T he British Journal of Radiology, 71 (1998), 587594

1998 The British Institute of Radiology

Review article

Target volume definition for three-dimensional

conformal radiation therapy of lung cancer
J G ARMSTRONG
St Lukes Hospital, Highfield Road, Rathgar, Dublin 6, Ireland
Abstract. Three-dimensional conformal radiation therapy (3DCRT) is a mode of high precision
radiotherapy which has the potential to improve the therapeutic ratio of radiation therapy for
locally advanced non-small cell lung cancer. The preliminary clinical experience with 3DCRT has
been promising and justifies further endeavour to refine its clinical application and ultimately test
its role in randomized trials. There are several steps to be taken before 3DCRT evolves into an
effective single modality for the treatment of lung cancer and before it is effectively integrated with
chemotherapy. This article addresses core issues in the process of target volume definition for the
application of 3DCRT technology to lung cancer. The International Commission on Radiation
Units and Measurements Report no. 50 definitions of target volumes are used to identify the
factors influencing target volumes in lung cancer. The rationale for applying 3DCRT to lung
cancer is based on the frequency of failure to eradicate gross tumour with conventional approaches.
It may therefore be appropriate to ignore subclinical or microscopic extensions when designing a
clinical target volume, thereby restricting target volume size and allowing dose escalation. When
the clinical target volume is expanded to a planning target volume, an optimized margin would
result in homogeneous irradiation to the highest dose feasible within normal tissue constraints. To
arrive at such optimized margins, multiple factors, including data acquisition, data transfer, patient
movement, treatment reproducibility, and internal organ and target volume motion, must be
considered. These factors may vary significantly depending on technology and techniques, and
published quantitative analyses are no substitute for meticulous attention to detail and audit of
performance.

The prognosis for non-small cell lung cancer

(NSCLC) patients who have locally advanced
unresectable disease is poor because of persistence
of thoracic disease and the development of distant
metastases [1]. In view of the poor rate of local
control following conventional radiation therapy,
there is a clear need for methods to improve its
efficacy. Radiation dose escalation could enhance
local disease eradication but if conventional techniques were utilized the resulting normal tissue
effects would probably cause prohibitive toxicity.
Three-dimensional conformal radiation therapy
(3DCRT) is a mode of high precision radiotherapy
which accurately conforms the isosurface of a given
radiation dose to the anatomical boundaries of the
tumour in its entire three-dimensional configuration [2]. Technical analysis for lung cancer demonstrated that 3DCRT had the potential to
enhance delivery of high dose radiation with a
reduction in dose to normal tissues [3]. These
phenomena suggested that 3DCRT may improve
the therapeutic ratio of radiation therapy for
Received 15 October 1997 and accepted 21 January 1998.
Supported by a grant from the Irish Cancer Society.
T he British Journal of Radiology, June 1998

locally advanced non-small cell lung cancer. This

was the basis for the clinical utilization of 3DCRT
for lung cancer. The preliminary clinical experience
with 3DCRT has been promising and justifies
further endeavours to refine its clinical use and
ultimately test it in randomized trials [4]. There
are several steps to be taken before 3DCRT evolves
into an effective single modality for the treatment
of lung cancer and before it is effectively integrated
with chemotherapy. This article addresses the issues
involved in the process of target volume definition
for lung cancer using 3DCRT technology.

Traditional target volumes

As experience with this approach has developed,
problems pertaining to target volume definition
have emerged. The application of 3DCRT technology to the treatment of lung cancer is a fundamental departure from the standard traditional
methods of designing treatment portals for lung
cancer. We are used to prescribing to treatment
volumes being defined by field sizes, surface anatomy, and plain radiological anatomy. To make the
change to using target volumes is a cultural shift
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J G Armstrong

in itself and the difficulties are compounded by the

concurrent transition to CT scan based planning.
Valley and Mirimanoff demonstrated enormous
variations in target volume definitions when CT
scan based planning is used [5]. The improved
refinement and accuracy of the anatomical information provided by CT scan planning poses a
simple question which is difficult to answer. What
do I want to treat? The answer to this question is
the clinical and biological basis of target volume
definition.

