THE ICRU SYSTEM OF DOSE ANDTHE ICRU SYSTEM OF DOSE AND DOSE REPORTINGDOSE REPORTINGICRU Report 38 Dose and

Volume Specifications for Reporting Intracavitary Therapy in Gynecology THE ICRU SYSTEM OF DOSE ANDTHE ICRU SYSTEM OF DOSE AND DOSE REPORTINGDOSE REPORTINGICRU Report 38 Dose and Volume Specifications for Reporting Intracavitary Therapy in Gynecology The ICRU SystemThe ICRU SystemnRecommends that reference points like Point A not be used because, such points are located in a region where the dose gradient is high and any inaccuracy in the determination of distance results in large uncertainties in the absorbed doses evaluated at these points. The ICRU SystemThe ICRU SystemnRecommends that doses be reported in terms of, total reference air kerma, description of a reference volume, and calculated values of dose to specific normal tissue reference points within the treatment volume. nRecommends a system of dose specification that relates the dose distribution to a target volume.

The Target Volume is defined anatomically, and contains those tissues that are to be treated to a specific dose according to a specified time-dose pattern. The target volume should include the demonstrated tumor and any presumed or microscopic disease. Tumor Volume From ICRU. Dose and volume specification for reporting intracavitary therapy gynecology. ICRU reoprt no. 38 Bethesda, MD: International Commission on Radiation Unit s and sures, 1985. The Target Volume is defined anatomically, and contains those tissues that are to be treated to a specific dose according to a specified time-dose pattern. The target volume should include the demonstrated tumor and any presumed or microscopic disease. Tumor Volume From ICRU. Dose and volume specification for reporting intracavitary therapy gynecology. ICRU reoprt no. 38 Bethesda, MD: International Commission on Radiation Unit s and sures, 1985. Definition of Target Volume for OnlyDefinition of Target Volume for Only Intracavitary TreatmentIntracavitary Treatment Data for Reporting IntracavitaryData for Reporting Intracavitary TherapyTherapy-ICRUICRUnDescription of the Technique nTotal reference air kerma nDescription of the reference volume nAbsorbed dose at reference points nTime-dose pattern DESCRIPTION OF THE TECHNIQUEDESCRIPTION OF THE TECHNIQUE

In Mea

In Mea

Description of the TechniqueDescription of the TechniquenDescribed in terms of t he radionuclide, source strength, shape and filtration. nThe applicator type. nThe source arrangement. Description of the TechniqueDescription of the TechniquenDescribed in terms of t he radionuclide, source strength, shape and filtration. nThe applicator type. nThe source arrangement. TOTAL REFERENCE AIR KERMATOTAL REFERENCE AIR KERMA Total Reference AirTotal Reference Air KermaKermanThe total air kerma at 1 meter from the implant. nIs equal to the air kerma strength times the duration (in hours) of the implant. nIs analogous to mgRaeq-hr, which is the total implanted activity times the number of hours of the implant.

Total Reference AirTotal Reference Air KermaKermanTRAK = total mgRaeq x hours (d uration of implant) x 8.25 (gamma for Ra-226) x 0.876 (cGy /R) = uGy m2. Total Reference AirTotal Reference Air KermaKermanTRAK = total mgRaeq x hours (d uration of implant) x 8.25 (gamma for Ra-226) x 0.876 (cGy /R) = uGy m2. DESCRIPTION OF THEDESCRIPTION OF THE REFERENCE VOLUMEREFERENCE VOLUME Definition of Target and TreatmentDefinition of Target and Treatment Volumes for Only Intracavitary TreatmentVolumes for Only Intracavitary Treatment Target Volume Tumor Volume Treatment Volume Reference Volume is the volume of the isodose surface that just surrounds the Target Volume. From ICRU. Dose and volume specification for reporting intracavitary therapy In gynecology. ICRU reoprt no. 38 Bethesda, MD: International Commission on Radiation Unit s and Mea sures, 1985.

