Index. T1 and T2-weighted images, 189

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1 Index A Aarhus University Hospital, Denmark applicator selection and BT application clinical assessment, insertion, US guidance, 188 metastatic para-aortic node cases, 187 contouring protocol, 188 documentation, 191 GTV, CTV, OAR nodal clinical target volume (CTV-N), PDR BT fractions, 191 PET-CT signal and CT simulation, 190 imaging protocol, 188 MRI (see Magnetic resonance imaging) quality assurance/ errors avoidance dose delivery, in vivo dosimetry, 192 MR and CT imaging, Aarhus standard plan stopping positions, 189 non-optimized standard dose plans, DVH, optimization, 190 standard and optimized BT, dosevolume, 189, 190 T1 and T2-weighted images, 189 B Balanced steady state free precession (bssfp) scan, 219 Brachytherapy (BT) gynaecological malignancies computed tomography, magnetic resonance imaging, positron emission tomography, 106 ultrasound, procedure applicator selection, contouring, , 255 imaging protocol, insertion technique, patient preparation, post-imaging, 253 radiobiology, 3D imaging applicators, 137 chemoradiotherapy, 135 distribution effect, dose, 135 dose prescription, dose rates, 132 LDR to HDR movement, LQ model, physical biological, principles, recovery kinetics, 134, Brigham and Women s Cancer Center, USA insertion techniques anesthesia and barium insertion, 226 chemotherapy and brachytherapy, 228 imaging and contouring, 227 MRI treatment, physician calls up, template note, 228, 229 LDR and HDR treatments, 225 quality assurance, treatment plan, 228, 230 Brigham and Women s hospital (BWH) description, 225 dwell times, 230 BT. See Brachytherapy C Cervical cancer, external beam planning deformation 299

2 300 Index modeled structures, software, 55 image guidance Sagittal T2-weighted images, tumor target positioning, 56 organ motion, 55 significance, 58 tumor motion orthogonal X-rays and MRI, 52 shrinks and deforms, 53 uterus and cervix motion, volume regression, tumor, 52 Cervical cancer treatment, using IGBT CT-based Addenbrooke experience, 270 STIC 2004 results, 271 University of Pittsburgh Cancer Institute experience, DVH parameters, correlation 3D image-based framework, 274 disease outcome, Vienna, dose effect curves, patients group, 275 EBRT ± chemotherapy, 273 MRI-guided Brigham and women s hospital/ Dana-Farber cancer institute experience, 269 experience, Institut Gustave Roussy, Tata Memorial Hospital experience, Vienna experience, surgery and preoperative MRI-guided, US-guided, Cervical carcinoma MR imaging, PET and PET-CT, 8 9 ultrasound imaging, 6 Clinical target volume (CTV) analysis, 53 components, 53 definition, 22 delineation, 101 GTV, 87, 171 high risk function, 126 image-based 3D BT, 123 pelvic nodal, defined, 90 target doses, 125 Clinical tumor volume (CTV) cervical and endometrial cancer, 77 nodal, 75 parameters, 80 superior, upper and inferior, 77, 78 Computed tomography (CT) applicator reconstruction, 148 artifacts, 34 BT, 99 carcinoma cervical and vulvar/vaginal, 6 7 endometrial, 6 description, 33 image characteristics IGRT and IGBT, image fusion, 23 pearls and pitfalls, tumor shrinkage, 21 imaging protocols, gynecological BT, 34 linear attenuation coefficient, 34 oral and intravenous contrast, 6 Contrast agents, imaging gadolinium-based compounds, 12 positive and negative, 11 renal function tests, CT. See Computed tomography CTV. See Clinical target volume; Clinical tumor volume D 3D-based external beam radiation and image-guided brachytherapy cervical cancer treatment CT-based, DVH parameters, correlation, EBRT ± chemotherapy, 273 MRI-guided, surgery and preoperative MRI-guided, US-guided, endometrial cancer treatment, IGABT technique, vaginal cancer treatment, D-conformal EBRT and IMRT extended para-aortic nodal field, to pelvis, as replacement, BT, Delineation, OAR automatic contour generation, 111 DVH parameters, 111 imaging modality, Diffusion-weighted imaging (DWI), 10 Doppler ultrasound techniques, 4 Dose calculation algorithms, 20 Dose volume histograms (DVHs) analysis, 27

