Basics of Anatomy, Planning,

and Delivery:
Gastrointestinal Cancers

Karyn A. Goodman, M.D.

Department of Radiation Oncology
Memorial Sloan-Kettering Cancer Center
 Learning Objectives
• Basic abdominal and pelvic anatomy

• Essentials of radiation therapy planning for

upper and lower GI malignancies

• Options for image guidance and

techniques to account for motion
Gastroesophageal Junction
Anatomy

Siewert’s Classification Lymph Node Stations

Matzinger O, Radiother Oncol, 2009

 Pancreas Anatomy

Surgery of the Liver and Biliary Tract. LH Blumgart, et al. 4th

edition. W. B. Saunders. 2007

Courtesy of Corinne Winston, MD

 Classic Arterial Anatomy

Celiac Axis

SMA

Winston CB, et al. CT Angiography for Delineation of Celiac and SMA Arterial
Variants in Patients Undergoing Hepatobiliary and Pancreatic Surgery. AJR. 2007.
Celiac SMA Portal vein

SMV Jejunal vein SMV

 Abdominal Nodal Anatomy

Celiac nodes SMA nodes

Abdominal Nodal Anatomy
Gastrohepatic
ligament node
CBD

Porta hepatis ln Porta caval ln

Hepatic
artery
Hepatic artery ln
 Abdominal Nodal Anatomy

Anterior and posterior Pancreatico duodenal and

peripancreatic LN splenic nodes
Anatomy of the Rectum and Anus
Peritoneal Reflection

Mesorectal fat

12-15 cm
 Rectal Anatomy

Mesorectal Fascia Mesorectal Fascia

• T2 axial images
• Mesorectal fascial involvement associated with higher
risk of positive circumferential resection margin
Nodal Drainage Patterns
 Pelvic Nodal Anatomy

Superior Hemorrhoidal Vessels Mesorectal Nodes

Courtesy of Corinne Winston, MD

 Pelvic Nodal Anatomy

External Iliac Nodes Inguinal Nodes Great Saphenous Vein

Internal Iliac Nodes

Courtesy of Corinne Winston, MD

Pelvic Nodal Anatomy
Pelvic Nodal Anatomy
 Learning Objectives
• Basic abdominal anatomy

• Essentials of radiation therapy planning for

upper and lower GI malignancies

• Options for image guidance and

techniques to account for motion
Gastroesophageal Junction Tumors
Standard 4-Field Plan
 Target Delineation
Normal Tissues Nodal Regions
• Spinal Cord • Peri-esophageal
• Stomach nodes
• Lungs • Gastrohepatic
• Kidneys ligament nodes
• Liver • Celiac nodes
• Bowel • Mediastinal/
• Heart subcarinal nodes
• Esophagus
Lymph Node Drainage Patterns

Leers J, J Thorac Cardiovasc Surg, 2009

Intensity Modulated Radiotherapy (IMRT)

••• •••

a n z a..+..n..+..z
Improving the Delivery of Radiotherapy
4-Field IMRT

Kole T, Int J Rad Onc Biol Phys,

2012
 Cardiac Sparing
• IMRT resulted in significant reduction (p <
0.05) compared with 3DCRT in:
– mean heart dose (23 vs. 28 Gy)
– V30 to heart (24.8% vs. 61.0%)
– mean RCA dose (24 Gy vs. 36 Gy)

Kole T, Int J Rad Onc Biol Phys, 2012

 Post-operative Pulmonary Complications
(PPC)
• Impact of RT may be greater in V10* PPC Risk
patients who undergo surgical <40% 8%
resection 40%+ 35%
• Even relatively low doses less
V15*
tolerable given pre-op with
concurrent chemo <30% 10%
• Concern about low dose 30%+ 35%
spread to larger volume with V20
IMRT
<20% 10%
20%+ 32%
Lee et al. IJROBP 2003
Pancreatic Cancer: Locally Advanced
Disease
4-Field “Box” Fields
 Target Delineation
Normal Tissues Nodal Regions
• Spinal Cord • Celiac nodes
• Stomach • SMA nodes
• Duodenum • Peripancreatic
• Kidneys • Porta Hepatis
• Liver • PA/RP Lymph Nodes
• Bowel • Splenic hilum (tail
• Heart lesions)
Pancreatic Protocol CT
Martinez-Monge R. Radiology; 1999
 GTV

PTV
Pancreatic Cancer: Adjuvant Therapy for
Resectable Disease

Pre-operative CT Post-operative CT
 Radiotherapy Quality Assurance

• RT fields prospectively reviewed in RTOG 97-04

– 48% of treatment plans did not meet protocol requirements.

