ICRU Report 91 Was ist neu, was ändert sich?

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1 DEGRO Stereotaxie Meeting ICRU Report 91 Was ist neu, was ändert sich? Lotte Wilke, Stephanie Tanadini-Lang, Matthias Guckenberger Klinik für Radio-Onkologie, Universitätsspital Zürich

2 History of IRCU Reports 1993

3 History of IRCU Reports

4 History of IRCU Reports

5 History of IRCU Reports

6 Content of new ICRU91 report Total 145 Pages Introduction Aim of Report History of SRS and SRT Comparison 3D, IMRT and SRT Clinical experience Small Field Dosimetry Definition of Volumes Treatment Planning Algorithms Image-Guided Beam Delivery Quality Assurance Prescribing, Recording, and Reporting Appendix with clinical Examples

7 Prescribing / Recording / Reporting ICRU50 Documentation should include (ICRU91) Including Clinical decisions Volumes Prescription Planning aims and constraints Description of TPS and settings Dose Reporting (target and PRVR) IGRT Plan verification / Patient QA Delivered treatments Follow-up Data amount to be recorded increased significantly over time

8 Volumes

9 Definition and Reporting of Volumes IV TV PTV CTV GTV OAR 1993

10 Definition and Reporting of Volumes IV TV PTV ITV CTV GTV PRV OAR

11 Definition and Reporting of Volumes TV PTV ITV CTV GTV PRV OAR RVR

12 Definition and Reporting of Volumes Imaging for GTV deliniation - Which modality for what Recomendations for: Liver, H&N, Brain, Vascular Lesions, Lung, Pancreas, Bone, Prostate TV PTV ITV CTV GTV PRV OAR RVR

13 Prescribing

14 Prescribing the classical SRT way Dose maximum GTV

15 Prescribing ICRU reference point PTV GTV 1993

16 Prescribing ICRU reference point PTV GTV

17 Prescribing (Median) Dose to PTV PTV GTV

18 Prescribing Covering Isodose Surface PTV GTV

19 Prescribing Covering Isodose Surface PTV GTV

20 Comparison of different normalization methods D 98 Max ITV median PTV median D 98 Max ITV median PTV median D 98 Max ITV median PTV median D 98 Max ITV median PTV median Only one dose parameter can be fixed, other parameters will always vary between patients and techniques Stephani Tanadini-Lang

21 Reporting

22 Reporting: 3 Levels of Reporting Dose Level 1: Basic Techniques Dose can be computed at ICRU reference Point Level 2: Advanced Techniques Dose distribution can be computed for plane(s) Level 3: Developmental Techniques Dose distribution can be computed for volumes In all cases dose at ICRU ref. Point and min/max dose in PTV reported 1993

23 Reporting: 3 Levels of Reporting Dose Level 1: Basic Techniques Dose can be computed at ICRU reference Point Level 2: Advanced Techniques Dose distribution can be computed for plane(s) or volumes Level 3: Developmental Techniques For which reporting criteria are not yet established In all cases dose at ICRU ref. Point and min/max dose in PTV reported

24 Reporting: (3) 2 Levels of Reporting Dose Level 1: Basic Techniques Dose at ICRU reference Poin Level 2: Advanced Techniques DVHs calculated PTV: D mean, D 50%, D 2%, D 98% OAR/PRV: D mean, V D, D 2% Level 3: Developmental Techniques In addition: Dose Homogeneity and Conformity, TCP, EUD

25 Reporting: (3) 2 Levels of Reporting Dose Level 1: Basic Techniques Dose at ICRU reference Poin Level 2: Advanced Techniques DVHs calculated PTV: D 50%, D near-min, D near-max GTV/CTV/ITV: D 50% must for Lung OAR/PRV: Vol, D mean, V D, D 2% Dose Homogeneity and Conformity and Gradient Index Level 3: Developmental Techniques In addition: Integral Dose Biology based evaluation metrics

