Index A Aarhus University Hospital, Denmark applicator selection and BT application clinical assessment, 187 188 insertion, US guidance, 188 metastatic para-aortic node cases, 187 contouring protocol, 188 documentation, 191 GTV, CTV, OAR nodal clinical target volume (CTV-N), 190 191 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, 191 192 Aarhus standard plan stopping positions, 189 non-optimized standard dose plans, DVH, 189 190 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, 103 105 magnetic resonance imaging, 105 106 positron emission tomography, 106 ultrasound, 101 103 procedure applicator selection, 250 251 contouring, 253 244, 255 imaging protocol, 252 253 insertion technique, 251 252 patient preparation, 249 250 post-imaging, 253 radiobiology, 3D imaging applicators, 137 chemoradiotherapy, 135 distribution effect, dose, 135 dose prescription, 138 139 dose rates, 132 LDR to HDR movement, 135 137 LQ model, 133 134 physical biological, 137 138 principles, 132 133 recovery kinetics, 134, 99 100 Brigham and Women s Cancer Center, USA insertion techniques anesthesia and barium insertion, 226 chemotherapy and brachytherapy, 228 imaging and contouring, 227 MRI treatment, 227 228 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
300 Index modeled structures, 55 56 software, 55 image guidance Sagittal T2-weighted images, 56 57 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, 53 54 volume regression, tumor, 52 Cervical cancer treatment, using IGBT CT-based Addenbrooke experience, 270 STIC 2004 results, 271 University of Pittsburgh Cancer Institute experience, 270 271 DVH parameters, correlation 3D image-based framework, 274 disease outcome, Vienna, 274 275 dose effect curves, 275 276 patients group, 275 EBRT ± chemotherapy, 273 MRI-guided Brigham and women s hospital/ Dana-Farber cancer institute experience, 269 experience, Institut Gustave Roussy, 267 269 Tata Memorial Hospital experience, 269 270 Vienna experience, 264 267 surgery and preoperative MRI-guided, 276 277 US-guided, 272 273 Cervical carcinoma MR imaging, 13 14 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, 21 22 image fusion, 23 pearls and pitfalls, 24 25 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, 11 12 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, 270 271 DVH parameters, correlation, 274 276 EBRT ± chemotherapy, 273 MRI-guided, 264 270 surgery and preoperative MRI-guided, 276 277 US-guided, 272 273 endometrial cancer treatment, 278 279 IGABT technique, 263 264 vaginal cancer treatment, 277 278 3D-conformal EBRT and IMRT extended para-aortic nodal field, 286 287 to pelvis, 284 286 as replacement, BT, 287 289 Delineation, OAR automatic contour generation, 111 DVH parameters, 111 imaging modality, 110 111 Diffusion-weighted imaging (DWI), 10 Doppler ultrasound techniques, 4 Dose calculation algorithms, 20 Dose volume histograms (DVHs) analysis, 27
Index 301 assessment, 63 calculation, 157 158 constraints, 124 D0.1cc, D1cc, and D2c identification, 235 236 delineation protocol, 62 OAR dose, 243 DVH analysis, 123 parameters, 122, 145 Dwell time distributions characteristics, 151 standard loading patterns, 150 Vienna, 151 152 Dynamic multileaf collimation (DMLC), 79 E EBRT. See External beam radiation therapy EBT. See External beam therapy Endometrial cancer treatment, using MRI-guided BT, 278 279 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), 286 287 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, 65 66 MR-guided, 63 64 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, 217 218 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, 110 111 high and intermediate-risk, 107 TPS tool, 108 Gynaecologic malignancies imaging CT, carcinoma cervical and vulvar/vaginal, 6 8 endometrial, 6 MRI, carcinoma cervical, 13 15 endometrial, 13 scanner hardware, 10 13 vaginal and vulvar, 15 16 PET and PET-CT, carcinoma cervical, 8 9 endometrial, 8 vulvo/vaginal, 9 radiation therapy complications, 16 17 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, 229 230 cervical cancer, 136 dose distributions, 242 epidural anesthesia, 226 iridium-192, 239 nucletron,, 234 planning system, 227 228 radiation survey meter, 238 radiobiological characterization, 132 tandem and ovoid (T/O), 225 treatments, 150 151 vaginal cylinder, 241 242 High-risk clinical tumor volume (HR CTV) concept, 158 defined, 144