Definition of Target and TreatmentDefinition of Target and Treatment Volumes for Combined Intracavitary andVolumes for Combined Intracavitary and External Beam TreatmentExternal Beam TreatmentFrom ICRU. Dose and volume specifi cation for reporting intracavitary therapy In gynecology. ICRU reoprt no. 38 Bethesda, MD: International Commission on Radiation Unit s and Mea sures, 1985. Tumor Volume Target Volume of Intracavitary Treatment Treatment Volume of Intracavitary TreatmentTarget Volume of EBRT Treatment Volume of EBRT Definition of Target and TreatmentDefinition of Target and Treatment Volumes for Combined Intracavitary andVolumes for Combined Intracavitary and External Beam TreatmentExternal Beam TreatmentFrom ICRU. Dose and volume specifi cation for reporting intracavitary therapy In gynecology. ICRU reoprt no. 38 Bethesda, MD: International Commission on Radiation Unit s and Mea sures, 1985. Tumor Volume Target Volume of Intracavitary Treatment Treatment Volume of Intracavitary TreatmentTarget Volume of EBRT Treatment Volume of EBRT Description of the Reference VolumeDescription of the Reference VolumenThe value of the isodose surface prescription, based on the Paris experience, is set at 60 Gy. nThis prescription isodose value is determined by the following two factors: Description of the Reference VolumeDescription of the Reference Volumen1. The do se contribution from the external beam treatment. nThe contribution of the EBRT is subtracted from the 60 Gy total dose, then a relevant isodose surface from the intracavitary plan is divided by the duration of the insertion.

Description of the Reference VolumeDescription nEBRT total dose = 40 Gy whole pelvis n60 Gy -40 Gy = 20 Gy n20 Gy is the total dose to be delivered from brachytherapy. nThus 20 Gy / x hr = y cGy/hr isodose surface. Description of the Reference VolumeDescription nEBRT total dose = 40 Gy whole pelvis n60 Gy -40 Gy = 20 Gy n20 Gy is the total dose to be delivered from brachytherapy. nThus 20 Gy / x hr = y cGy/hr isodose surface. Description of the Reference VolumeDescription e intracavitary portion of the treatment in dimensions of height, width, and thickness of the pear-shaped reference volume. Description of the Reference VolumeDescription sions of height, width, and thickness of the pear-shaped reference volume can be measured from the oblique frontal and oblique sagittal planes. nThe reference volume is approximated by the equation ( dh x dw x dt ) cm3.

of the Reference VolumenExample:

of the Reference VolumenExample:

of the Reference Volumen2. And th

of the Reference VolumenThe dimen

Determination of the ReferenceDetermination of the Reference VolumeVolumed height d width b Oblique Frontal Plane Pear-shaped reference volume d thickness a Pear-shaped reference volume Oblique Sagittal Plane From ICRU. Dose and volume specification for reporting intracavitary therapy in gynecology. ICRU report no. 38. Bethesda, MD: International Commission on Radiation Units and Measures, 1985. Determination of the ReferenceDetermination of the Reference VolumeVolumed height d width b Oblique Frontal Plane Pear-shaped reference volume d thickness a Pear-shaped reference volume Oblique Sagittal Plane From ICRU. Dose and volume specification for reporting intracavitary therapy in gynecology. ICRU report no. 38. Bethesda, MD: International Commission on Radiation Units and Measures, 1985. Description of the Reference VolumeDescription of the Reference VolumenThus the determination of the reference isodose volume is predominantly based upon implant duration and external beam. ABSORBED DOSE AT REFERENCEABSORBED DOSE AT REFERENCE POINTSPOINTS

Absorbed Dose at Reference PointsAbsorbed Dose at Reference PointsnBladder Point nRectal Point nLymphatic Trapezoid of Fletcher nPelvic Wall Points Absorbed Dose at Reference PointsAbsorbed Dose at Reference PointsnBladder Point nRectal Point nLymphatic Trapezoid of Fletcher nPelvic Wall Points Bladder PointBladder PointnThe bladder point is localized by using a Foley catheter, with the balloon filled with 7 cc of a radiopaque fluid. nThe catheter is then pulled downwards to bring the balloon against the urethra. Localization of Bladder and Rectal PointsLocalization of Bladder and Rectal Poin ts from ICRU Report No. 38from ICRU Report No. 38xballoon with 7 cc of contrast bladder reference point on LAT film tandem sources vaginal sources vaginal posterior wall rectal reference point 0.5 cm from most posterior aspect of system/packing From ICRU. Dose and volume specification for reporting therapy in gynecology. ICRU report no. 38. Bethesda, MD: International Radiation Units and Measures, 19 85.

