Beruflich Dokumente
Kultur Dokumente
RU
recommedations on volume and dose
David Sjstrm,, Physicist
Herlev Hospital,, Denmark
Backkground
kground
Tumour cells
T
ll contained
t i d in
i the
th
red volume throughout the
treatment course
Backkground
kground
Tumour cells
T
ll contained
t i d in
i the
th
red volume throughout the
treatment course
Backkground
kground
Tumour cells
T
ll contained
t i d in
i the
th
red volume throughout the
treatment course
Backg
ground
Problem:
We need the same definition
ns of:
- volume that has been treated
- dose given to this volume
- dose received by organs at risk
Backg
ground
ICRU Report No
No.78
78 (2
2007)
Backg
ground
Solution:
ICRU reports - International
recommendations for definittions
of dose and volume in RT
Backg
ground
ICRU Report No.29 (1978)
Dose specification for reportiing external beam therapy with
Dose
photons and electrons
ICRU Report No
No.50
50 (1993)
Prescribing, recording and re
eporting photon beam therapy
(Superseded ICRU Repo
ort No.29)
ICRU Report No.62 (1999)
Supplement
Supplement to ICRU Report No.50
N 50
No
(Updated the ICRU Repo
ort No.50 with some new
concepts.
p ICRU 50 still valid.)
v
)
Backg
ground
ICRU Report No.71 (2004)
Prescribing, recording and reportin
ng electron beam therapy
(Extends concepts and recommenda
ations from ICRU 50 and 62 from
photons to electrons)
ICRU Report No.78 (2007)
Prescribing, recording and reportin
ng proton-beam therapy
ICRU Report No.83 (2010)
Prescribing, Recording and Reportiing intensity-modulated photon-beam
therapy (IMRT)
(IMRT)
Volumes in IC
CRU29 - 1978
The Target Volume
The target volume consists of the tumours (if
present) and any other tissue with presume
ed
tumour
expected movements of tissues containin
ng
the target volume
variations in shape and size of the target
volume
variations in treatment set-up
Volumes
Volumes
1978 ICRU29
Organs at risk
Volumes
Why all these
e updates?
Improvements in staging and
a
imaging procedures
Improvements in the delivery and
a
precision of radiotherapy
more detailed and accurate set of defin
nitions to maximize the benefit of the
develop
pment.
Volumes in IC
CRU29 - 1978
Example
p
Target volume
Primary + Boost
Treatment fields defined
from anatomical land marks
in 2D
Computerised Tom
mography (X Ray)
Possible to define and delineate
Outline of patient body
Tumour
Sensitive organs
Possible to
Optimize how to irradiate
Volumes
1978 ICRU29
1993 ICRU50
Organs at risk
a realization th
hat better tools were needed
Volumes in IC
CRU50 - 1993
Gross Tumour Volume (GTV)
The GTV is the gross demonstrable extent
and location of the malignant growth.
GTV consists of:
primary tumour
metastatic
t t ti lymphnodes
l
h d
other metastases
Volumes in IC
CRU50 - 1993
Clinical Target Volume (CTV)
The CTV is a tissue volume that contains a
demonstrable GTV and/or subclinical,
microscopical malignant disease.
Suspected lymph nodes
Suspected disease around GTV
CTV = GTV (if there) + subclinical disease
Cannott b
C
be d
detected
t t d - subclinical.
b li i l
Based on clinical experience.
Volumes in IC
CRU50 - 1993
Planning Target Volume (PTV)
The PTV is a geometrical concept
Movements of tissues containing CTV
Movements of patient
Variations in size and shape
Variations in beam geometry characteristic
cs
PTV = CTV + margin for geometrical variatiions
Aid for treatment p
planning;
g; dose to PTV
representing dose to CTV
Volumes in IC
CRU50 - 1993
CRU50
Volumes in IC
CRU50 - 1993
Organs at risk
The Organs at Risk are normal tissues who
ose
radiation sensitivity may significantly
influence treatment planning and/or
prescribed dose
Any
Any possible movement of the organ at as
s
well as uncertainties in the set up must be
considered
Volumes in IC
CRU50 - 1993
Treated Volume
The Treated Volume is the volume which
w
receives at least the dose
specified as being appropriate to ac
chieve the purpose of the
treatment.
