Target volume definition(GTV, HR-CTV and IR-CTV):

GYN GEC-ESTRO Recommendations

Richard Pöttera, Elena Fidarovaa, Primož Petrič a,b

aMedical University ViennabInstitute of Oncology Ljubljana

Vienna, 25-26 March, 2013

GYN GEC ESTRO RECOMMENDATIONS-BACKGROUNDFrom 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 brachytherapytarget 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,...

Macroscopictumour load

Significant microscopicdisease

Potential microscopic tumour spread

Pelvic wall region

Pelvic wallregion

Significant microscopicdisease

Potential microscopictumour spread

Three different target volumesaccording to cancer cell density

cervix

HR IR LRIRLR

HR: High risk CTVIR : Intermediate risk CTVLR: Low risk CTVIR : Intermediate risk CTVLR: Low risk CTV

GTV

HR CTV

Tumor at timeof diagnosis.

GTV

Grey zones (MRI)+palpableresidual

disease

IR CTV

• Extensive Disease (IIB-IVA): no alternatives for surgery(beyond cervix)

Radiother Oncol 2005, 74:235-245

Bladder UreterCervix Parametr

ium

GTVHR CTV

IR CTV

Tumor at timeof diagnosis.

GTV

Grey zones (MRI)+palpableresidual

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 tumourextension

Residual disease

Completeremission

Poor partialremission

Noremission

10 mm

10 mm

10 mm

10 mm

cervix

Good partialremission

> 10 mm

> 10 mm

10 mmcervix cervix

cervix

HR and IR-CTVExtent at diagnosis

and degree of remission

Clinical examples

1. Limited disease (tumour size < 4cm)2. Large tumour, sufficient response3. 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

GTVBHR-CTVIR-CTV

Clinical examples

1. Limited disease (tumour size < 4cm)2. Large tumour, sufficient response3. 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 responseGTVD

GTVBHR-CTVIR-CTV

B

RS

B

R

S

R

B

VC

B

GTV

IR-CTV

HR-CTV

cervix endometrium vagina

HR-CTVHR-CTV

GTV

GTV

IR-CTV IR-CTV

Gyn GEC ESTRO Recommendationsare applicable for Gyn BT in general

(vagina, endometrium, vulva, recurrent tumours)

Petric, Pötter, van Limbergen, Haie-Meder: Adaptive Contouring of CTV and Organs at Riskin: Viswanathan, Erickson, Kirisits, Pötter (eds): Gynaecologic RadiationTherapy: Novel approaches to Image-Guidance and Management, 2010