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22 February 2011 Jacob (Jake) Van Dyk Consultant, IAEA Professor, University of Western Ontario, Canada
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International Atomic Energy Agency
Acknowledgement
Slides from
Morten Hyer Richard Ptter Larry Marks Stewart Gaede
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Aim
To introduce target volume and organ at risk
concepts as defined by ICRU
Dose Escalation
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R Ptter
MINIMIZE
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5 2/25/2011
1993 1978
1999
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ICRU 29
Target volume & uniform
prescription concepts 2-D era
1978
Single slice (or few) External contour Coplanar beams Simple calculations Dose prescription to ICRU reference point
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ICRU 50 - Purpose
1993
Replaces ICRU 29, 1978
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
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ICRU 50
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GTV with CT
Right!
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Wrong!
Inter
Agreement GTV United GTV
Max. PTV
Intra
Min PTV
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Uncertainties Inter-fraction
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Courtesy S Gaede
Perez et al 1998
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Prostate
Contours for GTV, PTV, bladder, rectum. CTV=GTV Non-uniform margin
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PTV
PTV depends on the precision of tools
immobilization devices lasers
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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ICRU 62 - Purpose
3-D imaging Conformal radiation therapy
1999
Irradiation techniques have advanced 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) IAEA
25
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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
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
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28 2/25/2011 ICRU
62
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Microscopic Spread
Internal Motion
Set-up Errors
On board imaging
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OAR
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PRV
CI=1.00
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2010
More detailed dose-volume information on TPS Use of dose-volume constraints IAEA Automated optimization, IMRT
40
ICRU 83
2010
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2010
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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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 technical margins ... but not biological margins
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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
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MEDICAL PHYSICISTS