title: Optimized planning target volume for intact cervical cancer.
abstract: OBJECTIVE
  To model interfraction clinical target volume (CTV) variation in patients with intact cervical cancer and design a planning target volume (PTV) that minimizes normal tissue dose while maximizing CTV coverage.
  
  
  METHODS
  We analyzed 50 patients undergoing external-beam radiotherapy for intact cervical cancer using daily online cone-beam computed tomography (CBCT). The CBCTs (n = 972) for each patient were rigidly registered to the planning CT. The CTV was delineated on the planning CT (CTV(0)) and the set of CBCTs ({CTV(1)-CTV(25)}). Manual (n = 98) and automated (n = 668) landmarks were placed over the surface of CTV(0) with reference to defined anatomic structures. Normal vectors were extended from each landmark, and the minimum length required for a given probability of encompassing CTV(1)-CTV(25) was computed. The resulting expansions were used to generate an optimized PTV.
  
  
  RESULTS
  The mean (SD; range) normal vector length to ensure 95% coverage was 4.3 mm (2.7 mm; 1-16 mm). The uniform expansion required to ensure 95% probability of CTV coverage was 13 mm. An anisotropic margin of 20 mm anteriorly and posteriorly and 10 mm superiorly, inferiorly, and laterally also would have ensured a 95% probability of CTV coverage. The volume of the 95% optimized PTV (1470 cm(3)) was significantly lower than both the anisotropic PTV (2220 cm(3)) and the uniformly expanded PTV (2110 cm(3)) (p < 0.001). For a 95% probability of CTV coverage, normal lengths of 1-3 mm were found along the superior and lateral regions of CTV(0), 5-10 mm along the interfaces of CTV(0) with the bladder and rectum, and 10-14 mm along the anterior surface of CTV(0) at the level of the uterus.
  
  
  CONCLUSIONS
  Optimizing PTV definition according to surface landmarking resulted in a high probability of CTV coverage with reduced PTV volumes. Our results provide data justifying planning margins to use in practice and clinical trials.
authors.affiliation: Department of Radiation Oncology, Center for Advanced Radiotherapy Technologies, University of California, San Diego, La Jolla, CA, USA.
authors.forename: Alvin
authors.initials: A
authors.lastname: Khan
authors.forename: Lindsay G
authors.initials: LG
authors.lastname: Jensen
authors.forename: Shuai
authors.initials: S
authors.lastname: Sun
authors.forename: William Y
authors.initials: WY
authors.lastname: Song
authors.forename: Catheryn M
authors.initials: CM
authors.lastname: Yashar
authors.forename: Arno J
authors.initials: AJ
authors.lastname: Mundt
authors.forename: Fu-Quan
authors.initials: FQ
authors.lastname: Zhang
authors.forename: Steve B
authors.initials: SB
authors.lastname: Jiang
authors.forename: Loren K
authors.initials: LK
authors.lastname: Mell
mesh_terms: D059925:Anatomic Landmarks / Q000000981:diagnostic imaging; D002140:California; D002681:China; D054893:Cone-Beam Computed Tomography / Q000379:methods*; D005260:Female; D057918:Fiducial Markers; D006801:Humans; D009068:Movement; D058958:Organs at Risk / Q000000981:diagnostic imaging / Q000528:radiation effects; D011832:Radiation Injuries / Q000517:prevention & control; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D047368:Tumor Burden; D002583:Uterine Cervical Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology / Q000532:radiotherapy*