Final simulation protocols in GYN malignancies
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Simulation is the most critical step of radiation planning for an optimal outcome
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Final simulation protocols in GYN malignancies
- 1. Simulation Protocol: GYN Dr Ajeet Kumar Gandhi MD (AIIMS), DNB, UICCF (MSKCC,USA) Assistant professor, Radiation oncology Dr RMLIMS, Lucknow
- 2. Patient preparation, Immobilization, Imaging, Simulation etc. Target /OAR delineation DRR, Beam placement, Plan generation, Evaluation Treatment verification, Treatment delivery
- 3. Prior to simulation Clinical examination and documentation Review imaging, staging Anatomical variations/need of nodal boost/para-aortic irradiation Finalize intended treatment plan Technique of RT (Conventional/conformal) Counselling about treatment course, expected outcome, acute and late side effects
- 4. Prior to simulation Written informed consent Part preparation (perineum) Bowel preparation Bisacodyl tablets Treatment of constipation Instructions to maintain bowel clearance throughout treatment
- 5. Positioning of patient Should be reproducible, comfortable Supine position Most commonly used in GYN EBRT Hands on chest or above head Legs straight and heel together Prone position May be used with a belly board In post-operative cases of cervix and Endometrium
- 7. Positioning of patient Frog Leg position Used in vulvar and vaginal cancer Intended treatment volume: Inguinal nodes
- 9. Immobilization Avoid in obese patients Use a six-clamp device Tattoo upper and lower borders for reproducibility May cut the orifit and put skin tattoos Avoid in frog leg position
- 10. Immobilization
- 11. Organ filling protocols: Bladder Bladder: Empty bladder Full bladder (varying protocols 500-1000 ml) Comfortable filling (450-500 ml before 1 hour)
- 12. ITV Concept Scan empty bladder with Intravenous contrast Administer oral contrast Scan full bladder Both in treatment position Fuse both the images
- 13. Organ filling protocols: Rectum Maintain rectal clearance throughout Advice on day of simulation and throughout Don’t hesitate to repeat scan if rectum is too much loaded
- 14. Markers and wires Put internal vaginal marker (lower extent of disease or vault) Temporary manual Titanium clips Barium soaked gauze Marker at the perineum Wire palpable nodes, post-op scars
- 15. Contrast materials Intravenous contrast (Inj. Omnipaque/Iomerol @ 2cc/kg) preferably via an automatic timed contrast injector), unless medically contraindicated or patients had history of contrast allergy.
- 16. Contrast materials An oral contrast may be used to opacify small bowel (optional) Per-rectal barium for localizing the rectum Per-vaginal barium
- 17. CT Simulation Field of view: Large (80-85 cm) Pelvic RT: Upper border of T12 Vertebrae to 5cm below ischial tuberosity Slice thickness: (2.5-5 mm) ≤ 5 mm No interslice gap Table increments: 3mm Flat table couch
- 18. PET-CT Simulation: Investigational Active bone marrow delineation: Bone marrow sparing IMRT Nodal boost: SIB-IMRT
- 19. Adaptive RT: Investigational Uncertainties Dosimetric Radiobiological Contouring
- 20. Take home message!! Simulation is one of the most important step of radiation therapy planning Requires pre-planning, counselling Comfortable and reproducible immobilization and positioning Take care of organ filling (inter and intra- fraction) PET-CT simulation and adaptive RT are investigational
- 21. Thank you!!