TVD In Carcinoma

Cervix
 Target Volume

delineation
For definitive treatment of carcinoma cervix with conformal radiation
techniques, accurate target delineation is vitally important,
 Various guidelines for CTV delineation are published in the literature yet a
consensus definition of clinical target volume (CTV) remains variable
 Clinical judgement remains the most important aspect of determining the
target volumes
 Contourin
g contouring guidelines available for CTV
Several
 Taylor et al pelvic nodal delineation (CT based)
 Toita et al for CTV delineation in intact cervix EBRT (CT based)
 Lim et al for CTV delineation in intact cervix IMRT (MRI based)
 Small et al for CTV delineation in post operative IMRT (CT based)
 PGI literature review & guidelines for delineation of CTV for intact carcinoma cervix (CT based)

Guidelines for organ at risk

 Pelvic Normal Tissue Contouring Guidelines for Radiation Therapy: A Radiation Therapy Oncology
Group Consensus Panel Atlas (CT based)
Components of CTV

The group consensus was that

entire uterus should be
included in the CTV because:
• Uterus & cervix are
embryologically one unit with
interconnected lymphatics and
no clear separating fascial
plane
• Second, determination of
myometrial invasion can be
difficult
• uterine recurrences have been
reported (2%), but exact
location of these
recurrences(fundal vs. corpus)
have not been stated
Parametrial contouring
guidelines
superior boundaries of parametria are at the
top of the fallopian tube, and contours
should stop once loops of bowel are seen next
to the uterus as this is clearly above the
broad ligament
For the very anteverted uterus, particularly
where the fundus lies below the cervix,
the parametrial volume should stop once
the cervix is seen

Inferiorly, the parametrial tissue finish at the

muscles of the pelvic floor
Anteriorly boundary lies at the posterior wall of the bladder
Laterally, the parametrial volume should extend
Bladder or In patients with a very small bladder (which lies
to the pelvic sidewall (excluding bone and muscle).
deep in the pelvis), posterior border of the external iliac vessel
some overlap of this volume with nodal CTV,
particularly along the obturator strip
Posteriorly: bounded by the mesorectal fascia and uterosacral
ligaments
parametrial volumes would extend up to the rectal contour in
advances stages
Taylor A, Rockall A, Powell M. An Atlas of the Pelvic Lymph Node Regions to Aid Radiotherapy Target Volume
Definition. Clinical Oncology. 2007 Sep ;19(7):542-550.
 External iliac :7 mm margin
around vessels.
 Extend anterior border by a
further 10 mm
anterolaterally along the
iliopsoas muscle to include
the lateral external iliac
nodes

 Internal iliac: 7 mm margin

around vessels. Extend
lateral borders to pelvic side
wall
 lateral external iliac nodes (blue),
 inguino-femoral nodes (green)
 parametria and upper vagina
(red).
 pre-sacral (PS), internal iliac (II),
 obturator (Obt),
lateral (EIl), medial(EIm) and
anterior (EIa) external iliac,
 parametrial and paravaginal
(Pm),
CTV definition for the post-operative therapy of endometrial and cervical cancernshould include the common, external,
and internal iliac lymph node regions.
The upper 3.0 cm of vagina and paravaginal soft tissue lateral to the vagina should also be included.
For patients with cervical cancer, or endometrial cancer with cervical stromal invasion, it is also recommended that the
CTV include the presacral lymph node-region
• Upper Common Iliac CTV • Mid CI (red) , Pre-sacral CTV (blue) • Lower C.I (red) ,Pre-sacral CTV (blue)

• Upper El and II (red) PS blue • Parametrial/Vaginal (green) CTV Vaginal CTV

Conclusion:
GTV definition
 Gross tumor seen or contrast enhanced in Abdomen and Pelvis CT Simulation

CTV
 CTV Pelvic Nodes:
o Obturator, internal and external and common iliac nodes up to the bifurcation of the aorta using blood vessels as a
surrogate with a 7 mm margin modified.
o
 CTV Tumour:
o Gross tumour, uterus and parametrium and upper third of vagina (unless there is involvement by disease, in which case a 2
cm margin below apparent disease should be used). Consider inclusion of proximal half of utero-sacral ligaments. Cervix
and uterus can be outlined as a separate volume from parametruim and upper vagina unless the INTERLACE guidelines are
being followed.

PTV
 PTV Nodes = CTV Pelvic Nodes + 7- 8mm
 PTV parametrium and upper vagina = CTV Tumour + 7mm
 PTV cervix and uterus lateral margins 7mm. Sup/Inf and Ant/Post 12-18mm

However, there is an alternative by INTERLACE guidelines which produce PTV1, PTV2, and PTV3 as per table below:
2
 Clinical Target Volume 1 CTV1 should include the whole cervical tumour
(CTV1) and its local extension (GTV). Also, the cervix and uterus.
Planning guidelines and expansions from INTERLACE trial
Clinical Target Volume 2 Proximal half of the uterosacral ligament,
(CTV2) bilateral parametria and upper half of the vagina, or 2 cm below known vaginal disease.
If there is uterosacral involvement, the entire ligament needs to be encompassed.
The external iliac, obturator, internal iliac and common iliac nodes are also included in
this volume. The superior extent is at the aortic bifurcation. The nodal areas are defined
by using a 7mm around blood vessels. It should be extended to include visible disease
and lymphoceles.
It should be modified to exclude bone, psoas muscle, bladder and bowel. The subaortic
presacral nodes can be covered by connecting the nodal areas either side of S1 and S2
with a 10 mm strip volume.
Where nodes at the aortic bifurcation or at the level of the common iliac vessels are
positive (histology/CT PET /> 15mm on imaging) the most superior extent of CTV3 will
be at the renal hilum. In general, a margin of at least 2cm should be added above the
highest involved lymph node region.

Clinical Target Volume 3 (CTV3) (Extended field)

Planning Target Volume 1 Add 15 to 20mm to CTV1

(PTV1) anterior/posterior/superior and inferior, 7 to 10mm in the lateral extension.
Planning Target Volume 2 Add 7 to 8mm to CTV2.
(PTV2)
Planning Target Volume 3 Add 5 to 7mm to CTV3.
(PTV3)

3
 Normal Tissue Delineation
(RTOG)
• Bowel: The small and large bowel can be contoured together as a Bowel-Bag.
• Inferiorly, the bowel bag should begin with the first small or large bowel loop or
above the ano-rectum, whichever is most inferior.
• The contours should end 1 cm. above the PTV .
• Ano-Rectum: Ano-Rectum should be contoured from the level of the anus to the
sigmoid flexure. It should extend from the anal verge (marked by a radiopaque marker
at simulation) to superiorly where it loses its round shape in the axial plane and
connects anteriorly with the sigmoid.
• Bladder: Contoured inferiorly from its base, and superiorly to the dome.
• Femoral Heads:The ball of the femur, trochanters, and proximal shaft to the level
of the bottom of ischial tuberosities

Gay HA, Barthold HJ, O′Meara E, Bosch WR, El Naqa I, Al-Lozi R, et al. Pelvic normal tissue contouring guidelines
for radiation therapy: A Radiation Therapy Oncology Group consensus panel atlas. Int J Radiat Oncol Biol Phys
2012;83:e353-62.
 Problems with contouring for gynaec
cancer
on CT images
• The GTV itself may/ may not be well seen
• The parametrial disease is usually not visualized
• Though pelvic nodal contouring is systematic, but we still tend to end up
replicating the traditional cranio-caudal boundaries of a 4-field box
• MR based guidelines are difficult to implement on CT
• It is expensive to do routine MR-based planning
• Problems with the availability of MR-based TPS