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Practical Radiotherapy Planning
Fifth Edition

Stephen Morris, MRCP, FRCR

Consultant Clinical Oncologist, Guy’s and
St Thomas’ Cancer Centre, London
Tom Roques, MRCP, FRCR
Consultant Clinical Oncologist, Norfolk and Norwich University
Hospitals NHS Foundation Trust, Norwich
Shahreen Ahmad, MRCP, FRCR, MD (Res)
Consultant Clinical Oncologist, Guy’s and St Thomas’ Cancer Centre, London
Suat Loo, MRCP, FRCR
Consultant Clinical Oncologist, East Suffolk and
North Essex NHS Foundation Trust, Colchester
Fifth edition published 2024
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DOI: 10.1201/9781315171562

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Contents

Preface...................................................................................................................................................... vii

1 What You Need to Know before Planning Radiotherapy Treatment.......................................... 1

2 Principles of Radiotherapy Planning.............................................................................................. 7

3 Radiobiology and Treatment Planning......................................................................................... 27

4 Organs at Risk and Tolerance of Normal Tissues....................................................................... 38

5 Principles of Brachytherapy........................................................................................................... 49

6 Emergency and Palliative Radiotherapy...................................................................................... 56

7 Skin................................................................................................................................................... 65

8 Head and Neck: General Considerations...................................................................................... 81

9 Lip, Ear, Nose and Treatment of the Neck in Skin Cancer...................................................... 103

10 Oral Cavity.....................................................................................................................................112

11 Oropharynx Cancer and Unknown Primary Tumours of the Head and Neck...................... 122

12 Hypopharynx................................................................................................................................. 136

13 Nasopharynx...................................................................................................................................145

14 Larynx............................................................................................................................................ 154

15 Salivary Glands..............................................................................................................................163

16 Sinuses: Maxilla, Ethmoid and Nasal Cavity Tumours.............................................................170

17 Orbit................................................................................................................................................179

18 Central Nervous System................................................................................................................186

19 Thyroid and Thymoma................................................................................................................. 205

20 Lung.................................................................................................................................................214

21 Mesothelioma................................................................................................................................. 234

22 Breast.............................................................................................................................................. 240

v
vi Contents

23 Haematological Malignancies...................................................................................................... 260

24 Oesophagus and Stomach............................................................................................................. 283

25 Pancreas and Liver........................................................................................................................ 296

26 Rectum........................................................................................................................................... 305

27 Anus.................................................................................................................................................318

28 Prostate........................................................................................................................................... 328

29 Bladder........................................................................................................................................... 348

30 Testis............................................................................................................................................... 358

31 Penis................................................................................................................................................ 364

32 Cervix............................................................................................................................................. 368

33 Uterus..............................................................................................................................................381

34 Vagina............................................................................................................................................. 393

35 Vulva............................................................................................................................................... 399

36 Sarcoma.......................................................................................................................................... 405

37 Paediatric Tumours........................................................................................................................415

38 Radiotherapy for Benign Disease.................................................................................................431

Index....................................................................................................................................................... 439
Preface

The practice of radiotherapy has changed in many ways since the last edition of Practical Radiotherapy
Planning was published in 2009. Advances in imaging have been incorporated into radiotherapy plan-
ning to improve the accuracy of volume definition. CT has advanced with new algorithms enhancing
image quality and new techniques such as perfusion CT and dynamic contrast-enhanced CT improving
the accuracy of tumour delineation. Diffusion-weighted MRI has been widely adopted to enhance soft
tissue contrast, and apparent diffusion coefficient (ADC) maps can identify areas of increased cellularity
due to tumour growth. Quantitative functional assessment with MRI has improved, so whole-body scans
can be used for the accurate staging of some tumour types. Intensity-modulated radiotherapy (IMRT)
has been superseded by more advanced techniques such as volumetric modulated arc therapy (VMAT).
Stereotactic ablative radiotherapy (SABR) has been commissioned in most cancer centres in the UK, and
proton beam therapy is now available in Manchester and London. Hypofractionation is increasingly used
in breast and prostate cancers. Image-guided radiotherapy (IGRT) has become more advanced, with
image-guided adaptive radiotherapy implemented for some tumour types.
There are now target volume and organ at-risk contouring guidelines and atlases for most body sites,
many of which are available online. The ICRU has continued to update and publish international recom-
mendations such as the principles of prescribing, recording and reporting photon therapy (ICRU report
62), electron beam therapy (ICRU report 71), intensity modulated photon beam therapy IMRT (ICRU
report 82) and stereotactic treatments (ICRU report 91). Newer systemic treatments such as immuno-
therapy have changed treatment options for some cancers, and sometimes provided new indications for
radiotherapy.
The previous edition of this book introduced the newly developing concepts of IMRT and IGRT.
This edition explains how these new techniques have advanced and are now being used to deliver very
advanced, highly accurate radiotherapy. Simpler techniques are also described where relevant to cur-
rent practice. The overall aim of the book remains the same – to provide a clear description of modern
radiotherapy treatment that is based on sound pathological and anatomical principles and backed by
high-quality evidence.
Most radiotherapy treatment is given according to local, national and international protocols, which
should always be consulted as appropriate. In a rapidly changing discipline like radiotherapy there will
often be alternative protocols and techniques to those described here. We intend our text to provide guid-
ance for radiotherapy that can be followed by practitioners anywhere in the world so they can deliver safe
and effective treatment.
To improve the optimal reproduction of plans we have tried to use the following colour scheme in
illustrations unless indicated otherwise:

