Scribd Logo
Upload

Welcome to Scribd!

    • 32 views

    IGBRT (Image Guided Brachytherapy)

    Uploaded by

    nitin
    This document discusses limitations of traditional point A based brachytherapy planning and summarizes the concepts and guidelines of Image Guided Brachytherapy (IGBT). Key points include: 1) Point A dosimetry can over or under estimate target dose and optimization is not possible; 2) IGBT aims to localize sources, target, and organs at risk in 3D for accurate planning; 3) CT and MRI are imaging modalities used but each have advantages and limitations; 4) Target volumes like GTV, HRCTV, and IRCTV are delineated based on imaging and response to treatment.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    IGBRT (Image Guided Brachytherapy)

    Uploaded by

    nitin
    32 views39 pages
    This document discusses limitations of traditional point A based brachytherapy planning and summarizes the concepts and guidelines of Image Guided Brachytherapy (IGBT). Key points include: 1) Point A dosimetry can over or under estimate target dose and optimization is not possible; 2) IGBT aims to localize sources, target, and organs at risk in 3D for accurate planning; 3) CT and MRI are imaging modalities used but each have advantages and limitations; 4) Target volumes like GTV, HRCTV, and IRCTV are delineated based on imaging and response to treatment.

    Original Title

    Intracavitary igbrachytherapy

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document discusses limitations of traditional point A based brachytherapy planning and summarizes the concepts and guidelines of Image Guided Brachytherapy (IGBT). Key points include: 1) Point A dosimetry can over or under estimate target dose and optimization is not possible; 2) IGBT aims to localize sources, target, and organs at risk in 3D for accurate planning; 3) CT and MRI are imaging modalities used but each have advantages and limitations; 4) Target volumes like GTV, HRCTV, and IRCTV are delineated based on imaging and response to treatment.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    32 views39 pages

    IGBRT (Image Guided Brachytherapy)

    Uploaded by

    nitin
    This document discusses limitations of traditional point A based brachytherapy planning and summarizes the concepts and guidelines of Image Guided Brachytherapy (IGBT). Key points include: 1) Point A dosimetry can over or under estimate target dose and optimization is not possible; 2) IGBT aims to localize sources, target, and organs at risk in 3D for accurate planning; 3) CT and MRI are imaging modalities used but each have advantages and limitations; 4) Target volumes like GTV, HRCTV, and IRCTV are delineated based on imaging and response to treatment.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 39

    IGBRT (Image Guided Brachytherapy)

    Fallacies of point A
     The location of the point A is at a point where significant cranio-caudal dose gradients exist, and
    therefore use of this point for prescription and reporting of doses can lead to substantial inaccuracies.
     Dose point A does not correlate significantly with the complications or the control rates in various forms
    of cervical brachytherapy.
     Prescription to this point, without regarding cervical anatomy can lead to substantial under dosing of a
    large cervix.
     The location of the point A is determined based upon the applicator geometry instead of the anatomy of
    the patient.
     ICRU bladder point is actually a point estimate of dose in the trigone. Doses may
    vary in the bladder base, neck etc.
     ICRU bladder point dose not estimate the dose to hottest part of the bladder.
    Which is usually 2cm superior. The dose in that area will be usually 2-4 times the
    dose to ICRU bladder point.
     ICRU rectal point do not represent the maximum dose area which will be usually 2-4 cm cephalad.
    Maximum dose is usually 3 time the ICRU rectal point.
     Dose to bowel is not checked in 2D
     Tandem insertion can be safe and easy if done under visualization, especially when large tumour
    obscures the canal and also a retroverted uterus can be identified
     The original concept or the dose-limiting para-cervical triangle is now considered
    invalid in light of recent clinical data, which show that the tolerance of this area
    far exceeds that of the bladder or the rectum.
     Dose calculated to point A use in the Manchester system rules can be significantly
    inaccurate with the use of modern-day radioisotopes and new applicator design,
    where the arrangement of the applicator and the radioactive source do not follow
    the recommendations of the Manchester system.

