Unveiling artistic signatures in modern radiation oncology contouring

Dear Editor, The link between art and medicine dates to ancient times. Texts like the Charaka Samhita, Sushruta Samhita, and the Edwin Smith Papyrus used drawings and descriptions to document medical knowledge,[1,2] which was probably the first use of visual aids in medicine. Even though medicine has advanced a lot since then, the role of art has always remained in some form. Clinical signs in medicine use a lot of visual analogies. They range from microscopic to macroscopic, and are seen in physiology, anatomy, pathology, radiology, and clinical examination. Doctors have long used comparisons with common objects—foods like cheese or fruit, flowers, clothing, car parts, animals, birds—to make these signs easy to recognize and remember. This creates a kind of universal language that clinicians everywhere can understand. Radiation oncology also has many such examples. The portal designs for treatment fields themselves carried artistic names—the “German Helmet” for CNS tumors,[3] the “Mantle Field” for Hodgkin’s lymphoma, the “Four-Field Box” for pelvic tumors,[4] or the “Dog-Leg” for para-aortic and iliac fields. With newer techniques like 3D contouring, many new patterns are seen that look like familiar shapes. These can be catalogued just like other signs in medicine. Beyond novelty, these analogy-based “artistic signs” may also have a teaching value—helping young oncologists remember patterns more easily, making learning engaging, and even reducing variation between observers during contouring. CONCLUSION We have shown a few such signs as examples, of this artistic crossover in contouring [Figures 1-5]. Our hope is that young oncologists continue to notice these patterns, and in doing so, make their learning both fun and memorable.Figure 1: Eiffel Tower sign: (a) Eiffel Tower and (b) pelvic and lower para-aortic lymphatic chain in a coronal cross-sectional CT imageFigure 2: Commode sign: (a) Commode seat and (b) post-operative bed contours drawn for carcinoma prostate in a sagittal cross-sectional CT imageFigure 3: Tribal Mask sign: (a) Tribal mask and (b) target volumes for the sacral bone lesion with sparing of the spinal canal, drawn in an axial cross-sectional CT imageFigure 4: Angel Wings sign: (a) Angel wings and (b) cervical lymph nodal chain (covering bilateral levels Ib, II, V, and retropharyngeal nodes) in an axial cross-sectional CT imageFigure 5: Mickey Mouse sign: (a) Mickey Mouse and (b) pelvic lymph nodal chain in an axial cross-sectional CT imageAuthor contributions All authors: Concepts, design, definition of intellectual content, literature search, manuscript preparation, manuscript editing, manuscript review, guarantor. Financial support and sponsorship Nil. Conflict of interest Nil.