3 Index 301 assessment, 63 calculation, constraints, 124 D0.1cc, D1cc, and D2c identification, delineation protocol, 62 OAR dose, 243 DVH analysis, 123 parameters, 122, 145 Dwell time distributions characteristics, 151 standard loading patterns, 150 Vienna, Dynamic multileaf collimation (DMLC), 79 E EBRT. See External beam radiation therapy EBT. See External beam therapy Endometrial cancer treatment, using MRI-guided BT, Endometrial carcinoma CT, 6 MRI, 13 PET and PET-CT, 8 ultrasound imaging, 4 5 ERD. See Extrapolated response dose Extended-field IMRT (EF-IMRT), External beam radiation therapy (EBRT) BT, 171 calculation method, 122 conservative approach, 122 cumulative dose, 121 dose delivery, 138 fair approximation, 135 External beam therapy (EBT) cone-beam CT (CBCT) image, 64 electronic portal imaging system, 63 intracavitary BT, MR-guided, treatment, pretreatment imaging, 62 Extrapolated response dose (ERD), 236 F Fast spin echo (FSE) MR images, 209 T1 and T2 axial, 208 T2-weighted, 175 Fine needle aspiration (FNA), 86 Fletcher CT/MR applicator sets, FSE. See Fast spin echo G Glomerular filtration rate (GFR), 12 Gross tumor volume (GTV) BT procedure, 107 defined, 144 delineation automatic contour generation, 111 DVH parameters, 111 imaging modality, high and intermediate-risk, 107 TPS tool, 108 Gynaecologic malignancies imaging CT, carcinoma cervical and vulvar/vaginal, 6 8 endometrial, 6 MRI, carcinoma cervical, endometrial, 13 scanner hardware, vaginal and vulvar, PET and PET-CT, carcinoma cervical, 8 9 endometrial, 8 vulvo/vaginal, 9 radiation therapy complications, technical advances, 16 ultrasound, carcinoma Doppler, techniques, 4 endometrial carcinoma, 4 5 modes, 4 vaginal bleeding, 3 4 H High dose rate (HDR) BT fraction, 231 template note, cervical cancer, 136 dose distributions, 242 epidural anesthesia, 226 iridium-192, 239 nucletron,, 234 planning system, radiation survey meter, 238 radiobiological characterization, 132 tandem and ovoid (T/O), 225 treatments, vaginal cylinder, High-risk clinical tumor volume (HR CTV) concept, 158 defined, 144

4 302 Index I Image-guided adaptive brachytherapy (IGABT), Image-guided brachytherapy (IGBT) applicator reconstruction CT images, 148 digitization, library, 146 MR images, cervical cancer treatment, dose optimization DVH constraints, inverse square law, 125 standard 2D vs. optimized 3D, dose specification, 3D based OAR, 145 target structures, DVH constraints and dose prescription clinical dose-effect relationships, 124 steep dose gradient, 125 and reporting, 122 volume parameters, 123 dwell time distributions characteristics, 151 standard loading patterns, 160 Vienna, EBRT calculation method, 122 conservative approach, 122 cumulative dose, 121 implant and fractionation, gynecology intracavitary/interstitial (IC/IS), radiation morbidity, 121 rules and principles, 120 tumor regression, 120 isodose distributions, 68 medical challenges and concepts, 119 optimization graphical, inverse planning, LDR/PB, 157 manual, uncertainties and variations applicator stability and organ movement, 160 contouring, 158 dose accumulation, DVH calculation, fractions, reconstruction, Image-guided external beam radiation therapy BT, 90 oral and intravenous contrast, 88 pelvis, MRI scan, 89 tumor and nodal basins, 88 Image-guided therapy, FDG-PET BT cervical cancer, 44 CT compatible applicators, 45 fraction 1 vs. fraction 5 tandem, 45, 46 tumor coverage, 46 external radiation anatomic matching, 43 images, cervix and local lymph node, lymph node metastasis, 42 MTV cervix, pelvic and para-aortic lymph nodes, target delineation, 42 tumor contouring, 42 functional imaging, 46 Image-guided BT, 92 doses, radiation, 91 EBRT, GTV and CTV, 87 high-energy electrons, 90 hybrid fractionation scheme, 91 preoperative chemoradiation, 91 radiation, tolerance, 93 Imaging, postoperative vaginal cylinder brachytherapy 2D CT scout film, limitation, 241 3D cylinder placement, 241 dose optimization and dose homogeneity, 242 HDR cylinder, vaginal mucosa, noninvasive evaluation, DVH, 243 IMPT. See Intensity modulated proton therapy IMRT. See Intensity modulated radiation therapy Institut Gustave-Roussy, France applicator, mould technique impression, vaginal, low and pulse dose-rate BT, 193 vaginal catheter placement and length, 194 contouring protocol, 195 GTV, CTV, OAR, 196 imaging protocol/caveats, 195 insertion techniques