     The use of point A as a prescription point is not recommended in applicators where


    the vaginal sources are parallel to the uterine sources.
    Limitations of 2D planning
     Point A based dosimtery- Point A may over or under estimate the target dose
     Tumour dose escalation not feasible
     Optimization not feasible
    IGBT

     Aim to
     1. localize the source positions.
     2. Localize the target.
     3. Localize the organs at risk.
     4. Determine the relationships between all the above
    CT SCAN Plain CT scan is obtained after applicator insertion with 3-5mm
    cuts Advantages:

     • verifies proper placement of applicator


     • reasonable estimate of the location of uterus
     • fairly good for visualizing bladder and rectum.
     • analyses 3D BT dose distribution
     • depicts changes in the OAR related to tumor shrinkage & filling status.
     • 3D dose calculations & optimization possible
     • long experience in treatment planning for EBRT
     • readily available in radiotherapy departments
    Problems with CT treatment planning

     • produce artifact with metallic applicators • expensive • GTV not identified


     • overestimate tumor contours compared to MRI (although additional width
    contoured on CT may not be detrimental)
     • fails to provide differentiation between the uterus, cervix, parauterine tissues so
    CT-based contouring guidelines recommend delineating entire cervix and uterus.
     • contouring sigmoid difficult due to lack of contrast
     • contrast placed in OAR may cause artifact.in contouring wall of organ.
     • requiresmoving patient after application from CT to
    treatment room: can produce motion artifact that nullifies the
    increased accuracy of IGBT 
    MRI Planning ADVANTAGES

     • multiplaner imaging
     • excellent soft tissue contrast
     • better visualization of tumor & parametrium. involvement
     • differentiate between uterus, cervix, tumor, other pelvic tissues & OAR
     • particularly useful in patients with advanced or deeply infiltrating tumors.
     • specific signal intensities allow for distinct separation on T1- and T2 WI cervix
    (low T1, low T2), parametrium (high T1, high T2), tumor (low T1, high T2)
     • regression of cervical tumors can be documented so dose escalation possible
     • organ wall may be more clearly visualized for contouring OAR
    DISADVANTAGES

     • requires special applicators. non-ferromagnetic metal or plastic/graphite


     • very expensive
     • can produce motion artifact
    DELINEATION
      Advances in image guidance for applicator insertion and treatment planning have resulted
    in 3D tissue contouring guidelines (GEC-ESTRO)
      After insertion of applicators, the target volumes and normal-tissue structures are
    delineated on images in TPS.
      The delineation is to be performed at time of each BT application.
      The delineation process is based on clinical examination at diagnosis and at BT and on a
    set of sectional images (preferably MRI T2 weighted) taken at diagnosis and at BT with
    applicator in place
    ICRU 38 to ICRU 89
    Conceptual Changes

     Shift from an anatomical point based prescription to


    “Residual high risk volume based” prescription.

     Unlike Point A, “HRCTV” Takes Disease Biology and Response into account

    GTV D, GTV BT, HRCTV,IRCTV,LRCTV


    Basic Concepts: GTV D and GTV BT

    GTV D

    GTV BT
    HRCTV (Stage III B): Partial Responder

    GTV Diagnosis

    GTV BT

    HRCTV (Including Gey Zones)

    Zones that were signal intensive on the initial MRI depicting GTV-T but became gray indication
    pathologic residual fibrotic tissue which might or might not contain macroscopic or microscopic
    tumour

    Grey Zones
    Schmid, 2013 Strahlentherap Oncol
    HRCTV (Stage II B) :Partial Responder

    GTV baseline GTV baseline


    GTV baseline

    GTV BT
    GTV BT
    GTV BT HRCTV
    HRCTV

    HRCTV
    Safety margins are more for a
    complete responder to take
    cognizance of initial disease

    ICRU 89
    Stage II B: IRCTV

    GTV Diagnosis GTV Diagnosis


    GTV Diagnosis

    IRCTV
    IRCTV IRCTV
    HRCTV HRCTV HRCTV

    GTV BT
    GTV BT
    GTV BT
    CT Based Target Contouring
    CT Based Contouring for IGBT

    IB2/IIA IIB/IIIA IIIB

    2cm

    3 cm

    IB2/IIA IIB/IIIA IIIB


    HRCTV Cervix Cx+ 2 cm from lat edge of Cervix Cervix+Para Upto LPW
    Inf Extent EUA
    IRCTV 1 cm 1 cm 1 cm limited to LPW

    IJROBP, Viswanathan,2007
    NCCN 2018
     Intact Cervix 45(40-50) Gy EBRT followed by 30- 40 2cc Rectal dose 65-75 Gy
    Gy LDR equivalent 2cc sigmoid dose 70 -75 Gy
    2cc bladder dose 80-90 Gy
     80 gy for small volume d/s
     > 85-87 Gy for large volume d/s

     HDR
     6 Gy in 5 settings 30 Gy HDR = 48 LDR
     7 Gy in 4 settings 28 Gy HDR = 44.8 LDR
     7 Gy in 3 settings 21 HDR =33.6

    You might also like