Treatment planning in radiation oncology pdf

Concurrent chemoradiotherapy is indicated for laryngeal preservation in locally advanced disease. Consider unilateral field for disease involving 1 cord Figure 4. Can cone down with this border moved anteriorly by 0. This can be done only in the absence of gross disease in the posterior half of the vocal cords Figure 4. Include retropharyngeal nodes if extension to pharyn- geal wall possibly glossopharyngeal sulcus or BOT.

Some advocate the addition of radiosensitizing chemotherapy in this setting. Coverage of superior esophagus may be necessary. Exception is T1N0 when recommendation is radiation alone. MRI fusion can delineate intracra- nial OARs, locate tumor infiltration, and visualize nerves that need to be included. The cavernous sinus should be included in high-risk patients T3, T4, bulky disease involving the roof of the nasopharynx. Focal PNI is not an indication.

If named nerve is extensively involved eg, lingual, hypoglossal , cover up to base of skull. Consider contralateral neck irradiation if primary lesion approaches midline eg, floor of mouth and central mobile tongue. Take skin cancer history and examine scalp for primary lesion. IGRT is preferred to limit margins and help reduce dose to critical structures ie, optic nerves. If involved, treat the entire eye while trying to shield the lacri- mal gland if uninvolved by disease.

Shaded blue is PTV. Representative a—c axial and d coronal images are displayed. If not, can electively treat superior mediastinum only. Note inclusion of upper mediastinal lymphatics. IMRT can be used. Use skin bolus for electrons. Orthovoltage has a maximum dose at the surface, and less beam constriction at depth. Electrons have sharper dose fall off and are more widely available.

Desmoplastic histology is controversial. Semin Nucl Med. A dynamic supraclavicular field-matching technique for head-and-neck cancer patients treated with IMRT. Matching intensity-modulated radiation therapy to an anterior low neck field.

Adaptive replanning strategies account- ing for shrinkage in head and neck IMRT. Defining the risk of involvement for each neck nodal level in patients with early T-stage node-positive oropha- ryngeal carcinoma. Dosimetric comparison of three different treatment techniques in extensive scalp lesion irradiation. Radiother Oncol. Tendulkar General Principles Attaching the breast board to the treatment table makes the immobiliza- tion system more rigid, translating into more reproducible treatments.

IV con- trast may help delineate nodal regions. Placement above the inferior aspect of the clavicular head may result in underdosing of the level III lymph nodes by the SCV field The acromioclavicular joint is usually blocked superolaterally.

An electron field may supplement dose to the chest wall blocked in the partially wide tangents. The matched electron field may be separated into multiple fields of different energies to spare deep structures such as heart and lung. Relative to a supine technique, chest wall and breast movement in the prone position is minimal. As a result, portions of the chest wall may typically receive less dose.

The degree of chest wall included in the treatment field can be adjusted based on the location of the tumor. Balloon volume is subtracted from the breast volume. Treatments are delivered BID over 5 to 7 days with an interfraction interval of 6 hours or more. A delayed or two-stage reconstruction may be preferred. A medial field of 9 MV electrons and a lateral field of 12 MV electrons, SSD at skin surface using 5 mm tissue equivalent bolus were used for the electron fields.

An en—face boost with a 3 cm radial margin on the mastectomy scar was designed for an electron boost c. Brisk erythema at the completion of treatment is desirable. Definition of postlumpectomy tumor bed for radiotherapy boost field planning: CT versus surgical clips. Comparison of wedge versus segmented techniques in whole breast irradiation: effects on dose exposure outside the treatment volume. Strahlenther Onkol. Comparison between hybrid direct aperture optimized intensity-modulated radiotherapy and forward planning intensity-modulated radiotherapy for whole breast irradiation.

Is there an increased risk of local recur- rence under the heart block in patients with left-sided breast cancer? Cancer J. Randomized trial of breast irradiation schedules after lumpectomy for women with lymph node—negative breast cancer.

J Natl Cancer Inst. Lancet Oncol. Definition of the supraclavicular and infraclavicular nodes: implications for three-dimensional CT-based conformal radiation therapy. Postmastectomy radiotherapy of the chest wall: dosimetric comparison of common techniques.