Use of ICRU 50 definitions

The International Commission on Radiation
Units and Measurements (ICRU) have provided
definitions for target volumes [6] which can be
used as a template to address the issues pertaining
to the design of target volumes for the 3DCRT of
lung cancer. These definitions can be summarised
as follows:
GTV, gross tumour volume.
CTV (clinical target volume), GTV and/or subclinical microscopic malignant disease.
PTV, planning target volume. The volume containing the CTV, taking into account the geometric
variations due to CTV motion, set-up variations,
data transfer etc.
Examining each of these definitions in turn provides a logical sequence for the exploration of this
topic. The definition of the GTV is dependent on
the imaging modality and the data acquisition
process. The CTV is the clinical target volume and
must take account of the GTV and subclinical and
microscopic anatomical spread patterns. The most
radical possible CTV for lung cancer would be
high dose total body irradiation which would be
uniformly fatal. So, obviously, the extent of the
CTV is limited by critical normal tissue tolerance.
The selection of a CTV is therefore basically a
process of informed clinical compromise. The PTV
must include a margin around the CTV. This
margin must account for the uncertainties involved
in planning and implementation of treatment.
Target volume and normal structure motion must
also be addressed. Finally, as the various target
volumes are discussed it is necessary to examine
the clinical implications of the strategies proposed
in response to the above issues.

The GTVdata acquisition

Simulation and planning CT scan
The technique used to acquire planning data
varies from institution to institution, but the general elements are the same. One established technique is described in the following section [3, 4].
Patients are immobilized supine for simulation,
588

treatment planning CT scan and treatment. They

are immobilized in a custom alpha cradle or
vacuum pack with the arms placed above the head.
This position allows selection of oblique treatment
fields. A set of orthogonal (anterior and a lateral )
simulation films are taken and are used to define
an initial isocentre.
By reviewing diagnostic CT scans and radiographs the clinician attempts to place that isocentre
at the centre of gross disease in the cephalad
caudal direction. The track of the three alignment
lasers on the patient are marked with a radioopaque catheter which is taped to the skin and
will then be visible on all CT slices, and the point
of intersection of these three lines indicates the
transverse location of the initial isocentre if it
were projected to that particular cephaladcaudal
position. This can be checked against the orthogonal simulation films to ensure that the patient
position for the CT scan is the same as the initial
simulation. Eventually, the CT scan is used as the
basis for subsequent planning and the final plan
will usually involve designation of a new isocenter
which can be identified by a process of translation
from the initial isocentre. It is therefore vital that
the CT scan is taken in the same position as the
initial simulation and shares the same isocentre.
That isocentre is used as the origin for the
subsequent treatment planning CT scan. CT slices
should be labelled with a y-value indicating how
many centimetres they are superior to the origin/
isocenter ( y has a positive value) or inferior to it
( y has a negative value). CT slices are taken at
0.5 cm intervals with a slice thickness of 0.5 cm
through gross disease. CT slices are taken at 1 cm
intervals with a slice thickness of 0.5 cm throughout the rest of the thorax. The CT should extend
from the bottom of the larynx to the bottom of
the second lumbar vertebra to include all the lung
parenchyma. This ensures that the dosevolume
histograms can include all of the relevant normal
structure of interest.

Methods of imaging
The imaging resolution of the CT is itself a
source of inaccuracy in the process of defining the
GTV and normal structures. The voxels have a
size dictated by the transverse resolution (typically
1 mm) and the slice thickness. Keeping the slice
thickness to a minimum, particularly through gross
disease, is therefore important. Spiral CT scanning
improves resolution and is a convenient fast way
to acquire multiple thin CT slices. The appearance
of the CT image used for delineation of the GTV
can be varied by the CT window display settings.
Soft tissue windows are most appropriate for imaging of central structures such as mediastinal nodes.
Harris et al compared the accuracy of soft tissue
T he British Journal of Radiology, June 1998

Review article: T arget volumes and lung cancer

settings using window width of 400 Hounsfield

units (HU) and level +20 HU to lung settings of
width 850 HU and level 750 HU [7]. For
simulated pulmonary nodules the soft tissue settings were highly inaccurate, whereas the lung
settings were accurate. The nodules however, were
rounded and not irregular or spiculated as true
cancers are. When outlining the GTV for a peripheral tumour it is important to refer to and to
use lung settings. However, the periphery of the
tumour can be spiculated and portions are very
fuzzy, and even with optimal settings it is next
to impossible to be completely sure about macroscopic limits of the tumour [8].

