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ICR

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

95% or more of the


prescribed
ib d dose
d
given
i
to
t
everything inside green area

Backkground
kground

Tumour cells
T
ll contained
t i d in
i the
th
red volume throughout the
treatment course

95% or more of the


prescribed
ib d dose
d
given
i
to
t
everything inside green area

How do we ensure that this


picture reflects the reality of
the treatment?

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

How to prescribe, record an


nd report

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(Superseded ICRU Repo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

+ Organs at risk whose presence


influence treatment planning

Volumes
Volumes
1978 ICRU29

The Targett Volume

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

The Targett Volume

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

The demonstrated tumour

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.

CTV I - GTV with margin


margin, and CTV II
lymph nodes

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

CTV with margin forming the PTV

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

The Targett Volume

GTV

CTV

PTV

Organs at risk

Organs at risk

Volumes
1978 ICRU29

The Targett Volume

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

Structures within a body are not static

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

Breathing positional variations

Breathing cycle (3-5 s) during treatment (intra


(
fraction variation)
Movement of organs and tumours in the ab
bdomen region.
region Examples: lung
tumours, kidneys, liver, breasts.
Example: Diaphragm moves 1 - 4 cm underr normal free-breathing conditions
conditions. For
deep-breathing, the corresponding figure can
c be 10 cm!
Necessary to quantify organ motion individ
dually for curative
curative lung cancer patients

Breathing positional variations

Ekberg et al. Radiother Oncol 48: 71


71--77, 1998: 20 nsclc patients
organ motion measured with fluorroscopy
Mean CTV movement with quiet re
espiration:
2.4 mm (med(med-lat
lat))
2.4 mm (ant(ant-post)
3.9 mm (sup(sup-inf
inf))
Range (sup(sup-inf
inf):
): 0 12 mm

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)

Internal reference point

New conceptts replacing ITV

Wolthaus et al
al. Int.
Int J
J. Radiation Oncolo
ogy Biol
Biol. Phys 70 (4): 12291229-1238,
1238 2008

Mid ventilation (Time


e averaged position)

Time avg
avg.

Geometric avg.

Wolthaus et al. Int. J. Radiation Oncology


Biol. Phys 64 (5): 15601560-1571, 2006

35

Summary o
of problem

Extent of geometric variations:


abdomen target mm to cm (iintra-fx amplitude)
pelvis target a few mm (1 SD
D inter-fx)
inter fx)

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

Example H&N patient with tumour shrinkage/weight loss.


Call for adaption?

PROB
BLEM

Setting up the patient and the irradiation fields


can not be done identically from day-to-day

High/Low dose area is moving


when set-up of patient
p
is varying

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

M (CTV PTV ) 2 .5 Pop 0 .7 Pop

Set-up
Set
up variations
CTV to PTV margin
m
recipe

ICRU Report No.83 (2010)

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)

Internal reference point

External reference point

Summary o
of problem

Extent of geometric variations:


often a few mm (1 SD inter-fx)

Strategies for dealing with geom


metric variations in practice:
fixation
off-line portal imaging with de
ecision rule protocols
on-line portal imaging
IGRT

+ set-up margin (SM)

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.

Planning Organ at Risk Volume (PRV)


The PRV is the OR with an integrate
ed geometric margin added
added, in
analogue with the CTV-to-PTV expa
ansion.

Volumes in ICRU62 - 1999


Conformity index
Conformity index (CI) defined as the
e quotient of the treated volume
(TV) and the volume of PTV (CI = VTV
1).
T /VPTV 1).

<
Treated Volume

>
Irradiated
d Volume

Volumes
1978 ICRU29

The Targett Volume

1993 ICRU50

GTV

CTV

1999 ICRU62

GTV

CTV

Organs at risk

Organs at risk

PTV

ITV

PTV

OR

PRV

Volumes
1978 ICRU29

The Targett Volume

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)

Clinical Target Volume (CTV)


The CTV is a tissue volume that contains a
demonstrable GTV and/or subclinical,,
microscopical malignant disease,
which must be eliminated.
CTV = GTV (if there) + subclinical disease
(CTV T CTV-N,
(CTV-T,
CTV N CTV
CTV-M)
M)

Planning Target Volume (PTV)


As above: PTV-T, PTV-N, PTV-M

Comparison between macroscopic and


microscopic section of malign and
benign breast tumor

ICRU Report No
No.83
83 (2010)

Volumes
1978 ICRU29

The Targett Volume

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

The Targett Volume

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

Stenbakkers et al. Int J Ra


adiat Oncol Biol Phys
y 2005

Target-locatio
on might shift,
depending on wh
ho is delineating it

KC Chao et al. Int J Radiat Oncol Biol Phys 68(5):2007

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

Stenbakkers et al. Int J Ra


adiat Oncol Biol Phys
y 2005

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

Extent of geometric variations:


Delineation variation the largest geometrrical variation in radiotherapy often cm

Strategies for dealing with geom


metric variations in practice:

radiologists input in GTV delineation


use optimal imaging modalities
e.g. contrast
workshops/audits
Autocontouring (?)