Treatment optimization using computed tomography—delineated targets should be used for supra-clavicular irradiation for breast cancer. Breast cancer regional radiation fields for supraclavicular and axillary lymph node treatment: is a posterior axillary boost field technique optimal? Internal mammary node cover- age: an investigation of presently accepted techniques.

The impact of immediate breast reconstruction on the technical delivery of postmastectomy radiotherapy. In the setting of IMRT, clinicians must be able to control respira- tory motion to limit excursion. Also, the periphery of the tumor may be underdosed due to the greater build-up region , especially with small field sizes.

Therefore, heterogeneity corrections are now recom- mended in general treatment planning see Chapter 1 for more details. Target Volume Definitions A. Definitive TRT see Figure 6. If daily IGRT used, margins reduced to 0. Preoperative RT Figure 6. Postoperative TRT Figure 6. Preoperative RT: 45 to Adjuvant TRT routinely indicated for resected thymic carcinomas.

In the postoperative setting, oral contrast is not given. Figure 6. CTV is shown in red. Target Volume Definitions Figure 6. Axial a , coronal b , and sagittal c images are shown, with PTV depicted in blue. Note the costophrenic angles and sternopericardial recess. Initial versus delayed accel- erated hyperfractionated radiation therapy and concurrent chemotherapy in limited small-cell lung cancer: a randomized study.

J Clin Oncol. Importance of timing for thoracic irradiation in the combined modality treatment of limited-stage small-cell lung cancer. Multimodal therapy for limited small- cell lung cancer: a randomized study of induction combination chemotherapy with or without thoracic radiation in complete responders; and with wide-field versus reduced-field radiation in partial responders: a Southwest Oncology Group Study. Twice-daily compared with once-daily thoracic radiotherapy in limited small-cell lung cancer treated concurrently with cisplatin and etoposide.

N Engl J Med. Chemoradiotherapy after sur- gery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. The role of surgery and postoper- ative chemoradiation therapy in patients with lymph node positive esophageal carcinoma. Intensity-modulated radio- therapy following extrapleural pneumonectomy for the treatment of malig- nant mesothelioma: clinical implementation. Intensity-modulated radiation therapy: a novel approach to the management of malignant pleural mesothe- lioma.

Intensity-modulated radiotherapy for resected mesothelioma: the Duke experience. A range of immobilization systems are available. One should allow a 2-hour transit time for the agent through the small bowel.

Elective nodal irradiation of non- clinically involved regional lymphatics was standard in this approach. Its main advantage lies in potential reduction in normal tissue toxicity. Specific use of pancreatic contrast timing protocols will improve resolution. EBRT technique: 4-field noncoplanar beam arrangement optimized liver sparing a.

The initial fields b covered the primary tumor red and immediate primary LN drainage green with 1 cm radial and 1. The cone down c covered the primary tumor with 1 cm block margins.

EBRT plan: 4-field noncoplanar beam arrangement opti- mized liver sparing a. The initial fields b covered the tumor bed red and associated LN green. The cone down c covered the tumor bed with a 2 cm block margin. The tumor bed was delineated by fusion of the preoperative CT scan d to the planning CT scan e. Daily image guidance for confirma- tion is strongly suggested in this setting.

EBRT plan: 3-field coplanar beam arrangement a was chosen to limit dose to the liver and kidney. The initial fields b covered the regional lymph nodes green and the tumor bed red. May con- sider from 5. The ini- tial PA a and lateral fields b covered the primary tumor red as well as the internal iliac green , external iliac green , presacral green , and mesorectal blue LN. The cone down posterior c and lateral fields d covered the pri- mary tumor and clinically involved LN red with margin.

If using the prone setup for primary fields, may consider supine positioning for the boost which is typically away from small bowel so that desquamated patients may be positioned more comfortably.

Prescribed 45 Gy to the regional nodes and 54 Gy to the primary tumor volume. Lower image e shows the dose-volume histogram DVH of the treatment plan. Shrinking field or dose-painting technique may be employed. RTOG treatment volumes and doses are described below.

Expansion will reflect the parameters of the particular delivery system, tumor motion control, and dose planning algorithm. Uniform margins are used for ITV approach, otherwise greater margin should be given cranio-caudally than in the radial aspect. Lower image c shows the DVH of the treatment plan. Single-fraction regimens have used 18 to 30 Gy, but generally doses between 30 to 60 Gy in 3 to 5 fx are used. Reference 1. Stephans General Principles Please refer to the pertinent sections.

