imaging in the guidance of bt cervical cancer workshop on ...€¦ · imaging in the guidance of bt...
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Imaging in the guidance of BT cervical cancer
Workshop on GYN IGABT
Alina Sturdza Umesh Mahanshety
Nicole Nesvacil Maximilian Schmid
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Outline
• MR delineation • CT delineation • US use in IGBT for cervical cancer • Modalities for improving target and OAR
delineation • Tips for contouring and treatment planning
in the absence of MRI for each BT application
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Image guided adaptive brachytherapy (IGABT)
• Individualized: Personalized medicine
• It is adapted to the tumour size at BT, after concurrent EBRT
• Allows dose escalation while sparing the organs at risk
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This house believes in MRI at
each application
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MRI is the gold standard imaging modality for LACC
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Tumor / Target at different points in time • Signs for judgement of tumor at time of
diagnosis • Signs for judgement of tumor / target at time
of brachytherapy (signs of regression and persistance)
Tumor Regression
Workshop on GYN IGBT CT and MR Imaging
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Signs for judgement of tumor at time of diagnosis (GTVD)
vaginal invasion
invasion into the parametria
corpus invasion
High signal intensity tumor mass
necrosis GTVD
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Signs for judgement of tumor/target at time of brachytherapy (regression - persistance)
IJROBP 2006
Fluid surrounding the cervical canal
Low signal intensity Cervical stroma
measurable tumor mass grey zones in the parametria
HR-CTV
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61,0
7,99,010,516,3
0
10
20
30
40
50
60
70
prior to therapy 1. brachytherapy 2. brachytherapy 3. brachytherapy 4. brachytherapy
Abs
olut
e V
ol (c
m³)
Strahlenther Onkol 2009, 5
Quantitative tumor regression EBRT: tumor regression 75% Brachytherapy: tumor regression 10%
EBRT
BT
easy to predict
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Workshop on GYN IGBT CT and MR Imaging
Comparison between imaging modalities EXAMPLE
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Workshop on GYN IGBT CT and MR Imaging
Comparison between imaging modalities EXAMPLE
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Workshop on GYN IGBT CT and MR Imaging
Comparison between imaging modalities EXAMPLE
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Workshop on GYN IGBT CT and MR Imaging
Comparison between imaging modalities EXAMPLE
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Workshop on GYN IGBT CT and MR Imaging
Comparison between imaging modalities EXAMPLE
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Workshop on GYN IGBT CT and MR Imaging
Comparison between imaging modalities EXAMPLE
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Workshop on GYN IGBT CT and MR Imaging
Comparison between imaging modalities EXAMPLE
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Workshop on GYN IGBT CT and MR Imaging
Comparison between imaging modalities EXAMPLE
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axial sagittal coronal
Grey zone Gross tumour
Cervix
Target / Patho-anatomical structures / GTV, HR-CTV contouring on MRI
residual tissue =grey zones
Tumour mass
Workshop on GYN IGBT CT and MR Imaging
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HR-CTV
Rectum
Bladder
CTMR
Viswanathan et al. IJROBP 2007
parametrial space
Dimopoulos et al. IJROBP 2006
patho-anatomical structures CT/MRI
parametrial space
nodal structures? Soft tissue?
Workshop on GYN IGBT CT and MR Imaging
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Organs at Risk – MRI High resolution multiplanar capability
Workshop on GYN IGBT CT and MR Imaging
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HR-CTV
Rectum
Bladder
CTMR
Viswanathan et al. IJROBP 2007
NEEDLES
Applicator MRI /CT
TANDEM
Workshop on GYN IGBT CT and MR Imaging
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excellent depiction poor quality
improvement for needles / loss of soft tissue depiction quality
proton weighted
T2 - weighted T2 - weighted
Applicator MRI
Workshop on GYN IGBT CT and MR Imaging
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Workshop on GYN IGBT CT and MR Imaging
uterine border and pre-vesical space not visible
uterine border and pre-vesical space visible
Multiplanar Imaging CT / only with reconstruction (improvement with specific protocols and modern scanners)
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Workshop on GYN IGBT CT and MR Imaging
Lateral uterine/tumour border not visible Lateral uterine/tumour border visible
Multiplanar Imaging CT / only with reconstruction (improvement with specific protocols and modern scanners)
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B
FR
B
RS
FF
GP
RB
S
at diagnosis without vaginal
marking
at diagnosis with vaginal
marking at brachytherapy with specific protocol
IJROBP 2006
Improvement with specific protocol
Workshop on GYN IGBT CT and MR Imaging
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PLANE COVERAGE-BORDERS
T2 axial discus L5 inferior border of symphysis pubis
T2 sagittal pelvic wall (obturator muscle) pelvic wall (obturator muscle) T2 frontal or frontal oblique
entire uterus - cervix - vagina - tumor
Axial Sagittal Frontal
Improvement with specific protocol
Workshop on GYN IGBT CT and MR Imaging
Slice orientation parallel/orthogonal to applicator axis
Paracoronal orientation
Paratransverse orientation
Parasagittal orientation
GEC-ESTRO HANDBOOK OF BRACHYTHERAPY
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This house believes in MRI at
each application, But also in our good old
finger
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/ / dd/mm/yy
Signature
w = __ _ cm h = __ _ cm t = __ _ cm
Vagina Involvement = _ _ cm
w
Infiltrative Exophytic
Cervix
Vagina
Parametria
Rectum or
Bladder
Clinical Drawing Patient: At Diagnosis
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w Infiltrative Exophytic
Cervix
Vagina
Parametria
Rectum or
Bladder
Tumour size:
Width: 10 cm
Thickness: - cm
Height: - cm
Vaginal inv.: 5 cm
Clinical drawings at diagnosis
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MRI findings
Before BT
Diagnosis