• Based on “per protocol” versus “not per protocol”

radiation delivery
– Grade 3/4 toxicity did not vary significantly on the 5-FU arm
but did show a trend of less toxicity for patients on the
gemcitabine arm
• Survival was significantly increased for patients
treated per protocol (p=0.019)
 Radiotherapy QA on RTOG 0848
• Prospective radiation quality control is
required
• Central review will be performed prior to
treatment delivery
• CT-based planning is required
• Either 3DCRT or IMRT planning

• http://www.rtog.org/CoreLab/ContouringAtlases/Pancreas
Atlas.aspx
 ROI’s
A B C D

E F G H
A
ROI Expansion 1 Expansion 2 CTV/PTV

C
 Coronal/Sagittal Views

A
B
C
D
E
F
G

H
IMRT Beam Arrangement
IMRT Dose Distributions

• Highly conformal
around targets
• Overall hot spot is
inside of high dose
target

IMRT 4F Box
 Advances in Pelvic
Radiotherapy Techniques

Standard Pelvic RT Fields

Gunderson, Cancer;1974
 Advances in Pelvic
Radiotherapy Techniques
• Understand lymphatic drainage patterns

• Better delineate primary tumor using

imaging
– MRI
– PET
• Deliver radiotherapy more accurately and
conformally
 Advances in Imaging Techniques
MRI PET
– Determine extent of extramural – Identify distant
1
tumor metastases and
– Identify risk of CRM positivity 2 delineate primary tumor
and involved nodes

1- Mercury Study group, Radiology, 2007

2- Mercury Study group, British Medical Journal, 2006
MRI to Risk Stratify Rectal
Cancer
 Rectal Cancer – Simulation
CT Simulation
– Supine (thin) or Prone
– Belly Board / Bowel Compression if Prone
– Aquaplast / Vac-loc Bag (or equivalent)
– Full Bladder
– IV Contrast if possible
– Oral Contrast
– Anal marker; consider vaginal marker
– ≤ 3mm CT slice thickness
Rectal Cancer – Target Definition
• GTV: Primary tumor + involved nodes
– As defined on physical exam, ERUS, MRI, CT, and/or
PET
– Include tumor + entire rectal circumference at that level

• CTV: Elective nodal regions

– Standard: Peri-rectal, internal iliac, and superior
hemorrhoidal (CTV A)
– For T4 tumors extending anteriorly: include external iliac
(CTV A + B)
– For tumors invading anal canal: include inguinal and
external iliac (CTV A+B+C)
Myerson RJ, IJROBP, 2009;74:824-30.
 Contouring Guidelines
RTOG Atlas
CTV A includes:
• Mesorectal nodes
– Perirectal
– “Presacral”
• Internal iliac nodes
CTV B includes:
• External iliac nodes
CTV C includes: Images from RTOG anorectal atlas:
www.rtog.org/CoreLab/ContouringAtlases/Anorectal.aspx
• Inguinal nodes
Myerson RJ, IJROBP, 2009;74:824-30.
Australasian Contouring Atlas

Ng M, Int J Radiat Oncol Biol Phys, 2012

Ng M, Int J Radiat Oncol Biol Phys, 2012
 Learning Objectives
• Basic abdominal anatomy

• Essentials of radiation therapy planning for

upper and lower GI malignancies

• Options for image guidance and

techniques to account for motion
Respiratory Motion
How to Assess Internal Motion?
4D CT Scans
• Provide 3D spatial information and temporal
changes of the anatomy
• Position-monitoring system is interfaced with CT
scanner, so CT data acquired in correlation with
real-time positioning
 4-D PET/CT Simulation
GE Discovery ST8 PET/CT and Varian RPM
Phase Sorting

