IMRT and 3 DCRT in cervical Cancers - Principles, Uses, Methods and Planning. A short summary of results of contemporary series are also provided.

1. 3D CRT and IMRT in Cervical Cancers Department of Radiotherapy PGIMER Chandigarh

7. Comparision

8. MLC based IMRT

13. Conformal Radiation Planning

15. Patient Preperation

18. Thermoplastics

20. Patient Positioning

21. Our Method

22. Immobilization: Other methods Elekta Body Frame Body Fix system

23. Accuracy of systems With the precision of the body fix frame the target volume will be underdosed (< 90% of prescribed dose) 14% of the time!!!

26. Importance of MRI Dimopoulos JC, Schard G, Berger D, Lang S, Goldner G, Helbich T, et al. Systematic evaluation of MRI findings in different stages of treatment of cervical cancer: Potential of MRI on delineation of target, pathoanatomic structures, and organs at risk. International Journal of Radiation Oncology*Biology*Physics. 2006 Apr 1;64(5):1380-1388.

31. Concept

33. Image Registration

40. Nodal Anatomy Superficial common iliac – 24% Deep Common iliac – 20% Internal Iliac – 12% External Ilac – 24% Superficial Obturator – 92% Deep Obturator – 8% Presacral - 8%

41. Delineation of Nodal Volume Common Iliac Nodes : 7 mm margin around vessels. Extend posterior and lateral borders to psoas and vertebral body Taylor A, Rockall A, Powell M. An Atlas of the Pelvic Lymph Node Regions to Aid Radiotherapy Target Volume Definition. Clinical Oncology. 2007 Sep ;19(7):542-550.

42. Delineation of Nodal Volume External iliac Nodes : 7 mm margin around vessels. Extend anterior border by a further 10 mm anterolaterally along the iliopsoas muscle to include the lateral external iliac nodes Internal iliac Nodes : 7 mm margin around vessels. Extend lateral borders to pelvic side wall Taylor A, Rockall A, Powell M. An Atlas of the Pelvic Lymph Node Regions to Aid Radiotherapy Target Volume Definition. Clinical Oncology. 2007 Sep ;19(7):542-550.

43. Delineation of Nodal Volume Presacral Nodes : Subaortic: 10 mm strip over anterior sacrum; Mesorectal: cover entire mesorectal space Taylor A, Rockall A, Powell M. An Atlas of the Pelvic Lymph Node Regions to Aid Radiotherapy Target Volume Definition. Clinical Oncology. 2007 Sep ;19(7):542-550.

44. Delineation of Nodal Volume Taylor A, Rockall A, Powell M. An Atlas of the Pelvic Lymph Node Regions to Aid Radiotherapy Target Volume Definition. Clinical Oncology. 2007 Sep ;19(7):542-550.

45. Delineation of Nodal Volume Taylor A, Rockall A, Powell M. An Atlas of the Pelvic Lymph Node Regions to Aid Radiotherapy Target Volume Definition. Clinical Oncology. 2007 Sep ;19(7):542-550. Obturator Nodes : Join external and internal iliac regions with a 17 mm wide strip along the pelvic side wall

46. Delineation of Nodal Volume Taylor A, Rockall A, Powell M. An Atlas of the Pelvic Lymph Node Regions to Aid Radiotherapy Target Volume Definition. Clinical Oncology. 2007 Sep ;19(7):542-550.

47. Extent of Nodes Covered

50. Planning workflow Define a dose objective Total Dose Total Time of delivery of dose Total number of fractions Choose Number of Beams Choose beam angles and couch angles Organ at risk dose levels Choose Planning Technique Forward Planning Inverse Planning

52. Planning Beam orientation Beams Eye View Display Room's Eye View Digital Composite Radiograph

53. Beam Arrangement

54. “Inverse” Planning 1. Dose distribution specified Forward Planning 2. Intensity map created 3. Beam Fluence modulated to recreate intensity map Inverse Planning

58. Normal Organ Constraints Mundt AJ, Lujan AE, Rotmensch J, Waggoner SE, Yamada SD, Fleming G, et al. Intensity-modulated whole pelvic radiotherapy in women with gynecologic malignancies . International Journal of Radiation Oncology*Biology*Physics. 2002 Apr 1;52(5):1330-1337.

62. Optimization

67. Clinical Results

69. WPIMRT: Clinical Results

75. Thank You