International Guideline
Delineation of the primary tumour Clinical Target Volumes (CTV-P) in laryngeal, hypopharyngeal, oropharyngeal and oral cavity squamous cell carcinoma: AIRO, CACA, DAHANCA, EORTC, GEORCC, GORTEC, HKNPCSG, HNCIG, IAG-KHT, LPRHHT, NCIC CTG, NCRI, NRG Oncology, PHNS, SBRT, SOMERA, SRO, SSHNO, TROG consensus guidelines

https://doi.org/10.1016/j.radonc.2017.10.016Get rights and content

Abstract

Purpose

Few studies have reported large inter-observer variations in target volume selection and delineation in patients treated with radiotherapy for head and neck squamous cell carcinoma. Consensus guidelines have been published for the neck nodes (see Grégoire et al., 2003, 2014), but such recommendations are lacking for primary tumour delineation. For the latter, two main schools of thoughts are prevailing, one based on geometric expansion of the Gross Tumour Volume (GTV) as promoted by DAHANCA, and the other one based on anatomical expansion of the GTV using compartmentalization of head and neck anatomy.

Method

For each anatomic location within the larynx, hypopharynx, oropharynx and oral cavity, and for each T-stage, the DAHANCA proposal has been comprehensively reviewed and edited to include anatomic knowledge into the geometric Clinical Target Volume (CTV) delineation concept. A first proposal was put forward by the leading authors of this publication (VG and CG) and discussed with opinion leaders in head and neck radiation oncology from Europe, Asia, Australia/New Zealand, North America and South America to reach a worldwide consensus.

Results

This consensus proposes two CTVs for the primary tumour, the so called CTV-P1 and CVT-P2, corresponding to a high and lower tumour burden, and which should be associated with a high and a lower dose prescription, respectively.

Conclusion

Implementation of these guidelines in the daily practice of radiation oncology should contribute to reduce treatment variations from clinicians to clinicians, facilitate the conduct of multi-institutional clinical trials, and contribute to improved care of patients with head and neck carcinoma.

Section snippets

Acquisition of the planning CT

  • The patient should lie in the supine position on the flat table-top of the simulation CT scanner with his head and neck immobilized in a neutral neck position by a reproducible immobilization device, e.g. 4–5 fixation point thermoplastic mask.

  • Thin CT sections should be acquired typically from above the base of skull, cranially, to below the sterno-clavicular joint, caudally; for accurate dose calculation, the upper and lower bound should ideally include at least 5 cm of tissue slab beyond the

Glottic carcinoma

  • T1 glottic tumour (Fig. 2): CTV-P1 = GTV-P with a concentrically isotropic margin of 5 mm in all directions. In the axial plane, CTV-P1 does include the paraglottic space, the anterior commissure for anterior vocal cord tumour, the anterior part of the contralateral vocal cord for tumour extending to the anterior commissure, and the vocal process of the arytenoid cartilage for tumour extending to the posterior vocal cord, but excludes the thyroid cartilage and the air cavity; in the

Guidelines for the delineation of the primary tumour CTV for hypopharyngeal SCC

  • T1 tumour (Fig. 10): CTV-P1 = GTV-P with a concentrically isotropic margin of 5 mm in all directions. CTV-P1 should always be delineated within CTV-P2.

  • CTV-P2 = GTV-P with a concentrically isotropic margin of 10 mm in all directions. Depending on the location of the GTV-P, CTV-P2 includes the posterior aspect of the para-laryngeal space (i.e. tumour of the anterior angle and the medial wall of the piriform sinus), the inter-arytenoid area and the arytenoid cartilage (i.e. post-cricoid tumour),

Guidelines for the delineation of the primary tumour CTV for oropharyngeal SCC

  • T1 tumour (Fig. 14, Fig. 15): CTV-P1 = GTV-P with a concentrically isotropic margin of 5 mm in all directions. CTV-P1 should always be delineated within CTV-P2.

  • CTV-P2 = GTV-P with a concentrically isotropic margin of 10 mm in all directions. The CTV-P2 does however not include any air cavity, bony structures (e.g. hyoid bone, mandible, hard palate), or the mobile tongue.

  • For tonsillar primaries, the CTV-P2 includes the superior pharyngeal constrictor muscle within the 5 mm expansion, but does

Guidelines for the delineation of the primary tumour CTV for oral cavity SCC

It is recognized that squamous cell carcinoma of the oral cavity are mainly treated by surgery followed by radiotherapy or concomitant chemo-radiotherapy. However, for the sake of completion, the following guidelines are proposed for patients who will receive primary radiotherapy because of contraindications to surgery (e.g. poor general conditions of the patient, and/or anticipated very poor functional outcome) and/or refusal of surgery.

  • T1 tumour: CTV-P1 = GTV-P with a concentrically isotropic

Discussion

When considering implementing these guidelines, several issues potentially impacting on their clinical use need to be addressed. These are briefly discussed below.

Funding source

None to report.

Ethical considerations

None to declare.

Conflict of interest

All authors declare no conflict of interest.

Acknowledgments

The authors wish to thank A. Bacigalupo, E. Brun, R. Corvò, E. Dale, F. Freire de Arruda, S. Friesland, J. Kazmierska, H. Minn, K. Saarilahti, M.A. Villavicencio Queijeiro, E. Weltman for careful reading of the manuscript and for providing constructive comments.

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