Definitions of Target Volumes and

Organs at Risk
22 February 2011
Jacob (Jake) Van Dyk
Consultant, IAEA
Professor, University of Western Ontario, Canada

IAEA
International Atomic Energy Agency
Acknowledgement

Slides from
Morten Hyer
Richard Ptter
Larry Marks
Stewart Gaede

IAEA
Definitions of Target Volumes and OARs

Aim
To introduce target volume and organ at risk
concepts as defined by ICRU
Specific Learning Objectives
Introduce ICRU reports 29/50/62/71/83
Define volume definitions of ICRU
GTV, CTV, PTV, OAR, PRV
Describe margins and how they are determined

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Evolution of Modern Radiation
Therapy Technology

Dose Escalation

Decrease normal tissue dose

Tighter margins

IAEA R Ptter
 MINIMIZE

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 1993
1978
1999

Replaces
ICRU 29, 1978

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ICRU 29 1978

Target volume & uniform

prescription concepts Single slice (or few)
External contour
2-D era Coplanar beams
Simple calculations
Dose prescription to
ICRU reference point

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 1993
ICRU 50 - Purpose Replaces
ICRU 29, 1978

Specification of volume(s) & dose(s)

For prescription, recording, reporting
Purpose
Consistent treatment policy
Compare results of treatment - departmental colleagues
Enable other radiation oncologists to benefit from
departments experience
Enable departments treatment results to be compared
with those of other centers
Especially multi-centered clinical trials

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ICRU Volumes

IAEA 9 ICRU 50
Gross Tumor Volume (GTV)

Gross palpable or visible/demonstrable

(imaging) extent and location of disease
GTVprimary, GTVnodal

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GTV with CT

Right! Use right window settings Wrong!

Use right contrast and delay
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Purdy, Sem Rad Oncol 14: 27, 2004
Intra- and Inter-observer Variability
In contouring on CT

Inter
Agreement GTV

United GTV Max. PTV

Intra Min PTV

IAEA Leunens et al, Radiother Oncol 29: 169; 1993

Inter-observer variation in delineation
for cervix cancer

IAEA Dimopoulos J et al. R&O 2008 EPUB

Clinical Target Volume (CTV)

Contains GTV and/or subclinical microscopic

malignant disease, which has to be
eliminated.
This volume needs to be treated adequately to
achieve cure or palliation

Perez et alIAEA
1998
Uncertainties Inter-fraction

IAEA Courtesy D. Yan & M. van Herk

Intra-fraction Respiratory Motion

IAEA Courtesy S Gaede

Planning Target Volume (PTV)

Geometrical concept - To select appropriate beam

sizes/arrangements, accounting for the net effect
of all the possible geometrical variations and
inaccuracies to ensure that the prescribed dose is
actually absorbed in the CTV

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Perez et al 1998 17 2/25/2011
 Prostate

Contours for
GTV, PTV,
bladder,
rectum.
CTV=GTV
Non-uniform
margin

Purdy, Sem Rad

IAEA Oncol 14: 27, 2004
PTV

PTV depends on the precision of tools

immobilization devices
lasers
PTV does NOT include margin for dosimetric
characteristics beam
these will require additional margin during
treatment planning and shielding design
penumbral areas
build-up region

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Dose Volumes
Treated volume - enclosed by an isodose surface
selected by rad. onc. as appropriate to achieve
purpose of treatment
Irradiated volume - receives a dose that is
significant in relation to normal tissue tolerance

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Treated Volume - NSCLC

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Irradiated Volume - NSCLC

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Organs at Risk (OAR)

Normal tissues whose radiation sensitivity

may significantly influence treatment
planning and/or prescribed dose

OARs
Lung
Spinal cord

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ICRU 50 Dose Reporting

ICRU Reference Dose

Dose at ICRU reference point
Centre of PTV
Near central axis of beam(s)
Dmax Maximum dose in PTV
Dmin Minimum dose in PTV
Dave Average dose in PTV
Dmedian Median dose in PTV
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 1999
ICRU 62 - Purpose
Irradiation techniques have advanced
3-D imaging
Conformal radiation therapy
More accurately formulate definitions & concepts
Issues
Reference points and coordinate systems
Introduction of
Internal margin (IM)
Setup margin (SM)
Internal target volume (ITV)
Planning organ at risk volume (PRV)
Conformity index (CI)
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Reference Points and Coordinate Systems

