Target volume definition

(GTV, HR-CTV and IR-CTV):

GYN GEC-ESTRO Recommendations

Richard Pöttera, Elena Fidarovaa, Primož Petrič a,b

aMedical University Vienna
bInstitute of Oncology Ljubljana

Vienna, 11-12 November, 2013

GYN GEC ESTRO RECOMMENDATIONS-BACKGROUND
From 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 brachytherapy
target volumes

HR CTV IR CTV

GTV GTV

HR CTV IR CTV
 Change in GTV, CTV and pelvic
topography during treatment (4D RT)
High signal intensity
tumor mass Residual high signal
intensity mass

grey zones in
the parametria
EBRT + CHT
corpus invasion Residual high signal
intensity mass
 DEFINITION OF CTVB1, CTVB2,...
Three different target volumes
according to cancer cell density

LR IR HR IR LR

Pelvic wall cervix Pelvic wall

region region

Potential microscopic Macroscopic Potential microscopic

tumour spread tumour load tumour spread
Significant Significant
microscopic microscopic
disease disease

HR: High risk CTV

IR : Intermediate risk CTV
LR: Low risk CTV
• Extensive Disease (IIB-IVA): no alternatives for surgery
(beyond cervix)

GTV

IR CTV
Tumor at time
of diagnosis.

GTV
HR CTV Grey zones
(MRI)+palpable
residual
disease

Radiother Oncol 2005, 74:235-245

 Bladder Ureter
• Extensive Disease Cer
vix
(beyond cervix) Parametr
ium
GTV

Tumor at time
of diagnosis.

HR CTV GTV
Grey zones
IR CTV (MRI)+palpable
residual
disease

GYN GEC ESTRO Recommendations (I)

Haie-Meder et al. Radiother Oncol 2005, 74:235-245
 HR and IR-CTV Initial tumour
extension
Extent at diagnosis
Residual disease
and degree of
remission cervix
HR-CTV

IR-CTV

Complete Good partial Poor partial No

remission remission remission remission
10 mm
10 mm

> 10 mm

cervix cervix 10 mm cervix cervix

> 10 mm
10 mm
10 mm
 Clinical examples
1. Limited disease (tumour size < 4cm)
2. Large tumour, sufficient response
3. Large tumour, insufficient response
2. Large tumour - sufficient response
•INITIAL clinical findings: GTVD
•St.p. Conisation, Cervix to
the right
•Invasion of:
•Right and dorsal fornix
•Right PM to middle 1/3
•Left PM free

GTVB
HR-CTV
•Clinical findings at BT: IR-CTV
•No macroscopic residuum
in vagina
•Residuum in:
•Right PM - inner third
 Clinical examples
1. Limited disease (tumour size < 4cm)
2. Large tumour, sufficient response
3. Large tumour, insufficient response
3. 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
GTVD

GTVB
HR-CTV
IR-CTV
 Gyn GEC ESTRO Recommendations
are applicable for Gyn BT in general
(vagina, endometrium, vulva, recurrent
tumours)

cervix endometrium vagina

IR-CTV IR-CTV
HR-CTV B B
S HR-CTV HR-CTV
R GTV S
R
VC
B
B IR-CTV
GTV
GTV
R

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