GTV dark blue

CTVs cyan (light blue), magenta (purple)
PTVs red, lime green
OARs yellow, light yellow, light green, dark green

We are very grateful for all those in our hospitals and further afield with whom we work and col-
laborate; they challenge and inspire us. The current authors would like to thank the initial authors of
this book – Jane Dobbs, Ann Barrett, and Dan Ash – and hope this edition continues to inspire many
future versions. It would be impossible to produce a book like this one in the age of specialized practice
and multidisciplinary team working without particular collaboration from expert colleagues who have
helped with certain sections of the text. Special thanks to Omar Al-Salihi, Jessica Brady, Yen Chang,

vii
viii Preface

Adam Dobson, Dinos Geropantas, Andrew Ho, Simon Hughes, Sarah Jefferies, Pei Lim, Asad Qureshi,
Angela Swampillai, Nicky Thorp, Alison Tree, Rob Urwin and Sadaf Usman.
This small textbook cannot describe all the research which has been undertaken to develop radio-
therapy schedules. We have aimed to describe evidence-based treatment protocols as used in our depart-
ments around the UK. We have included a list of key trials and information sources at the end of each
chapter where more detailed information may be found. We give an introduction to the principles and
practice of brachytherapy, but more detailed information can be found in dedicated brachytherapy papers
and books. Commonly used abbreviations have been spelled out at first mention in the book and are
included in the appendix for further reference.
We hope that trainees in clinical and radiation oncology, therapeutic radiographers, dosimetrists and
physicists, all working collaboratively within their multidisciplinary teams, will continue to use our
book to produce safe and appropriate plans for common tumours.

Shahreen Ahmad, Suat Loo, Stephen Morris, Tom Roques, 2023

1
What You Need to Know before Planning
Radiotherapy Treatment

Introduction
Radiotherapy has been used to treat cancer for more than a hundred years. Following the discovery of
X-rays by William Röntgen in 1895, X-rays were used to treat breast cancer in Chicago in 1896. The
first reported cancer cured by radiotherapy was a squamous cell cancer on the nose treated in 1899.
Radiotherapy is now the most important nonsurgical treatment for cancer.
Radiotherapy can only produce beneficial effects if it is delivered in an appropriate clinical context.
Attempting curative radical treatment for a patient with metastatic disease or one who is likely to die
soon from cardiac or lung disease is inappropriate. These decisions require a fine balance of judgement
between therapeutic optimism and nihilism, and must be firmly based in good clinical history taking and
examination. The clinician must then be able to synthesise all the information about the patient, tumour,
investigations and previous treatment to make a decision about whether radiotherapy should be used and,
if so, with curative radical or palliative intent. Comorbidities which could affect the toxicity of treatment,
such as diabetes or vascular disease, must also be considered.
Sometimes the decision to offer radiotherapy may be relatively simple if the disease is common,
the treatment effective and standardised, the histological features are well categorised and imaging
is easy to interpret. Some breast cancers fit well into this category. In contrast, decisions may be very
difficult if there is no treatment of proven benefit, the prognosis is uncertain, the patient’s general
performance status is poor, imaging is of limited utility or there is histological uncertainty. Clinical
experience and judgement then become critically important. This expertise is built on the foundation
of good history taking which enables clinicians to set a patient’s disease in the context of their own
ideas, concerns and expectations. Have other family members had radiotherapy with good or bad
outcomes? Are they so claustrophobic that they will not go into a scanner or treatment room? Do they
have other problems which would affect the feasibility of radiotherapy – arthritis which limits joint
movement, shortness of breath which prevents them lying flat, pacemakers or prostheses which may
affect dose delivery?
Clinicians may consider that the new era of cross-sectional and functional imaging has made exami-
nation of the patient irrelevant, but it remains the essential foundation of appropriate clinical judge-
ments; for example, detection of a lymph node in the axilla, otherwise overlooked in imaging, or the
progression of a tumour since the last scan, may change a decision taken earlier in a multidisciplinary
team meeting.