Volumes in IC
CRU50 - 1993
Irradiated Volume
The Irradiated Volume is the volume
e which receives a dose that is
considered significant in relation to
o normal tissue tolerance.
tolerance
Volumes
1978 ICRU29
1993 ICRU50
GTV
CTV
PTV
Organs at risk
Organs at risk
Volumes
1978 ICRU29
CTV
PTV
Organs at risk
Organs at risk
1993 ICRU50
GTV
1999 ICRU62
a lot of focus on
o g
geometrical variations in
this time period
PROB
BLEM
Positional variations
CT before treatment
e.g.
Physological processes
Variations in filling of
bladder and rectum
Positional variations
CBCT first fraction
e.g.
Physological processes
Variations in filling of
bladder and rectum
Positional variations
Dose calculation CBCT
Concequenses
Concequenses,
underdosage of
target or overdosage
of OAR.
Positional variations
Organs and
O
d tumours
t
in
i the
th pelvis
l i region
i moves
m
mainly
i l due
d to
t changes
h
in
i the
th
digestive system and filling of bladder and rectum from day-to-day. Example:
prostate, bladder, rectum, cervix.
Mainly inter-fraction positional variation
Typical values (1 SD) are 3 - 5 mm
mm.
Breathing posit
positional
ional variations
Volumes in IC
CRU62 - 1999
Internal Target Volume (ITV)
CTV with margin added to compensate for expected
e
physiologic movements and
variations in size shape and position of CTV
V in relation to Internal Reference Point.
ITV = CTV + IM (Internal Margin)
Wolthaus et al
al. Int.
Int J
J. Radiation Oncolo
ogy Biol
Biol. Phys 70 (4): 12291229-1238,
1238 2008
Time avg
avg.
Geometric avg.
35
Summary o
of problem
Strategies
g
for dealing
g with geom
g metric variations in practice:
p
breathing control
real-time tumour tracking
reproducible
d ibl filling
filli off bl
bladder
dd and
d rectum
t
Adaptive treatment
+ internal margin
g (IM)
( )
Example brea
athing control
Expiration
Deep inspiration
Example a
adaptation
PROB
BLEM
Set-up variations
Vrt
Lat
Long
Pitch
Roll
Rot
Set-up variations
30
Numb
ber of settups
VRT
LNG
LAT
20
10
-0.5
Shift / [cm]
[
]
0.5
NSCLC setup
W. Ottosson, M. Baker, M. Hedman, C.F Behren
ns, D Sjstrm Evaluation of setup accuracy for
NSCLC studying the impact of different types off cone-beam CT matches on whole thorax,
columna vertibralis, and GTV Acta Oncol. 2010
0; 49: 11841191
Set-up variations
Population Setup Errors
1
Long.
Long.
Systematic
Vert.
Vert.
Standard
Deviation
Pop
p
Long.
V t
Vert.
Long.
Random
V t
Vert.
Standard
Deviation
Pop
Set-up
Set
up variations
CTV to PTV margin
m
recipe
Set-up variations
0
We need to know the magnittude of these set-up
variations (set-up
variations
set up and set-up
set up)..
set-upp and set-upp should be minimised.
m
Remaining set-up and set-up should
s
be taken into
account.
t
Volumes in IC
CRU62 - 1999
Planning Target Volume (PTV)
ITV with margin added to compensate fo
or external geometric uncertainties in
relation to External Reference Point.
PTV = ITV + SM (Set-up Margin)
Summary o
of problem
E ample IGRT
Example
Ottosson et al. Evaluation of setup accuracy forr NSCLC studying the impact of different types of
cone-beam CT matches on whole thorax, columna vertibralis, and GTV Acta Oncol. 2010; 49:
11841191
Volumes in IC
CRU62 - 1999
Organ at Risk (OR)
Organs
g
at Risk are normal tissues whose
w
radiation sensitivity
y may
y
significantly influence treatment pla
anning and/or prescribed dose.
Volumes in IC
CRU62 - 1999
Organ at Risk (OR)
Organs
g
at Risk are normal tissues whose
w
radiation sensitivity
y may
y
significantly influence treatment pla
anning and/or prescribed dose.
