GYN GEC-ESTRO /ICRU Target Concept

1. GYN GEC-ESTRO/ICRUTarget Concept Richard Pötter Medical University Vienna

2. 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…, midline block) • CTV according to GTV at diagnosis? • CTV according to GTV at BT? Building the tower of Babel (confusion of languages) Brueghel, 16th century (1563) Vienna, Museum of Fine Arts We need a common language!

3. Target volume concepts High Risk CTV : GTV at time of brachytherapy In all cases includes: • GTV + wholecervix • Presumedtumour extension in adjacent tissues • Clinicalassessment • Residualgrey zones on MRI NO SAFETY MARGINS IntermediateRisk CTV : GTV at time of diagnosis In all cases includes: • HR-CTV • integrates initial GTV SAFETY MARGINS : 1-1.5 cm cranially 0.5cm antero-posteriorly 1cm laterally

4. Target volume concepts High Risk CTV (IB1): • GTV at time of brachytherapy • In all cases includes: • Wholecervix • MRI and clinicalassessment • NO SAFETY MARGINS

5. Stage IB1 IR CTV GTV HR CTV

6. Stage IB1 HR CTV GTV IR CTV

7. Stage IB1 7

8. Stage IB1 8

9. Stage IB1 9

10. Adaptive MRI based planning concept Dimopoulos et al. IJROBP 2006

11. w w h h t t Findings at time of diagnosis Findings at time of brachytherapy Dimensions (cm): Width: 3.5 Thickness: 2 Height: 2 Vaginal inv.: 0 Dimensions (cm): Width: 7 Thickness:>5 Height: >5 Vaginal inv.: 0.5 (right fornix) Fig.5.1

12. Various patterns of tumor response and adaptive CTV Residual GTV Residual pathologic tissue Adaptive CTV ICRU/GEC ESTRO report 88 Fig. 5.4

13. Overview of adaptive target concept in cervix cancer ICRU/GEC ESTRO report 88 Fig. 5.9-11

14. Initial GTV, Residual GTV, Residual Pathologic Tissue expansive with spiculae + infilt. part → grey zones in the PM PL PL expansive with spiculae → no patholgic tissue in the PM WR WR infiltrative outer half → grey and bright zones HU HU

15. Target volume concepts High Risk CTV (IB2): • Residual GTV at time of brachytherapy (bright (MRI)) • In all cases includes: • Wholecervix • (intra-uterine GTV extension) • NO SAFETY MARGINS

16. w h t Stage IB2 : initial clinical examination Infiltrating Exophytic Cervix Vagina Parametrium Rectum or Bladder Dimensions (cm): Width : 6 Thickness : 5 Height : 5

17. Stage IB2 : initial MRI 6 cm 5 cm 6 cm

18. w h t Stage IB2 : at the time of brachytherapy Infiltrating Exophytic Cervix Vagina Parametrium Rectum or Bladder Dimensions (cm): Width : 2.5 Thickness : 2 Height : 2.5

19. Stage IB2 : at the time of brachytherapy

20. Stage IB2

21. Stage IB2

22. Stage IB2

23. Stage IB2

24. Target volume concepts High Risk CTV (IIB): • Residual GTV at time of brachytherapy • Residualpathologic tissue • at time of brachytherapy • In all cases includes: • Wholecervix • residual GTV (clinical and MRI) • residualpathologic tissue • (clinical and MRI (grey zones)) • locatedwithin the initial GTV • NO SAFETY MARGINS

25. Overview of adaptive target concept in cervix cancer ICRU/GEC ESTRO report 88 Fig. 5.9-11

26. w h t Stage IIB : initial clinical examination Infiltrating Exophytic Cervix Vagina Parametrium Rectum or Bladder Dimensions (cm): Width : 5 Thickness:5 Height : 5 Fornix involv 1

27. Stage IIB : initial MRI 50 mm 50 mm 52 mm

28. w h t Stage IIB : at the time of brachytherapy Infiltrating Exophytic Cervix Vagina Parametrium Rectum or Bladder Dimensions (cm): Largeur : 3 Epaisseur : 3 Hauteur : 3 Env. vaginal : 1

29. Stage IIB : MRI at the time of brachytherapy 30 mm 30 mm 30 mm

30. Stage IIB GTV Tumor at time of diagnosis IR CTV GTV HR CTV

31. Stage IIB GTV Tumor at time of diagnosis. HR CTV GTV IR CTV

32. Stage IIB 50 mm 50 mm 52 mm 30 mm 30 mm 30 mm 32

33. Stage IIB 50 mm 50 mm 52 mm 30 mm 30 mm 30 mm 33

34. Stage IIB 50 mm 50 mm 52 mm 30 mm 30 mm 30 mm 34

35. Target volume concepts High Risk CTV (IIIB): • Residual GTV and • Residualpathologic tissue • at time of brachytherapy • In all cases includes: • Wholecervix • residual GTV (clinical and MRI) • residualpathologic tissue • (clinical and MRI (grey zones)) • locatedwithin the initial GTV • NO SAFETY MARGINS

36. Overview of adaptive target concept in cervix cancer ICRU/GEC ESTRO report 88 Fig. 5.9-11

37. w h t Stage IIIB : initial clinical examination Infiltrating Exophytic Cervix Vagina Parametrium Rectum or Bladder Dimensions (cm): Width : 6 Thickness :4 Height : 4

38. Stage IIIB : initial MRI 40 mm 45 mm 62 mm

39. w h t Stage IIIB : at the time of brachytherapy Infiltrating Exophytic Cervix Vagina Parametrium Rectum or Bladder Dimensions (cm): Width: 4.5 Thickness : 3 Height : 3

40. Stage IIIB : MRI at the time of brachytherapy 30 mm 30 mm 45 mm 40

41. Stage IIIB 30 mm 30 mm 30 mm 41

42. Stage IIIB 30 mm 30 mm 30 mm 42

43. Stage IIIB 30 mm 30 mm 30 mm 43

44. Stage IIIB 44

45. Stage IIIB 45

46. Stage IIIB 46

47. Stage IIIB 47

48. cervix HR and IR-CTVExtent at diagnosis and degree of remission Initial tumour extension Residual disease HR-CTV cervix IR-CTV Complete remission No remission Good partial remission Poor partial remission 10 mm 10 mm > 10 mm 10 mm cervix cervix cervix > 10 mm 10 mm 10 mm

49. cervix endometrium vagina B HR-CTV IR-CTV B IR-CTV HR-CTV GTV S VC R HR-CTV IR-CTV B GTV GTV R S R B Gyn GEC ESTRO Recommendationsare 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