THE BRACHIAL PLEXUS

Contouring Accuracy Program

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 Outline
1. Refresher Course on the Brachial Plexus
A. The location of the brachial plexus
B. What are the critical functions?
C. “Did you know…?”
2. Locating the Brachial Plexus in medical
images
A. Finding the axial slice range (superior and inferior limits)
B. Steps for contouring on axial images
C. Useful window/level settings
3. Special considerations for radiation therapy
A. Radiosensitivity
B. Notable Protocols
C. Useful publications and links

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 1A. The Location of the Brachial Plexus
The brachial plexus originates from the spinal nerves exiting the
spinal canal through the neural foramen, from the C4-C5 (C5
nerve roots) to the T1-T2 (T1 nerve roots) level.

http://pubs.rsna.org/doi/pdf/10.1148/rg.304095105

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 1A. The Location of the Brachial Plexus
The trunks of the brachial
plexus pass between the
anterior and middle
scalene muscles.
The trunks merge to form
cords which pass over the
first rib and continue
under the clavicle
posterior to the subclavian
artery.
Shown to right is an axial
CT image viewed from the
feet, showing anterior and
middle scalene muscles
with the right brachial
plexus in between.

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 1B. The Function of the Brachial Plexus
 The brachial plexus are a collection of nerves that
innervate the skin and muscles of the entire upper
limb.
 Why do we care about the brachial plexus in
radiation therapy?
- In general, damage to the brachial plexus can result in pain and
difficulty moving the arm (brachial plexopathy).
- Radiation can cause brachial plexopathy.
 For more detail about the brachial plexus in general, you
can visit:
- https://en.wikipedia.org/wiki/Brachial_plexus

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 1C. “Did You Know…?”
The root word “Brachium” is Latin for arm.
The dinosaur name Brachiosaurus
means literally “armed lizard.”

A “brachiopod” (derivation: arm + foot)

is a marine animal that anchors to the
seabed with a long, stalk-like pedicle.

The etymology of the word “brassière”

(more commonly shortened to “bra”)
traces to the root word brachium, as
brassière in French really means a
child’s vest, i.e. something they put their
arms through.

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 2A. Superior and Inferior Limits
Superior:
Contours of the brachial plexus
originate at the nerve roots from C5
(the interspace of C4-C5).
Inferior:
The inferior nerve roots for the
brachial plexus end at T1 (the
interspace of T1-T2), but the brachial
plexus volume extends approximately
until the neurovascular structures
cross the second rib.
A published standard recommends
contouring 1-2 slices (for 3 mm
spacing) inferior to the clavicular
heads for head & neck contouring.
http://pubs.rsna.org/doi/pdf/10.1148/rg.304095105

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 2B. Steps for Contouring on Axial Slices
1. Identify* C5, T1 and T2.
2. Identify* the subclavian and axillary neurovascular bundle.
3. Identify* anterior and middle scalene muscles from C5 onto the first rib.
4. Using a paint brush tool (~5 mm) contour the nerve roots exiting the neural
foramen, from C5 to T1. Extend the contour from the lateral aspect of the
spinal canal to the small space between the anterior and middle scalene
muscles.
5. On slices where there is no neural foramen, contour only the space between
the anterior and middle scalene muscles.
6. Eventually the middle scalene will end in the region of the subclavian
neurovascular bundle. Contour the brachial plexus as the posterior aspect of
the neurovascular bundle inferiorly and laterally 1-2 CT slices** below the
clavicular head.
7. The first and second ribs serve as the medial limit of the brachial plexus
contour

* You may also contour these supporting structures as precursors to contouring the
brachial plexus.
** In the publication that recommended “1-2 CT slices” below the clavicular head, the CT
slice spacing was 3 mm.

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 2C. Useful Window/Level Settings

Window = 2500
Level = 500

Use this type of W/L is best to identify C5, T1, and T2 vertebral
bodies and the neural foramen.

Nerve root exiting the neural foramen

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 2C. Useful Window/Level Settings
Window = 400
Level = 40

Use this type of W/L to delineate the

adjacent muscles, i.e. the anterior and
middle scalenes.

