Abstract
Background
Materials and Methods
Results
Conclusions
Introduction
Materials and Methods
2D T2 frFSE | 2D T2 PROPELLER | 3D T2 CUBE | |
---|---|---|---|
MRI scanner model | GE DISCOVERY MR750w | GE SIGNA Artist | GE SIGNA Artist |
RF receive coil array | AIR RT Head&Neck | GEM Head&Neck | GEM Head&Neck |
B0 [T] | 3 | 1.5 | 1.5 |
BW [kHz] | 62.5 | 83.3 | 125 |
TR [ms] | 11866 | 7624 | 2002 |
TE [ms] | 99.3 | 87.3 | 76.6 |
ETL | 22 | 26 | 100 |
Scan time [s] | 332.6 | 229.1 | 259.0 |
Scan orientation | axial | axial | sagittal |
FOV [mm^2] | 300 × 300 | 300 × 300 | 340 × 340 |
AcqRes [mm^2] | 1.04 × 1.04 | 1.04 × 1.04 | 1.18 × 1.18 |
InterpRes [mm^2] | 0.59 × 0.59 | 0.59 × 0.59 | 0.66x.066 |
Dz [mm] | 3 | 3 | 1 |
Nz | 100 | 80 | 340 |
Results
Parotid glands
Contouring suggestions
- •The delineation of the external carotid artery and retromandibular vein was carried out in a few cases in order to precisely define the medial border of the organ and to distinguish between the vessels and the styloid process, as well as the muscles arising from the latter.
- •An accessory parotid gland is sometimes present alongside the parotid duct, on the outer surface of the masseteric muscle that has to be included in the contour.
- •Fatty infiltration/replacement of the secretory tissue may be present at older ages, which may make the outline of the organ more difficult to define [17]. This may also arise as a therapeutic side effect of previous irradiation.
- •See Table 2. for the recommended anatomical boundaries.Table 2Anatomical borders of the salivary glands.
Organ boundaries Parotid glands Submandibular glands Anterior Masseteric muscle, man-dibular ramus, pterygoid muscles Posterior margin of mylohyoid muscle, with the deep process spreading above the mylohyoid muscle Posterior Sternocleidomastoid mus-cle and the posterior belly of the digastric muscle Parapharyngeal space, great vessels of the neck Medial Styloid process, styloglos-sus, stylohyoid and stylo-pharyngeal muscles Superior: lateral surface of hyoglossus and partly mylohyoid muscles Middle: lateral surface of styloglossus and stylohyoid muscles, digastric muscle Inferior: lateral surface of the body of hyoid bone, pharyngeal constrictor muscles Lateral Platysma, subcutaneous tissue Superior: medial surface of medial pterygoid muscleMiddle: medial surface of the body of the mandibular bone Inferior: platysma, investing layer of deep cervical fascia, fat tissue Cranial Superior wall of of the external auditory canal, mastoid process Medial pterygoid muscle Caudal No distinct border, the organ gradually disappears in the fat tissue of the neck No distinct border, the organ gradually disappears in the fat tissue of the neck
Submandibular glands
Contouring suggestions
- •See Table 2. for the recommended anatomical boundaries.
Mandible
Contouring suggestions
- •The alveoli or teeth sockets of the mandibular corpus are still included in the contour, but not the teeth.
- •We have omitted the coronoid process from the contour since its cranial border is hard to define univocally on axial MRI slices and radiation necrosis affects primarily the body [18].
Supraglottic larynx
Glottic larynx/glottic area
Contouring suggestions
- •See Table 3. for the recommended anatomical boundaries of the laryngeal structures.Table 3Anatomical borders of the laryngeal structures and the oral cavity.
Organ boundaries Supraglottic larynx Glottic larynx Oral cavity Anterior Hyoid bone, pre-epiglottic space, thyroid cartilage [1] Thyroid angle Inner surface of superior and inferior dental arches Posterior Posterior pharyngeal wall Inner surface of cricoid and arytenoid cartilages Posterior border of soft palate and uvula, root of the tongue [1] Medial NA (lumen of the larynx) NA Lateral Inner surface of thyroid cartilage Inner surface of dental arches, maxilla and mandible Cranial Tip of epiglottis [1] Caudal boundary of supraglottic larynx, i.e. the arytenoids Mucosa of hard and soft palate Caudal 1-2 slices below the appearance of arytenoid cartilages, individually. Thus, the false vocal cords fall within the borders of the structure. Clinically, it varies from 0 to 1 cm below the free level of the true vocal cord, extending inferiorly from the lateral margin of the ventricle [19; 23]. From practical point of view, the disappearance of the thyroid angle is a good landmark. Anterior: mylohyoid muscle + anterior belly of the digastric muscle Posterior: root of the tongue and hyoid bone [1]
Oral cavity
Contouring suggestions
- •See Table 3. for the recommended anatomical boundaries.
