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Practice Guideline
. 2015 Jul 15;92(4):911-20.
doi: 10.1016/j.ijrobp.2015.03.030. Epub 2015 Apr 2.

Expert Consensus Contouring Guidelines for Intensity Modulated Radiation Therapy in Esophageal and Gastroesophageal Junction Cancer

Abraham J Wu  1 , Walter R Bosch  2 , Daniel T Chang  3 , Theodore S Hong  4 , Salma K Jabbour  5 , Lawrence R Kleinberg  6 , Harvey J Mamon  7 , Charles R Thomas Jr  8 , Karyn A Goodman  9
Affiliations
Practice Guideline

Expert Consensus Contouring Guidelines for Intensity Modulated Radiation Therapy in Esophageal and Gastroesophageal Junction Cancer

Abraham J Wu et al. Int J Radiat Oncol Biol Phys. .

Abstract

Purpose/objective(s): Current guidelines for esophageal cancer contouring are derived from traditional 2-dimensional fields based on bony landmarks, and they do not provide sufficient anatomic detail to ensure consistent contouring for more conformal radiation therapy techniques such as intensity modulated radiation therapy (IMRT). Therefore, we convened an expert panel with the specific aim to derive contouring guidelines and generate an atlas for the clinical target volume (CTV) in esophageal or gastroesophageal junction (GEJ) cancer.

Methods and materials: Eight expert academically based gastrointestinal radiation oncologists participated. Three sample cases were chosen: a GEJ cancer, a distal esophageal cancer, and a mid-upper esophageal cancer. Uniform computed tomographic (CT) simulation datasets and accompanying diagnostic positron emission tomographic/CT images were distributed to each expert, and the expert was instructed to generate gross tumor volume (GTV) and CTV contours for each case. All contours were aggregated and subjected to quantitative analysis to assess the degree of concordance between experts and to generate draft consensus contours. The panel then refined these contours to generate the contouring atlas.

Results: The κ statistics indicated substantial agreement between panelists for each of the 3 test cases. A consensus CTV atlas was generated for the 3 test cases, each representing common anatomic presentations of esophageal cancer. The panel agreed on guidelines and principles to facilitate the generalizability of the atlas to individual cases.

Conclusions: This expert panel successfully reached agreement on contouring guidelines for esophageal and GEJ IMRT and generated a reference CTV atlas. This atlas will serve as a reference for IMRT contours for clinical practice and prospective trial design. Subsequent patterns of failure analyses of clinical datasets using these guidelines may require modification in the future.

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Figures

Figure 1
Figure 1
Examples of consensus contours encompassing defined nodal regions. A: CTV contour (yellow) encompasses level 3 retrotracheal (blue) and level 2 upper paratracheal (purple) nodes. B: CTV encompasses level 4 lower paratracheal (blue) and level 8 periesophageal nodes. C: CTV encompasses lesser curvature/gastrohepatic ligament (blue) and paracardial (purple) nodes. D) CTV encompasses para-aortic (blue) and celiac (purple) nodes.
Figure 1
Figure 1
Examples of consensus contours encompassing defined nodal regions. A: CTV contour (yellow) encompasses level 3 retrotracheal (blue) and level 2 upper paratracheal (purple) nodes. B: CTV encompasses level 4 lower paratracheal (blue) and level 8 periesophageal nodes. C: CTV encompasses lesser curvature/gastrohepatic ligament (blue) and paracardial (purple) nodes. D) CTV encompasses para-aortic (blue) and celiac (purple) nodes.
Figure 2
Figure 2
Example of consensus contour generation. Top: Superimposed panelists’ contours relative to the reference GTV (red). Bottom: STAPLE consensus contour (green) and final consensus contour (yellow).
Figure 3
Figure 3
Consensus contours for case 1 (T3N0, Siewert II gastroesophageal junction cancer. GTV in red)
Figure 4
Figure 4
Consensus contours for T3N1 distal esophageal cancer
Figure 5
Figure 5
Consensus contours for T3N1 proximal esophageal cancer.
See this image and copyright information in PMC

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