……
phase j
phase i
 Motion Management Options
• Large margins
• Internal Target Volume (ITV)
• Active Breathing Coordinator (ABC)
• Synchrony/Tracking
• Deep Inspiration Breath Hold
• Respiratory Gating
• Compression Belt
 Respiratory Gating
• Machine delivers dose only during part of the
breathing cycle (expiration)
• Fiducial markers used as surrogates of tumor
position
• Monitor with fluoroscopy or gated port films
 Selecting Gating Interval
• End-expiration
– Most stable phase
• End-inspiration
– the expansion of lung
tissue may result in less
lung toxicity

• Interval width
– Respiratory cycle runs 0% to 90% phase, divided into 10
– End-inspiration falls at 0%
– End-expiration is at 50%
– 30% - 70% standard gating interval for expiration
 Accounting for Irregular Breathing
• All patients receive
3

coaching instructions and 2

No Instruct

CD at consultation 1

Marker Position (cm)

• Choose comfortable
0

3 0 5 10 15 20 25 30

breathing rhythm 2
With Instruct

– “breathe in, breathe out” 1

– “breath in…two…breath
0

out….two..three”
0 5 10 15 20 25 30

Time (s)

Courtesy of Ellen Yorke, PhD

• Coaching during simulation
and treatment
 Abdominal Compression
• Abdominal belt with inflatable bladder
• Inflation: 15-40 mmHg
 How do we know what we are targeting
during treatment?

• Esophageal/GE junction tumors are not

readily visible on 2D imaging, even with
diagnostic KV imaging

• Need surrogate marker

– Fiducial marker
– Stent
Fiducial Markers

Visicoil
EUS-Guided Placement

Fiducial Outer Trocar

Needle Carrier
EUS-guided placement
Typical Fiducial Placement on Simulation
CT
Daily Verification
 4DCT Study of Pancreas
Tumor Motion

Left-Right Ant-Post Sup-Inf

(cm) (cm) (cm)
Total cycle 0.42 0.65 1.50
In gate 0.24 0.26 0.59
 4DCT Study of GE Junction
Tumor Fiducial Motion
Total respiratory cycle and “in-gate” fiducial motion

Left-Right Ant-Post Sup-Inf

(cm) (cm) (cm)
Total Cycle
Median 0.25 0.41 1.25
Range 0.06-1.08 0.03-2.24 0.15-2.48
In-gate
Median 0.13 0.20 0.54
Range 0.01-0.51 0-0.81 0.01-1.25
 Rectal Tumor Motion
• IMRT for rectal cancer limited by uncertainty in
targeting rectal tumors
• Consequence of rectal motion due to filling and
deformation
• Data from studies of prostate gland motion using
cine-MRI demonstrate
– Rectal motion and filling was a main determinant of
prostate intra-fraction motion
• Inter-fraction motion for rectal tumors may be
even greater

Ghilezan M, IJROBP, 2005

 Rectal CBCT Study
• Weekly cone-beam CT
– to quantify degree of rectal motion and volume
change during RT
– to measure accuracy and precision of a
simulated IMRT treatment delivery model
• 9 patients (8 rectal, 1 anal cancer) underwent
> 1 CBCT during a course of pelvic RT
• Co-registered to respective simulation CT
scan by matching bony anatomy
Serial CT Scans
 Degree of Rectal Deformation
• IMRT plans generated for 8 rectal cases
and forward calculations were applied to
the subsequent CBCT scans
• 7 of 8 patients had adequate rectal
coverage with IMRT plan using 15 mm
margin despite rectal motion and
deformation
Max RL Mean RL Max AP Mean AP
Centroid
motion (cm) 2.6 0.71 3.77 0.97
 Conclusions
• Knowledge of abdominal anatomy is
essential for RT planning using more
conformal techniques for GI malignancies
• Improvements in delivery of RT allow for:
– More accurate treatment of the target and
reduced toxicity
– Better integration with other therapies
including surgery, chemotherapy, and
potentially, targeted agents
– Further dose escalation
 Conclusions
• Further research is necessary to verify
clinical impact of these techniques