Prostate Fossa Contouring Guide Jill Gunther, MD Modified by the eContour Team
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ProstateFossaContouringGuide
JillGunther,MDModifiedbytheeContourTeam
Youwanttocontour:Post-opProstateWhatnow?
• Findyourreferences– RTOGProstateFossaContouringAtlas
• hDps://www.rtog.org/CoreLab/ContouringAtlases/ProstatePostOp.aspx
– ConsensusguidelinepublicaJons• Michalski,IJROBP2010• Wiltshire,IJROBP2007
– RTOGtrialswithcontouringdescripJonsforIMRTdescribedintheprotocol
• RTOG0534(ongoing)– eContour.orgaimstobeyourone-stopshopforhighyieldanatomyandcontouringguidelines,includinghyperlinkstoeachoftheabove!
Youwanttocontour:Post-opProstateCheckeContour.orgforguidance!
1. FromHOMEPAGEclickCASES
2. GUàProstateàpost-prostatectomy(notintact)
3. Reviewanatomy
4. DrawOARs(rectumandpenilebulb)
5. DrawtheCTV
6. Addmargin/expansiontocreatefinalPTVfortreatmentplanning.
Quickreviewofbasicanatomyofprostate/pelvis
BladderSacrum
Seminalvesicles(proximaljustmeanssegmentclosetoprostate)
Rectum
Prostate
Pubicsymphysis
SagiDalviewBaseofprostate
Apexofprostate
SeminalVesicles
CoronalviewBladder
Prostate
Rectum
Bladder
Prostate
Femoral heads
Axial view
AnatomicalBordersofPost-OpCTVforProstateCancer
Michalski,IJROBP,2010
StarJngInferiorly• Findthelowestsliceaccordingtoyourguidelines
• Locatethevesicourethralanastomosis(VUA)whichiswherethebladderwasreaDachedtotheurethraaberremovaloftheprostate
• IfdifficulttolocateVUA,usesliceabovepenilebulb
VUA
StartCTV:4slicesbelowVUA
Eachslice=2.5mm,so4slicesputsus10mmbelowVUA
ScrollingthroughCTimages,movingsuperiorly
Levatorani
Posterioredgeofpubicbone
Boundaries(inferiortopubicsymphysis)
Anteriorrectalwall
Obturatorinternusmuscle
Posterioredgeofpubicbone
Anteriorrectalwall
Obturatorinternus
Boundaries(inferiortopubicsymphysis)
Whataboutthebladder?
Includeit!ThisisthepreviouslocaJonoftheprostate
Mayneedtobeconcavearoundlateralaspects
WhendoIstop?
Theseboundariesapplyonlytobelow(inferior)thesuperioredgeofpubicsymphysis
Soabovesymphysisweneednewboundaries
NeedtotransiJondowntoincludingonly1-2cmposteriorbladderwall
Startpullingbackposteriorly
ConJnuepullingbackposteriorlyoverafewslicesunJl…
Green=BladderminusCTV
ConJnuethisstepwisereducJoninvolumeoverseveralCTslices
Include1-2cmposteriorbladderwall
Obturatorinternus*
Posterior1-2cmbladderwall
Mesorectalfascia/rectalwall
Vasdeferensmayretractpost-op;includeSVremnantsifpathologicalyinvolved
Includeallsurgicalclipsthatarefelttobeintheprostatebed
(canhaveclipsfromnodaldissecJon)
WhendoIstop?
WhendoIstop?
SagiDalview 3-4cmabovepubicsymphysis
8-12mmbelowvesico-urethralanastomosis(justabovepenilebulb)
Coronalview
AlwayscheckcoronalandsagiDalviewstomakesureyourvolumemakessense
Guidelinesareguidelines
• ConsiderwhatiscorrectforeachpaJent• WherewashisiniJaldisease?• WasthereextraprostaJcextension?
– Where?• Weretheseminalvesiclesinvolved?• WasthereaposiJvemargin?Ifso,where?
• Thatsaid,usingconsensusguidelinesortreatedperprotocolisusuallyasafeapproach!
DISCLAIMER:EachcaseisuniqueandrequiresdecisionmakingbasedonclinicaljudgmentofthetreaHngphysician.
SomeaddmoremargintoguidelineswithconsideraJonofspecificpaJentriskfactors
Extendintopubicsymphysis(ex.PaJentwithanteriorlesionwithanteriorEPE
SVfossacontouredseparately
Extendedintoanteriorrectalwall(ex.PaJenthasclipssikngalongrectalwall)
References• RTOGcontouringatlas
– hDp://www.rtog.org/CoreLab/ContouringAtlases/ProstatePostOp.aspx
• Wiltshire,K.L.,etal.(2007)."Anatomicboundariesoftheclinicaltargetvolume(prostatebed)aberradicalprostatectomy."IntJRadiatOncolBiolPhys69(4):1090-1099.
• Michalski,J.M.,etal.(2010)."DevelopmentofRTOGconsensusguidelinesforthedefiniJonoftheclinicaltargetvolumeforpostoperaJveconformalradiaJontherapyforprostatecancer."IntJRadiatOncolBiolPhys76(2):361-368.
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