoma
179

174. Intrahepatic cholangiocarcinoma
180

175. CTV - extrahepatic cholangiocarcinoma
181

176. Extrahepatic cholangiocarcinoma
182

177. CTV – Gallbladder carcinoma
183

178. Gall bladder
184

179. 185

180. 186

181. Japanese lymph node stations
187

182. LYMPH
NODE
NAMINGS
188

183. CTV N0
• In this CTV-N delineation, a 10 mm margin of soft
tissue around vessels, ligament and ducts was
suggested, based on several literature data, without
overlap with radiosensitive structures (duodenum,
liver, small bowel, stomach).
• Only for para-cardials nodes and lesser gastric
curvature nodes, the suggested target was defined
without any further expansion to preserve the
surrounding OARs
189

184. See the continuity
See the contour
See the location
Follow the vessel
0.7 to 2.5 cm margin to vessel
190

185. DIFFERENTIATING NODE FROM VESSEL
8 C
• CLINICAL
• CONTRAST
• CONTINUITY
• CONTUR
• CONTRALATERALITY
• CONGLOMERATION
• CYSTIC COMPONENET
• CIRCULAR
191

186. 192
Black-gastro esophageal

187. 193

188. 194

189. 195

190. 196
CRURAL GROUP
MIDDLE COLIC

191. 197
GASTRO ESOPHAGEAL
ANTERIOR DIAPHRAGMATIC

192. 198
LT GASTRIC
GREATER
CURVATURE
PHRENIC

193. 199
HEPATIC ARTERY
GROUP

194. 200
PYLORIC

195. 201
COFLIC GROUP

196. 202
SUPERIOR
MASENTRIC
GASTRO DUODENAL

197. 203
SUPERIOR
MASENTRIC

198. 204
PERIPORTAL

199. 205
PANCREATICO
DUODENAL

200. 206
RENAL HILAR

201. 207
AORTOCAVAL

202. 208
RENAL HILAR

203. 209
PARAAORITC

204. 210
PARAAORITC

205. 211
INFERIOR
MASENTRIC

206. 212

207. 213

208. 214

209. 215

210. 216

211. OAR
217

212. BOWEL BAG
VS
INDIVIDUAL BOWEL LOOP
218

213. 219

214. 220

215. For liver contouring
• Gallbladder should be excluded
• IVC should be excluded when it is discrete from the liver
• Portal vein (PV) should be included in the liver contour
when Segment (Seg) I (caudate lobe) is seen to the left
of PV
221

216. 222

217. 223

218. Thank You.
224