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1.Introduction Toronto 2016 KT_RP_full resolution.pdf 		1
WELCOMEESTRO-CARO Teaching CourseImage-guided cervix radiotherapy – with a special focus on adaptive brachytherapyToronto 4.-6. April 2016 		1
Image-guided cervix radiotherapy – with a special focus on adaptive brachytherapy 		2
Faculty 		3
Slide Number 4 		4
Slide Number 5 		5
Advanced image guided EBRT 		6
Contents of the course 		7
RetroEMBRACE 		8
EMBRACE study 		9
Slide Number 10 		10
Who are you? 		11
How is external beam pelvic radiotherapy typically delivered? 		12
How do you perform image guidance for EBRT? 		13
How is cervical cancer brachytherapy typically prescribed at your institution? 		14
How often do you use a combined intracavitary-interstitial applicator for cervix cancer brachytherapy? 		15
What imaging do you perform after applicator insertion? 		16
Support by industry 		17
Organisation 		18
2.Anatomic consideration in cervical cancer, T. May 2016 		19
Anatomical considerations, clinical examination, and staging 		19
Disclosure 		20
Objectives 		21
Slide Number 4 		22
Slide Number 5 		23
Slide Number 6 		24
Slide Number 7 		25
Slide Number 8 		26
Surgical treatment options 		27
Hysterectomy 		28
Slide Number 11 		29
Slide Number 12 		30
Slide Number 13 		31
Slide Number 14 		32
Retroperitoneal Lymphadenectomy 		33
Pelvic Lymphadenectomy 		34
Minimally Invasive Surgery vs. Laparotomy 		35
Introduction to MIS 		36
Laparoscopy vs. Robotic 		37
Canadian Gyn Oncology Experience 		38
Slide Number 21 		39
Slide Number 22 		40
Slide Number 23 		41
Advances in the surgical management of cervical cancer 		42
Radical Robotic Trachelectomy 		43
Radical Trachelectomy 		44
Trachelectomy 		45
Slide Number 28 		46
Slide Number 29 		47
Slide Number 30 		48
Slide Number 31 		49
Slide Number 32 		50
Slide Number 33 		51
Slide Number 34 		52
Slide Number 35 		53
Radical Trachelectomy Outcomes 		54
Radical Trachelectomy Obstetrical Outcomes 		55
Embryonal Rhabdomyosarcoma 		56
Ovarian Transposition 		57
Slide Number 40 		58
Slide Number 41 		59
Fusion of Technology 		60
Sentinel Lymph Node Biopsy 		61
SLNB - Multiple Advantages 		62
Techniques for SLN Biopsy 		63
Slide Number 46 		64
Slide Number 47 		65
Slide Number 48 		66
Pushing the envelope of MIS 		67
Slide Number 50 		68
3.MRI OF CA CX 		69
Slide Number 1 		69
Slide Number 2 		70
INDICATION 		71
MRI PROTOCOL 		72
MRI PROTOCOL 		73
MRI PROTOCOL 		74
Slide Number 7 		75
HI RES OBLIQUE T2 		76
DWI 		77
Normal Anatomy 		78
Slide Number 11 		79
Slide Number 12 		80
Pelvic Lymph Nodes: Anatomy 		81
Slide Number 14 		82
Slide Number 15 		83
Slide Number 16 		84
Slide Number 17 		85
Slide Number 18 		86
Histology 		87
Cervical Cancer : MRI 		88
FIGO Staging: Clinical 		89
KEY ISSUES FOR TREATMENT 		90
MRI Impact 		91
TUMOUR SIZE 		92
Internal Os 		93
IB-Cervix Stroma 		94
MRI Impact 		95
IIB- Parametrial Invasion?“To Be or Not To Be” 		96
IIB-Parametrial Spread 		97
IIIA -LOWER 1/3 VAGINA 		98
IIIB-Ureter 		99
IIIB- Pelvic side wall 		100
IVA-Bladder Invasion 		101
LYMPHADENOPATHY 		102
LYMPHADENOPATHY 		103
LYMPHADENOPATHY 		104
DWI- PELVIC NODES 		105
PET-MRI 		106
POST TREATMENT MRI 		107
Post Treatment Evaluation 		108
Slide Number 41 		109
FISTULA 		110
RECURRENT DISEASE 		111
SUMMARY 		112
Slide Number 45 		113
ADENOMA MALIGNUM 		114
Slide Number 47 		115
STRUCTURES THAT CAN MIMIC A LYMPH NODE ON IMAGING 		116
MRI Protocol: Pearls 		117
4.Radiologic pathology at BT_Cervical cancer_PPetric_Toronto 2016_clean 		118
Slide Number 1 		118
Gold standard: T2W MRI 		119
Interpretation of imaging findings at BTWhat is the High Risk CTV on this slice? (your best guess) 		120
Interpretation of imaging findings at BT 		121
Interpretation of imaging findings at BT 		122
Slide Number 6 		123
Slide Number 7 		124
STEPS of Assessment of MRI at BT 		125
1. Rule out FLOP 		126
Entrer le texte de la question 		127
1. Rule out FLOP 		128
1. Rule out FLOP 		129
1. Rule out FLOP 		130
Systematic Assessment of MRI at BT 		131
Systematic Assessment of MRI at BT 		132
Set the STAGE for contouring 		133
Set the STAGE for contouring 		134
Slide Number 18 		135
Slide Number 19 		136
Slide Number 20 		137
Slide Number 21 		138
Slide Number 22 		139
Slide Number 23 		140
Slide Number 24 		141
Set the STAGE before contouring 		142
Slide Number 26 		143
Set the STAGE before contouring 		144
Slide Number 28 		145
Set the STAGE before contouring 		146
Entrer le texte de la question 		147
Slide Number 31 		148
Slide Number 32 		149
Entrer le texte de la question 		150
Slide Number 34 		151
Slide Number 35 		152
Set the STAGE before contouring 		153
Slide Number 37 		154
Slide Number 38 		155
Slide Number 39 		156
Slide Number 40 		157
Slide Number 41 		158
Slide Number 42 		159
Applicator material, Field strength and Image sequence 		160
Choice of imaging modality for IGABT 		161