Inverting the CT pixels values on the display

is sometimes helpful.

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 2C. Useful Window/Level Settings

Window = 400
Level = 40

This type of W/L setting is useful for the bulk of the contouring.

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 3A. Radiosensitivity
Structure Name Type Volume Dose Notes

Conventional
Fractionation
Brachial Plexus Max Dose None <66Gy RTOG 0619

Brachial Plexus Volume (%) 5% <60Gy RTOG 0619

1 Fraction SRS

Brachial Plexus Max Dose None <17.5Gy TG 101- neuropathy

Brachial Plexus Volume (cc) <3cc 14Gy TG 101- neuropathy

3 Fraction SBRT

Brachial Plexus Max Dose None <24Gy TG 101- neuropathy

Brachial Plexus Max Dose <3cc 20.4Gy TG 101- neuropathy

5 Fraction SBRT

Brachial Plexus Max Dose None <30.5Gy TG 101- neuropathy

Brachial Plexus Max Dose <3cc 27Gy TG 101- neuropathy

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 3B. Notable Protocols
RTOG 0236 A Phase II Trial of Stereotactic Body Radiation Therapy (SBRT) in
the Treatment of Patients with Medically Inoperable Stage I/II Non-Small Cell
Lung Cancer

RTOG 0412 Phase III Randomized Trial of Preoperative Chemotherapy Versus

Preoperative Concurrent Chemotherapy and Thoracic Radiotherapy Followed by
Surgical Resection and Consolidation Chemotherapy in Favorable Prognosis
Patients with Stage IIIa (N2) Non-Small Cell
RTOG 0435 A Randomized, Phase III, Double-Blind, Placebo-Controlled Study to
Evaluate the Efficacy and Safety of Palifermin (NSC# 740548) for the Reduction
of Oral Mucositis in Patients with Locally Advanced Head and Neck Cancer
Receiving Radiation Therapy with Con
RTOG 0522 A Randomized Phase III Trial of Concurrent Accelerated Radiation
and Cisplatin versus Concurrent Accelerated Radiation, Cisplatin, and Cetuximab
(C225) [Followed by Surgery for Selected Patients] for Stage III and IV Head and
Neck Carcinomas

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 3B. Notable Protocols
RTOG 0615 A Phase II Study of Concurrent Chemoradiotherapy Using Three-
Dimensional Conformal Radiotherapy (3D-CRT) or Intensity-Modulated Radiation
Therapy (IMRT) + Bevacizumab (BV) For Locally or Regionally Advanced
Nasopharyngeal Cancer
RTOG 0617 A Randomized Phase III Comparison of Standard- Dose (60 Gy)
Versus Highdose (74 Gy) Conformal Radiotherapy with Concurrent and
Consolidation Carboplatin/Paclitaxel +/- Cetuximab (IND #103444) in Patients
with Stage IIIA/IIIB Non-Small Cell Lung Cance

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 3C. Useful Publications and Links
Truong MT et al. “Brachial Plexus Contouring with CT and MR Imaging in
Radiation Therapy Planning for Head and Neck Cancer.” Radiographics 2010;
30(4). http://www.ncbi.nlm.nih.gov/pubmed/20631370

Hall WH et al. “Development and Validation of a Standardized Method for

Contouring the Brachial Plexus: Preliminary Dosimetric Analysis Among Patients
Treated With IMRT for Head-and-Neck Cancer.” Int J Radiat Oncol Biol Phys.
2008; 72(5). http://www.ncbi.nlm.nih.gov/pubmed/18448267
Kong FM et al. “Consideration of dose limits for organs at risk of thoracic
radiotherapy: atlas for lung, proximal bronchial tree, esophagus, spinal cord,
ribs, and brachial plexus.” Int J Radiat Oncol Biol Phys. 2011; 81(5).
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3933280/
Chen AM et al. “Dose–Volume Modeling of Brachial Plexus-Associated
Neuropathy After Radiation Therapy for Head-and-Neck Cancer: Findings From
a Prospective Screening Protocol.” Int J Radiat Oncol Biol Phys. 2014; 88(4).
http://www.ncbi.nlm.nih.gov/pubmed/24606846

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