302 Index I Image-guided adaptive brachytherapy (IGABT), 263 264 Image-guided brachytherapy (IGBT) applicator reconstruction CT images, 148 digitization, 146 148 library, 146 MR images, 148 150 cervical cancer treatment, 264 277 dose optimization DVH constraints, 125 126 inverse square law, 125 standard 2D vs. optimized 3D, 125 126 dose specification, 3D based OAR, 145 target structures, 144 145 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, 151 152 EBRT calculation method, 122 conservative approach, 122 cumulative dose, 121 implant and fractionation, gynecology intracavitary/interstitial (IC/IS), 120 121 radiation morbidity, 121 rules and principles, 120 tumor regression, 120 isodose distributions, 68 medical challenges and concepts, 119 optimization graphical, 153 154 inverse planning, 155 157 LDR/PB, 157 manual, 153 155 uncertainties and variations applicator stability and organ movement, 160 contouring, 158 dose accumulation, 161 162 DVH calculation, 157 158 fractions, 160 161 reconstruction, 158 159 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, 42 43 lymph node metastasis, 42 MTV cervix, 43 44 pelvic and para-aortic lymph nodes, 42 43 target delineation, 42 tumor contouring, 42 functional imaging, 46 Image-guided BT, 92 doses, radiation, 91 EBRT, 92 93 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, 240 241 limitation, 241 3D cylinder placement, 241 dose optimization and dose homogeneity, 242 HDR cylinder, vaginal mucosa, 241 242 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, 193 194 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
Index 303 gynaecological examination, 194 195 hysteometer, 195 MRI images, 193 quality assurance/errors avoidance, 193 Institutional experiences Aarhus University Hospital, Denmark, 187 192 Dana-Farber/Brigham and Women s Cancer Center, USA, 225 230 Institut Gustave-Roussy, France, 193 196 Medical College of Wisconsin, USA, 231 238 Medical University of Vienna, Austria, 173 178 Mount Vernon Cancer Center, Great Britain, 199 205 Peter Maccullum Cancer Center, Australia, 167 172 Tata Memorial Hospital, India, 207 215 University Hospital Leuven (UZL), Belgium, 181 185 University Medical Center Utrecht, the Netherlands, 217 222 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, 286 287 gynecological malignancies, pelvic, 62 input parameters, 90 91 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, 285 286 para-aortic lymph nodes (PAN), 285 planning, 90 91 postoperative pelvic, 26 as replacement, BT 4-field (4F) plan, 288 high-risk and intermediate-risk CTV, 288 survival rate by stage, 287 288 Intermediate-risk clinical tumor volume (IR CTV), 144 International Commission on Radiation Units (ICRU), 217 Interstitial brachytherapy, image-based approaches cervical cancer patients, 247 248 described, 247 follow-up, 257 image guidance MRI vs. CT, 248 249 radiation dose assessment, 248 Iridium 192 use, 247 limitations, 258 outcomes, 257 prescription cervical and vaginal cancer, 256 intracavitary vs. interstitial implants, 256 257 procedure applicator selection, 250, 251 contouring, 253 254, 255 imaging protocol, 252 253 insertion technique, 251 252 patient preparation, 249 250 protocol, post-imaging, 253 CT-based dosimetry and DVH analysis, 255 dose distribution, 254 255 implants, 255 256 LDR techniques, 255 Paterson Parker system, 254 255 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
304 Index radiobiological characterization, 132 tandem and ovoid (T/O), 225 vaginal cylinder, 239 240 LQ model. See Linear-quadratic model M Magnetic resonance imaging (MRI) Aarhus University Hospital 3D optimization, 189 planning scan, 188 protocol, 188 applicator, 231 232 artifacts gynecologic BT, 38 39 magnetic susceptibility, 37 TrueFISP image, 38 carcinoma cervical, 13 15 endometrial, 13 vaginal and vulvar, 15 16 features, 35 GTV and CTV assessment, 106 gynaecologic imaging radiotherapy, diagnosis, 35 scan parameters, 35 36 T1 and T2 weighted sequences, 37 heating, 38 39 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, 10 11 contrast agents, 11 12 imaging protocol, 12 13 magnet strength, 10 radiofrequency coils, 11 single image set, 149 150 soft tissue characteristics, 105 transversal and coronal, 148 149 treatment plan, 227 system, 170 3-T scanner, 233 234, 237 Medical college of Wisconsin (MCW), USA applicators, 231 232 contouring, 233 234 documentation dosimetry generated, 237 ERD worksheet, 236 dose and fractionation GTV identification, 236, 237 isodose curves, OAR, 235 rectal and bladder contrast points, CT, 235 236 imaging 3T MAGNETOM Verio scanner, 233 visualization, dummy catheter, 232 insertion techniques, 232 quality assurance, 237 238 dose optimization points, vagina, 234 235 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, 177 80 90 Gy (EQD2), HR CTV, 177 vaginal dose, 177 imaging protocol axial images, 175 176 caveats, 176 T1 and T2-weighted, 175 quality assurance/errors avoidance, 178 final dose distribution, 177 optimization procedure, 177 tandem/ring applicator reconstruction, 176 177 Medium dose rate (MDR), 132 Metabolic target volume (MTV) cervix, 43 44 defined, 44 Mount Vernon Cancer Center, Great Britain applicator selection, 200 contouring, 201 dosimetry, 204 imaging, 201 insertion, 200 quality assurance, 204 205 cranio-caudal level, ring, 201 202 DVHs structure, 204 dwell positions, 203 ring applicator end imaging, 202, 203 spacer cap, MR, 202