Pharyngeal constrictor muscles (PCMs)
Contouring suggestions
- •Apart from the PCMs, various other structures play an indispensable role in the process of swallowing. These structures are the muscles of the floor of the mouth (the anterior belly of digastric muscle, mylohyoid and geniohyoid muscle), the thyrohyoid muscle, the posterior digastric/stylohyoid muscle complex, the longitudinal pair of the pharyngeal constrictors i.e. the longitudinal pharyngeal muscles (LCMs), the hyoglossus/styloglossus complex, the genioglossus muscle and, finally, the muscles responsible for tongue motion; the intrinsic tongue muscles, which are referred to collectively as functional swallowing units (abbreviated as FSUs [9; 21]). The three major physiological roles of these structures are tongue motion, tongue base retraction and hyolaryngeal elevation. The usefulness of FSU delineation in daily routine is a source of debate, due to the extreme workload demand and eventual overlaps with other sensitive areas, such as the oral cavity and certain laryngeal structures. The contouring process might be facilitated in some cases by the usage of automatic OAR segmentation, as stated in the article of the MD Anderson Head and Neck Cancer Symptom Working Group [22]. To the best of our knowledge, neither dose constraints, nor exact fields of implication have been defined for these structures.
- •See Table 4. for the recommended anatomical boundaries.Table 4Anatomical borders of the pharyngeal constrictor muscles.
Organ boundaries Superior pharyngeal constrictor muscle (SC) Middle pharyngeal constrictor muscle (MC) Inferior pharyngeal constrictor muscle (IC) Anterior Caudal tip of the pterygoid plates [13] Hyoid bone, root of the tongue [13] Soft tissue of the larynx [13] Posterior Longus capitis and colli muscles 1, i.e. the prevertebral muscles [13; 24]The former muscle stretches between the base of the skull (insertion: basilar part of occipital bone) and the upper cervical vertebrae (origin: transverse processes of third to sixth cervical vertebrae). The latter lies beneath the longus capitis muscle, on the anterior surface of vertebral bodies and can be followed all the way down to the level of upper thoracic vertebrae (origin: bodies of C5 – Th3 vertebrae, insertion: anterior arch of the atlas)Medial NA/pharyngeal lumen [13] Lateral Medial pterygoid muscle [13], parapharyngeal space Greater horn of hyoid bone [13] Superior horn of thyroid cartilage [1; 13] Cranial Caudal tip of pterygoid plates [13; 25] Cranial edge of C3 vertebra [13] First slice caudal to the caudal edge of hyoid bone [13] Caudal Caudal edge of C2 vertebra [13] Caudal edge of hyoid bone [13; 25] Caudal edge of arytenoid cartilages [13] 1 The former muscle stretches between the base of the skull (insertion: basilar part of occipital bone) and the upper cervical vertebrae (origin: transverse processes of third to sixth cervical vertebrae). The latter lies beneath the longus capitis muscle, on the anterior surface of vertebral bodies and can be followed all the way down to the level of upper thoracic vertebrae (origin: bodies of C5 – Th3 vertebrae, insertion: anterior arch of the atlas)2 The pterygopharyngeal part of the superior pharyngeal constrictor muscle originates from the lower third of the medial pterygoid plate and its hamulus. Finding the pterygoid process on MRI images may be challenging, therefore CT correlation is advisable.
Inner ear
Contouring suggestions
- The cochlea and vestibular system have been delineated separately in some cases. However, due to the proximity of the two structures, we have defined the inner ear as one single OAR, following the practice of Sun et al. [27].
Eye (eyeball)
Contouring suggestions
- •A meticulous delineation of the fluid filling the anterior chamber and the vitreous body can be carried out. The extension of this contour by 1 mm (corresponding to the outer layers of the eye) in all dimensions may also lead us to an adequate OAR contour.
Lens
Optic nerve
Contouring suggestions
- •The optic nerve can be confused for the rectus superior and inferior muscles. The muscles have a flat, shorter appearance, while the nerve is slimmer and longer.
- •The meningeal layers ensheathing the nerve have also been included in the contour.
Optic chiasm
Contouring suggestions
- •The X-shape is not always visible on one single section, especially when operating with small slice thickness (1 mm or below). In such cases, the fibers of the optic nerve entering the chiasma and the axons forming the optic tract can be delineated on consecutive MRI slices.
- •The pituitary stalk and internal carotid arteries may additionally be delineated to help distinguish between the chiasm and the surrounding structures.
Lacrimal gland
Contouring suggestions
- •The easiest way to find the gland is to look for an approximately 15 × 20 × 5 mm area with low signal intensity, above the lateral rectus muscle and laterally to the superior rectus muscle [28].
- •The volume of the lacrimal gland is usually around 0.6 cm3 with a slight right-sided dominance [29; 30].
Brainstem
Contouring suggestions
- •The average volume of the brainstem is expected to fall between 27 and 43 cm3 [31].
Spinal cord
Brain
Contouring suggestions
- •The contouring of this organ mainly involves following the outline cerebrospinal fluid in the subarachnoid space.
Pituitary gland
Contouring suggestions
- •The hypophysis rests in a small, saddle-shaped bony nest of the sphenoid bone, the sella turcica. The organ itself is usually well visible on any diagnostic T2 weighted MRI sequences, though the sella itself is difficult to find. On CT scans with appropriate bone window, we can localize the clinoid processes, the dorsum and the tuberculum sellae, important anatomical landmarks bordering the hypophyseal fossa, and thus, the hypophysis.