Classification Systems
Many classification systems have been developed to ensure that clinicians throughout the world share a
common language as they describe patients, tumours and treatment. This is essential to allow effective
cancer registration and comparisons of incidence, prognosis and outcome of treatments. Many protocols
for treatment are also based on such classification systems.

DOI: 10.1201/9781315171562-1 1
2 Practical Radiotherapy Planning

Pathological Classification
The International Classification of Disease (ICD) version 11, of the World Health Organization (WHO),
was updated in 2019. It is the international standard diagnostic classification for epidemiology and health
management. It is used in hospital records and on death certificates, which, in turn, are the basis for
compiling mortality and morbidity statistics nationally and internationally. There is a subclassification,
the International Classification of Disease for Oncology version 3 (ICD-O-3.2, updated 2019), which is
used in cancer/tumour registries to code site (topography) and type (morphology) of neoplasms from the
histopathology report.
Information about malignancy (malignant, benign, in situ or uncertain) and differentiation is also
coded. In the UK, this information is abstracted from clinical notes by trained coders. The introduction
of computerised systems suggests that clinicians will be required to develop greater awareness of this
classification, at least in their own areas of expertise, especially if the information becomes essential data
before income is assured. ICD 11 and ICD-O-3.2 are available online.
The morphological information for ICD-O-3.2 coding comes from the pathologist, whose expertise is
essential to establish a precise diagnosis and choose appropriate treatment volumes. A pathology report
will contain a description of the macroscopic appearance of the gross tumour specimen, its size, resec-
tion margins and anatomical relationships. It will describe the microscopic appearance after appropriate
staining of cut sections of the tumour, including features such as areas of necrosis. Recognition of the
tissue of origin and grading of the tumour will then often be possible.
There has been an explosion of new techniques in pathology, such as immunocytochemical staining,
immunophenotyping and fluorescence in situ hybridisation, which may help to remove uncertainties
about diagnoses following conventional histopathological examination. New molecular diagnostic tests
and genetic profiling methods are increasingly being developed to identify tumour-targeted molecular
profiles which inform the choice of targeted treatments. Oncologists must be in constant dialogue with
their pathology colleagues to ensure that they understand the significance of results of these special
investigations and know how to assess the degree of certainty of the report.

Staging
Tumour stage, histological classification and grade determine prognosis and treatment decisions. An
internationally agreed staging system is essential to interpret outcomes of treatment and compare results
in different treatment centres. The behaviour of tumours in different sites is determined by the anatomi-
cal situation, blood supply and lymphatic drainage, along with the histological classification and grading.
Any staging system must take into account this variability. The most commonly used systems are the
UICC (Union Internationale Contre le Cancer) TNM, AJCC (American Joint Committee on Cancer)
and FIGO (Federation Internationale de Gynecologie et d’Obstetrique) for gynaecological malignancy.
The TNM system describes the tumour extent (T), nodal involvement (N) and distant metastases (M).
This defines a clinical classification (cTNM) or a pathological classification (pTNM) which incorporates
information derived from an excised tumour and any draining lymph nodes that are also removed or
sampled. Details of this system are given in the TNM atlas, which should be available and used wherever
patients are seen or results of investigations are correlated.
T staging includes measurement of the tumour either clinically, by imaging techniques, or by macro-
scopic examination of an excised specimen. Correct pathological T staging can only be assured if the
pathologist receives a completely excised tumour with a rim of surrounding tissue. The tumour should
not be cut into or fixed except by the pathologist. Examination of the whole specimen is needed to deter-
mine the highest grade of tumour (as there is frequently inhomogeneity across the tumour), any vascular
or lymphatic invasion or invasion of adjacent tissues. Spread into a body space such as the pleural or
peritoneal cavity affects T staging, as it changes prognosis.
Numbers are added to indicate the extent of the disease. For example, T0 implies no primary tumour
(as after spontaneous regression of a melanoma). Categories T1–4 indicate tumours of increasing size
and/or involvement of lymphatic vessels or surrounding tissue. If it is impossible to ascertain the size or
extent of the primary tumour, it is designated Tx.
What You Need to Know before Planning Radiotherapy Treatment 3