26 Reporting: (3) 2 Levels of Reporting Dose D near-max : D 2% for V 2 cm 2 D 35mm 2 for V < 2 cm 2 Level 1: Basic DTechniques near-min : D 98% for V 2 cm 2 D V-35mm 2 for V < 2 cm 2 Dose at ICRU reference Poin Level 2: Advanced Techniques DVHs calculated PTV: D 50%, D near-min, D near-max GTV/CTV/ITV: D 50% must for Lung OAR/PRV: Vol, D mean, V D, D 2% Dose Homogeneity and Conformity and Gradient Index Level 3: Developmental Techniques In addition: Integral Dose Biology based evaluation metrics

27 Examples

28 Example 1: Lung metastasis, 63yr female Prescription: 40.5 Gy in 3 fractions on the 65% Isodose

29 Example 1: Lung metastasis, 63yr female Prescription: 40.5 Gy in 3 fractions on the 65% Isodose Delinitated on 4D CT ITV: 92.4 cm 2 PTV: cm 2 Margin ITV zu PTV 5mm

30 Example 1: Lung metastasis, 63yr female Prescription: 40.5 Gy in 3 fractions on the 65% Isodose Delinitated on 4D CT ITV: 92.4 cm 2 PTV: cm 2 Margin ITV zu PTV 5mm

31 Example 1: Lung metastasis, 63yr female ITV mean = 59.3 Gy ITV median = 59.3 Gy Prescription: PTV mean = 51.3 Gy 40.5 PTV Gy median in 3 = fractions 51.3 Gy on the 65% Isodose ITV D 2% = 63.8 Gy ITV D Delinitated on 4D CT 98% = 54.7 Gy PTV D 2% = 62.3 Gy PTV D ITV: 92.4 cm 2 98% = 40.5 Gy PTV: cm 2 Margin ITV zu PTV 5mm

32 Example 1: Lung metastasis, 63yr female ITV mean = 59.3 Gy ITV median = 59.3 Gy Prescription: PTV mean = 51.3 Gy 40.5 PTV Gy median in 3 = fractions 51.3 Gy on the 65% Isodose ITV D 2% = 63.8 Gy ITV D Delinitated on 4D CT 98% = 54.7 Gy PTV D 2% = 62.3 Gy PTV D ITV: 92.4 cm 2 98% = 40.5 Gy PTV: cm 2 Margin ITV zu PTV 5mm

33 Example 2: Brain metastases, 57yr male

34 Example 2: Brain metastasis, 57yr male GTV: 0.03 cm 2 PTV: 0.12 cm 2 Margin ITV zu PTV 1mm Planning CT with Stereotactic Mask + MRI fused with CT Deliniation on MRI

35 Example 2: Brain metastasis, 57yr male GTV: 0.03 cm 2 PTV: 0.12 cm 2 Margin ITV zu PTV 1mm Planning CT with Stereotactic Mask + MRI fused with CT Deliniation on MRI

36 Example 2: Brain metastasis, 57yr male GTV mean GTV median PTV mean PTV median = 23.9 Gy = 23.9 Gy = 22.5 Gy GTV: 0.03 cm 2 PTV: = Gy cm 2 Margin ITV zu PTV 1mm PTV D 35mm 2 PTV D V-35mm 2 = 23.2 Gy = 21.8 Gy Planning CT with Stereotactic Mask + MRI fused with CT Deliniation on MRI

37 Example 2: Brain metastasis, 57yr male GTV mean = 23.9 Gy GTV median = 23.9 Gy PTV mean = 22.5 Gy PTV median = 22.6 Gy GTV D max = 24.9 Gy GTV: 0.03 cm 2 PTV: 0.12 cm 2 Margin ITV zu PTV 1mm GTV D min = 22.5 y PTV D 35 = 23.2 Gy PTV D V-35 = 21.8 Gy Planning CT with Stereotactic Mask + MRI fused with CT Deliniation on MRI

38 Summary A lot to read not everything could be covered in 20 minutes Concepts for Volumes unchanged to ICRU83 Guidelines on imaging modalities for GTV delineation Prescription on PTV dose coverage, not on median/mean Dose reporting adjusted for small volumes Conformity and homogeneity should be reported

39 Vielen Dank für Ihre Aufmerksamkeit!

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