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, 264 270 endometrial, 278 279 vaginal, 277 278 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, 154 155 inverse planning dose constraints, 156 157 dosimetric parameters, 156 dwell times, 155 156 intracavitary treatments, 157 LDR/PB, 157 manual, 153 Organs at risk (OAR) acceptability criteria, 211 BT, 99 constraints, 125 126 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, 110 111 dose constraints, 292 293 distributions, 69 isodose curves, 235 236 optimization and quantification, 241 242 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, 103 105 MR imaging, 105 106 PET, 106 ultrasound, 101 103 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, 68 69 PET. See Positron emission tomography PET-CT. See Positron emission tomography-computed tomography Peter Maccullum Cancer Center, Australia applicators available and selection parameters, 167 168 caveats, imaging, 169 170 contouring protocol, 170 documentation, 171 dose and fractionation, 171 imaging protocol, 168 169 insertion techniques, 168 quality assurance, 171 172, 170 171 Photon beam therapy computerized treatment plan, 62 IMRT, 61 integrated boost technique, 62 OARs, 62 Planning target volumes (PTVs) cervix cancer, 62 deformation dynamics, 51 52 PLATO planning system, 176 Point of interest (POI), 55 Positron emission tomography (PET) carcinoma cervical, 8 9 endometrial, 8 vulvo/vaginal, 9 diagnosis
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, 77 78 pelvic radiotherapy, 76 77 radiation oncology, 76 nodal location, delineation bony anatomy, 75 76 feasible technique, 74 75 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, 79 80 Postoperative vaginal cylinder brachytherapy imaging 2D, 240 241 3D, 241 243 LDR vaginal cylinder, structure, 239 240 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, 42 43 lymph node metastasis, 42 MTV cervix, 43 44 pelvic and para-aortic lymph nodes, 42 43 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, 293 294 RF coils. See Radio frequency coils S Sectional imaging, image-guided therapy acquisition, issues, 20 21 CT/MR image characteristics IGRT and IGBT, 21 22 image fusion, 23 pearls and pitfalls, 24 25 tumor shrinkage, 21 high-precision radiotherapy techniques, 19 lymph-node delineation IGRT, 22 23 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, 207 208 caveats, imaging, 208 209 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, 213 214 treatment delivery requirement, 214 standard loading pattern, 211 treatment outcome and toxicities, 213 215 normalization and optimization, 210, 211 point A definition, 210 reconstruction, 209 210
Index 307 source loading, 211 Thermoluminescence detector (TLD) monitoring, 185 Three-dimensional conformal radiotherapy (3D-CRT) post-therapy imaging, 94 treatment, image guidance, 93 94 vulvar and vaginal cancer image-guided external beam radiation therapy, 88 imaging roles, 87 post-therapy imaging, 94, image-guided, 88 92 Three-dimensional image-guided brachytherapy (3D IGBT) dose constraints, OARs, 292 293 Institutional experiences Brigham and Women s Hospital/ Dana-Farber Cancer Institute experience, 290 CT-guided BT, 291 dose constraints, OARs, 292 293 The Institut Gustave Roussy experience, 290 preliminary results, STIC 2004, 291 292 Tata Memorial Hospital experience, 291 US-Guided Brachytherapy Peter MacCallum Cancer Centre experience, 291 Vienna experience with MRI-Guided BT, 289 290 5-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, 182 183 documentation, 184 GTV, CTV and OAR D90, HR CTV, 183 184 dose values, 184 optimization process, pulses, 184 imaging protocol, 182 insertion techniques uterus retroversion, 181 182 vaginal/paravaginal extensions, 182 quality assurance/error, avoidance applicator reconstruction, 184 185 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, 217 218 MR image signal production, 218 219 tandem ovoid, 218 BT application, 219 caveats, imaging, 219 220 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), 220 221 MRI-guided and optimization, 221 V Vaginal cancer treatment, using MRI-guided BT, 277 278 Vaginal CT/MR applicator, 219 Vienna applicator, 174 Vulvar and vaginal cancer 3D imaging roles groin and pelvis abnormalities, 87
308 Index lymph node metastases, 86 MRI, staging, 86 PET, 87 preoperative magnetic resonance, 85 86 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, 92 93 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, 65 66 MR-guided, 63 64 particle therapy dosimetric advantages, 68 isodose distributions, 68 69 treatments, 79