N classification describes whether there is lymph node involvement and, if so, how many nodes are
involved. Pathological staging requires adequate excision of the relevant lymph node compartment, and
a minimum number of nodes which indicates that this has been achieved may be defined for each site. If
there are positive nodes, the ratio of negative to positive is of prognostic significance. For example, one
node positive out of four removed indicates a worse prognosis than one out of 12. The size of tumour in
the nodes must be recorded, along with any extension through the capsule. Micrometastases are classi-
fied differently from tumour emboli in vessels, and this affects the N staging.
Identification and sampling of a sentinel node may give useful prognostic information about other
potential node involvement and help to choose appropriate treatment strategies. In breast cancer, for
example, it appears highly predictive (90 per cent) for axillary node involvement.
M category indicates presence (M1) or absence (M0) of metastases to distant sites.
For some sites, other staging systems have proved clinically more useful. These include the FIGO
system for gynaecological malignancy and Dukes’ classification of colonic tumours. Useful atlases of
patterns of lymph node involvement have been devised for several tumor sites. These are included in
subsequent chapters where relevant. Recommendations for the most appropriate imaging techniques for
staging in different sites have been published.
Residual tumour after surgical excision is an important poor prognostic factor. Examination of resec-
tion margins assigns tumours to categories: R0, no residual tumour; R1, histologically detectable tumour
at margins; and R2, macroscopic evidence of residual tumour. Where serum markers (S) convey impor-
tant prognostic information, as in tumours of the testis, an S category has been introduced to the TNM
system.
TNM categorisation is often used to group tumours subsequently into stages indicating local and
metastatic extent and correlating with likely outcome.
Grading is defined by degree of differentiation: G1, resemblance to tissue of origin; G2, moderately
well differentiated; G3, poorly differentiated; and G4, undifferentiated tumours; with Gx used when it is
not possible to determine grading, as for example from a damaged specimen. GB signifies a borderline
malignant tumour (for example in the ovary). Grading systems reduce the subjective element of these
assessments.

Performance Status and PROMs

Performance status measures attempt to quantify cancer patients’ general well-being. They are used
to help to decide whether a patient is likely to tolerate a particular treatment such as curative radical
radiotherapy or palliative chemotherapy, whether doses of treatment need to be adjusted or whether the
patient’s life expectancy is good enough to allow them to survive to see a benefit from treatment. The
status of all patients should be recorded using one of these scores at presentation and with any change in
treatment or the disease. They are also used as a measure of quality of life in clinical trials.
There are various scoring systems; the most commonly used are the Karnofsky (KPS) and WHO per-
formance status scales for adults, and the Lansky score for children. The SF-36 is a short form (SF) sur-
vey (originally with 36 questions, now 12) which gives a profile of overall mental and physical health. It
has produced statistically reliable and valid results in many reported studies. There are modifications of
this questionnaire for specific tumour sites. Another commonly used scale in quality-of-life assessment
is the HADS (Hospital Anxiety and Depression Scale), which is used to measure changes in mental and
emotional well-being during treatment or with the progression of the disease. For palliative radiotherapy,
the Chow score and TEACHH models use factors such as site of metastases, primary cancer site, previ-
ous radiotherapy and KPS to produce a score that may assist in identifying those patients most likely to
benefit from treatment.
Patient-reported outcome measures (PROMs) are increasingly used in cancer patients. They are valuable
to collect data on a patient’s quality of life. The data is documented by patients directly without interpre-
tation or bias from a clinician. PROMs were initially developed for use in research but are being increas-
ingly introduced in routine clinical settings. PROMs provide more detailed and patient-centred measures
than performance status alone. Patients complete questionnaires on their health and quality of life.
4 Practical Radiotherapy Planning

Patients are often involved in the designing and development of PROMs, including the time points during
their cancer journey that the data is collected. The data from PROMs can be used to tailor an individual
patient’s care as well as being utilised by health care providers to improve patient services in general.
EORTC QLQ-C30 is an example of a questionnaire with a nine multi-item scale that evaluates functional
status, symptoms, and global health and quality of life.

