CT Guided Contouring: Challenges and Pitfalls
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1 CT Guided Contouring: Challenges and Pitfalls Dr Umesh Mahantshetty, Associate Professor, GYN & Urology Disease Management Group (DMG) Member Tata Memorial Hospital, Mumbai, India GYN GEC ESTRO NETWORK MEMBER AND FACULTY
2 Tata Memorial Hospital ACTREC
3 DOWN THE DECADES CANCER CERVIX : TATA MEMORIAL HOSPITAL: '51-60 '61-70 '71-80 '81-90 ' Stage I Stage II Stage III Stage IV
4 Vienna Applicator Applicators Imaging Planning systems rectum sigmoid Bladder SBR IR CTV HR-CTV GTV w GOLD STANDARD w = 7 cm h = 5 cm t = 4 cm
5 Screen shots at 1st Brachytherapy Clinical Drawing w Screen shots at 2nd Brachytherapy w
6 Why CT for At Brachy Contouring GEC-ESTRO Recommendations MRI Imaging of choice Defined target and Organ at Risk Conventional brachy planning: Point Based Then Why CT? CT Imaging : Gold STD for RT planning! Vast experience with CT based contouring! Wide acceptability due to its use in XRT! Availability : CT Vs MR in RT dept.
7 Don t s CT Guided Contouring Do not use the metallic applicators made of stainless steels Do not use contrast agents in foley s bulb / rectum / sigmoid Do not use radio-opaque gauze / rectal seperator (SS) for vaginal packing Do not use dummies meant for X-rays based planning Do s CT / MR Compatible Brachy Applicators Use saline/ water as contrast in foley s bulb & dilute urograffin for rectum/ sigmoid/ bladder CT protocol: 2-3 mm slice axial sections with / without IV Contrast Dummies : Copper / low density metal Proper Documentation and mapping: Clinical / Imaging
8 CT Artifacts Applicators, Folley s catheter, Dummies, Rectal retractors
9 CT Guided Contouring Pre-requisites Delineation Target & OARs Dosimetric Implications Optimized plans Vs Un-optimized plans Logistical Alternatives Single fraction MRI maybe Pre Brachy MRI only Evidence Learning Curve etc
10 Pre-requisites Experience of MR Based Approach: Mandatory Clinical diagrams, MR (Pre Rx and at brachy) & GEC-ESTRO target definitions Standardization of the CT protocol: - CT compatible applicators - follow the do s and don t s - bladder filling protocol with dilute contrast - Intravenous contrast Adopt the MR based definitions
11 Comparison of various parameters required for target definition / contouring Clinical examination MR GTV good excellent V poor Outline of cervix good excellent good Uterine corpus invasion Parametrium (normal & abnormal) CT poor excellent poor (good) good poor Vaginal disease excellent Excellent for paravaginal disease Various targets at brachytherapy on CT: GTV at brachy: no visualization of residual tumor on CT poor HR-CTV: on CT feasible with Clinical & CT findings IR-CTV: safety margins to HR-CTV
12 Target definition / Contouring High Risk CTV: Clinical + MR Based Clinical + CT Based Whole of Cervix GTV-B + Whole cervix Presumed tumour extension - Clinical extent - Residual grey zones on MR NO SAFETY MARGINS Presumed extensions at brachy - Parametrium: Clinical + CT imaging (Trans rectal US) + Pre Rx MR findings - Endocervical: Clinical + PreRx MR + EUA at brachy findings - Vagina: Disease at Diagnosis + EUA at Brachy -? Safety margins: at Superior end
13 HRCTV Delineation On CT Some landmarks for Whole Cervix Superior extent Inferior extent Level of uterine vessels first abut cervical tissue (need i/v contrast) Point of volume expansion Point of uterine cavity appearance conical cervical apex or the isthmus At superior level of Ring/Ovoid