5 Index 303 gynaecological examination, hysteometer, 195 MRI images, 193 quality assurance/errors avoidance, 193 Institutional experiences Aarhus University Hospital, Denmark, Dana-Farber/Brigham and Women s Cancer Center, USA, Institut Gustave-Roussy, France, Medical College of Wisconsin, USA, Medical University of Vienna, Austria, Mount Vernon Cancer Center, Great Britain, Peter Maccullum Cancer Center, Australia, Tata Memorial Hospital, India, University Hospital Leuven (UZL), Belgium, University Medical Center Utrecht, the Netherlands, Intensity modulated proton therapy (IMPT) cervix cancer boost treatments, 65 isodose distributions, 68 Intensity modulated radiation therapy (IMRT) dosimetric parameters, 27 and EBRT, 20 extended para-aortic nodal field, gynecological malignancies, pelvic, 62 input parameters, isodose distributions, 68 pelvic inguinal radiotherapy, 92 to pelvis BMS-IMRT, 286 clinical target volume (CTV), 285 conformal vs. conventional treatment analysis, 284 IM-WPRT, para-aortic lymph nodes (PAN), 285 planning, postoperative pelvic, 26 as replacement, BT 4-field (4F) plan, 288 high-risk and intermediate-risk CTV, 288 survival rate by stage, Intermediate-risk clinical tumor volume (IR CTV), 144 International Commission on Radiation Units (ICRU), 217 Interstitial brachytherapy, image-based approaches cervical cancer patients, described, 247 follow-up, 257 image guidance MRI vs. CT, radiation dose assessment, 248 Iridium 192 use, 247 limitations, 258 outcomes, 257 prescription cervical and vaginal cancer, 256 intracavitary vs. interstitial implants, procedure applicator selection, 250, 251 contouring, , 255 imaging protocol, insertion technique, patient preparation, protocol, post-imaging, 253 CT-based dosimetry and DVH analysis, 255 dose distribution, implants, LDR techniques, 255 Paterson Parker system, Intracavitary brachytherapy (ICBT) Gy fractions, 167 tandem ring applicator, 265 Intravaginal brachytherapy defined, 239 fraction, 243 OAR dose, 241 L LDR. See Low dose rate Library reconstruction method (LIB), 146 Linear-quadratic (LQ) model time-dose-fractionation schemes, 132 uniform dose distribution, 135 validity, 133 Low dose rate (LDR) advantage, 134 calculation, 135 cesium 137, 239 distributions, 242 dosimetric systems, 136 epidural anesthesia, 226

6 304 Index radiobiological characterization, 132 tandem and ovoid (T/O), 225 vaginal cylinder, LQ model. See Linear-quadratic model M Magnetic resonance imaging (MRI) Aarhus University Hospital 3D optimization, 189 planning scan, 188 protocol, 188 applicator, artifacts gynecologic BT, magnetic susceptibility, 37 TrueFISP image, 38 carcinoma cervical, endometrial, 13 vaginal and vulvar, features, 35 GTV and CTV assessment, 106 gynaecologic imaging radiotherapy, diagnosis, 35 scan parameters, T1 and T2 weighted sequences, 37 heating, image registration, 150 new units, 225 organ dose-volume relationships, CT, 231 patient positioning and immobilization procedures, 34 pelvic nodal involvement, 10 reference points, 150 roles, 86 sagittal view, 169 scanner hardware configuration, contrast agents, imaging protocol, magnet strength, 10 radiofrequency coils, 11 single image set, soft tissue characteristics, 105 transversal and coronal, treatment plan, 227 system, T scanner, , 237 Medical college of Wisconsin (MCW), USA applicators, contouring, documentation dosimetry generated, 237 ERD worksheet, 236 dose and fractionation GTV identification, 236, 237 isodose curves, OAR, 235 rectal and bladder contrast points, CT, imaging 3T MAGNETOM Verio scanner, 233 visualization, dummy catheter, 232 insertion techniques, 232 quality assurance, dose optimization points, vagina, dwell position identification, 234 Medical University of Vienna, Austria applicator selection and BT application insertion, 174 interstitial implantations, 174 MRI verification, 175 tandem/ring combination, 174 contouring protocol, 176 documentation, 178 GTV, CTV and OAR bladder, D2 cc, Gy (EQD2), HR CTV, 177 vaginal dose, 177 imaging protocol axial images, caveats, 176 T1 and T2-weighted, 175 quality assurance/errors avoidance, 178 final dose distribution, 177 optimization procedure, 177 tandem/ring applicator reconstruction, Medium dose rate (MDR), 132 Metabolic target volume (MTV) cervix, defined, 44 Mount Vernon Cancer Center, Great Britain applicator selection, 200 contouring, 201 dosimetry, 204 imaging, 201 insertion, 200 quality assurance, cranio-caudal level, ring, DVHs structure, 204 dwell positions, 203 ring applicator end imaging, 202, 203 spacer cap, MR, 202

