Consensus Guidelines for Delineation of Clinical Target Volumes for Intensity-Modulated Radiotherapy for Intact Cervical Cancer: An Update.

Abstract

Purpose: Accurate target delineation is essential when using intensity-modulated radiotherapy (IMRT) for intact cervical cancer. In 2011, the Radiation Therapy Oncology Group (RTOG) published a consensus guideline using magnetic resonance imaging (MRI). The current project expands on the previous atlas by including computed tomography (CT)-based contours, contours with MRI and positron- emission- tomography (PET) registrations, the addition of common and complex scenarios, and to incorporate information on simulation and treatment planning techniques.

Methods and materials: Twenty-eight experts in gynecologic radiation oncology contoured three cases, first on a non-contrast CT simulation scan, then with registered diagnostic scans. The cases included (1) FIGO IIIC1 with a bulky tumor and vaginal metastasis, (2) FIGO IIB with calcified uterine fibromas, and (3) FIGO IIIC2 with large lymph nodes. The contours on all six datasets (three CT simulations without diagnostic images and three with registered images) were analyzed for consistency of delineation using an expectation-maximization algorithm for simultaneous truth and performance level estimation (STAPLE) with kappa statistics as a measure of agreement. The contours were reviewed, discussed, and edited in a group meeting prior to finalizing.

Results: Contours showed considerable agreement between experts in each of the cases with kappa statistics of 0.67-0.72. For each case, diagnostic PET±MRI was associated with an increase in volume. The largest increase was the CTV primary for Case 2 with a 20% increase in volume and 54% increase in STAPLE estimate volume, which may be due to variance in registration priorities. For the third case, 92.9% increased their CTVs based on the addition of the diagnostic PET scan. The main areas of variance were in determining the superior extent of CTV coverage, coverage of the mesorectum, and simulation and planning protocols.

Conclusions: This study shows the value as well as the challenges of using co-registered diagnostic imaging, with an average increase in volumes when incorporating MRI and PET.