Other imaging modalities

There is no role for the routine use of MRI
scanning in treatment planning for lung cancer. It
can be of use for detection of chest wall invasion
and can identify neurovascular involvement by
Pancoast tumours. It is only as accurate as CT for
detection of mediastinal nodal metastases. MRI is
more accurate than CT scanning in detecting nodal
enlargement at the aortopulmonary window and
the hila [9, 10]. Nodes at these sites stand out
against the signal void of air in the bronchi and
blood flowing in the vessels [11]. The advantages
of MRI are offset by image degradation due to
motion artefact from adjacent vessels. Positron
emission tomography is a very expensive imaging
technique which requires the availability of a cyclotron and is not, therefore, widely employed.
Preliminary reports have demonstrated accuracy
rates of 80100% in the detection of nodal metastases compared with approximately 65% for CT
and MRI [12]. The diagnostic image does not
give as clear a picture of the anatomy as CT or
MRI. Consequently, it would not be easy to use
the image for treatment planning, and sophisticated
image registration and matching to the CT would
be required. Its main role may therefore be as a
diagnostic aid to help determine which nodal stations should be included in the target volume as
defined on the CT scan.

Atelectasis
Tumour induced atelectasis can make it impossible to determine the extent of macroscopic disease.
If the combined radiological opacity of tumour
and atelectasis is too massive to be encompassed
in a tolerable radiation port then the patient is
not suitable for treatment with 3DCRT. In that
situation, options include the use of brachytherapy
(and laser) or conventional radiation focused on the
major airways to resolve the atelectasis. Thereafter,
conventional radiation can be directed at the
residual radiological abnormality which may be a
T he British Journal of Radiology, June 1998

more accurate reflection of gross tumour. If, on

the other hand, the entire radiological abnormality
can be encompassed in a tolerable radiation port
then the entire abnormality can be regarded as
gross tumour volume. Such a patient can be treated
with 3DCRT.

After the planning CT scan

After the CT is obtained, the target volumes
are outlined as discussed elsewhere. Contours for
normal structures of interest, including skin, lungs,
oesophagus, spinal cord and heart, are also outlined. An important source of inaccuracies is the
set-up transfer between the CT and the simulator.
There are two stages of data transfer from simulator to the CT. Initially, at the start of the planning
process the set-up parameters of the first simulation
are used to position the patient for the CT scan.
Subsequently, when a plan is derived the selected
fields must be simulated for the purposes of block
design and subsequent verification. Bel et al [13]
concluded that this latter transfer can be the predominant factor in overall treatment geometric
deviations. By careful simulation, including the use
of digitally reconstructed radiographs, the amount
of these transfer errors can be reduced
considerably.

The CTVpatterns of spread

The clinical target volume must include the
GTV as a minimum. According to ICRU 50 it
should also include a margin around the GTV to
encompass subclinical or microscopic malignant
disease immediately adjacent to it [6]. In other
words it should include the invisible extensions
around the tumour itself. The extent of such disease
around visible cancer is unknown and is probably
influenced by the imaging modality, tumour biological characteristics and anatomical variables.
Following a variable period of time as a primary
tumour growing within lung parenchyma or within
the bronchial wall, the tumour ultimately invades
the vascular and lymphatic channels resulting in
spread by these channels to regional draining
lymph nodes and distant metastatic sites.
Occasionally airway-borne metastases can be seen
in lung parenchyma near the primary tumour. In
most instances, it appears that lymphatic spread
occurs earlier than spread to metastatic sites elsewhere. The regional lymphatic drainage of the lung
is outlined in Figure 1. In the lung tissue, lymphatic
drainage follows the bronchoarterial branching
pattern, with lymph nodes situated at the origin
of these branchings. Ultimately, these lymphatic
channels coalesce, draining into lymph nodes situated around segmental and lobar bronchi. For
lung cancers on both the left and right, the hilar
589

J G Armstrong

Figure 1. American Thoracic Society nodal station map.

