Tim J Kruser1, Walter R Bosch2, Shahed N Badiyan2, Joseph A Bovi3, Amol J Ghia4, Michelle M Kim5, Abhishek A Solanki6, Sean Sachdev7, Christina Tsien2, Tony J C Wang8, Minesh P Mehta9, Kevin P McMullen10. 1. Department of Radiation Oncology, Northwestern Memorial Hospital, 251 E Huron St, LC-178, Galter Pavilion, Chicago, IL, 60611, USA. tkruser@nm.org. 2. Department of Radiation Oncology, Washington University, St. Louis, MO, USA. 3. Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA. 4. Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA. 5. Department of Radiation Oncology, University of Michigan Hospital, Ann Arbor, MI, USA. 6. Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA. 7. Department of Radiation Oncology, Northwestern Memorial Hospital, 251 E Huron St, LC-178, Galter Pavilion, Chicago, IL, 60611, USA. 8. Department of Radiation Oncology, Columbia University Medical Center, New York, NY, USA. 9. Miami Cancer Institute, Miami, FL, USA. 10. Columbus Regional Health, Columbus, IN, USA.
Abstract
INTRODUCTION: NRG protocols for glioblastoma allow for clinical target volume (CTV) reductions at natural barriers; however, literature examining CTV contouring and the relevant white matter pathways is lacking. This study proposes consensus CTV guidelines, with a focus on areas of controversy while highlighting common errors in glioblastoma target delineation. METHODS: Ten academic radiation oncologists specializing in brain tumor treatment contoured CTVs on four glioblastoma cases. CTV expansions were based on NRG trial guidelines. Contour consensus was assessed and summarized by kappa statistics. A meeting was held to discuss the mathematically averaged contours and form consensus contours and recommendations. RESULTS: Contours of the cavity plus enhancement (mean kappa 0.69) and T2-FLAIR signal (mean kappa 0.74) showed moderate to substantial agreement. Experts were asked to trim off anatomic barriers while respecting pathways of spread to develop their CTVs. Submitted CTV_4600 (mean kappa 0.80) and CTV_6000 (mean kappa 0.81) contours showed substantial to near perfect agreement. Simultaneous truth and performance level estimation (STAPLE) contours were then reviewed and modified by group consensus. Anatomic trimming reduced the amount of total brain tissue planned for radiation targeting by a 13.6% (range 8.7-17.9%) mean proportional reduction. Areas for close scrutiny of target delineation were described, with accompanying recommendations. CONCLUSIONS: Consensus contouring guidelines were established based on expert contours. Careful delineation of anatomic pathways and barriers to spread can spare radiation to uninvolved tissue without compromising target coverage. Further study is necessary to accurately define optimal target volumes beyond isometric expansion techniques for individual patients.
INTRODUCTION: NRG protocols for glioblastoma allow for clinical target volume (CTV) reductions at natural barriers; however, literature examining CTV contouring and the relevant white matter pathways is lacking. This study proposes consensus CTV guidelines, with a focus on areas of controversy while highlighting common errors in glioblastoma target delineation. METHODS: Ten academic radiation oncologists specializing in brain tumor treatment contoured CTVs on four glioblastoma cases. CTV expansions were based on NRG trial guidelines. Contour consensus was assessed and summarized by kappa statistics. A meeting was held to discuss the mathematically averaged contours and form consensus contours and recommendations. RESULTS: Contours of the cavity plus enhancement (mean kappa 0.69) and T2-FLAIR signal (mean kappa 0.74) showed moderate to substantial agreement. Experts were asked to trim off anatomic barriers while respecting pathways of spread to develop their CTVs. Submitted CTV_4600 (mean kappa 0.80) and CTV_6000 (mean kappa 0.81) contours showed substantial to near perfect agreement. Simultaneous truth and performance level estimation (STAPLE) contours were then reviewed and modified by group consensus. Anatomic trimming reduced the amount of total brain tissue planned for radiation targeting by a 13.6% (range 8.7-17.9%) mean proportional reduction. Areas for close scrutiny of target delineation were described, with accompanying recommendations. CONCLUSIONS: Consensus contouring guidelines were established based on expert contours. Careful delineation of anatomic pathways and barriers to spread can spare radiation to uninvolved tissue without compromising target coverage. Further study is necessary to accurately define optimal target volumes beyond isometric expansion techniques for individual patients.
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