Technical guidelines for head and neck cancer IMRT on behalf of the Italian association of radiation oncology - head and neck working group

Merlotti, Anna; Alterio, Daniela; Vigna-Taglianti, Riccardo; Muraglia, Alessandro; Lastrucci, Luciana; Manzo, Roberto; Gambaro, Giuseppina; Caspiani, Orietta; Miccichè, Francesco; Deodato, Francesco; Pergolizzi, Stefano; Franco, Pierfrancesco; Corvò, Renzo; Russi, Elvio G; Sanguineti, Giuseppe

doi:10.1186/s13014-014-0264-9

Table 1 Volumes at risk in HNC

From: Technical guidelines for head and neck cancer IMRT on behalf of the Italian association of radiation oncology - head and neck working group

Burden of disease	Description	ICRU definition	Adopted definition	Finality	T – level	N – level	Dose level definition	Dose level NTD	Solution examples (Total-dose Gy/single-fraction Gy/numbers of fractions
									Definitive		Postoperative
									Conventional	Slightly accelerated	Conventional	Slightly accelerated
Macroscopic	Known gross disease	GTV	GTV	Definitive	Primary tumor	Each Positive-nodes	High Dose	70 Gy	70/2/35[18]	70/2.12/33[20]
High risk of microscopic disease	Risk of relapse > 10-20% [54],[55]	CTV	CTV_HD^	Definitive	Peri-GTV areas considered to contain potential microscopic disease [38] (T + 10 mm)*	Positive Nodes + 5[41]-10[53]mm				66/2.2/30[17],[18]
			(CTV1)							65/2.17/30[77]
				Post-S	Surgical bed with soft tissue involvement (Positive or close margins): PTB +0.5-1 cm according to anatomical barriers [41].	Nodal region with extracapsular extension [41]: PTB plus 1 cm up to the skin [56].^ç		66-70 Gy			≥63/1.8/35[78]	65/2.17/30[77]
												66/2/33[79]
			CTV_HR	Definitive	Preferential areas of diffusion.(Optional) [56]	Border-line lymph-nodes [51],[57]	Intermediate Dose	60 Gy	63/1.8/35[18]	60/2/30[17],[18]
			(CTV2)	Post-S	Surgical bed without soft tissue involvement [41]	Nodal region without extracapsular extension		66§ Gy		59.4/1.8/33[20]	≥63/1.8/35[78]
Low risk of microscopic disease	Risk of relapse 5-10% [41],[80]	CTV	CTV_LR	Definitive	Structure or compartment adjacent to tumor [56]	Elective nodal regions, defined for each primary-tumor subsite#	Low dose	50 Gy	58.1/1.66/35[18]	54/1.8/30[17],[18],[77]		54/2/27[79]
			(CTV3)	Post-S				50 Gy		50.4/1.8/28[20]	57.6/1.8/32[78]	54/1.8/30[77]

*Depending from anatomic barrier;§ though one prospective study failed to show a benefit for 66 Gy over 60 Gy in the high risk post-operative region [78], this is the dose recommended by some cooperative groups (EORTC [79]); PTB: postoperative tumour bed; ^ definition of the high-risk region is controversial [18] ; D = Definitive RT; Post-S = postoperative. CTV_HD: High Disease; CTV_HR=High Risk; LR = Low risk. ^Çin case of muscular infiltration (i.e. sternocleidomastoid muscle) at least the portion of the muscle surrounding the node [47] should be included. # Similarly, it would be appropriate to include the whole muscle (i.e. sternocleidomastoid muscle) in CTV3/LR or when grossly infiltrated at some level.

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