The stations are denoted numerically and are as follows:
level 1, superior mediastinum; level 2, upper paratracheal;
level 3, pre-tracheal; level 4, lower paratracheal; level 5,
aortopulmonary window; level 6, pre-vascular; level 7,
subcarinal; level 8, paraoesophageal; level 9, pulmonary
ligament. Levels 10 to 14 include the hilar nodes and
more peripheral nodes. Level 10, hilar; level 11, interlobar; level 12, reproduced with kind permission of
American Review of Respiratory Diseases (Am Rev Resp
Dis 1983;127:3447).

nodes are most frequently involved. For right sided

tumours in general, the most frequently involved
mediastinal nodes are the lower paratracheal
( level 4) followed by the subcarinal nodes ( level 7).
For both right and left lower lobe tumours the
subcarinal nodes may be the first involved nodes
in the mediastinum. In general, on the left, the
most commonly involved mediastinal nodal area
involved is the subaortic ( level 5, also known as
the aortopulmonary window nodes) followed by
the subcarinal nodes. Retrograde lymphatic spread
to the pleural surface can occur, especially in
peripheral tumours.
The cross-sectional location of the American
Thoracic Society (ATS) nodal stations (Figure 1)
on CT scans have been described by Murray and
Breatnach [14]. The ease with which the nodal
map can be applied to CT scans is clear.

CTVelective nodal irradiation

Radiation therapy is the only cancer treatment
modality where the intensity of treatment can be
modified to be in proportion to the anatomical
concentration of infesting malignant cells. This
advantage of the modality has been used with
excellent clinical results in the treatment of head
and neck cancers. Elective nodal radiation is an
integral part of the management of many head and
neck cancers.
Following in this tradition, it has been usual to
590

administer elective nodal irradiation when radically treating NSCLC. However, despite the high
risk of nodal spread in lung cancer the value of
inclusion of elective nodal irradiation (ENI) is not
proven. There are theoretical reasons why elective
radiation may be inappropriate for lung cancer.
When routine bronchoscopy was performed after
high dose radiation for locally advanced NSCLC,
one group reported that less than 20% of patients
were locally controlled at 1 year [15]. This demonstrates the need for more intense treatment to gross
disease. The decision to include ENI in a treatment
strategy can have a major effect on dose to lung
and therefore prevent dose escalation to levels
which might achieve gross disease eradication. This
is illustrated in Figure 2. In attempting to maximize
the prospects of benefiting from enhanced local
disease eradication it is important to remember
that in the long term the likely role for 3DCRT
will be to achieve gross disease eradication as part
of a combined chemotherapyradiation strategy. If
chemotherapy is effective as a systemic adjuvant
therapy it is reasonable to hypothesize that it may
also control occult microscopic nodal disease and
obviate the need for ENI. In the following section
the inclusion and exclusion of ENI in the CTV is
discussed.

Figure 2. The impact of omission of elective nodal

irradiation on the lung dosevolume histogram. The yaxis depicts the percent lung volume. The x-axis depicts
the dose levels in Gy. The curve with the larger area
under the curve (thin line) was produced for a treatment
which delivered 50 Gy elective nodal irradiation (ENI)
and 70.2 Gy to the gross disease. The percent lung
volume receiving a minimum of 25 Gy is in excess of
30% which exceeds the maximum safe limit permitted
by institution policy. The curve with the smaller area
under the curve (thick line) was produced for a treatment which omitted elective nodal irradiation and delivered 81 Gy to the gross disease. The percent lung volume
receiving a minimum of 25 Gy is below 30% and is
within the defined limit. The omission of elective nodal
irradiation reduced lung irradiation and allowed concomitant gross disease dose escalation. Reproduced with
kind permission of Chest Surgery Clinics of North
America (Chest Surg Clin North Am 1994;4:2943).
T he British Journal of Radiology, June 1998