Prognostic Factors
All possible information which may help in predicting prognosis should be collected in order to advise
the patient and help make the most appropriate treatment decision.
Screen-detected cancers may have a better prognosis than tumours presenting symptomatically
because diagnosis is made earlier. The UK has three screening programmes: bowel cancer, breast cancer
and cervical cancer. Screening for prostate cancer is available but controversial. There is no national lung
cancer screening programme, but the NHS offers a service called Targeted Lung Health Checks.
Histological tumour type, grading and staging are most influential in determining the outcome for
an individual patient, and new techniques of tumour examination are yielding more information on
gene function and expression, which may affect prognosis. Other factors which must also be considered
include epidemiological factors such as age and sex; lifestyle factors such as smoking, alcohol and other
drug use; obesity; and family history of disease. Other biological factors such as performance status,
which may reflect comorbidities, must be considered.
Biochemical tumour markers may be specific enough to give prognostic information by their absolute
value, as for example β subunit of human chorionic gonadotrophin (β-hCG) levels in testicular cancer.
Tumour markers may be only relatively poorly correlated with tumour volume, such as carcinoembry-
onic antigen (CEA) in bowel cancer, but still be useful to indicate treatment response or disease progres-
sion by their rise or fall.
One of the most important prognostic factors is whether there is effective treatment for the condition.
Because new treatments are being introduced all the time, prognostic predictions must also be constantly
reviewed and validated in prospective controlled clinical trials. An example is Oncotype DX assay (21
gene assay) test predicting the likelihood of chemotherapy benefit in women with early breast cancer
based on TailorX study.
For some tumours, predictive tools based on population data sets are available, such as ‘Predict’ for
breast cancer, and Partin tables and the Memorial Sloane Kettering nomogram for prostate cancer.
Predictive indicators are variables determined before treatment which give information on the probabil-
ity of a response to a specific treatment. Predictive indices based on multiple indicators give an individual
score which may help to make decisions. These tools can only be developed by painstaking retrospec-
tive analysis and careful prospective studies, but it is likely that their use will increase steadily. They are
important in determining strategies for treating different tumour subsets in guidelines and protocols.
Increasingly, specific genetic profiles are correlated with natural history of disease or outcome of
treatment. Examples are the predictive value of MYCN amplification in neuroblastoma, oestrogen/
HER2 receptor status and response to hormone therapy or trastuzumab, and predilection of patients with
Li–Fraumeni syndrome to develop second tumours. Microarray technology will provide more geneti-
cally determined prognostic factors which will have to be taken into account in planning treatment.

Influence of Other Treatments on Radiotherapy

Surgery is most commonly used as a primary treatment for cancer. If performed before radiotherapy, it
removes the gross tumour volume (GTV) so that a clinical target volume alone (CTV) is used for plan-
ning (see Chapter 2).
If it is known from the time of diagnosis that both treatments will be needed, the best sequence has to
be decided. If the tumour is initially inoperable, radiotherapy first may produce tumour shrinkage which
makes complete excision possible, thereby improving outcome. Radiotherapy may increase surgical
What You Need to Know before Planning Radiotherapy Treatment 5