7 Index 305 tandem applicator, para-transaxial alignment, 202, 203 MR-compatible Varian system, 200 MRI. See Magnetic resonance imaging MRI-guided BT, cancer treatment cervical, endometrial, vaginal, N Nephrogenic systemic fibrosis (NSF), 11 O OAR. See Organs at risk Optimization, 3D graphical dose plans, 155, 156 isodose lines, 153 on-screen manipulation, 154 standard loading, inverse planning dose constraints, dosimetric parameters, 156 dwell times, intracavitary treatments, 157 LDR/PB, 157 manual, 153 Organs at risk (OAR) acceptability criteria, 211 BT, 99 constraints, contoured,, 233 contouring, interobserver variability conformal radiotherapy approach, 111 DVH parameters, 112 standardization and training, 112 delineation automatic contour generation, 111 DVH parameters, 111 imaging modality, dose constraints, distributions, 69 isodose curves, optimization and quantification, reporting, 138 response curves, 119 DVH analysis, 123 parameters, 145 FIGO stages, 100 GTV and CTV BT procedure, 107 delineation, 106 high and intermediate-risk, 107 TPS tool, 108 gynecological malignancies, BT CT, MR imaging, PET, 106 ultrasound, LDR vaginal cylinder, 240 plain film determination, VBT, 241 potential benefits, 62 rectum, bladder and sigmoid loop, 209 sparing, 58, 62 tumor volume, 126 P Particle therapy dosimetric advantages, 68 isodose distributions, PET. See Positron emission tomography PET-CT. See Positron emission tomography-computed tomography Peter Maccullum Cancer Center, Australia applicators available and selection parameters, caveats, imaging, contouring protocol, 170 documentation, 171 dose and fractionation, 171 imaging protocol, insertion techniques, 168 quality assurance, , Photon beam therapy computerized treatment plan, 62 IMRT, 61 integrated boost technique, 62 OARs, 62 Planning target volumes (PTVs) cervix cancer, 62 deformation dynamics, PLATO planning system, 176 Point of interest (POI), 55 Positron emission tomography (PET) carcinoma cervical, 8 9 endometrial, 8 vulvo/vaginal, 9 diagnosis

8 306 Index accuracy, 8 procedure, 106 Positron emission tomography-computed tomography (PET-CT), 86 Postoperative gynecologic malignancies conventional 2D treatment distal vaginal extension, 74 pelvic radiation, 73 image-guided 3D treatment clinical target volume, pelvic radiotherapy, radiation oncology, 76 nodal location, delineation bony anatomy, feasible technique, four-field technique, 76 pelvic lymph nodes, 74 planning and treatment, image-guided, 80 radiation therapy, image-guided advantage, 79 risk, recurrence, 79 WPRT and IMRT, Postoperative vaginal cylinder brachytherapy imaging 2D, D, LDR vaginal cylinder, structure, VBT defined, 239 Proton therapy (PT), 68 PTVs. See Planning target volumes Pulsed dose rate (PDR), 120, 219 R Radiation anatomic matching, 43 functional imaging, 46 images, cervix and local lymph node, lymph node metastasis, 42 MTV cervix, pelvic and para-aortic lymph nodes, target delineation, 42 tumor contouring, 42 Radio frequency (RF) coils MRI pulses, 11, 35 radiation, 38 SNR, 11 Radio-opaque gauze, vaginal packing, 208 Rectum DVH parameters, 293 incidence, G1 G4 late toxicity, RF coils. See Radio frequency coils S Sectional imaging, image-guided therapy acquisition, issues, CT/MR image characteristics IGRT and IGBT, image fusion, 23 pearls and pitfalls, tumor shrinkage, 21 high-precision radiotherapy techniques, 19 lymph-node delineation IGRT, location, 26 nodal metastases, 23 technical issues, 20 tumor volume regression and organ motion, 27 Sigmoid, 294 Signal-to-noise ratio (SNR) imaging, 10 RF signals, 11 Sonography, transabdominal and transvaginal, 4 Specific absorption rate (SAR), 39 Suit Fletcher applicator, 65 T Tata Memorial Hospital, India applicators and selection parameters CT/MR, 208 intracavitary brachytherapy, caveats, imaging, contouring gross tumor volume (GTV), 209 MR-based brachytherapy principles, 209, 210 on oncentra, 209 documentation, 212 dose and fractionation HR CTV D90, D100, 212 point A, ICRU point doses and DVH parameters, 213 imaging protocol, 208 insertion techniques, 208 quality assurance (QA) acceptability criteria, 214 dosimetric evaluation, 214 HR CTV delineation, treatment delivery requirement, 214 standard loading pattern, 211 treatment outcome and toxicities, normalization and optimization, 210, 211 point A definition, 210 reconstruction,