Slide Number 45 		162
5.Combined Intracvitary -Interstitial Techniques Cervical cancer_clean 		163
Slide Number 1 		163
Slide Number 2 		164
What brachytherapy technique would you do for this tumor topography after external radiation and chemotherapy? 		165
What brachytherapy technique would you do for this tumor topography after external radiation and chemotherapy? 		166
Slide Number 5 		167
Slide Number 6 		168
Slide Number 7 		169
Slide Number 8 		170
Slide Number 9 		171
Slide Number 10 		172
Slide Number 11 		173
Slide Number 12 		174
Slide Number 13 		175
Slide Number 14 		176
Slide Number 15 		177
Slide Number 16 		178
Slide Number 17 		179
Slide Number 18 		180
Slide Number 19 		181
Slide Number 20 		182
Slide Number 21 		183
Slide Number 22 		184
Slide Number 23 		185
Slide Number 24 		186
Slide Number 25 		187
Slide Number 26 		188
Slide Number 27 		189
Slide Number 28 		190
Slide Number 29 		191
Slide Number 30 		192
Slide Number 31 		193
Slide Number 32 		194
Slide Number 33 		195
Slide Number 34 		196
Slide Number 35 		197
Slide Number 36 		198
Slide Number 37 		199
Slide Number 38 		200
Slide Number 39 		201
Slide Number 40 		202
Slide Number 41 		203
Slide Number 42 		204
Slide Number 43 		205
Slide Number 44 		206
Slide Number 45 		207
Slide Number 46 		208
Slide Number 47 		209
Slide Number 48 		210
Slide Number 49 		211
Slide Number 50 		212
Slide Number 51 		213
Slide Number 52 		214
Slide Number 53 		215
Slide Number 54 		216
Adaptive BT applicators 		217
Slide Number 56 		218
What brachytherapy technique would you do for this tumor topography after external radiation and chemotherapy? 		219
What brachytherapy technique would you do for this tumor topography after external radiation and chemotherapy? 		220
Slide Number 59 		221
6.Clinical diagrams_Umesh_clean 		222
Slide Number 1 		222
Clinical drawings aid in 		223
Slide Number 3 		224
Slide Number 4 		225
Slide Number 5 		226
Slide Number 6 		227
Slide Number 7 		228
Slide Number 8 		229
Slide Number 9 		230
Slide Number 11 		231
Slide Number 13 		232
Slide Number 15 		233
Slide Number 21 		234
Slide Number 23 		235
Slide Number 25 		236
Slide Number 27 		237
Slide Number 28 		238
Slide Number 29 		239
Slide Number 35 		240
Slide Number 36 		241
Slide Number 37 		242
SUMMARY 		243
Slide Number 39 		244
7.Applicators_IC_BT_Cervix_PPetric_TORONTO_2016_clean 		245
Slide Number 1 		245
Slide Number 2 		246
Slide Number 3 		247
Slide Number 4 		248
Slide Number 5 		249
Slide Number 6 		250
Slide Number 7 		251
Slide Number 8 		252
Slide Number 9 		253
Slide Number 10 		254
Slide Number 11 		255
Slide Number 12 		256
Slide Number 13 		257
Slide Number 14 		258
Slide Number 15 		259
Slide Number 16 		260
Slide Number 17 		261
Slide Number 18 		262
Limitations of modern IC applicatorsHow far from point A can we “push” the prescription isodose? 		263
Slide Number 20 		264
Slide Number 21 		265
Slide Number 22 		266
Slide Number 23 		267
Overcoming limitations of IC applicatorsHow would you boost this area? 		268
Slide Number 25 		269
Slide Number 26 		270
Slide Number 27 		271
Slide Number 28 		272
Slide Number 29 		273
Slide Number 30 		274
Slide Number 31 		275
Slide Number 32 		276
Slide Number 33 		277
Slide Number 34 		278
Slide Number 35 		279
Slide Number 36 		280
Slide Number 37 		281
Slide Number 38 		282
Slide Number 39 		283
Slide Number 40 		284
Slide Number 41 		285
Slide Number 42 		286
8.Gyn GEC ESTRO recommendations_with TP RP_clean 		287
Slide Number 1 		287
gynaecologic brachytherapyevolution 		288
Slide Number 3 		289
Slide Number 4 		290
Slide Number 5 		291
Slide Number 6 		292
Slide Number 7 		293
Slide Number 8 		294
MRI: Initial tumour extension (3D RT)pattern of response (4D RT) for adaptive MRI based planning 		295
Slide Number 10 		296
HR-CTV includes: 		297
IR-CTV includes: 		298
Slide Number 13 		299
The language challenge I Risk orientated (“High Risk”)adaptive Target concept 		300
Slide Number 15 		301
Overview of the adaptive target concept cervix cancer stage IB, IIB, IIIB: HR+IR CTV-T 		302
Risk orientated adaptive Target Concept Terms: GTVres, residual pathologic tissue, CTVHR, CTVIR, GTVinit, 		303
The challengeof MRI availability 		304
Slide Number 19 		305
Slide Number 20 		306
Slide Number 21 		307
Overview of the adaptive target concept cervix cancer stage IB, IIB, IIIB: HR+IR CTV-T 		308
Slide Number 23 		309
Slide Number 24 		310
Cervix cancer stage IB1 initial GTV, HR CTV, IR CTV, LR CTV 		311
1. Limited disease (tumour size 2cm) 		312
1. Limited disease (tumour size 2cm) 		313
1. Limited disease (tumour size 2cm) 		314
1. Limited disease (tumour size 2cm) 		315
1. Limited disease (tumour size 2cm) 		316
Slide Number 31 		317
Slide Number 32 		318
Stage IB1 		319
Slide Number 34 		320
Stage IB1 		321
Slide Number 36 		322
Cervix cancer stage IB1 initial and residual GTV, HR CTV, IR CTV, LR CTV 		323
Slide Number 38 		324