Review article: T arget volumes and lung cancer

CTVwith ENI
When ENI is included there are two CTVs.
CTV1 includes both gross disease and microscopic
(radiologically invisible) and could be prescribed
to 50 Gy in 25 fractions. CTV2 is restricted to
include the gross disease and after it receives 50 Gy
as part of CTV1 it is continued to approximately
70 Gy in 35 fractions. Such a simple scheme needs
to be modified to take account of the fact that
some lymph nodes may be visible and be smaller
than 1 cm. At that size it may or may not be
involved. If it is involved it should be in CTV2
and if not it should only be in CTV1. There are
no strict rules available as to how such a situation
should be handled. The following scheme based
on ATS stations is proposed. If there are no visible
nodes in a lymph node station then that station
should be in CTV1 only. If the station contains
visible node(s), of any size, then the station should
be included in CTV2.

CTVwithout ENI
As there is only one target volume it is simply
designated as the CTV and is prescribed to a
radical dose, e.g. 70 Gy in 35 fractions. The difficulty with such a simple system arises with nodes
which are visible on CT scan and yet are less than
or equal to 1 cm. Such nodes may or may not be
involved. There are no strict rules available as to
how such a situation should be handled. The
following scheme based on ATS stations is proposed. If the nodes within a station are not visible
then that station is excluded from the GTV. If a
single node is less than or equal to 1 cm size in
maximum dimension then it alone (not its entire
station) is included in the GTV. If there is more
than one node in the station which is less than or
equal to 1 cm in maximum size or if one (or more)
node is greater than 1 cm then the entire station
should be included in the GTV.

The PTVplanning target volume

The PTV is created by adding a margin to the
CTV. The margin added to the CTV accounts for
variations and uncertainties in the execution of
treatment, including patient movement and set-up
displacements as well as organ movement and
variations in size and shape of the CTV.

Patient movement and set-up displacements

The factors contributing to this source of uncertainty in delivery of treatment are many. They
include transfer of information in both directions
from simulation to CT scanner. Reproducibility of
patient position from day-to-day is affected by the
use of custom immobilization. Custom-moulded
T he British Journal of Radiology, June 1998

polyurethane foam immobilization or vacuumpack immobilization devices are essential. Bentel

et al from Duke University compared 30 patients
treated with custom immobilization with 30
patients treated without custom immobilization
[16]. They compared the frequency of physicianrequested isocentre shifts in the two groups. Using
this somewhat subjective endpoint the use of
immobilization was associated with fewer shifts.
This difference was significant when oblique fields
were used. The descriptive statistics of simulator
to port film isocenter displacements for the two
groups were not presented.
Skin marks which are often used to assist setup can be 23 mm in diameter and are a source
of uncertainty. As treatment proceeds they can
fade and successive touch-ups may lead to a shift
of that alignment point. Tattoos can help prevent
such a progressive migration of an alignment point.
They are smaller and indelible. However, they are
not easily visible in a dark room and need to be
emphasized by more readily visible marks. The
skin itself is not a rigid structure and can move
from day to day as a result of obesity or variations
in muscle tone or patient posture. It is recognized
anecdotally that set-up accuracy can improve as
treatment progresses. This may be a function of
the patient relaxing as they become more familiar
with the process or because the radiographers
become more accustomed to the requirements of
the particular technique and the patients shape
and habitus.
Despite the best efforts of a meticulous team,
day-to-day reproducibility is never perfect. These
deviations from the ideal position (as defined in
treatment planning) are either systematic or
random. Until recently, X-ray films have been
the only technique routinely available for field
placement assessment and block shape and position verification. These standard films suffer from
the inherent disadvantages of inconvenience [17,
18] and availability for retrospective study only.
With the increasing clinical use of the electronic
portal imaging device (EPID), on-line portal
images are now available for immediate evaluation.
EPID images are generated in a digital form which
enables image processing. This processing can
either enhance the quality of the image to make
interpretation easier or can allow comparison with
digitized reference images. Further processing of
the EPID and comparison with reference images
such as digitally reconstructed radiographs can
facilitate important clinical decision making.
Set-up deviations are assumed to be the sum of
random and systematic deviations. At the start of
treatment, when a film is taken and a deviation is
detected, it is not possible ( by inspection of the
port film alone) to determine if the deviation is
random (in which case no correction is required),
591

