Target volume definition(GTV, HR-CTV and IR-CTV):
GYN GEC-ESTRO Recommendations
Richard Pöttera, Elena Fidarovaa, Primož Petrič a,b
aMedical University ViennabInstitute of Oncology Ljubljana
Vienna, 25-26 March, 2013
GYN GEC ESTRO RECOMMENDATIONS-BACKGROUNDFrom 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 brachytherapytarget 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,...
Macroscopictumour load
Significant microscopicdisease
Potential microscopic tumour spread
Pelvic wall region
Pelvic wallregion
Significant microscopicdisease
Potential microscopictumour spread
Three different target volumesaccording to cancer cell density
cervix
HR IR LRIRLR
HR: High risk CTVIR : Intermediate risk CTVLR: Low risk CTVIR : Intermediate risk CTVLR: Low risk CTV
GTV
HR CTV
Tumor at timeof diagnosis.
GTV
Grey zones (MRI)+palpableresidual
disease
IR CTV
• Extensive Disease (IIB-IVA): no alternatives for surgery(beyond cervix)
Radiother Oncol 2005, 74:235-245
Bladder UreterCervix Parametr
ium
GTVHR CTV
IR CTV
Tumor at timeof diagnosis.
GTV
Grey zones (MRI)+palpableresidual
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 tumourextension
Residual disease
Completeremission
Poor partialremission
Noremission
10 mm
10 mm
10 mm
10 mm
cervix
Good partialremission
> 10 mm
> 10 mm
10 mmcervix cervix
cervix
HR and IR-CTVExtent at diagnosis
and degree of remission
Clinical examples
1. Limited disease (tumour size < 4cm)2. Large tumour, sufficient response3. 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
GTVBHR-CTVIR-CTV
Clinical examples
1. Limited disease (tumour size < 4cm)2. Large tumour, sufficient response3. 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 responseGTVD
GTVBHR-CTVIR-CTV
B
RS
B
R
S
R
B
VC
B
GTV
IR-CTV
HR-CTV
cervix endometrium vagina
HR-CTVHR-CTV
GTV
GTV
IR-CTV IR-CTV
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 Riskin: Viswanathan, Erickson, Kirisits, Pötter (eds): Gynaecologic RadiationTherapy: Novel approaches to Image-Guidance and Management, 2010