Slide Number 39 		325
Slide Number 40 		326
Slide Number 41 		327
Slide Number 42 		328
Slide Number 43 		329
Slide Number 44 		330
Slide Number 45 		331
HR-CTV includes: 		332
IR-CTV includes: 		333
Slide Number 48 		334
Cervix cancer stage IB2 initial and residual GTV, HR CTV, IR CTV, LR CTV 		335
Slide Number 50 		336
Slide Number 51 		337
Slide Number 52 		338
Slide Number 53 		339
Slide Number 54 		340
Slide Number 55 		341
Slide Number 56 		342
Slide Number 57 		343
Slide Number 58 		344
HR-CTV includes: 		345
IR-CTV includes: 		346
Slide Number 61 		347
Slide Number 62 		348
Slide Number 63 		349
Slide Number 64 		350
Slide Number 65 		351
Slide Number 66 		352
Slide Number 67 		353
Slide Number 68 		354
Slide Number 69 		355
Slide Number 70 		356
Slide Number 71 		357
Slide Number 72 		358
Cervix cancer stage IIB, 		359
Slide Number 74 		360
Slide Number 75 		361
Slide Number 76 		362
Slide Number 77 		363
Slide Number 78 		364
Slide Number 79 		365
Slide Number 80 		366
Slide Number 81 		367
Slide Number 82 		368
Slide Number 83 		369
Slide Number 84 		370
Slide Number 85 		371
Slide Number 86 		372
Slide Number 87 		373
Slide Number 88 		374
Slide Number 89 		375
Slide Number 90 		376
Overview of the adaptive target concept cervix cancer stage IB, IIB, IIIB: HR+IR CTV-T 		377
Slide Number 92 		378
Slide Number 93 		379
Slide Number 94 		380
Slide Number 95 		381
Slide Number 96 		382
Slide Number 97 		383
Slide Number 98 		384
Slide Number 99 		385
Slide Number 100 		386
Slide Number 101 		387
Slide Number 102 		388
Overview of the adaptive target concept cervix cancer stage IB, IIB, IIIB: HR+IR CTV-T 		389
Risk orientated adaptive Target Concept Terms: GTVres, residual pathologic tissue, CTVHR, CTVIR, GTVinit, 		390
HR-CTV includes: 		391
IR-CTV includes: 		392
ICRU 88 Prescribing, Recording, and ReportingBrachytherapy (BT) for Cancer of the Cervix 		393
Slide Number 108 		394
Slide Number 109 		395
Slide Number 110 		396
9.Berger_Applicator_Reconstruction_Toronto 2016 TurningPoint_clean 		397
Slide Number 1 		397
Presentation overview 		398
Slide Number 3 		399
Slide Number 4 		400
Slide Number 5 		401
Slide Number 6 		402
Slide Number 7 		403
Defining the source pathin relation to the patients anatomy 		404
Localization techniques in “2D” and 3D 		405
Sectional Imaging CT / MRI 		406
Presentation overview 		407
Direct Visualizing the Source Path 		408
Slide Number 15 		409
Direct-reconstruction on sectional images 		410
Slide Number 17 		411
Orientation of applicator/image plane 		412
Direct reconstruction - challenge 		413
Slide Number 20 		414
3D (SPACE) T2 weighted MR imaging 		415
Slide Number 23 		416
Where to start the reconstruction of the ring 		417
Slide Number 25 		418
Quality Check of the reconstruction process 		419
Presentation overview 		420
In-Direct Visualizing the Source Path 		421
Slide Number 29 		422
Slide Number 30 		423
Slide Number 31 		424
Slide Number 32 		425
Slide Number 33 		426
Slide Number 34 		427
Slide Number 35 		428
Predefined applicator geometry - library 		429
Presentation overview 		430
Commissioning of Applicators 		431
Applicator material! 		432
Indexer Length and Off-set 		433
Off-set will effect the insertion depth 		434
Visibility !!! 		435
Auto-radiography to verify the reconstruction of the source path in the TPS (or pre-defined Applicator Library) 		436
Verify the source path using Auto-radiography 		437
Slide Number 48 		438
Quality Control in applicator reconstruction 		439
Presentation overview 		440
Slide Number 51 		441
Slide Number 52 		442
Slide Number 53 		443
Slide Number 54 		444
Slide Number 55 		445
10.TATA_2_Large tumour, Good Response_AD_final 		446
Slide Number 1 		446
Slide Number 2 		447
Slide Number 3 		448
Slide Number 4 		449
Slide Number 5 		450
Slide Number 6 		451
Slide Number 7 		452
Slide Number 8 		453
Slide Number 9 		454
Slide Number 10 		455
Slide Number 11 		456
Slide Number 12 		457
Slide Number 13 		458
Slide Number 14 		459
Slide Number 15 		460
Slide Number 16 		461
Slide Number 17 		462
11.VIE002 Large GoodMS 		463
Slide Number 1 		463
Slide Number 2 		464
Slide Number 3 		465
Slide Number 4 		466
Slide Number 5 		467
Slide Number 6 		468
Slide Number 7 		469
Slide Number 8 		470
Slide Number 9 		471
Slide Number 10 		472
Slide Number 11 		473
Slide Number 12 		474
Slide Number 13 		475
Slide Number 14 		476
Slide Number 15 		477
12.CTV-ITV & OAR at EBRT IS_PP_2015 met TP questionsRP_clean 		478
Slide Number 1 		478
Slide Number 2 		479
The CTV of the primary tumor always includes ? 		480
Slide Number 4 		481
Slide Number 5 		482
Slide Number 6 		483
Slide Number 7 		484
Slide Number 8 		485
Slide Number 9 		486
Slide Number 10 		487
Slide Number 11 		488
Slide Number 12 		489
Future LR-CTV-Tinitial and CTV-E 		490
Slide Number 14 		491
Slide Number 15 		492
Slide Number 16 		493
Slide Number 17 		494
Slide Number 18 		495
