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Definitions of Target Volumes and Organs at Risk

22 February 2011 Jacob (Jake) Van Dyk Consultant, IAEA Professor, University of Western Ontario, Canada

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International Atomic Energy Agency

Acknowledgement
Slides from

Morten Hyer Richard Ptter Larry Marks Stewart Gaede

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Definitions of Target Volumes and OARs

Aim
To introduce target volume and organ at risk
concepts as defined by ICRU

Specific Learning Objectives


Introduce ICRU reports 29/50/62/71/83 Define volume definitions of ICRU
GTV, CTV, PTV, OAR, PRV

Describe margins and how they are determined


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Evolution of Modern Radiation Therapy Technology

Dose Escalation

Decrease normal tissue dose Tighter margins

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R Ptter

MINIMIZE
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5 2/25/2011

1993 1978

1999

Replaces ICRU 29, 1978

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ICRU 29
Target volume & uniform
prescription concepts 2-D era

1978

Single slice (or few) External contour Coplanar beams Simple calculations Dose prescription to ICRU reference point

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ICRU 50 - Purpose

1993
Replaces ICRU 29, 1978

Specification of volume(s) & dose(s)


For prescription, recording, reporting

Purpose
Consistent treatment policy Compare results of treatment - departmental colleagues Enable other radiation oncologists to benefit from
departments experience Enable departments treatment results to be compared with those of other centers Especially multi-centered clinical trials
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ICRU Volumes

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ICRU 50

Gross Tumor Volume (GTV)


Gross palpable or visible/demonstrable
(imaging) extent and location of disease
GTVprimary, GTVnodal

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GTV with CT

Right!
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Use right window settings Use right contrast and delay

Wrong!

Purdy, Sem Rad Oncol 14: 27, 2004

Intra- and Inter-observer Variability


In contouring on CT

Inter
Agreement GTV United GTV

Max. PTV

Intra

Min PTV

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Leunens et al, Radiother Oncol 29: 169; 1993

Inter-observer variation in delineation for cervix cancer

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Dimopoulos J et al. R&O 2008 EPUB

Clinical Target Volume (CTV)


Contains GTV and/or subclinical microscopic
malignant disease, which has to be eliminated.
This volume needs to be treated adequately to
achieve cure or palliation

Perez et al 1998 IAEA

Uncertainties Inter-fraction

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Courtesy D. Yan & M. van Herk

Intra-fraction Respiratory Motion

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Courtesy S Gaede

Planning Target Volume (PTV)


Geometrical concept - To select appropriate beam
sizes/arrangements, accounting for the net effect of all the possible geometrical variations and inaccuracies to ensure that the prescribed dose is actually absorbed in the CTV

Perez et al 1998

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Prostate
Contours for GTV, PTV, bladder, rectum. CTV=GTV Non-uniform margin

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Purdy, Sem Rad Oncol 14: 27, 2004

PTV
PTV depends on the precision of tools
immobilization devices lasers

PTV does NOT include margin for dosimetric


characteristics beam these will require additional margin during
treatment planning and shielding design
penumbral areas build-up region IAEA

Dose Volumes
Treated volume - enclosed by an isodose surface
selected by rad. onc. as appropriate to achieve purpose of treatment Irradiated volume - receives a dose that is significant in relation to normal tissue tolerance

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Treated Volume - NSCLC

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Irradiated Volume - NSCLC

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Organs at Risk (OAR)


Normal tissues whose radiation sensitivity
may significantly influence treatment planning and/or prescribed dose
OARs Lung Spinal cord

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ICRU 50 Dose Reporting


ICRU Reference Dose
Dose at ICRU reference point Centre of PTV Near central axis of beam(s) Dmax Maximum dose in PTV Dmin Minimum dose in PTV Dave Average dose in PTV Dmedian Median dose in PTV
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ICRU 62 - Purpose
3-D imaging Conformal radiation therapy

1999

Irradiation techniques have advanced More accurately formulate definitions & concepts Issues
Reference points and coordinate systems Introduction of Internal margin (IM) Setup margin (SM) Internal target volume (ITV) Planning organ at risk volume (PRV) Conformity index (CI) IAEA
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Reference Points and Coordinate Systems

