Brachytherapy

Recommendations in
Cancer of the Cervix:
ICRU 38 and Gyn GEC
ESTRO
Ahmad Lutfi Yusoff
Dept. CME, JPNRO, PPSP, USM KK
3 May 2006
 Manchester Applicator

• Tandem of variable length and angles

• Ovoids of different sizes and shapes
 BT Planning for Cervix
• Source localization
– 2 radiographs (orthogonal)
• Computer dose calculation
• Dose
– Point A
– ICRU 38
• Optimization
– Dose points
– Dose volume - shape
Computer planning

Dose distributions

AP and lateral radiograph

 Point A and Isodose Shape

• Point A was first introduced inthe Manchester dosimetric system

– Not recommended by ICRU 38
• The isodose line is pear shaped (dotted line)
 ICRU 38 Treatment Reporting
• Description of the technique used
• Total reference air kerma (cGy @ 1m)
• Reference volume
– Usually at isodose with Dtotal of 60Gy, must specify otherwise
• Dtotal = DEBRT + DBT
– Shape (pear) and dimensions
• Absorbed dose at reference point
– Bladder
– Rectum
– Lymphatic trapezoid
– Pelvic wall reference point
• Time dose pattern
 Volumes – ICRU 50
Gross Tumor Volume (GTV) -- The palpable or
visible/demonstrable extent and location of the
malignant growth
Clinical Tumor Volume (CTV) – GTV + subclinical
microscopic malignant disease which has to
be eliminated
Planning Target Volume (PTV) – the
volume of tissue receiving the
prescribed irradiation (in BT, PTV = CTV)

Treated Volume (TV) – the volume encompassed

by an isodose surface that has been
specified by the radiation oncologist (= min target dose)

Irridiated Volume (IV) – the volume that

received a significant dose regarding tissue
tolerance
 ICRU 38: Reference Volume

• Reference volume covered by 60 Gy isodose surface

• Critical dimensions: Height (dh), width (dw) and
thickness (dt)
 ICRU 38: Bladder and Rectal
Dose Points

• Bladder point is located at the center of the posterior surface of the

bladder Foley balloon
• Rectal point is located directlyposterior to the lower end of the
intrauterine source, 0.5cm behind the posterior vaginal wall
 ICRU 38 Treatment Reporting
• Description of the technique used
• Total reference air kerma (cGy @ 1m)
• Reference volume
– Usually at isodose with Dtotal of 60Gy, must specify otherwise
• Dtotal = DEBRT + DBT
– Shape (pear) and dimensions
• Absorbed dose at reference point
– Bladder
– Rectum
– Lymphatic trapezoid
– Pelvic wall reference point
• Time dose pattern
 GYN GEC ESTRO – 3D Planning
• Source localization
– MRI (preferred over CT)
• Volume delineation
– GTV, HR CTV, IR CTV
– Organ at Risk – bladder, rectum, sigmoid, vagina
• Computer dose calculation
• Dose
– Point A
– ICRU 38 – only bladder and rectum
– D100, D90 for GTV, HR CTV, IR CTV
– D0.1cc, D1cc, D2cc for OARs if volumes are delineated
– D5cc, D10cc for OAR if walls are contoured
• Optimization
– Dose points
– Dose volume
• Shape
• DVH
 3D and 2D Planning Comparison
• Source localization • Source localization
– MRI (preferred over CT) – 2 radiographs
• Volume delineation (orthogonal)
– GTV, HR CTV, IR CTV
– Organ at Risk – bladder, rectum,
sigmoid, vagina
• Computer dose calculation • Computer dose calculation
• Dose • Dose
– Point A
– Point A
– ICRU 38 – only bladder and rectum
– D100, D90 for GTV, HR CTV, IR CTV – ICRU 38
– D0.1cc, D1cc, D2cc for OARs if volumes
are delineated
– D5cc, D10cc for OAR if walls are
contoured
• Optimization • Optimization
– Dose points – Dose points
– Dose volume – Dose volume - shape
• Shape
• DVH
 Volumes – GYN GEC ESTRO

∴ delineate GTV and CTVs everytime

• GTV changes during the course of EBT and BT,
 Volumes – GYN GEC ESTRO
• HR CTV
– Macroscopic + residual macroscopic tumor,
includes
• Whole cervix
• Extracervical tumor extension
– Dose as high as possible, aim to eradicate
• IR CTV
– Initial macroscopic extent of tumor + margins
(case by case, limited by OAR)
– Dose to cure microscopic desease (>60Gy)
 Volumes – GYN GEC ESTRO

• GTV, HR CTV and IR CTV delineation for responsive disease, after

EBT and chemotherapy (IR CTV = HR CTV + 10mm margin)
 Dose Volume Histogram (DVH) –
Tumor Volumes

• D100, D90 – minimum dose delivered to 100%, 90% of respective volumes,

D90 being more stable.
• V(60 GyEQD2) and V100 – Volume that receive 60 GyEQD2 and 100% of total
dose, respectively. V(D GyEQD2) is preferred for intercomparison purpose
 Dose Volume Histogram (DVH) –
OAR Volumes

• D2cc, D1cc, D0.1cc – minimum dose delivered to 2, 1, and 0.1 cm3,

respectively.
 Major Differences
2D planning 3D planning
Total dose (EBT + BT) Use physical dose Use biologically weighted
dose
Dose prescription point A target volume

Volumes only describe tumor • tumor and OAR

volumes volumes
• CTV splits into HR CTV,
IR CTV, LR CTV
Reference volume 60 Gy isodose volume 60 Gy and 85 GyEQD2
isodose volume
Dose optimization base on dose points, base on dose points,
isodose shape isodose shape and
coverage, DVH
Dose reporting Point A, bladder, rectum, Same as in 2D + other
shape ref isodose volumes specs