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