The initial LR CTV-T of the primary tumor always includes ? 		496
EMBRACE II: CTV-T: initial GTV, HR CTV, LR CTV: Stage IB1 		497
EMBRACE II: CTV-T: initial GTV, HR CTV, LR CTV: Stage IB2 		498
EMBRACE II: CTV-T: initial GTV, HR CTV, LR CTV: stage IIB 		499
EMBRACE II: CTV-T: initial GTV, HR CTV, LR CTV: stage IIIB 		500
EMBRACE II: CTV-T: initial GTV, HR CTV, LR CTV: stage IVA 		501
Slide Number 25 		502
The margin needed to include 99% of detectable lymph nodes is? 		503
Slide Number 27 		504
Slide Number 28 		505
Slide Number 29 		506
Slide Number 30 		507
Slide Number 31 		508
Slide Number 32 		509
Slide Number 33 		510
Slide Number 34 		511
Slide Number 35 		512
Slide Number 36 		513
Slide Number 37 		514
Slide Number 38 		515
Slide Number 39 		516
Slide Number 40 		517
Slide Number 41 		518
Slide Number 42 		519
Slide Number 43 		520
Slide Number 44 		521
Slide Number 45 		522
Slide Number 46 		523
Slide Number 47 		524
Slide Number 48 		525
Slide Number 49 		526
Slide Number 50 		527
Slide Number 51 		528
Slide Number 52 		529
Slide Number 53 		530
The margin needed to include 99% of detectable lymph nodes is? 		531
Slide Number 55 		532
Slide Number 56 		533
Slide Number 57 		534
Slide Number 58 		535
Slide Number 59 		536
Slide Number 60 		537
Slide Number 61 		538
Slide Number 62 		539
13. KT_image guidance and PTV_Toronto_final_clean 		540
Image guidance, organ motion and ITV/PTV ESTRO Teaching CourseImage-Guided Cervix Radiotherapy – with a special focus on adaptive brachytherapyToronto 2016 		540
ITV and PTV 		541
Margins in cervix cancer 		542
PTV elective target volume 		543
IGRT methods 		544
Skin marks versus daily bony registration 		545
Which PTV margin do you apply for CTV-E? 		546
Do you think it is worthwhile to implement daily IGRT and decrease margin from 10mm to 5mm? 		547
Why does the margin matter? 		548
Let’s take a look at the orange and the peel… 		549
Is it important? 		550
Is it risky to reduce margins?What is the dosimetric impact of margin reduction? 		551
Very first results on dose accumulation for elective target: 1 patient 		552
Where are the nodal failures?EMBRACE analysis 		553
Thinking Gray and grey... 		554
Current (EMBRACE I) and future (EMBRACE II) practice: EBRT volume 		555
Simultaneously integrated lymph node boost (SIB) 		556
Which PTV margin do you think is necessary for the pathological CTV-N? 		557
Margins for pathological lymph node boosting 		558
Margins for pathological lymph node boosting 		559
Target and organ doses 		560
Coverage probability planning recommended in EMBRACE II 		561
Which total margin (ITV+PTV) is appropriate for the mobile primary tumour related CTV (GTV+cervix+uterus)? 		562
Motion and dose – primary target 		563
Which total dose (EBRT+BT) do you think this patient received to the non-involved uterus? 		564
Which total dose (EBRT+BT) do you think this patient received to the non-involved uterus? 		565
Which total dose is appropriate for controlling the non-involved uterus (EBRT+BT)? 		566
Accumulated doses 		567
Thinking Gray and grey... 		568
Which of these motion patterns are of most concern? 		569
ITV-T LR recommended in EMBRACE IIExample: Full rectum 		570
ITV-T LR recommended in EMBRACE IIExample: Empty rectum + variable bladder 		571
Bladder filling strategy in your department? 		572
Slide Number 34 		573
Adaptive EBRT to further shrink margins/improve safety? 		574
What has most impact on bowel dose? 		575
Take home message: nodal CTV 		576
Take home message: primary CTV 		577
14.EBRT_medical aspects_Umesh_clean 		578
Slide Number 1 		578
Outline 		579
Slide Number 3 		580
Dosimetric meta-analysis 		581
Dosimetric meta-analysisSummary 		582
Conformal to IMRT: GYN Cancers 		583
Slide Number 7 		584
What percentage of cervical cancer patients with intact uterus undergo IMRT/VMAT treatment at your centre? 		585
Slide Number 9 		586
Slide Number 10 		587
Slide Number 11 		588
Slide Number 12 		589
Slide Number 13 		590
Slide Number 14 		591
Slide Number 15 		592
Slide Number 16 		593
Slide Number 17 		594
Slide Number 18 		595
IMPLEMENTATION OF IGRT IN AN IMRT ENVIRONMENT : PRE-REQUISTE TO SUCCESS 		596
Slide Number 20 		597
Slide Number 21 		598
Slide Number 22 		599
RTOG 0418 A phase II study of post op IMRT in gynecological cancer 		600
Slide Number 24 		601
Slide Number 25 		602
OAR Contouring & Dose Constraints 		603
Slide Number 27 		604
Slide Number 28 		605
BOWEL (acute toxicity): dose-volume effect 		606
Slide Number 31 		607
608
Slide Number 33 		609
Slide Number 34 		610
Prophylactic PA-IMRT 		611
Duodenal toxicity in Extended field RT 		612
Dose volume relationship for Gross nodes 		613
Slide Number 38 		614
PET- CT Based IMRT 		615
Slide Number 40 		616
Slide Number 41 		617
Slide Number 42 		618
Slide Number 43 		619
Slide Number 44 		620
Slide Number 45 		621
Slide Number 46 		622
Slide Number 47 		623