J G Armstrong

systematic (in which case corrective action is

required), or a combination. Systematic set-up
deviations can be identified by repeated daily
portal imaging to detect a reproducible error.
However, this is time-consuming, perpetuates an
error and delays appropriate corrections. On the
other hand, a correction based on one film alone
may introduce a systematic error by reacting to
a single random error. If workload was not a
consideration then a film could be taken every
day before treatment and corrections made. EPID
could facilitate this on-line correction. Ezz et al
performed a pilot study of such on-line correction
and reported major prolongation of treatment time
[19]. Bel et al performed a computer analysis of
the impact of decision rules on set-up accuracy
[20]. They proposed a procedure which uses an
action level proportional to the estimated standard
deviation of the distribution of random deviations
and shrinks as a function of the number of
measurements. The resulting accuracy was nearly
independent of the initial distribution of systematic
deviations. Using that procedure they suggested
that it would be unlikely that a set-up would have
to be repeatedly corrected while a large initial
systematic deviation would be corrected at an early
stage of the treatment. In addition to determining
a port film policy and intervention rules for the
initial part of treatment it is necessary to monitor
set-up accuracy throughout treatment. El-Gayed
et al demonstrated a significant progressive displacement with time throughout a course of pelvic
treatment in some patients [21]. Such analysis has
not been performed for lung cancer patients. In
formulating a port film policy and when determining action levels, accuracy data from the individual
institution should be audited and considered as a
parameter in the policy. The required accuracy is
dependent in part on the margin added to the
CTV in generating a PTV. The tighter the margin
the greater the need for monitoring and achieving
accuracy.
Ekberg et al evaluated the accuracy and reproducibility of patient and beam set-up [22]. EPIDs
were obtained from electronic portal images from
20 patients, who received radiotherapy for lung
cancer. They compared 553 EPID images with
the corresponding simulator films. Discrepancies
between planned and actual field edges were measured and the systematic and random errors identified. The systematic errors were on average 2.0 mm
in the transverse plane and 3.0 mm in the cranio
caudal direction. The random errors had standard
deviations of 3.2 mm in the transverse plane and
2.6 mm in the craniocaudal direction.

Internal organ motion

Internal organ motion can influence the position
of the CTV. Cardiac motion would have a greater
592

influence on targets which are close to it, particularly if the tumour is close to the apex of the
ventricle. Respiration can have a significant influence on the position of the CTV, and thus influences the size and shape of the PTV. The size of
the movements can vary considerably from patient
to patient and can be dependent on factors such
as tumour location in the lung, fixation to adjacent
structures, lung capacity, oxygenation, patient fixation, and patient anxiety [23]. Ekberg et al used
fluoroscopy to measure the clinical target volume
movements due to respiration and other internal
organ motion in 20 patients with lung cancer [22].
Average movement with quiet respiration was
about 2.4 mm in the mediolateral and dorso
ventral directions. Movement in the craniocaudal
direction was on average 3.9 mm with a range of
012 mm.
Routine measurements of respiratory movement
prior to treatment planning can therefore be of
importance when creating the individual PTV.
Fluoroscopy can be used to assess the range of
motion of the CTV in an individual patient and
these measurements can influence the margin used
to transform the CTV into a PTV. Another possible
way to overcome this problem is respiratory gating.
Huang et al assessed the feasibility of a self-gated
technique in 15 patients [24]. They compared
respiratory related motion during a normal simulation and compared it with simulation during
patient controlled intermittent breath-holding.
During the normal breathing pattern the respiration-induced motion of the position of the beam
centre was 0.54 mm. The distal hilum moved
11.5 cm and the arch 00.5 cm. Tumours in the
lower lobes moved 1.54 cm, whereas tumours in
the mid lung moved 0.52.5 cm. Reproducibility of
the beam centre during deep breath-hold was
13 mm. Tumour positions during this repetitive
pattern of breath-holding were also highly consistent with an average variation of 2 mm. To apply
such a technique, treatment would be delivered in
pulses during breath-holding.
When the PTV is drawn it is the final target
used to design the plan. However, even at this late
stage a further uncertainty is introduced by the
(in)accuracy of the dose calculation grid. In some
3DCRT planning systems the dose voxels are
555 mm. Sample PTVs are demonstrated in
Figures 3 and 4.