Hip prosthesis may limit the use of CBCT due to artifact. The rectum is approxi- mately 15 cm in length. The prostate apex is located about 1 cm above the urethrogram beak. When available, con- sider using MRI to define the prostate apex.

Consider treating the entire seminal vesicles if grossly involved. AP projection a and right lateral projection b. Quality assurance for IMRT should be accomplished using phantom measurements prior to the start of treatment. Brachytherapy can be used in particular cases such as prostate cancer and select penile and urethral cases.

Exclude bone, bowel, bladder, and muscle 1. Higher-energy beams can be used in testicular cancer and for the posterior- anterior PA beams for penile and urethral cancer to achieve better dose homogeneity with treatment planning.

For lymph node coverage, see section on Target Volumes and Organs of Interest. Treatment planning for IMRT is discussed in the plan- ning section. Grossly positive lymph nodes can be boosted to a higher dose. Other hypofractionated schedules include Planning Organs containing contrast are manually assigned water density during hetero- geneity calculation.

This arrangement prevents aiming through the rails of the table, which can cause attenuation of the beam on some treatment machines. Lateral fields are to be avoided if a hip prosthesis is noted. Instead, anterior oblique or posterior obliques are used. Use of PA fields is avoided to minimize dose to the rectum. VMAT can be conducted with two full arcs typically employing a 90 degree collimator rotation between arcs, and can decrease overall treatment time compared to multiple static IMRT beams.

Hot spots should not be located in or near the rectal wall. Hypofractionation 70 Gy in 2. Where this fascia is not visible one may alter- nately use the medial border of the obturator internus. Extend more superiorly for patients with pathological involvement of the prostate base or seminal vesicles. Begin contouring 1.

Alternatively start 4. Bladder Contour bladder from 1. The rectum should not be included in the CTV. Consider including entire seminal vesicles SV if SVs or the prostatic base is pathologically involved. The superior contour should be at or above the level of the vas deferens. Do not include hemostasis clips higher in the pelvis if the seminal vesicles are uninvolved.

Posteriorly toward the rectum, the margin may be reduced to 5 mm. Setup and Preparation Figure 8. Pelvis must be flexed so the pubic arch is elevated. Technique Figure 8. There should be minimum pubic bone interference using an exag- gerated dorsal lithotomy position Figure 8. The subtle differences in the number images planes acquired are due to volume averaging effects.

Loose seeds are placed centrally because they are easier to remove as a single source cystoscopi- cally and spontaneously if misplaced or if placed within the urethra or the bladder. Use of a Foley catheter or injected contrast is typically not needed and often obstructs the view of the anterior part of the prostate. Of note, this may lead to shadowing artifacts anteriorly. Using this graph as a general guideline for the brachytherapy plan helps reduce potential prescription errors eg, if the total prescription dose was not set properly, the plan will not plot in the area of the graph consistent with its volume-activity ratio.

Margins may vary based on institutional prefer- ence. However, there should never be a posterior PTV margin expansion into the rectum. If severe or persistent pain, further evaluation is required, including consideration of urine studies to rule out urinary tract infection.

If MRI unavailable, use retrograde urethrogram to help define apex and penile bulb. Dosing: variable dependent on protocol and fractionation. Typically 35 to 40 Gy administered in 5 fractions. Critical structures and constraints are protocol dependent eg, RTOG www.

Current RTOG studies and recommendations endorse empty bladder treatment. If poor tumor localization due to insufficient infor- mation on bladder mapping or surgical clip placement, boost entire bladder while empty to minimize boost volume.

L5-S1 may be recommended if superior nodal involvement within 1 cm of S2-S3. Ensure at least 2 cm margin around CTV for anterior and posterior borders.

Other options include chemo- therapy alone or active surveillance. Surveillance is the preferred option for most stage I patients. Full-dose chemotherapy is preferred for stage IIC and above. Sperm banking should be dis- cussed prior to simulation. Para-aortic fields are favored due to decreased toxicity at the expense of a slightly increased risk of pelvic relapse.

Careful attention should be paid to renal doses because wide lateral borders will result in increased dose to the kidney. Left renal hilar nodes are usually included when left lateral border is placed at tips of the trans- verse processes. Arteries are shown in red, veins in blue, with left and right kidneys in teal and orange, respectively. Frog-leg position if treating the inguinal region. Negative nodes should receive 50 Gy. Thus, they should be considered for pre- operative radiotherapy followed by exenterative surgery transpubic approach is common with inguinal lymph node dissection and urinary diversion.

