Target volume definition (GTV, HR-CTV and IR …...Target volume definition (GTV, HR-CTV and IR...
Transcript of Target volume definition (GTV, HR-CTV and IR …...Target volume definition (GTV, HR-CTV and IR...
Target volume definition (GTV, HR-CTV and IR-CTV):
GYN GEC-ESTRO Recommendations
Richard Pöttera, Elena Fidarovaa, Primož Petrič a,b aMedical University Vienna bInstitute of Oncology Ljubljana Vienna, 11-12 November, 2013
GYN GEC ESTRO RECOMMENDATIONS-BACKGROUND From 2D to 3D/4D
Historical difficulties in communicating results of cervical BT due to different traditions (60 Gy reference volume, point A…) •CTV according to GTV at diagnosis? •CTV according to GTV at BT?
We need a common language!
Definition of brachytherapy target volumes
GTV
IR CTV
GTV
HR CTV IR CTV
HR CTV
corpus invasion
High signal intensity tumor mass
grey zones in the parametria
Residual high signal intensity mass
Residual high signal intensity mass
Change in GTV, CTV and pelvic topography during treatment (4D RT)
EBRT + CHT
DEFINITION OF CTVB1, CTVB2,...
Macroscopic tumour load
Significant microscopic disease
Potential microscopic tumour spread
Pelvic wall region
Pelvic wall region
Significant microscopic disease
Potential microscopic tumour spread
Three different target volumes according to cancer cell density
cervix
HR IR LR IR LR
HR: High risk CTV IR : Intermediate risk CTV LR: Low risk CTV IR : Intermediate risk CTV LR: Low risk CTV
GTV
HR CTV
Tumor at time of diagnosis.
GTV
Grey zones (MRI)+palpable residual disease
IR CTV
• Extensive Disease (IIB-IVA): no alternatives for surgery (beyond cervix)
Radiother Oncol 2005, 74:235-245
Bladder Ureter Cervix Parametr
ium
GTV HR CTV
IR CTV
Tumor at time of diagnosis.
GTV
Grey zones (MRI)+palpable residual disease
• Extensive Disease (beyond cervix)
GYN GEC ESTRO Recommendations (I) Haie-Meder et al. Radiother Oncol 2005, 74:235-245
cervix
HR-CTV
IR-CTV
Initial tumour extension
Residual disease
Complete remission
Poor partial remission
No remission
10 mm
10 mm
10 mm
10 mm
cervix
Good partial remission
> 10 mm
> 10 mm
10 mm cervix cervix
cervix
HR and IR-CTV Extent at diagnosis
and degree of remission
Clinical examples
1. Limited disease (tumour size < 4cm) 2. Large tumour, sufficient response 3. Large tumour, insufficient response
2. Large tumour - sufficient response •INITIAL clinical findings:
•St.p. Conisation, Cervix to the right
•Invasion of:
•Right and dorsal fornix
•Right PM to middle 1/3
•Left PM free
•Clinical findings at BT:
•No macroscopic residuum in vagina
•Residuum in:
•Right PM - inner third
GTVD
GTVB HR-CTV
IR-CTV
Clinical examples
1. Limited disease (tumour size < 4cm) 2. Large tumour, sufficient response 3. Large tumour, insufficient response
• Initial findings: -No invasion of vagina -Distal involvement of right parametrium (clinical)
-Proximal invasion of the left parametrium
• Findings at brachytherapy: -Residual disease right parametrium middle third
-No invasion of left parametrium
3. Large tumour-insufficient response
3. Large tumour-insufficient response GTVD
GTVB HR-CTV IR-CTV
B
R S
B
R
S
R
B
VC
B
GTV
IR-CTV
HR-CTV
cervix endometrium vagina
HR-CTV HR-CTV
GTV
GTV
IR-CTV IR-CTV
Gyn GEC ESTRO Recommendations are applicable for Gyn BT in general
(vagina, endometrium, vulva, recurrent tumours)
Petric, Pötter, van Limbergen, Haie-Meder: Adaptive Contouring of CTV and Organs at Risk in: Viswanathan, Erickson, Kirisits, Pötter (eds): Gynaecologic RadiationTherapy: Novel approaches to Image-Guidance and Management, 2010