INTERTECC Trial: Multi-centric International Study 		624
Slide Number 49 		625
Slide Number 50 		626
INTERTECC Preliminary Data: Jan 2015 		627
Slide Number 52 		628
Slide Number 53 		629
Slide Number 54 		630
Slide Number 55 		631
SUMMARY 		632
15.GEC ESTRO II ICRU 89 RP2015v3_KTRP with TP_clean 		633
Slide Number 1 		633
Recommendations, DVH parameters 		634
Slide Number 3 		635
ICRU/GEC ESTRO recommendations for gyneacological brachytherapy 		636
Learning Objectives (I) 		637
Learning Objectives (II) 		638
Three levels of reporting 		639
Level 1 - Minimum standard for reporting 		640
Level 1 – minimum standard for reporting 		641
Slide Number 11 		642
Slide Number 13 		643
Level 1 – minimum standard for reporting 		644
Point-A based brachytherapy 		645
Slide Number 16 		646
Overall Treatment Time (BT, EBRT, total) 		647
When comparing total dose to point A and total dose to 90% of the HR CTV (D90) 		648
DVH Parameters and Reference Points, 		649
3D-based Dose Volume Parameters for OAR 		650
Slide Number 21 		651
Slide Number 22 		652
D2cm3 for rectum is endpoint for 		653
DVH Parameters for organs at risk (ICRU 89) 		654
Bladder 		655
Rectum 		656
Sigmoid 		657
ICRU point dose and D2cc doses 		658
D2cc and D0.1cc 		659
D2cm3 and D0.1cm3 for OAR 		660
Level 2 - Advanced standard for reportingAll that is reported in level 1 plus (ICRU 89): 		661
Overview of the adaptive target concept in cervix cancer stage IB, IIB, IIIB 		662
Slide Number 33 		663
Slide Number 34 		664
Level 2 - Advanced standard for reportingAll that is reported in level 1 plus (ICRU 89): 		665
DVH-parameters CTV-THR (ICRU 89) 		666
Dose and Volume Parameters (Vienna data 1998-2008) 		667
DVH parameters targets:GTV, CTV-HR, CTV-IR 		668
Dose in D90 and HR CTV for point A prescriptionHigh Target Doses in small tumoursLow Target Doses in large tumours 		669
Consequences of prescribing to Point-A 		670
Level 2 - Advanced standard for reportingAll that is reported in level 1 plus (ICRU 89): : 		671
DVH Parameters and Reference Points, 		672
Vaginal dose assessment and reporting 		673
Vaginal reference points 		674
Slide Number 45 		675
DVH Parameters and Reference Points, Vaginal point: variations in application 		676
D2cm3 and D0.1cm3 for OAR are recommended 		677
General principles for reporting of physical and equieffective EBRT and BT dose (ICRU/GEC ESTRO report 88) 		678
Pelvic EBRT (elective) + BT 		679
Calculation of EQD2 in spreadsheet 		680
When adding doses from EBRT and BT You assume for the HR CTV for BT that 		681
When adding doses from EBRT and BT You assume for the 2 cm3 for OAR that 		682
Limitations of adding doses according to „ICRU point-3D model“ both for CTV and OAR 		683
How could this happen? 		684
Be aware of IMRT hot spots in the BT region! 		685
DVHs for different contributions of EBRT and BTand specific morbidityendpoints 		686
From Planning aims to Prescription 		687
Need for common terminology according to ICRU reports on proton treatment and IMRT 		688
Planning aim and prescription dose 		689
Planning aim and prescription dose 		690
Example (Appendix case 5, ICRU 89) 		691
Example – disease at BT (Appendix case 5, ICRU 89) 		692
Example (Appendix case 5, ICRU 89) 		693
Example (Appendix case 5, ICRU 89)Applicators and EQD210 isodose surface volumes 		694
Example (dose points) (Appendix case 5, ICRU 89) 		695
Example (DVH parameters) (Appendix case 5, ICRU 89) 		696
16.KT_clinical evidence for dose effects Toronto_final_clean 		697
Clinical evidence for dose-effects for disease and morbidity/QoL outcome: Dose prescription, dose constraints and planning aims in brachytherapyESTRO Teaching CourseImage-Guided Cervix Radiotherapy – with a special focus on adaptive brachytherapyToronto 2016 		697
DOSE EFFECT RELATIONSHIP POINT A 		698
Slide Number 3 		699
Clinical Evidence in IGABT Cervix Cancer 		700
RetroEMBRACE 		701
EMBRACE study 		702
703
Heterogeneity of dose prescription: Bladder D2cc 		704
Recurrences according to dose and volume 		705
Actuarial local controlHR CTV dose and volume 		706
Dose, volume, and time effect 		707
Dose volume response for GTV 		708
Dose effect GTV, CTVHR and CTVIR 		709
Combined constraints for GTV and CTVHR 		710
Practice in EMBRACE I 		711
EMBRACE practice 		712
EMBRACE II dose prescription 		713
Beach boy approach – Barcelona 2013 		714
Bladder D2cm3 		715
Rectum D2cm3 		716
Slide Number 21 		717
Vaginal stenosis ICRU recto-vaginal point (630 pts) 		718
Slide Number 23 		719
Slide Number 24 		720
Sigmoid D2cm3, preliminary data 		721
Bowel D2cm3, preliminary data 		722
Slide Number 27 		723
Slide Number 28 		724
Planning aim and prescription dose 		725
Planning aim and prescription dose 		726
Conclusion (I) 		727
What is the proposed planning aim for CTVHR – indicate all correct answers 		728
Which treatment plan would you prefer? 		729
Which treatment plan would you prefer? 		730
