Elsevier

Radiotherapy and Oncology

Volume 130, January 2019, Pages 113-120
Radiotherapy and Oncology

Original article
Practical contouring guidelines with an MR-based atlas of brainstem structures involved in radiation-induced nausea and vomiting

https://doi.org/10.1016/j.radonc.2018.08.003Get rights and content

Highlights

  • Nausea and vomiting: a new side effect of radiotherapy for head and neck carcinomas.

  • Irradiation of some structures of the brainstem could explain this new side effect.

  • A new and reproducible atlas to accurately delineate these brainstem structures.

Abstract

Background and purpose

The objective of this project was to define consensus guidelines for delineating brainstem substructures (dorsal vagal complex, including the area postrema) involved in radiation-induced nausea and vomiting (RINV). The three parts of the brainstem are rarely delineated, so this study was also an opportunity to find a consensus on this subject.

Materials and methods

The dorsal vagal complex (DVC) was identified on autopsy sections and endoscopic descriptions. Anatomic landmarks and boundaries were used to establish radio-anatomic correlations on CT and Magnetic Resonance Imaging (MRI). Additionally, delineation of RINV structures was performed on MRI images and reported on CT scans. Next, guidelines were provided to eight radiation oncologists for delineation guidance of these RINV-related structures on DICOM-RT images of two patients being treated for a nasopharyngeal carcinoma. Interobserver variability was computed.

Results

The DVC and the three parts of the brainstem were defined with a concise description of their main anatomic boundaries. The interobserver analysis showed that the DVC, the midbrain, the pons, and the medulla oblongata delineations were reproducible with KI = 0.72, 0.84, 0.94 and 0.89, respectively. The Supplemental Material section provides an atlas of the consensus guidelines projected on 1-mm MR axial slices.

Conclusions

This RINV-atlas was feasible and reproducible for the delineation of RINV structures on planning CT using fused MRI. It may be used to prospectively assess dose–volume relationship for RINV structures and occurrence of nausea vomiting during intracranial or head and neck irradiation.

Section snippets

Population: Working group

A multidisciplinary working group (WG) was created to develop these new recommendations for central nervous system (CNS) substructures involved in RINV. All physicians who contributed to the creation of these guidelines are listed as co-authors of this manuscript. The general principles guiding the activities of the WG were: (1) to integrate as accurately as possible anatomic knowledge and previously defined surgical and radiological guidelines into a set of recommendations based on axial CT

Results

After the working group (WG) delineated the DVC and the three parts of the brainstem in patient A, a first interobserver analysis (Time 1) was performed and the variability in delineation was discussed. Subsequently, the WG agreed on consensus definitions for these structures and formulated the final consensus guidelines for these structures implicated in RINV (available in Supplemental data). A second interobserver analysis (Time 2) confirmed that the delineation of the DVC and the three parts

Discussion

Radiation-induced nausea and vomiting (RINV) were rare side effects with 3-dimensional conformal radiation therapy (3D-CRT) techniques. RINV seems to be more frequent since the development of new technologies such as intensity-modulated radiation therapy (IMRT) for the treatment of locally advanced head and neck cancer (HNC). The RINV atlas described above has thus been designed to prospectively assess dose–volume effects for structures previously identified as being involved in RINV.

In 2008,

Conflicts of interest

None declared.

Acknowledgments

The authors acknowledge AQUILAB SAS for their contribution to this study.

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