<
Treated Volume
>
Irradiated
d Volume
Volumes
1978 ICRU29
1993 ICRU50
GTV
CTV
1999 ICRU62
GTV
CTV
Organs at risk
Organs at risk
PTV
ITV
PTV
OR
PRV
Volumes
1978 ICRU29
1993 ICRU50
GTV
CTV
1999 ICRU62
GTV
CTV
2004 ICRU71
Organs at risk
Organs at risk
PTV
ITV
PTV
OR
PRV
Volumes in IC
CRU71 - 2004
Gross Tumour Volume (GTV)
The GTV is the gross demonstrable extent and
a
location of the malignant growth.
primary tumour (GTV-T)
metastatic regional node (GTV
(GTV-N)
N)
distant metastasis (GTV-M)
ICRU Report No
No.83
83 (2010)
Volumes
1978 ICRU29
Organs at risk
Organs at risk
1993 ICRU50
GTV
CTV
PTV
1999 ICRU62
GTV
CTV
ITV
PTV
OR
CTVCTV-T
CTV--N
CTV
CTV
CTV--M
(ITV)
2004 ICRU71
GTV-T
GTVGTV--N
GTV
GTV--M
GTV
PTVPTV-T
PTV--N
PTV
PTV--M
PTV
OAR
PRV
PRV
Volumes
1978 ICRU29
Organs at risk
Organs at risk
1993 ICRU50
GTV
CTV
1999 ICRU62
GTV
CTV
ITV
PTV
OR
CTVCTV-T
CTV--N
CTV
CTV
CTV--M
(ITV)
2004 ICRU71
GTV-T
GTVGTV--N
GTV
GTV--M
GTV
PTVPTV-T
PTV--N
PTV
PTV--M
PTV
OAR
ICRU
PTV
variations
i ti
in
i de
delineation
li
ti
a lot of work on
n imaging
dose sculpting is more readily done
the dosedose-bath
h might be a problem
PRV
PRV
PROB
BLEM
Target-location might sh
hift, depending on who is
delinea
ating it
Target-locatio
on might shift,
depending on wh
ho is delineating it
Target-locatio
on might shift,
depending on wh
ho is delineating it
PROB
BLEM
Target-locatio
T
tl
tion might
i ht shift,
hift
depending on im
maging modality
Target-location might sh
hift, depending on who is
delineating it and imaging modality
Target-locatio
on might shift,
depending on im
maging modality
CT
Target-locatio
on might shift,
depending on im
maging modality
MRI
Target-locatio
on might shift,
depending on im
maging modality
CT
Target-locatio
on might shift,
depending on im
maging modality
MRI
Target-locatio
on might shift,
depending on im
maging modality
Charnley
y et al. Britis
sh J Radiology
gy 2005
Summary o
of problem
Volumes in ICRU
U78 and ICRU83
Volumes in ICRU
U78 and ICRU83
Volumes in ICRU
U78 and ICRU83
Overlapping Volumes
Volumes in ICRU
U78 and ICRU83
Overlapping Volumes and
a buildup regions
Volumes in ICRU
U78 and ICRU83
Volumes in ICRU
U78 and ICRU83
PTV extending outsid
de body contour
Volumes in ICRU
U78 and ICRU83
Volumes
1978 ICRU29
Organs at risk
Organs at risk
1993 ICRU50
GTV
CTV
V
1999 ICRU62
GTV
CTV
V
ITV
PTV
OR
PRV
CTVCTV-T
CTV--N
CTV
CTV--M
CTV
(ITV)
2004 ICRU71
GTV-T
GTVGTV--N
GTV
GTV--M
GTV
PTV
PTV--T
PTV--N
PTV
PTV--M
PTV
OAR
PRV
2007 ICRU78
2010 ICRU83
e.g
e
e.g.
g.
GTV--T (MR, 0 Gy
GTV
Gy))
GTV--T (CT, 0 Gy
GTV
Gy))
GTV--T (PET, 16 Gy
GTV
Gy))
GTV--TN (PET, 16 Gy)
GTV
GTV--N (MR, 16 Gy)
GTV
GTV--N (CT, 0 Gy)
GTV
PTV
PTV
PTV--T (MR, 0 Gy
Gy))
PTV--T (CT, 0 Gy
PTV
Gy))
PTVPTV-T (PET, 16 Gy
Gy))
PTVPTV-TN (PET, 16 Gy)
PTV
PTV--N (MR, 16 Gy)
PTVPTV-N (CT, 0 Gy)
Volumes Do
oes it matter?