17.KT_physics aspects intracav interst Toronto 2016_final_clean 		731
Physics aspects of treatment planning intracavitary +/- interstitial techniques in cervix cancerESTRO Teaching CourseImage-Guided Cervix Radiotherapy – with a special focus on adaptive brachytherapyToronto 2016 		731
Limitation of standard loading pattern with dose prescription to point A 		732
With dose optimisation in a small tumour... 		733
Tools for dose optimisation 		734
Slide Number 5 		735
Graphical dose optimisation – “drag and drop” 		736
Inverse dose optimisation 		737
Slide Number 8 		738
Example 1: good response stage IB2 Standard plan 		739
Example 1Manual dose optimisation 		740
Example 1, DVH 		741
Example 1, summary 		742
Example 2, Stage IIBStandard plan 		743
Example 2Manual dose optimisation 		744
Example 2, DVH 		745
Example 2, summary 		746
Example 3, Stage IIIBStandard dose plan 		747
Example 3Manually optimised plan 		748
Loading of needles: dwell times and isodoses 		749
Example 3, DVH 		750
Example 3, summary 		751
Example 3, inverse planning 		752
When to use graphical dose optimisation (dose shaper)? 		753
When to use graphical dose optimisation (dose shaper)? 		754
Typical scenarios of dose optimisation 		755
Conclusion – optimisation techniques 		756
PTV margins 		757
Example contouring uncertainty 		758
Vaginal dose de-escalation 		759
Volume is important! 		760
Volume is important! 		761
Point A dose and HR CTV volumeEMBRACE - Intracavitary applications 		762
Importance of needles 		763
Take home message – dose optimisation 		764
I prefer to do optimisation 		765
With dose optimisation in a small tumour... 		766
18.RadioBiologyModels to combine EBRT and BT DB(Questions)Toronto_2016_clean 		767
Slide Number 1 		767
Which dose rates are you mainly using at your department for GYN ? 		768
Are you correcting for the radio-biological effect ? 		769
Which of the following radiobiological effect(s) is(are) taken into account in the EQD2 calculationwhen using the LQ-model? 		770
Slide Number 5 		771
Slide Number 6 		772
Slide Number 7 		773
Slide Number 9 		774
Slide Number 10 		775
Slide Number 11 		776
Slide Number 12 		777
Slide Number 13 		778
Slide Number 14 		779
Slide Number 15 		780
Slide Number 16 		781
Slide Number 17 		782
Slide Number 19 		783
Slide Number 20 		784
Slide Number 21 		785
Slide Number 22 		786
Slide Number 23 		787
Slide Number 24 		788
A single fraction HDR dose of 7Gy to the tumour corresponds to a EQD2 of 		789
Slide Number 26 		790
Slide Number 27 		791
Which of the following radiobiological effect(s) is(are) taken into account in the EQD2 calculationwhen using the LQ-model? 		792
Slide Number 33 		793
Slide Number 34 		794
Slide Number 35 		795
19.KT_inter and intra fraction uncertainties Toronto 2016_final_clean 		796
Inter- and intra-fraction uncertainties and imaging strategies (MRI/CT) in brachytherapy ESTRO Teaching CourseImage-Guided Cervix Radiotherapy – with a special focus on adaptive brachytherapyToronto 2016 		796
Largest dose uncertainty for target? 		797
Largest dose uncertainty OARs? 		798
Uncertainties in the high gradient BT dose distribution 		799
The 6 steps of IGABT 		800
Contouring uncertaintiesHR-CTV on MRI 		801
Impact of contouring uncertainties on dose 		802
Applicator reconstruction uncertaintiesMRI based intracavitary/interstitial brachytherapy 		803
Reconstruction uncertainties 		804
Fusion uncertainties 		805
Definition of inter-intra fraction/application uncertainties 		806
Slide Number 12 		807
”Worst case assumption”Calculation of DVH for several fractions 		808
Different location of hotspots 		809
Influence of organ deformation 		810
Bladder dose accumulation with deformable registration (biomechanical) 		811
DVH addition 		812
Largest dose uncertainty for target? 		813
Largest dose uncertainty OARs? 		814
Total uncertainties 		815
Impact of uncertainties on total dose 		816
Examples total dose and uncertainty 		817
Dosimetric uncertainties and dose-response relationships 		818
Effect of uncertainties on observed dose response relationships 		819
Slide Number 25 		820
Slide Number 26 		821
Image modality? 		822
Pre-BT MRI + CT 		823
Slide Number 29 		824
Slide Number 30 		825
Pre-BT MRI + CT 		826
1st application: MRI 		827
2nd application: CT 		828
2nd application: CT 		829
MR imaging and treatment planning for every fraction? 		830
What is possible in your department? 		831
20.CARO ESTRO course April 5 2016 (1) 		832
Slide Number 1 		832
Outline 		833
Why Brachytherapy? 		834
Brachytherapy utilization rate in 18 SEER registries 		835
Survival by brachytherapy use 		836
The Impact of New TechnologicalAdvancements 		837
Slide Number 7 		838
Canadian Practice Survey 		839
Slide Number 9 		840
What imaging do you perform after applicator insertion for applicator position verification and/or treatment planning? 		841
Dose prescription 		842
Brachytherapy Dose-Fractionation 		843