14 Lateral width Abnormal Parametrium??? Lateral width of HR-CTV: Clinical examination and objective documentation
15 Bowel/ovary/else?
16 Special situations but daily difficulties Ant/Post boundaries At the level of ring/ovoids & cervix difficult boundaries Especially in empty Bladder & Rectum Need good information of anatomy, correlation, scroll up & down images MRI image studies experience is vital
17 Dimensions Different DVH No difference???!!!! Viswanathan et al IJROBP 2007 Eskander et al IJGC 2010 Krishnatry et al JJCO 2012
18 HR-CTV Delineation On CT Extensions: Clinical examination + CT findings Whole cervix Parametrium: over-estimated Endocervical: under-estimated - Vagina : clinical examination w w = 7 cm h = 5 cm t = 4 cm none can be truly estimated on CT Summary: HR-CTV contouring seems feasible with clinical examination and CT findings and assisted by pre-rx MRI
19 Dosimetric Implications CT /MRI Optimized plans Vs Un-optimized plans Comparison Viswanathan: optimized to HRCTV plans Krishnatry: Non-optimized STD plans No difference in small series of patients May have importance in large series or individual patient data Especially when two HRCTV volume dimensions not comparable on CT & MR
20 OARs Delineation on CT Robust experience of OAR contouring for EBRT All studies show equivalent results for standard OARs Rectum Bladder Sigmoid
21 Clinical Outcome data on CT Guided Contouring and planning: few prospective series Tan et al, UK (N=28) HR-CTV D90 >74 Gy, 7/24 patient modification for OAR dose 2/24 for tumor 3 yr OS: 81%, Pelvic control rate of 96%, overall actuarial risk of serious late morbidity 14%. 20 improvement over conventional cohort Kang et al, Korea (N= 2D/3D=133/97) 2D 3D EQD2 Tumor Local Control 91% 97% Severe Late rectal Bleeding 13% 2%
22 CT alone CT/MR MR Learning Curve
23 Prospective Ongoing Study at TMH, MUMBAI Bladder filling protocol HR-CTV contoured without the knowledge of MR at brachy STD MR based contouring 11 pts recruited so far STUDY: Ongoing
24 Patient:- SM MUM 072 Clinical Drawing FIGO IIIB w At Diagnosis Cervix Infiltrative Exophytic Vagina Parametria Rectum or Bladder w = 7 cm h = 4 cm t = 5 cm Vagina Involvement = 2 cm dd/mm/yy umesh Signature
25 Screen shots at diagnosis - MUM 072
26 Patient:- SM MUM 072 Clinical Drawing w At Brachytherapy Cervix Infiltrative Exophytic Vagina Parametria Rectum or Bladder w = 5 cm h = 3 cm t = 3 cm Vagina Involvement = 0.5 cm dd/mm/yy umesh Signature
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31 Patient:- BD MUM 073 Clinical Drawing FIGO IIB w At Diagnosis Cervix Infiltrative Exophytic Vagina Parametria Rectum or Bladder w = 8 cm h = 5 cm t = 6 cm Vagina Involvement = 2 cm dd/mm/yy umesh Signature
32 Screen shots at diagnosis - MUM 073 Representative sagittal cut Representative Cor cut Representative axial cut
33 Patient:- BD MUM 073 Clinical Drawing w At Brachytherapy Cervix Infiltrative Exophytic Vagina Parametria Rectum or Bladder w =6cm h = 4cm t = 4 cm Vagina Involvement = 0.5 cm dd/mm/yy umesh Signature
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41 Target definition / Contouring on CT High Risk CTV: Clinical + MR Based Whole of Cervix Clinical + CT Based GTV-B + Whole cervix Presumed tumour extension - Clinical extent - Grey zones on MR NO SAFETY MARGINS Presumed extensions at brachy - Width: parametrium clinically & TRUS - Height: to be generous to include a larger volume of uterus superiorly (? Safety margins) while vaginal disease to be delineated based on clinical findings at brachy - thickness: anatomical boundaries (rectum/ bladder)
42 SUMMARY AND CONCLUSIONS MR Based Approach: Gold Standard for IGABT Practice CT Guide Contouring is feasible provided - MR Based Approach Experience - Assisted by one Pre-Rx MR series atleast - Standardized CT Protocol: IV contrast, slice thickness etc.. - HR-CTV & OAR s only No robust clinical data with the CT Image Guided Brachytherapy Ongoing Clinical studies
43 Acknowledgements : Departments of Radiation Oncology & Medical Physics Department of Radio-diagnosis Dr Umesh Mahantshetty GYN Disease Management Group TMC GYN GEC drumeshm@gmail.com ESTRO Research Network Tata Memorial Hospital Complex, Mumbai, India
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