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Internal Margin
Takes account of variation in size, shape, and
position of CTV in relation to anatomical
reference points, e.g.,
Filling of rectum
Movements due to respiration
Patient related

Set-up Margin
Accounts for all uncertainties in patient-beam
positioning
Technical factors
Patient immobilization
Machine stability
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 Margins
A.
PTV CTV IM SM
B.
PTV CTV IM 2 SM 2
C.
Global safety margin
Accounts for
OAR
Decrease of
subclinical spread
from GTV
IAEA 28 ICRU
2/25/2011 62
Internal Target Volume (ITV)

ITV = CTV + IM
Geometric
ITV accounts for
motion of CTV in the
patient
Does not account for
setup uncertainties

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GTV & CTV: NSCLC stage IIIA

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Internal Target Volume (ITV)

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Planning Target Volume (PTV)

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 Imaging Biology Respiratory
CT, PET, MRI gating
Gross Tumor Microscopic Internal Set-up
Volume (GTV) + Spread + Motion + Errors

Clinical Target Volume (CTV) On board

imaging
Internal Target Volume (ITV)

Planning Target Volume (PTV)

Organs at Risk (OAR)

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Planning Organ at Risk Volume (PRV)

Like CTV to PTV

Accounts for OAR movements
Shape, size, setup
PRV = OAR + margin
PTV and PRV may overlap

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Changes Over Time: ICRU 50 to 62

IRRADIATED VOLUME PRV: Includes margin

around the OAR to
TREATED VOLUME compensate for
PTV
changes in shape and
internal motion and for
ITV set-up variation.
CTV
GTV

OAR

IAEA PRV
Conformity Index (CI) in ICRU 62

Treated volume
CI
PTV

Note: In ICRU 83 discussion on conformity indices:

the applicability of above indices for
reporting results of IMRT is likely to be limited.
Ideal
CI=1.00

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ICRU 50 & 62 Summary

Consistent specification of dose and dose

homogeneity are essential
Facilitates communication
Improves knowledge of dose-response data
ICRU 50 & 62 are widely accepted

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Changes Over Time

IAEA Purdy, Sem Rad Oncol 14: 27, 2004

 2010
ICRU 83- Purpose

Irradiation techniques have advanced

3-D CRT to IMRT
More availability of CT
Additional imaging CT + MRI, PET, PET/CT,
functional
Improved conformality
Reduced doses to normal tissues
More detailed dose-volume information on TPS
Use of dose-volume constraints
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Automated optimization, IMRT 40
 2010
ICRU 83

Dose reporting adapted to IMRT

Use of DVH
No Dmin or Dmax , instead
D98% and D2%
Specify median dose, D50%
Close to old ICRU reference dose at ICRU
reference point

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ICRU 83 Dose Specification

~= dose to ICRU
reference point

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 2010
ICRU 83 Dose Accuracy

Old: dose accuracy 5%

New:
More statistical
Two regions
Low dose gradient (<20%/cm)
85% of target volume, dose within 5%
High dose gradient (20%/cm)
Specify distance to agreement
85% of dose samples, within 5 mm

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Remaining Volume at Risk (RVR)

2010
Optimization
Carcinogenisis

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3-D vs. IMRT
Implications for target definition

Concave vs. convex targets

Target volume quality assurance/peer review
3-D beams more readily compared to
historical beams 2-D beams
IMRT beams/plans are less able to be
checked via intuition.
Dose gradients
Margins
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3D-CRT: Convex Dose Distribution

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IMRT: Concave Dose Distribution

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Convex vs Concave

Careful definition of the concavity is more

important for IMRT than for 3-D CRT

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Reducing Margins

Technical margins can be reduced by

improving daily setup.
Daily setup verification by EPID, CBCT,
ultrasounds
Automatic repositioning of patients by external
systems (eg, ExacTrac).
Automatic repositioning with internal fiducials
(eg, Calypso).

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Note ...

IRRADIATED VOLUME

TREATED VOLUME We may be able to reduce

PTV technical margins ...
ITV but not biological
CTV margins
GTV

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Summary

ICRU reports provide

Consistency in target volume definition
Consistency in dose prescription
Consistency in reporting
Tumour doses
Normal tissue doses

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 MINIMIZE

THE WORLDS WAR AGAINST

NORMAL TISSUE DAMAGE

RADIATION MEDICAL
IAEA ONCOLOGISTS PHYSICISTS