The perineum should be treated to cover the entire urethra. Please refer to the appropriate gynecological radiotherapy section for EBRT simulation and treatment planning for urethral cancer. RTOG GU radiation oncology spe- cialists reach consensus on pelvic lymph node volumes for high-risk prostate cancer.

Ultrasound probe pressure as a source of error in prostate localization for external beam radiotherapy. Perirectal seeds as a risk factor for prostate brachytherapy-related rectal bleeding.

Probability of late rectal morbidity in I prostate brachytherapy. Rectal fistulas after prostate brachy- therapy. Defining the risk of developing grade 2 proctitis following I prostate brachytherapy using a rectal dose—volume histogram analysis.

Chung P, Warde P. Stage I seminoma: Adjuvant treatment is effective but is it necessary? Optimal planning target volume for stage I testicular seminoma: a Medical Research Council randomized trial. Radiotherapy treat- ment planning for testicular seminoma.

Adjuvant radiotherapy in stage I semi- noma: is there a role for further reduction of treatment volume? Acta Oncol. Kotecha and Sheen Cherian General Principles Oral or rectal contrast may be used caution for anatomical distortion. The vagina is packed to displace the bladder and rectum; alternatively, a rectal retractor can be used. Brachytherapy plan for definitive treatment of endome- trial cancer, coronal a and sagittal b views.

Also consider treating the PA nodes if common iliac nodes are involved. Consider midline block to avoid excess dose adjacent to the implant and to deliver a higher dose to potential tumor-bearing regions outside the implant, placed at 40 Gy. Point B receives approximately one-third to one-quarter of the dose to point A.

Foley balloon is filled with 7 cm3 radiopaque contrast and pulled down against urethra. This includes macroscopic tumor extension at diagnosis detected by clinical examination and T2-weighted MRI. In advanced disease the presumed tumor extension is delineated, taking into account the GTVD and residual grey zones seen on MRI at the time of brachy- therapy. Brachytherapy plan for cervical cancer: coronal view.

No need to cover the entire scar if well beyond area at risk. May be included with pelvic field or en face. Include caudal external iliac nodes if pelvic nodes are negative, or up to common iliac nodes if pelvic nodes are positive Figure 9.

The American Brachytherapy Society recommendations for high-dose-rate brachytherapy for carcinoma of the endometrium. Macklis General Principles When treating disease in the head-and- neck region, a thermoplastic mask should be used. Inferior border should be near the insertion of the diaphragm T Include the pulmonary hilar LN. The superior extent of lung blocks is drawn to expose the infraclavicular region lymphatic channels here communicate with the axillary and supraclavicular LN regions.

Therefore, lung blocks should begin at the 3rd rib and extend down laterally to the 6th rib. A posterior cervical cord block 5 HVL may be considered if the total dose to the cord is calculated to be high usually for doses.

Source: Adapted from Refs. Carina is delineated in green for reference. A subcarinal block 5 cm below the carina is placed after 30 Gy to further shield the heart. A HVL block is placed to shield transposed ovaries after oophoropexy.

Para-aortic lymph nodes are delin- eated in green; pelvic lymph nodes, in red; spleen, in blue; and kidneys, in light blue.

If both cervical regions involved, treat mantle field without axilla. The lateral boundaries of the CTV should not exceed the normal mediastinum or lymph node remnants. In mediastinum, 0. If medial Laryngeal block, add at nodes, include entire Contralateral trans- Posterior mouth block if verse process supine.

If stage I, block larynx and vertebral bod- ies above larynx. Flash axilla Ipsilateral transverse Arms up. Includes SCV process. Include process, or at porta hepatis if involved. Consider renal GTV perfusion study. Greater Medial border of If common iliac nodes trochanter, or at obturator foramen, involved, extend to L4-L5 least 2 cm from or at least 2 cm from interspace, at least 2 cm prechemotherapy prechemotherapy above prechemotherapy GTV.

Consider slight split femur. Double shield testicles with clamshell and cerrobend. Nodal disease is indicated in yellow, and carina is in green for reference. Disease is delineated in yellow, and carina is in green for reference.