ICRU: The uncertainty in the


delineation ((of GTV and CTV))
should be included in margin
considerations

Volumes in ICRU
U78 and ICRU83

Definition of volumes depends on the imaging modality

ICRU: A clear annotation has to


t be used e.g.

GTV-T (CT, 0 Gy)

GTV-T (MRI T2, fat sat, 0 Gy)

ICRU Report No.8


83 (2010)

GTV-T (FDG-PET, 0 Gy)

Volumes in ICRU
U78 and ICRU83

Definition of volumes depends on when imaging is done

ICRU: recommended to indiicate the dose and/or the time


when the GTV has been evaluatted/measured
ted/measured

GTV-T (CT, 20 Gy)

GTV-T (MRI T2,, fat sat, 20 Gy)

ICRU Report No.8


83 (2010)

GTV-T (FDG-PET, 20 Gy):

Volumes in ICRU
U78 and ICRU83
Overlapping Volumes

Volumes in ICRU
U78 and ICRU83
Overlapping Volumes and
a buildup regions

ICRU Report No.83


N
(2010)

Volumes in ICRU
U78 and ICRU83

The PTV might overlap an adjac


cent PRV or there might be
other reasons to subdivide the PTV
ICRU: the delineation of the PTV
margins should not be compromised
subdivision of the PTV into regions
with different
ff
prescribed doses
(so-called PTV sub-volumes,
PTVSV) may be used

ICRU Report No.83 (2010)

Volumes in ICRU
U78 and ICRU83
PTV extending outsid
de body contour

ICRU Reporrt No.83 (2010)

Volumes in ICRU
U78 and ICRU83

With new techniques,


q
, carcinogenesis
g
need
ds to be monitored;; there might
g also be
unsuspected regions of high dose within the
t patient

ICRU: The volume within the patient ex


xcluding any delineated OAR and the
CTV(s) should be identified as the remain
ning volume at risk (RVR)

Volumes
1978 ICRU29

The Targett Volume

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

OAR PRV RVR


MR, 0 Gy
Gy)) (ITV)
CTV-T (M
CTVCTV--T (CT, 0 Gy)
CTV
Gy)
CTV
CTV--T (PET, 16 Gy
Gy))
CTV
CTV--TN (PET, 16 Gy)
MR, 16 Gy)
CTV
CTV--N (M
CTV
CTV--N (C
CT, 0 Gy)

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

Level of reporting for IMRT

Leval 2. Minimum level of reporrting dose in IMRT


PTV and CTV
-Report the DV, where V refers to a percentage
p
of volume covered by the
specified dose, for each PTV and CTV
V:
-D95% (dose that covers 95% of the vo
olume)
-D50% (median dose)
-Dmean (mean dose)
-Dose near max: D2%
-Dose near min: D98%
OAR and PRV
-Dmean (parallell organs)
-D2% (serial organs)
-V
VD (Volume receiving more than e.g. 2
20 Gy).
AND
-State
State the treatment planning system a
and algorithm used for planning and
delivery system

Dose in ICRU83
Leval 2. Minimum level of reportting dose in IMRT
PTV and CTV
%

D2% close to max replaces Dmax

100

D50% = Dmedian
Dmean

OAR and PRV

Volume V

D98% close to min replaces Dmin

VD (e.g volume receiving more than 50 Gy)

75

50

25

V50Gy (parallel organs)


Dmean (parallel organs)

25

50

Dose D

75

100

Gy

D2% (serial organs)

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

ICRU Report No.83 (2010)

Dose in ICRU83
Reporting of absorbed dose
Why D50
50%
%?

Deviation between prescribed and planned absorbed


a
doses for 803 patients. The median
absorbed dose (D50) is th
he most accurate quantity
ICRU Report No.83 (2010)

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

ICRU Report No. 83 (2010)

Dose in ICRU83
Dose Homogeneity
y and Dose Conformity

Loic Feuvret et al.


Int. J. Radiation Oncology Biol.
Phys., 64 (2) 2006

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

Replaced by volumetric dose ac


ccuracy specification for IMRT
Not limited to single point
High gradient (20%/cm):85% of points
p
within 5 mm (1 SD of 3.5
mm))
Low gradient (<20%/cm): 85% of points within 5% of predicted dose
normalized to the prescribed dose
e

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?

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