Dirk Verelllen et al
Nature Reviews Cancer 7, 949-960
9
(December 2007)
ICRU recommen
ndations on Dose
Dose in ICRU5
50 and ICRU62
ICRU Referrence Point
- The dose at the point should be clinically relevant
- The point should be easy to define in a clea
ar and unambiguous way
- The point should be selected so that the dosse can be accurately determined
- The point should be in a region where there
e is no steep dose gradient
In central part of PTV at intersection of beam axes!
Dose in ICRU5
50 and ICRU62
Level 1. Minimum lev
vel of reporting
p
g dose
- The dose at the ICRU Reference Poin
nt
- Maximum dose to the PTV (Dmax)
- Minimum dose to the PTV (Dmin)
- Maximum
M i
d
dose tto th
the OR/PRV
OR/PRV:s
Dose in ICRU83
Level 1. Why is it not adequate today?
t
-The absorbed dose distribution for IMR
RT can be less
homogeneous then in CRT
-Each beam can produce absorbed dosse with large
dose gradients
- Large dose gradients (10%/mm) in the
e PTV boundary i.e. small shifts in delivery
can affect the reliability of using a single
e point to report the dose
- Because modern TPS have evaluation
n tools that makes it possible.
- Monte Carlo calculations have statisticcal fluctuation in the results for small
volumes which makes it difficult and uncertain to determine an absorbed dose to a
point.
Dose in ICRU83
Dose in ICRU83
Leval 2. Minimum level of reportting dose in IMRT
PTV and CTV
%
100
D50% = Dmedian
Dmean
Volume V
75
50
25
25
50
Dose D
75
100
Gy
AND
-State the treatment planning syste
em and algorithm used for planning
and delivery system used for treatm
ment
Dose in ICRU83
Reporting of absorbed
a
dose
Why not D100% and D0%(the earrlier definition of min and max
absorbed dose)?
E.g. PTV of 0.5 litres (radius 49.2 mm).
radius changed by less than 0.2 mm =>
1% change in volume
D98% and D2% serve the purpose to rep
port
an absorbed dose that is not reliant on a
single computation point.
Dose in ICRU83
Reporting of absorbed
a
dose
Median
ed a abso
absorbed
bed dose ((D50) is
s likely
e y to be a g
good measure
easu e of
o a typ
typical
ca abso
absorbed
bed dose in a
relatively homogeneo
ously irradiated tumor
Dose in ICRU83
Reporting of absorbed dose
Why D50
50%
%?
Dose in ICRU83
Reporting of absorbed dose
Example
p of two different approach
pp
es to p
prescribe the dose ((assuming
g that
D50 corresponds to the ICRU refere
ence point).
ICRU Report No.83 (2010)
Dose in ICRU83
Level of reporting for IMRT
Leval 3.
3 Techniques and concep
pts that are under development
-Dose Homogeneity
characterizes
h
t i
th
the uniformity
if
it off the
th absorbed
ab b d d
dose di
distribution
t ib ti within
ithi th
the
target
-Dose
D
C
Conformity
f
it
characterizes the degree to which the
t high dose region conforms to the
target volume
-Clinical and Biological evaluation (e.g.. TCP, NTCP, EUD)
-Confidence
C f
interval (e.g.
(
including sysstematic and random uncertainties))
Dose in ICRU83
Dose Homogeneity
y and Dose Conformity
Homogeneity Index
Dose in ICRU83
Dose Homogeneity
y and Dose Conformity
Conformity index = 1
Dose in ICRU83
Dose Homogeneity
y and Dose Conformity
Loic Feuvret et al
al.
Int. J. Radiation Oncology Biol.
Phys., 64 (2) 2006
Dose in ICRU83
Quality assurance for IMRT treatment plans
Previous
5% point dose accuracy specification
Dose in ICRU83
Example Quality Ass
surance measurement
Dose in ICRU83
Example Quality Assurrance Independent calculation
Dose in ICRU83
Example Quality Assurrance Independent calculation
Thank y
you forr your
y
attention!
Ques
stions?