Location of ICRU-38 Bladder Point Y axis X axis Foley balloon with 7 cc of contrast On the Lateral film the bladder point is obtained on a line drawn anteroposteriorly through the center of the balloon at the posterior surface. center Location of ICRU-38 Bladder Point Y axis X axis Foley balloon with 7 cc of contrast On the Lateral film the bladder point is obtained on a line drawn anteroposteriorly through the center of the balloon at the posterior surface. center Location of ICRULocation of ICRU-38 Bladder Point38 Bladder PointOn the AP film the bladder point is marked at the center of the balloon. Foley balloon with 7 cc of contrast Center of foley balloon Location of ICRU-38 Rectal Point Y axis X axis On the Lateral film the rectal point is located on a line drawn from the midpoint of the activity in the ovoids, 5 mm behind the posterior vaginal wall. The use of radiopaque gauze for the vaginal packing aids in the visualization of the posterior vaginal wall. 5 mm Midpoint of activity in the ovoids packing

Location of ICRULocation of ICRU-38 Rectal Point38 Rectal PointThe rectal point is identified at the midpoint of the activity of the sources in the ovoids or at the lower end of the intrauterine source. Midpoint of the activity in the ovoids Lower end of the intrauterine source Location of ICRULocation of ICRU-38 Rectal Point38 Rectal PointThe rectal point is identified at the midpoint of the activity of the sources in the ovoids or at the lower end of the intrauterine source. Midpoint of the activity in the ovoids Lower end of the intrauterine source LYMPHATIC TRAPEZOID OFLYMPHATIC TRAPEZOID OF FLETCHERFLETCHER Lymphatic Trapezoid of FletcherLymphatic Trapezoid of FletchernPoints correspond ing to the following nodes: nMid-external iliac lymph nodes nLow common iliac nodes nLow paraortic nodes

Lymphatic Trapezoid of FletcherLymphatic Trapezoid of FletcherS1S2 L5 L4 2 cm 6 cm 1/2 1/2 L. ParaR. Para R. Com R. Ext L. Com L. Ext Symphysis L4 L5 S1S2 Symphysis 1/2 1/2 From ICRU. Dose and volume specification for reporting intracavitary therapy in gynecology. ICRU report no. 38. Bethesda, MD: International Commission on Radiation Units and Mea sures, 1985. Lymphatic Trapezoid of FletcherLymphatic Trapezoid of FletcherS1S2 L5 L4 2 cm 6 cm 1/2 1/2 L. ParaR. Para R. Com R. Ext L. Com L. Ext Symphysis L4 L5 S1S2 Symphysis 1/2 1/2 From ICRU. Dose and volume specification for reporting intracavitary therapy in gynecology. ICRU report no. 38. Bethesda, MD: International Commission on Radiation Units and Mea sures, 1985. PELVIC WALL POINTSPELVIC WALL POINTS Pelvic Wall PointsPelvic Wall PointsnOn the AP film the pelvic wall points are located at the intersection of a horizontal tangent to the superior aspect of the acetabulum and a vertical line touching the medial aspect of the acetabulum.

Pelvic Wall PointsPelvic Wall PointsnOn the Lateral film these points are marked as the highest mid-distance points of the right and left acetabulums. nThese points are selected to estimate dose to the distal parts of the parametrium and the obturator lymph nodes. Pelvic Wall PointsPelvic Wall PointsnOn the Lateral film these points are marked as the highest mid-distance points of the right and left acetabulums. nThese points are selected to estimate dose to the distal parts of the parametrium and the obturator lymph nodes. Intersection of the superior aspect and the medial aspect of the acetabulum Rt. Pelvic wall Lt. Pelvic wall AP Film Highest middistance points of the right and left acetabulum LAT Film Dose to distal parts of the parametrium and the obturator nodes. From ICRU. Dose and volume specification for reporting intracavitary therapy in gynecology. ICRY report no. 38. Bethesda, MD: International Commission on Radiation Units and Mea sures, 1985>. Definition of Pelvic Wall PointsDefinition of Pelvic Wall Points TIMETIME-DOSE PATTERNDOSE PATTERN

TimeTime-Dose PatternDose PatternnThe duration and time sequence of the implant relative to the external beam treatment should be included. nExample: One 42 hour intracavitary implant one week after EBRT completed. TimeTime-Dose PatternDose PatternnThe duration and time sequence of the implant relative to the external beam treatment should be included. nExample: One 42 hour intracavitary implant one week after EBRT completed. CRITICISM OF ICRU REPORT 38CRITICISM OF ICRU REPORT 38 CRITICISM OF ICRU REPORT 38CRITICISM OF ICRU REPORT 38dwidth dheight Two pear-shaped reference volumes Region of underdosage By using ICRU dimensions of maximum width, height, and thickness for the evaluation of an intracavitary system, regions of underdosage may not be recognized. However if the entire surface of the intracavitary is evaluated, regions of underdosage can be recognized and addressed.

The ICRU SystemThe ICRU SystemnThe ICRU is currently reexamining its recommendations of dose specification and is expected to issue a new report. The ICRU SystemThe ICRU SystemnThe ICRU is currently reexamining its recommendations of dose specification and is expected to issue a new report.