How often do you use interstitial needles? 		844
Is MR simulation available? 		845
What is the current status of MR-guided brachytherapy (full 3D planning) at your centre? 		846
What are/were the barriers to implementing MR-guided brachytherapy? 		847
Slide Number 17 		848
Key Quality-of-Care Indicators 		849
Endorsed Brachytherapy KQIs 		850
Aspirational Brachytherapy KQIs 		851
Slide Number 21 		852
PM Brachytherapy Technique 		853
Increase in uterine volume & HRCTV during PDR brachytherapy 		854
PM Brachytherapy Technique 		855
PM HDR Brachytherapy Process 		856
Slide Number 26 		857
Slide Number 27 		858
PM Brachytherapy Technique 		859
Stage IVA Cervical SCC 		860
Stage IVA Cervical SCC 		861
Stage IVA Cervical SCC 		862
Slide Number 32 		863
PM Brachytherapy Technique 		864
Vaginal recurrence of cervical adenocarcinoma after trachelectomy 		865
Slide Number 35 		866
Slide Number 36 		867
Slide Number 37 		868
Slide Number 38 		869
Slide Number 39 		870
Planning Aims 		871
Inter-Observer Variability Among Experts 		872
Slide Number 42 		873
Slide Number 43 		874
Slide Number 44 		875
Slide Number 45 		876
MR-Guided Radiotherapy Suite 		877
MR-Guided Brachytherapy Suite 		878
MR-Guided Brachytherapy Suite 		879
Summary 		880
Acknowledgements 		881
21.Vie003_JR(caseSummary) 		882
Slide Number 1 		882
Slide Number 2 		883
Slide Number 3 		884
Slide Number 4 		885
Slide Number 5 		886
Slide Number 6 		887
Slide Number 7 		888
Slide Number 8 		889
Slide Number 9 		890
Slide Number 10 		891
Slide Number 11 		892
Slide Number 12 		893
Slide Number 13 		894
Slide Number 14 		895
Slide Number 15 		896
Slide Number 16 		897
22.Practical-DoseReporting 		898
Slide Number 1 		898
Slide Number 2 		899
Slide Number 3 		900
Slide Number 4 		901
Slide Number 5 		902
Bladder Bicru / D2cm3 ratio 		903
Slide Number 7 		904
„ICRU 89“ Reference Points 		905
Slide Number 9 		906
Slide Number 10 		907
Slide Number 11 		908
Slide Number 12 		909
Slide Number 13 		910
Slide Number 14 		911
Slide Number 15 		912
Slide Number 16 		913
24.Morbidity and QoL Rect, Bowel, Bladder, Vagina RP 2016 		914
Morbidity and QoL after IGABT in Cervix CancerRectum, Sigmoid, Bladder, Vagina 		914
Learning Objectives I 		915
Patients with baseline and follow up informationbladder, bowel, rectum 		916
Late Morbidity: Bladder 		917
Slide Number 5 		918
Slide Number 6 		919
Bladder frequency 		920
Bladder frequency 		921
PROM bladder frequency 		922
Bladder Incontinence 		923
Bladder incontinence 		924
PROM bladder incontinence 		925
Bladder cystitis 		926
Bladder cystitis 		927
Bladder bleeding 		928
Analysis of single- or groups of symptoms? 		929
Late Morbidity: GI, Rectum, Bowel 		930
Overview (CTCAE) 		931
Slide Number 19 		932
Prevalence for bleeding, proctitis, fistula, stenosis (rectum) 		933
Actuarial estimate of bleeding, proctitis, fistula, stenosis 		934
Prevalence and actuarial cumulative incidence: rectal morbidity 		935
Late Morbidity: GI, Rectum, Bowel 		936
Slide Number 24 		937
Prevalence rates for all gradings of diarrhea, CTCAE 		938
Slide Number 26 		939
Slide Number 27 		940
Prevalence rates for all gradings of diarrhea, EORTC 		941
Prevalence rates for all gradings of difficulty controlling bowel, EORTC 		942
Prevalence rates for all gradings of incontinence, CTCAE 		943
Slide Number 31 		944
Slide Number 32 		945
Late Morbidity: Vagina 		946
Vaginal stenosis 		947
Vaginal length reduction 		948
Telangiectasia 		949
Slide Number 37 		950
Adhesions 		951
Vaginal occlusion 		952
Patterns of manifestation: Prevalence rates and Actuarial estimates 		953
Patterns of manifestation: Prevalence rates and Actuarial estimates 		954
Vaginal morbidity after definitive radiochemotherapy + IGABT in LACC 		955
Crude incidence, rates for single vaginal endpoints 		956
Summary & Conclusion 		957
Late Morbidity: others 		958
Slide Number 46 		959
Slide Number 47 		960
summaryduring and early after treatment 		961
long-term Quality of life 		962
long-term patient reported symptoms 		963
long-term patient reported symptoms 		964
long-term impact on sexuality 		965
summary 		966
Learning Objectives II 		967
Slide Number 55 		968
Slide Number 56 		969
Inter-rater reliability of CTCAE morbidity assessment 		970
Slide Number 58 		971
Slide Number 59 		972
EORTC / FACT QoL 		973
Agreement physician assessed vs. Patient reported symptoms 		974
Slide Number 62 		975
Possible explanations 		976
Summary & Conclusion 		977
25.Disease Control_after IGABT RPv3 ESTRO TC Toronto 		978
Slide Number 1 		978
Slide Number 2 		979
Slide Number 3 		980
Slide Number 4 		981
Slide Number 5 		982
Clinical Evidence in IGABT Cervix Cancer 		983
Image guided adpative brachytherapy (IGBT) cervix cancerLocal Control and Cancer Specific Survival (1998-2003)TREATMENT PERIOD (-/+ IGABT) AND TUMOUR SIZE 		984
Slide Number 8 		985
CONTINUOUS COMPLETE REMISSION 3 YEARS*VIENNA 1993-2003: 335 patients 		986