9 Index 307 source loading, 211 Thermoluminescence detector (TLD) monitoring, 185 Three-dimensional conformal radiotherapy (3D-CRT) post-therapy imaging, 94 treatment, image guidance, vulvar and vaginal cancer image-guided external beam radiation therapy, 88 imaging roles, 87 post-therapy imaging, 94, image-guided, Three-dimensional image-guided brachytherapy (3D IGBT) dose constraints, OARs, Institutional experiences Brigham and Women s Hospital/ Dana-Farber Cancer Institute experience, 290 CT-guided BT, 291 dose constraints, OARs, The Institut Gustave Roussy experience, 290 preliminary results, STIC 2004, Tata Memorial Hospital experience, 291 US-Guided Brachytherapy Peter MacCallum Cancer Centre experience, 291 Vienna experience with MRI-Guided BT, year actuarial rates, 292, 293 Total Reference Air Kerma (TRAK), 185, 221 Treatment planning system (TPS) modern BT, 148 tools, 108 Tumor volume regression, 27 T2-weighted turbo spin echo (TSE) scans, 219 U Ultrasound (US) BT, guidance, 103 GTV and CTV, 102 gynecological malignancies detection, 101 imaging, carcinoma cervical and vulvo/vaginal, 6 Doppler, techniques, 4 endometrial carcinoma, 4 5 modes, 4 vaginal bleeding, 3 4 sagittal view, 169 University Hospital Leuven (UZL), Belgium applicators and selection parameters, 181 caveats, imaging, 182 contouring protocol, documentation, 184 GTV, CTV and OAR D90, HR CTV, dose values, 184 optimization process, pulses, 184 imaging protocol, 182 insertion techniques uterus retroversion, vaginal/paravaginal extensions, 182 quality assurance/error, avoidance applicator reconstruction, nucletron standard CT/MR tandem ovoid applicator, 185 pulsed dose rate (PDR) fraction, 183 X-ray and MRI data, 183 University Medical Center Utrecht, the Netherlands applicator selection Fletcher CT/MR applicator sets, MR image signal production, tandem ovoid, 218 BT application, 219 caveats, imaging, contouring, 220 documentation D90 and D100 GTV, 221 intracavitary/interstitial treatment, 221, 222 dose and fractionation, 221 imaging, 219 quality assurance MRI protocols, 222 Tax Group 43, 221 high risk clinical target volume (HR-CTV), MRI-guided and optimization, 221 V Vaginal cancer treatment, using MRI-guided BT, Vaginal CT/MR applicator, 219 Vienna applicator, 174 Vulvar and vaginal cancer 3D imaging roles groin and pelvis abnormalities, 87

10 308 Index lymph node metastases, 86 MRI, staging, 86 PET, 87 preoperative magnetic resonance, and staging features, 87 image-guided EBRT BT, 89 oral and intravenous contrast, 88 pelvis, MRI scan, 89 tumor and nodal basins, 88 image-guided BT, 92 doses, radiation, 91 external beam radiation therapy, GTV and CTV, 87 high-energy electrons, 90 hybrid fractionation scheme, 91 preoperative chemoradiation, 91 radiation, tolerance, 93 post-therapy imaging, 94 treatment, image guidance, 94 W Whole pelvic radiation therapy (WPRT) advanced photon beam therapy computerized treatment plan, 62 IMRT, 61 integrated boost technique, 62 OARs, 62 BT boost external beam dose, 66 pelvic and treatment, 69 topography changes, 67 EBT cone-beam CT (CBCT) image, 64 electronic portal imaging system, 63 intracavitary brachytherapy, MR-guided, particle therapy dosimetric advantages, 68 isodose distributions, treatments, 79

The New ICRU/GEC ESTRO Report in Clinical Practice. Disclosures

The New ICRU/GEC ESTRO Report in Clinical Practice Christian Kirisits, MSc, PhD; Richard Pötter, MD Medical University of Vienna, Vienna, Austria On behalf of the Committee: B. Erickson, C. Haie Meder,