CONSENSUS PANEL CONTOURINGCONSENSUS PANEL CONTOURING ATLAS FOR THE DELINEATION OF THE CLINICAL TARGET VOLUME INTHE CLINICAL TARGET VOLUME IN THE POSTOPERATIVE TREATMENT OF PANCREATIC CANCERCollaboratorsCollaborators Ross A Abrams M D1William F Regine M D2Ross A. Abrams, M.D. , William F. Regine, M.D. , Karyn A. Goodman, M.D.3, Laura A. Dawson, M D4Edgar Ben-Josef M D5KarinM.D. , Edgar Ben Josef, M.D. , Karin Haustermans, M.D.6, Walter R. Bosch, D.Sc.7, Julius Turian Ph D1Julius Turian, Ph.D1Rush University Medical College, Chicago, IL; 2University of Maryland School of Medicine, Baltimore, MD;3Memorial Sloan-Maryland School of Medicine, Baltimore, MD; Memorial Sloan Kettering Cancer Center, New York, NY; 4Princess Margaret Hospital, University of Toronto, Toronto, ON; 5University of Michigan Medical School, Ann Arbor, MI; 6University Hospital LLB l i7IG id d ThQA CtLeuven, Leuven, Belgium; 7Image-Guided Therapy QA Center (ITC),Washington University, St. Louis, MOBackgroundBackground Radiotherapy (RT) quality assurance is essential to lid t ttt ffivalidate treatment efficacy RT fields were prospectively reviewed in the RTOG 97-04 study demonstrating that 48% of treatment plans did notstudy demonstrating that 48% of treatment plans did not meet protocol requirements. Based on “per protocol” versus “not per protocol” pppp radiation delivery, the frequency of grade 3/4 toxicity did not vary significantly on the 5-FU arm but did show a td f lti it ftitthit bitrend of less toxicity for patients on the gemcitabine arm. Survival was significantly increased for patients treated per protocol (p=0 019)per protocol (p=0.019). BackgroundBackground In RTOG 0848, prospective radiation quality control , ppqy is required Central review will be performed prior to treatment deliverydelivery CT-based planning is required Either 3D conformal (3DCRT) or intensity-modulatedEither 3D conformal (3DCRT) or intensity modulated radiotherapy (IMRT) planning The normal tissues must be delineated and a clinical ttl(CTV)ill b d fidtarget volume (CTV) will be defined BackgroundBackground To ensure the adequacy of the post-operative CTV and to o e su ee adequacy oe pos ope aea d o develop standardized contouring guidelines for RTOG 0848, a consensus committee of six radiation oncologists, i hiiiil RT dldwith expertise in gastrointestinal RT, developed a stepwise contouring approach based on identifiable regions of interest (ROI) and margin expansions.regions of interest (ROI) and margin expansions. Using these ROIs and margin expansions, reproducible CTVs can be created that cover the post-operative bed, nodal regions at risk as well as minimize inclusion of the highly radiosensitive abdominal organs at risk (OAR). Treatment Volumes: GTVTreatment Volumes: GTV By definition there is no GTV (tumor has been resected)resected) Location of pancreatic tumor prior to resection m st be re ie ed and conto red based onmust be reviewed and contoured based on preoperative axial imaging/simulation Pre-operative diagnostic or simulation scans can be fused with post-operative CT to facilitate localization of tumor bed Surgical and pathological information must be reviewed at time of treatment planningTreatment Volumes: CTVTreatment Volumes: CTV The post operative CTV is that area where there is likely to be the highest concentration of residual sub-clinical tumor that can be treated with radiotherapy without resulting in a treatment volume that encompasses an excessive amount fldl tiof normal organs and normal tissue. 1.Post-operative bed Based on location of initial tumor from pre-operative imaging and pathology reportspathology reports 2.Anastomoses Pancreaticojejunostomy(PJ) Choledochal or hepaticojunostomypjy 3.Abdominal nodal regions Peripancreatic Celiac Superior mesenteric Porta hepatis Para-aorticROI Delineation: CA and SMAROI Delineation: CA and SMA The most proximal 1 0-1 5 cm of the celiacThe most proximal 1.0 1.5 cm of the celiac artery (CA) The most proximal 2 5 to 3 0 cm of the The most proximal 2.5 to 3.0 cm of the superior mesenteric artery (SMA)ROI Delineation: PVROI Delineation: PV Include the portal vein (PV) segment that runs slightly to thi ht f i ft f (ti)dtdi l t ththe right of, in front of (anterior) and anteromedial to the inferior vena cava (IVC). Contour from the bifurcation of the PV to, but do not l dhflhhhlinclude, the PV confluence with either the SMV or Splenic Vein (SV). The PV bifurcation can be extrahepatic or almost p intrahepatic. The PV most often will merge first with the SMV, but may merge with the SV.may merge with the SV. ROI Delineation: Post-op BedROI Delineation: Post op Bed The location of the pancreatic tumor prior to e ocat o o t e pa c eat c tu o p o to resection should be reviewed and contoured based on the preoperative imaging or simulation Surgical clips placed for purposes of deline