complications if the interval between the two treatments is not optimal. Surgery before radiotherapy will
alter normal anatomy, causing problems for planning unless pre- and postsurgical image co-registration
is used.
Effective systemic therapy may produce complete resolution of the primary tumour (no residual GTV),
and potentially increased acute normal tissue effects. The treatment the patient receives will be the best
possible only if all these potential interactions are taken into consideration by all members of the team
working together.
A true therapeutic gain from radiotherapy and chemotherapy together requires either more cell kill for
the same level of normal tissue damage (which is useful in radio-resistant tumours) or the same cell kill
with reduced normal tissue effects (useful for tumours cured with low-dose radiotherapy). Radiotherapy
with concomitant chemotherapy is now used for many tumours. It may improve outcomes by promoting
spatial cooperation in cell killing, where the chemotherapy kills metastatic cells and the radiotherapy
kills those cells in the local tumour, or in-field cooperation where exploitation of differing molecular,
cellular or tissue effects produces more cell kill than when the two agents are given sequentially. There
has been a recent increase in the use of immunotherapy, which has significantly improved outcomes in
some cancers. Radiation-induced cancer cell damage exposes tumour-specific antigens, making them
visible to immune surveillance, and can also modulate the tumour microenvironment, facilitating the
recruitment and infiltration of immune cells. Clinical studies are currently underway combining radia-
tion with immunotherapy check point inhibitors.
Patients themselves may be using alternative therapies with possible effects on efficacy and com-
plications of surgery, radiotherapy and systemic therapies. Antioxidants may interfere with free rad-
ical production, which effects radiotherapy cell kill. St John’s wort, used for depression, may affect
the metabolism of some drugs. Aspirin and gingko biloba may increase risk of bleeding, and phyto-­
oestrogens may affect hormonally sensitive cancers. Lifestyle factors such as smoking or eating too
many vegetables during radiotherapy may influence the severity of acute treatment side effects such as
mucositis or diarrhoea.

Systems for Recording Outcomes of Treatment

The most commonly used set of tumour response criteria is the Response Evaluation Criteria in Solid
Tumours (RECIST). There are other response criteria used for specific tumour types. Other outcomes
are recorded as the time to a specific event: time to progression for tumours with partial response
(progression-free survival), time to local recurrence where there has been a complete response (relapse-
free survival), time to distant metastases, time to death from any cause (overall survival) or time to sec-
ond malignancy. The start and end dates for these time periods must be clearly defined and stated as, for
example, date of first treatment, date of randomisation, date of imaging of relapse or date of histological
proof of relapse. There is still no clear convention for defining these dates.
Quality-of-life measures are also essential for assessing treatment effects. Standardised scales such as
the EORTC, QLQ-C36 and C30 have been validated and can be used for many cancer sites and in many
countries.
Acute side effects can be recorded using the Common Terminology Criteria for Adverse Events
(CTCAE V5.0, November 2017). This is a comprehensive system that is used in all clinical trials. Late
effects are recorded either using the Radiation Therapy Oncology Group (RTOG) criteria, the European
LENT-SOMA classification or other simpler schemes for individual body sites.

Clinical Anatomy
Modern radiotherapy planning requires a comprehensive knowledge of cross-sectional anatomy and
the ability to visualise structures in three dimensions. Formal teaching in anatomy should be part of
training, using standard atlases and various online resources, e.g. RTOG contouring atlases. We attempt
to give some relevant anatomical details in the following chapters, but collaboration with a diagnostic
6 Practical Radiotherapy Planning

radiologist can be essential for accurate GTV delineation. Oncologists will tend to develop expertise
in their own specialist areas but are unlikely to be familiar with all the possible normal variants and
anomalies which may occur.

Protocols and Guidelines

In the UK, there has been a proliferation of guidance, guidelines and protocols for the management of
cancer. Some, such as Improving Outcomes Guidance (IOG) and decisions of the National Institute for
Health and Clinical Excellence (NICE), have a mandatory element which ensures their adoption. The
firmest base for clinical decision-making is evidence of effectiveness of treatment from well-designed
prospective randomised clinical trials (RCTs). Where this is lacking, careful analysis of outcomes data
can be very informative and has the advantage of wider generalisability. National and international trial
protocols offer useful information for treatment planning, as they represent current consensus on best
clinical practice; for example, how to scan lung cancers for treatment planning, or what quality assurance
programme to use. Departments must have their own written protocols for treatment at different sites to
ensure consistency and quality and to avoid errors.
Not all patients’ circumstances will fit within standardised guidelines and protocols, although these
should be followed whenever possible for best outcomes. However, with the rate of change in treatment
in oncology, there should be a constant cycle of writing guidelines and then using, auditing, challenging
and rewriting them.

