Asim Farooki Conformal Terminology Discussion March 2014

Internal Target Volume (ITV) International Commission on Radiation Units and Measurements (ICRU) 62 defines ITV as an expansion of clinical tumor volume (CTV) for internal movement, which we can see in breathing for example. Internal margin (IM) was recommended to be added to CTV to compensate for the internal physiologic movements and variations in size, shape, and position of the CTV during therapy.1 ITV is important to look at because changes during therapy administration is possible due to various physiological movements that can be caused by respiratory or cardiac motion, peristalsis, and swallowing.2 By having IM around the CTV, it will allow the CTV to stay in the treatment field for the entire duration of the treatment, thus allowing the full delivery of the prescribed dose. ITV is usefully planned from a 4D CT scan, as it is able to provide an imaging method that quantifies and characterizes tumor and normal tissue shape as well as motion as a function of time. This is beneficial especially in the treatment of lung tumors because the data gathered from the scan can allow treatment to take into consideration the trajectory of the tumor as it moves during various phases of the respiratory cycle during treatment time, a process known as respiratory gating.

In the image above, we see a good example of the various positions for PTV in a variety of planning concepts: conventional free breathing, ITV, gating (at exhale) and mid-position.3 This helps us visualize that the ITV includes a margin to account for physiological patient movements that are unable to be accounted for during treatment. Volume Expansion: During any given treatment, a patients outer movement can be restricted with the use of an immobilization device. Internal structures cannot be restricted from movement, hence intrafractional motion or motion that might occur during treatment delivery requires that the radiation beam treat a volume that is larger than the CTV.2 We can see an example of volume expansion in treatment of lung cancer cases, where inhalation can lead to the lungs volume expansion, which may move the CTV out of the treatment field. This is why internal margins recommended by the ICRU should be placed around the CTV to account for the intrafractional motion.

Since radiation doses are measured within a persons lung volume and because it changes during each phase of the breathing cycle, we can use 4D CT Scans to visualize the relationship between lung volumes and dose-volume parameters. In the image below, we see with normal inhalation and expiration, the volume expansion of the lungs effect on the treatment target.

We also notice here that volume expansion in the lungs, which can result from respiration affects the tumor by shifting it from its original location.

References: 1. Khan F. The Physics of Radiation Therapy 4th ed. Philadelphia: Lippincott Williams & Wilkins 2010. 2. Khan F. Treatment Planning in Radiation Oncology 3rd ed. Philadelphia: Lippincott Williams & Wilkins 2012. 3. Wolthaus J, Schneider C, Mid-ventilation CT scan construction from fourdimensional respiration-correlated CT scans for radiotherapy planning of lung cancer patients. Int. J. Radiat. Oncol. Biol. Phys. 65(5), 15601571 (2006). 4. Image 2 retrieved from http://www.cancernetwork.com/articles/methodhelps-standardize-rt-dose-reporting#sthash.zOdR45pS.dpuf