Thyroid gland
Brachial plexus (BP)
Roots | Trunks | Divisions | Cords |
---|---|---|---|
First, the intervertebral foramina between C4-C5 and T1-T2 should be identified [14; 34]. Keep in mind that the cervical spinal nerves emerge above their corresponding vertebrae. This is the reason why the fifth cervical spinal nerve is to be found above the fourth cervical vertebra. | The next step is delineating the trunks of the brachial plexus in the scalene hiatus [14; 34]. The anterior and middle scalene muscles may also be contoured for better understanding anatomical relations. | The last two portions of the brachial plexus are defined as the posterior part of the subclavian and axillary neurovascular bundle, below the insertion of the middle scalene muscle and the sternal extremity of the clavicle [14; 35]. A 5 mm paint tool thickness is recommended for the delineation of the OAR [34; 35].Furthermore, a study by Van der Velde et al. suggests to add a margin of 4.7 mm around this BP contour in order to achieve full coverage of OAR and anatomical variants [36]. |
Organ | T1w | T2w | CT | Remarks |
---|---|---|---|---|
Parotid glands | 2 | 3 | 2 | Any diagnostic T2w MRI sequence is eligible for delineation purposes, since the saliva content of the glands creates a well-visible contrast with the surrounding tissues. |
Submandibular glands | 2 | 3 | 2 | Similar MRI morphology to the parotid glands. |
Mandible | 2 | 2 | 3 | Contouring the mandible on CT is easier, due to the sharp contrast between the hyperdense bone and the surrounding soft tissues. On T2w MRI the cortical bone appears as a low signal intensity layer enveloping the inhomogeneous spongious bone. |
Supraglottic larynx | 2 | 2 | 2 | |
Glottic larynx/glottic area | 2 | 2 | 2 | Nonossified cartilages appear with intermediate signal intensity on T2w images. Ossified cartilages are similar to bone, i.e. high signal central marrow and low signal cortical rim [39]. |
Oral cavity | 2 | 2 | 1 | The visibility of the muscles of the floor of the mouth and palate is poor on CT, therefore the cranial and caudal border of the region is hard to define. The usage of coronal and sagittal MRI slices beside the axial plane is crucial to correctly define the cranio-caudal and latero-lateral extent of the oral cavity [40]. |
Pharyngeal constrictor muscles | 2 | 3 | 1 | The constrictor muscles are virtually not distinguishable on CT. |
Inner ear | 1 | 2 | 2 | The fluid content of both the cochlea and semicircular canals is discernible on T2w MRI images. It is surrounded by a narrow, hypointense zone, corresponding to the compact substance of the bony labyrinth. |
Eye (eyeball) | 2 | 3 | 2 | Greater contrast on T2 between the tunics of the eyeball (i.e. the outer border of the organ; hypointense), fluid (hyperintense) and tissues of the orbit. |
Lens | 3 | 3 | 3 | Well visible on T1 and T2 as well. |
Optic nerve | 3 | 3 | 2 | |
Optic chiasm | 3 | 3 | 1 | |
Lacrimal gland | 1 | 2 | 1 | Similar MRI morphology to the parotid and submandibular glands. |
Brainstem | 3 | 3 | 1 | The demarcation of the organ from the liquor is clearly visible on T2w MR images. On these scans, the nigral substance (SN) appears as a longitudinal stripe of higher signal intensity, compared to the neighboring red nucleus and pes pedunculi [41]. |
Spinal cord | 2 | 3 | 1 | We have included only spinal cord proper in the contour, not the entire spinal canal. This practice (i.e. contouring the spinal canal) was performed mainly due to the poor image quality and low contrast on native topometric CT scans [42]. |
Brain | 3 | 3 | 2 | |
Pituitary gland | 2 | 2 | 2 | Thin MRI slices (slice thickness: 1 mm) with CT correlation is recommended for delineation purposes [43]. |
Thyroid gland | 2 | 2 | 2 | Similar MRI morphology to the parotid and submandibular glands. |
Brachial plexus | 2 | 2 | 1 | |
Esophagus | 2 | 2 | 2 | Hyperintense to muscle on T2w images [43]. |
Sum | 43 | 50 | 35 |
Esophagus
Contouring suggestions
- •Between the ventral trachea and the dorsal esophagus runs the shallow trache-oesophageal groove, which contains the recurrent laryngeal nerve. The sparing of this nerve may be desirable in order to prevent late-onset radiation induced neuropathy [37; 38].
Discussion
Conclusions
References
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The authors declare the following financial interests/personal relationships which may be considered as potential competing interests
Funding: This research is part of the Deep MR-only Radiation Therapy activity (project numbers: 19037, 20648, 210995) that has received funding from EIT Health. EIT Health is supported by the European Institute of Innovation and Technology (EIT), a body of the European Union receives support from the European Union´s Horizon 2020 Research and innovation program.
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