CONCLUSIONS (Vienna experience 1998-2008) 		987
Better local control = improved survival 		988
Overall treatment time (OTT) 		989
morbidity 3y ≥G3: 10% 3% 		990
Multicenter studies with IGABT in cervix ca. 		991
From 2D – 3DX Ray vs CT/MRI (STIC trial) 		992
993
Slide Number 17 		994
Slide Number 18 		995
Local control – advanced treatment adaptationincluding interstitial brachytherapy (RetroEMBRACE) 		996
Slide Number 20 		997
Slide Number 21 		998
Slide Number 22 		999
Systemic (distant) recurrence analysis (EMBRACE data, 133 events in 753 patients) 		1000
Slide Number 24 		1001
Slide Number 25 		1002
Provisional comparison DVH parameters & local controlbased on multi-centre experience 		1003
Interpretation of RetroEMBRACE results (IGABT compared to large population based cohorts 2D BT) 		1004
Slide Number 28 		1005
Interpretation of RetroEMBRACE results (IGABT compared to large population based cohorts 2D BT) 		1006
Paradoxon! 		1007
Slide Number 31 		1008
LOCAL CONTROL - CLINICAL DATA/AIMSDOSE at POINT A vs. as D90 IN IMAGE GUIDED ADAPTIVE BT 		1009
Slide Number 33 		1010
Acknowledgements Gyn GEC ESTRO networkEMBRACE study and research group, ICRU report committee 		1011
26.KT_Embrace and GYN network RP KT Toronto_final 		1012
GEC-ESTRO gyn network and EMBRACE I and II 		1012
Gyn GEC ESTRO NETWORK R&D, Educ. since 5/2005, coordinator Medical Uni.Vienna and Aarhus Uni.Hosp. 		1013
RetroEMBRACE 		1014
EMBRACE study 		1015
Slide Number 5 		1016
EMBRACE II design 		1017
EMBRACE II interventions 		1018
EMBRACE II dose prescription 		1019
EMBRACE II interventions 		1020
Vaginal dose de-escalation 		1021
EMBRACE II interventions 		1022
IMRT + daily IGRT 		1023
EMBRACE II interventions 		1024
Target concept related to primary tumour 		1025
Workflow target contouring 		1026
Internal target volume 		1027
EMBRACE II interventions 		1028
EBRT dose prescription 		1029
EMBRACE II interventions 		1030
Target concept related to elective lymph nodes 		1031
Target concept related to elective lymph nodes 		1032
EMBRACE II interventions 		1033
Administration of chemotherapy in EMBRACE I 		1034
EMBRACE II interventions 		1035
Control of OTT: 3 examples of schedules 		1036
Accreditation and dummy run for new centers 		1037
Accreditation and dummy run for new centers 		1038
Roadmap EMBRACE II 		1039
Information about EMBRACE, retro-EMBRACE and 3D Gyn GEC ESTRO network 		1040
27.Tips_and_tricks_RP-DB-UM_Toronto 		1041
Slide Number 1 		1041
Slide Number 2 		1042
Slide Number 3 		1043
Slide Number 4 		1044
Slide Number 5 		1045
Slide Number 6 		1046
Slide Number 7 		1047
DOWN THE DECADES CANCER CERVIX : TATA MEMORIAL HOSPITAL 1941-2010 		1048
Slide Number 9 		1049
Slide Number 10 		1050
Slide Number 11 		1051
Slide Number 12 		1052
Slide Number 13 		1053
Slide Number 14 		1054
Slide Number 15 		1055
Slide Number 16 		1056
Slide Number 17 		1057
Slide Number 18 		1058
Slide Number 19 		1059
Slide Number 20 		1060
Slide Number 21 		1061
Slide Number 22 		1062
Dosimetric Comparison (1# BT) 		1063
Slide Number 24 		1064
Slide Number 25 		1065
Slide Number 26 		1066
Slide Number 27 		1067
Slide Number 28 		1068
Slide Number 29 		1069
Slide Number 30 		1070
Slide Number 31 		1071
Slide Number 32 		1072
Slide Number 33 		1073
Slide Number 34 		1074
Train Your Contouring and passyour knowledge to your friends ;) 		1075
Slide Number 36 		1076
28.Wiebe EdmontonEstro-CaroCOP_EW 		1077
MR-based Brachytherapy for Cervical Cancer 		1077
Cross Cancer Institute 		1078
MR-BT at CCI 		1079
Current workflow for MR-BT 		1080
The Team (2007 – present) 		1081
Radiotherapy for Cervix Ca 		1082
Slide Number 7 		1083
Bulky Tumour, Partial Response 		1084
Implementation of MR-BT 		1085
What helped 		1086
What helped 		1087
Current Topics of Interest 		1088
Future opportunities? 		1089
Slide Number 14 		1090
Milestones 		1091
29.Velker London Experience MR Guided Cervix Brachytherapy 		1092
MR Guided Cervix Brachytherapy:London Experience 		1092
London….Ontario 		1093
London Ontario Brachytherapy Program 		1094
Dose and fractionation 		1095
Brachytherapy Work flow (Implant #1) 		1096
Brachytherapy Work flow (Implant #2) 		1097
MR utilization 		1098
MR guided planning 		1099
“Hybrid” Interstitial 		1100
Slide Number 10 		1101
Challenges 		1102
Current refinements in progress 		1103
Thank you 		1104
MR Guided Cervix Brachytherapy:London Experience 		1105
30.Contouring Study Proposal_EL APRIL 6 		1106
Canadian Interstitial Brachytherapy Contouring Study:Vaginal Tumours 		1106
SunnybrookGYN Interstitial Brachytherapy 		1107
Interstitial Brachytherapy 		1108
3D Imaging 		1109
Contouring Variability 		1110
Contouring Study 		1111
Methods 		1112
Collaboration 		1113
Definitions 		1114
Contouring Variability 		1115
Slide Number 11 		1116
Slide Number 12 		1117
Methods 		1118
Slide Number 14 		1119
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