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Final simulation protocols in GYN malignancies

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Final simulation protocols in GYN malignancies

  1. 1. Simulation Protocol: GYN Dr Ajeet Kumar Gandhi MD (AIIMS), DNB, UICCF (MSKCC,USA) Assistant professor, Radiation oncology Dr RMLIMS, Lucknow
  2. 2. Patient preparation, Immobilization, Imaging, Simulation etc. Target /OAR delineation DRR, Beam placement, Plan generation, Evaluation Treatment verification, Treatment delivery
  3. 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. 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. 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
  6. 6. Positioning of patient  Frog Leg position  Used in vulvar and vaginal cancer  Intended treatment volume: Inguinal nodes
  7. 7. Immobilization
  8. 8. 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
  9. 9. Immobilization
  10. 10. Organ filling protocols: Bladder  Bladder:  Empty bladder  Full bladder (varying protocols 500-1000 ml)  Comfortable filling (450-500 ml before 1 hour)
  11. 11. ITV Concept  Scan empty bladder with Intravenous contrast  Administer oral contrast  Scan full bladder  Both in treatment position  Fuse both the images
  12. 12. 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
  13. 13. 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
  14. 14. 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.
  15. 15. Contrast materials  An oral contrast may be used to opacify small bowel (optional)  Per-rectal barium for localizing the rectum  Per-vaginal barium
  16. 16. 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
  17. 17. PET-CT Simulation: Investigational Active bone marrow delineation: Bone marrow sparing IMRT  Nodal boost: SIB-IMRT
  18. 18. Adaptive RT: Investigational  Uncertainties Dosimetric Radiobiological Contouring
  19. 19. 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
  20. 20. Thank you!!

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