IMRT is generally avoided due to concerns over higher integral dose, especially in young patients. Recently, there has been a move in radiation therapy practice to distinguish the heterogeneous nature to more accurately predict dose, dose deposition, normal tissues toxicities, and outcomes.

Therefore, heterogeneity corrections are now recommended in general treatment planning. Options for field arrange- ment include IMRT, opposed laterals D-shaped if attempting to spare lenses , or anterior electrons with lens shielding. A separate isotope, Indium, is used for imaging, e-capture decay, 2. Dose is based on individual patient pharmacokinetics due to variable excretion.

Table Thus, cold Ab blocks binding of the radiolabeled antibody to the normal organs and depletes normal B cells. It also allows deeper penetration and more homogenous distribution. For Zevalin, these scans 6 B scan on day 4 is are used to ensure that pooling does not optional occur.

Bexxar scans are used to calculate the clearance and therapeutic dose because elimination is less predictable than Yttrium This allows for the same area under the curve for patients who have fast and slow clearance.

For Zevalin, absorbed dose by the marrow is not predictive of toxicity; hence, detailed dosimetry is not required. Infuse over several minutes, monitoring for any infusion related reactions. Radiation safety precautions need to be observed closely. Usually, the patient is supine without any special immobilization, but proper reproducibility of setup in the target site is ensured.

Coverage of the entire bone is not needed in long bones, except in cases where almost the entirety of the bone would get treated otherwise and whole bone treatment would allow for easier field matches in the future. Multiple myeloma is especially radiosensi- tive; consider 15 to 20 Gy or single fraction 8—10 Gy. Yahalom J, Mauch P. Ann Oncol. J Am Acad Dermatol. NCCN Guidelines. Multiple Myeloma. Version 2. Short-course radiotherapy is not opti- mal for spinal cord compression due to myeloma.

Prognostic factors in solitary plasma- cytoma of the bone: a multicenter Rare Cancer Network study. BMC Cancer. Version 1. Ng A, Yahalom J. Updated roles and rules for radiation therapy of indo- lent and aggressive lymphomas. Murphy General Principles A strip of skin is spared to limit the risk of lymphedema. Clinical presentations will favor one over the other.

Using a coregistered MRI for tar- get delineation b , a 4-field plan with 6-MV photons c was used to deliver 50 Gy in 25 fractions d. Image guidance using kV-cone-beam CT was used for daily localization e. Wedges were used for the lateral beams, and beams were weighted , favoring lateral beams. Interdigitated chemotherapy is typically delivered after 22 Gy 11 fx.

Opti- mized treatment planning can be used to deliver a more homogeneous dose. However, the radioactive sources may be loaded earlier as soon as 2—3 days after surgery if doses of less than 20 Gy are given with brachytherapy as a supplement to EBRT.

Doses of 40 to 50 Gy are given in 12 to 15 fx if the HDR is given alone. Preop- erative CT images were coregistered with the simulation CT to aid in target localization a. Bowel and abdominal wall were displaced with sterile temporary packing. Preoperative versus postoperative radiotherapy in soft-tissue sarcoma of the limbs: a randomised trial. RTOG sarcoma radiation oncologists reach consensus on gross tumor volume and clinical target volume on com- puted tomographic images for preoperative radiotherapy of primary soft tis- sue sarcoma of extremity in radiation therapy oncology group studies.

The American Brachytherapy Society rec- ommendations for brachytherapy of soft tissue sarcomas. Use of tissue expanders and pre-operative external beam radiotherapy in the treatment of retroperitoneal sarcoma. Ann Surg Oncol. Murphy Introduction Proton therapy is an option for pediatric malignancies and is cur- rently being investigated at several institutions. Because of the young age of children at the time of treatment, understanding normal tissue treatment effects is paramount and techniques should be used to minimize the long-term toxicities.

Consider a lower dose for children younger than 1 year. Each tumor should be staged separately. Flank EBRT is recommended for patients with positive margins or positive nodes to a dose of Gross disease should receive a boost of New contributors bring a fresh perspective and provide current insight in their areas of expertise.

New Key Points and Study Questions at the end of each chapter online help you assess your understanding of the material. Discussions of the scientific background and the key aspects of clinical approach ensure that you gain a well-rounded understanding of how to plan treatment from both a technical and a clinical perspective.

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