Summary
In designing the final PTV the variables influencing the GTV, CTV and PTV must all be
considered. A margin which accounts for all uncertainties, deviations and movements would be
unreasonably large, particularly for larger GTVs.
Such very large margins would limit the extent of
T he British Journal of Radiology, June 1998

Review article: T arget volumes and lung cancer

Figure 3. This CT slice shows a large

radiologically positive subcarinal
node (ATS station VII). The CTV is
restricted to including the GTV and
is depicted in red. In this instance the
PTV (yellow) has been created by
placing a 1 cm margin around the
CTV.

Figure 4. This CT slice shows an

involved right paratracheal node
(ATS station IV). The CTV is restricted to including the GTV and is
depicted in red. In this instance the
PTV (yellow) has been created by
placing a 1 cm margin around the
CTV. There is no elective nodal
irradiation so the nearby aortopulmonary nodal area (ATS station V)
is not included in the CTV.

dose escalation or if the dose were high would be

associated with an unacceptable risk of pneumonitis. By limiting the margins around the GTV we
are increasing two risks: geographic missing of part
of the GTV and partial or complete missing of
microscopic disease associated with it. These risks
should be considered separately.
The basic reason to apply 3DCRT to lung cancer
is because we fail to eradicate the vast majority of
GTVs with conventional approaches. If we design
successful escalation strategies which eradicate the
majority of GTVs then the control of microscopic
disease may be of renewed importance. Meanwhile
the eradication of the GTV is paramount. If this
principle is accepted then it is logical to select
a CTV which does not include elective nodal
irradiation. Similarly, when expanding the GTV
into a CTV and PTV it may be logical to ignore
subclinical or microscopic extensions of tumour.
In applying such a strategy it is always vital to be
aware of the limitations of the imaging modalities
T he British Journal of Radiology, June 1998

used. The complicated scheme for irradiation of

nodal disease proposed in this paper attempts to
take this into account.
It is therefore proposed that the step of designing
a CTV should be fundamentally modified. Around
the primary tumour the GTV should be expanded
into a CTV only to account for the uncertainties
associated with the particular diagnostic image
being used. Close collaboration with a radiologist
is very useful to scrutinize carefully the less clearly
defined portions of the GTV. The involved nodal
areas should be included as discussed previously.
When the CTV is designed in this manner it
must then have a margin placed around it to
become the PTV. If this margin is too tight it will
increase the probability of geographic miss of part
of the GTV with reduced gross tumour control
probability. Excessive margins will increase the
dose to normal structures such as lung. In response
to this the physician will either expose the patient
to a high risk of pneumonitis or reduce the dose
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J G Armstrong

to the PTV with resulting decreased gross tumour

control probability. If these two options of tight
versus generous margins are compared in a situation with equivalent lung dosevolume histograms (or derived parameter such as effective
volume) it becomes a choice between aiming for
homogeneous delivery of a moderate dose to the
GTV (generous margins) or inhomogeneous delivery of a higher dose to the GTV (tight margins).
Optimized margins would combine homogeneous
irradiation of the GTV to the highest dose feasible
within normal tissue constraints.
For an institution to arrive at such optimized
margins it must address all the factors affecting
data acquisition, data transfer, patient movement,
treatment reproducibility, and internal organ and
target volume motion. These factors may vary
significantly depending on technology and techniques and published quantitative analyses are no
substitute for meticulous attention to detail and
audit of performance.

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Principles and practice of oncology (4th edn).
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2. Armstrong JG. Three-dimensional conformal radiotherapy: precision treatment of lung cancer. Chest
Surg Clin North Am 1994;4:2943.
3. Armstrong J, Burman C, Leibel S, Fontenla D,
Kutcher G, Fuks Z. Conformal three dimensional
treatment planning may improve the therapeutic
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T he British Journal of Radiology, June 1998