William Small1, Walter R Bosch2, Mathew M Harkenrider3, Jonathan B Strauss4, Nadeem Abu-Rustum5, Kevin V Albuquerque6, Sushil Beriwal7, Carien L Creutzberg8, Patricia J Eifel9, Beth A Erickson10, Anthony W Fyles11, Courtney L Hentz3, Anuja Jhingran9, Ann H Klopp9, Charles A Kunos12, Loren K Mell13, Lorraine Portelance14, Melanie E Powell15, Akila N Viswanathan16, Joseph H Yacoub3, Catheryn M Yashar13, Kathryn A Winter17, David K Gaffney18. 1. Loyola University Stritch School of Medicine, Maywood, Illinois. Electronic address: wmsmall@lumc.edu. 2. Washington University School of Medicine, St. Louis, Missouri. 3. Loyola University Stritch School of Medicine, Maywood, Illinois. 4. Northwestern University, Chicago, Illinois. 5. Memorial Sloan Kettering Cancer Center, New York, New York. 6. UT Southwestern Medical Center, Dallas, Texas. 7. UPMC-Hillman Cancer Center, Pittsburgh, Pennsylvania. 8. Leiden University Medical Center, Leiden, The Netherlands. 9. MD Anderson Cancer Center, Houston, Texas. 10. Froedtert and the Medical College of Wisconsin, Milwuakee, Wisconsin. 11. Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada. 12. National Institutes of Health, Bethesda, Maryland. 13. UC San Diego Moores Cancer Center, La Jolla, California. 14. University of Miami Miller School of Medicine, Miami, Florida. 15. Saint Bartholomew's Hospital, London, United Kingdom. 16. Johns Hopkins University/Sidney Kimmel Cancer Center, Baltimore, Maryland. 17. NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania. 18. Huntsman Cancer Institute/University of Utah, Salt Lake City, Utah.
Abstract
PURPOSE: Accurate target definition is critical for the appropriate application of radiation therapy. In 2008, the Radiation Therapy Oncology Group (RTOG) published an international collaborative atlas to define the clinical target volume (CTV) for intensity modulated pelvic radiation therapy in the postoperative treatment of endometrial and cervical cancer. The current project is an updated consensus of CTV definitions, with removal of all references to bony landmarks and inclusion of the para-aortic and inferior obturator nodal regions. METHODS AND MATERIALS: An international consensus guideline working group discussed modifications of the current atlas and areas of controversy. A document was prepared to assist in contouring definitions. A sample case abdominopelvic computed tomographic image was made available, on which experts contoured targets. Targets were analyzed for consistency of delineation using an expectation-maximization algorithm for simultaneous truth and performance level estimation with kappa statistics as a measure of agreement between observers. RESULTS: Sixteen participants provided 13 sets of contours. Participants were asked to provide separate contours of the following areas: vaginal cuff, obturator, internal iliac, external iliac, presacral, common iliac, and para-aortic regions. There was substantial agreement for the common iliac region (sensitivity 0.71, specificity 0.981, kappa 0.64), moderate agreement in the external iliac, para-aortic, internal iliac and vaginal cuff regions (sensitivity 0.66, 0.74, 0.62, 0.59; specificity 0.989, 0.966, 0.986, 0.976; kappa 0.60, 0.58, 0.52, 0.47, respectively), and fair agreement in the presacral and obturator regions (sensitivity 0.55, 0.35; specificity 0.986, 0.988; kappa 0.36, 0.21, respectively). A 95% agreement contour was smoothed and a final contour atlas was produced according to consensus. CONCLUSIONS: Agreement among the participants was most consistent in the common iliac region and least in the presacral and obturator nodal regions. The consensus volumes formed the basis of the updated NRG/RTOG Oncology postoperative atlas. Continued patterns of recurrence research are encouraged to refine these volumes.
PURPOSE: Accurate target definition is critical for the appropriate application of radiation therapy. In 2008, the Radiation Therapy Oncology Group (RTOG) published an international collaborative atlas to define the clinical target volume (CTV) for intensity modulated pelvic radiation therapy in the postoperative treatment of endometrial and cervical cancer. The current project is an updated consensus of CTV definitions, with removal of all references to bony landmarks and inclusion of the para-aortic and inferior obturator nodal regions. METHODS AND MATERIALS: An international consensus guideline working group discussed modifications of the current atlas and areas of controversy. A document was prepared to assist in contouring definitions. A sample case abdominopelvic computed tomographic image was made available, on which experts contoured targets. Targets were analyzed for consistency of delineation using an expectation-maximization algorithm for simultaneous truth and performance level estimation with kappa statistics as a measure of agreement between observers. RESULTS: Sixteen participants provided 13 sets of contours. Participants were asked to provide separate contours of the following areas: vaginal cuff, obturator, internal iliac, external iliac, presacral, common iliac, and para-aortic regions. There was substantial agreement for the common iliac region (sensitivity 0.71, specificity 0.981, kappa 0.64), moderate agreement in the external iliac, para-aortic, internal iliac and vaginal cuff regions (sensitivity 0.66, 0.74, 0.62, 0.59; specificity 0.989, 0.966, 0.986, 0.976; kappa 0.60, 0.58, 0.52, 0.47, respectively), and fair agreement in the presacral and obturator regions (sensitivity 0.55, 0.35; specificity 0.986, 0.988; kappa 0.36, 0.21, respectively). A 95% agreement contour was smoothed and a final contour atlas was produced according to consensus. CONCLUSIONS: Agreement among the participants was most consistent in the common iliac region and least in the presacral and obturator nodal regions. The consensus volumes formed the basis of the updated NRG/RTOG Oncology postoperative atlas. Continued patterns of recurrence research are encouraged to refine these volumes.
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