INFORMATION SOURCES
Amin JB, et al. AJCC Cancer Staging Manual, 8th ed. Springer, 2017: www.cancerstaging.org.
Chow E, et al. Predictive model for survival in patients with advanced cancer. J Clin Oncol 2008;26:5863–5869.
Common Terminology Criteria for Adverse Events (CTCAE) v5.0, 2017: www.ctep.cancer.gov.
Eisenhauer EA, et al. New response evaluation criteria in solid tumors: Revised RECIST guideline (Version 1.1).
Eur J Cancer 2009;45:228–247.
Krishan MS, et al. Predicting life expectancy in patients with metastatic cancer receiving palliative radio-
therapy: The TEACHH model. Cancer 2014;120:134–141.
National Institute for Clinical Excellence (NICE), Guidelines: www.nice.org.uk/guidance.
Schwartz LH, et al. RECIST 1.1 – Update and clarification: From the RECIST committee. Eur J Cancer 2016
Jul;62:132–137.
World Health Organization, International Classification of Disease (ICD), v11, 2020: https://www.who.int/
standards/classifications/classification-of-diseases.
World Health Organization, International Classification of Disease for Oncology, v3 (ICD-O-3.2), 2019:
https://www.who.int/standards/classifications/other-classifications/international-classification-of-
diseases-for-oncology.
2
Principles of Radiotherapy Planning

The practice of radiotherapy requires not only excellent clinical skills but also appropriate technical
expertise. Chapter 1 considered some of the factors that contribute to making good clinical judgements;
Chapter 2 outlines the specialist knowledge required to plan radiotherapy treatment.

Target Volume Definition

A common international language for describing target volumes is found in International Commission
on Radiation Units (ICRU) published recommendations Report 50 (1993), 62 (1999), 71 (2004) and 83
(2010). These contain clear definitions (Figure 2.1) to enable centres to use the same criteria for delin-
eating tumours for radiation so that their treatment results can be compared. The latest report includes
definitions for Intensity Modulated Radiotherapy (IMRT).
The American Association of Physicists in Medicine Report 263 gives guidance on the naming of
target volumes. These should be followed wherever possible to enable better data analysis within and
between departments.

Gross Tumour Volume

Gross tumour volume (GTV) is the primary tumour or other tumour mass shown by clinical examina-
tion, at examination under anaesthetic (EUA) or by imaging. GTV is classified by staging systems such as
TNM (UICC), AJCC or FIGO. Tumour size, site and shape may appear to vary depending on the imaging
technique used, and an optimal imaging method for each particular tumour site must therefore also be
specified. A GTV may consist of a primary tumour (GTVp) and/or a metastatic lymphadenopathy (GTVn).
GTV always contains the highest tumour cell density, and is absent after complete surgical resection.

Clinical Target Volume

Clinical target volume (CTV) contains the GTV when present and/or subclinical microscopic disease
that has to be eradicated to cure the tumour. The CTV definition is based on histological examination

FIGURE 2.1 ICRU target volume definitions showing GTV, CTV, PTV, treated volume and irradiated volume. (Reproduced
with permission from ICRU [1993] Prescribing, Recording and Reporting Photon Beam Therapy. ICRU report 50.)

DOI: 10.1201/9781315171562-2 7
8 Practical Radiotherapy Planning

of postmortem or surgical specimens that assesses the extent of tumour cell spread around the gross
GTV, as described by Holland et al. (1985) for breast cancer. The GTV-CTV margin is also derived
from biological characteristics of the tumour, local recurrence patterns and experience of the radiation
oncologist. A CTV containing a primary tumour may lie in continuity with a nodal CTV to form a con-
tiguous combined CTV (e.g. tonsillar tumour and ipsilateral cervical nodes). When a potentially involved
adjacent lymph node which may require elective irradiation lies at a distance from the primary tumour,
separate CTVp and CTVn are used (Figure 2.2), e.g. an anal tumour and the inguinal nodes.
Variation in CTV delineation by the clinician (‘doctor’s delineation error’) is the greatest geometrical
uncertainty in the whole treatment process. Studies comparing outlining by radiologists and oncologists
have shown a significant inter-observer variability for both the GTV and/or CTV at a variety of tumour

FIGURE 2.2 ICRU illustrations to show (a) GTV-T plus GTV-N in continuity (CTV-TN) and (b) CTV-T and CTV-N at a
distance. (Reproduced with permission from ICRU [2004] Prescribing, Recording and Reporting Electron Beam Therapy.
ICRU report 71.)