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Internal Margin
Takes account of variation in size, shape, and
position of CTV in relation to anatomical reference points, e.g., Filling of rectum Movements due to respiration Patient related

Set-up Margin
Accounts for all uncertainties in patient-beam positioning Technical factors

Patient immobilization IAEA Machine stability

Margins
A.
PTV CTV IM SM

B.
PTV CTV IM 2 SM 2

C.
Global safety margin Accounts for
OAR Decrease of
subclinical spread from GTV
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28 2/25/2011 ICRU

62

Internal Target Volume (ITV)


ITV = CTV + IM Geometric
ITV accounts for
motion of CTV in the patient Does not account for setup uncertainties

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GTV & CTV: NSCLC stage IIIA

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Internal Target Volume (ITV)

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Planning Target Volume (PTV)

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Imaging Biology Respiratory gating CT, PET, MRI


Gross Tumor Volume (GTV)

Microscopic Spread

Internal Motion

Set-up Errors

Clinical Target Volume (CTV)

On board imaging

Internal Target Volume (ITV)

Planning Target Volume (PTV)

Organs at Risk (OAR)

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Planning Organ at Risk Volume (PRV)


Like CTV to PTV Accounts for OAR movements
Shape, size, setup PRV = OAR + margin PTV and PRV may overlap

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Changes Over Time: ICRU 50 to 62


IRRADIATED VOLUME TREATED VOLUME

PRV: Includes margin


around the OAR to compensate for changes in shape and internal motion and for set-up variation.

PTV ITV CTV GTV

OAR
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PRV

Conformity Index (CI) in ICRU 62


Treated volume CI PTV
Note: In ICRU 83 discussion on conformity indices: the applicability of above indices for reporting results of IMRT is likely to be limited. Ideal

CI=1.00

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ICRU 50 & 62 Summary


Consistent specification of dose and dose
homogeneity are essential Facilitates communication Improves knowledge of dose-response data ICRU 50 & 62 are widely accepted

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Changes Over Time

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Purdy, Sem Rad Oncol 14: 27, 2004

ICRU 83- Purpose

2010

Irradiation techniques have advanced


3-D CRT to IMRT More availability of CT Additional imaging CT + MRI, PET, PET/CT,
functional Improved conformality
Reduced doses to normal tissues

More detailed dose-volume information on TPS Use of dose-volume constraints IAEA Automated optimization, IMRT

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ICRU 83

2010

Dose reporting adapted to IMRT



Use of DVH No Dmin or Dmax , instead D98% and D2% Specify median dose, D50%
Close to old ICRU reference dose at ICRU
reference point

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ICRU 83 Dose Specification

~= dose to ICRU reference point

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ICRU 83 Dose Accuracy


Old: dose accuracy 5% New:
More statistical Two regions

2010

Low dose gradient (<20%/cm) 85% of target volume, dose within 5% High dose gradient (20%/cm) Specify distance to agreement 85% of dose samples, within 5 mm
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Remaining Volume at Risk (RVR)


Optimization Carcinogenisis
2010

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3-D vs. IMRT Implications for target definition


Concave vs. convex targets Target volume quality assurance/peer review 3-D beams more readily compared to
historical beams 2-D beams IMRT beams/plans are less able to be checked via intuition. Dose gradients Margins
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3D-CRT: Convex Dose Distribution

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IMRT: Concave Dose Distribution

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Convex vs Concave
Careful definition of the concavity is more
important for IMRT than for 3-D CRT

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Reducing Margins
Technical margins can be reduced by
improving daily setup. Daily setup verification by EPID, CBCT,
ultrasounds Automatic repositioning of patients by external systems (eg, ExacTrac). Automatic repositioning with internal fiducials (eg, Calypso).
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Note ...
IRRADIATED VOLUME TREATED VOLUME

PTV ITV CTV GTV

We may be able to reduce technical margins ... but not biological margins

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Summary
ICRU reports provide
Consistency in target volume definition Consistency in dose prescription Consistency in reporting
Tumour doses Normal tissue doses

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MINIMIZE

THE WORLDS WAR AGAINST NORMAL TISSUE DAMAGE


RADIATION ONCOLOGISTS

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MEDICAL PHYSICISTS