Rectal

Cancer Contouring Guide

eContour Team
 You want to contour: Rectal Cancer
What now?
•  Find your references
–  RTOG contouring atlas for anorectal:
•  h<ps://www.rtog.org/CoreLab/ContouringAtlases/Anorectal.aspx
•  NOTE: this was created for BOTH anal and rectal cancer, which are treated quite
differently, so pay a<enIon!
•  PublicaIon validaIng the above atlas: Myerson et al. IJROBP 2009:
h<p://www.ncbi.nlm.nih.gov/pubmed/19117696
–  RTOG protocols?
•  RTOG 0822 actually showed no difference between IMRT and 3D-CRT. While this could
sIll be a reference to guide contouring for 3D block placement per the 3D-CRT arm, let’s
sIck with the published atlas.
–  ARROContour: CAUTION! not peer-reviewed, but a resident presentaIon
created by ARRO (ASTRO’s Resident Commi<ee)
•  h<ps://www.astro.org/uploadedFiles/_MAIN_SITE/Affiliate/ARRO/Resident_Resources/
EducaIonal_Resources/ARROcase/Content_Pieces/ARROContourRectal.pdf

*eContour.org aims to be your one-stop shop for contouring guidelines, with

hyperlinks to above high-yield references!
 Let eContour.org help you!

1.  Select CASES

2.  From dropdown case list:

GI à Rectal à pre-op
3.  Draw the GTV

4.  Review pelvic anatomy

5.  Draw CTV

6.  Add margin/expansion to

create final PTV for treatment
planning

7.  BONUS: Draw “blocks”

 Step 1: Contour the GTV

In eContour:

1.  Turn contours OFF
2.  Toggle overlay to
MRI Gross
3.  Scroll through tumor
slices to view
extent of tumor
4.  Start your contour
where the tumor is
obvious
 Contour GTV inferiorly
Assessment à

ALWAYS check
your volume
against exam/
colonoscopy
findings since
imaging is less
sensiIve


Toggle between
MRI and CT
Measure distance GTV to anal verge
(OpIon 1)
Look in lower lek of
your screen for the “Z”
coordinate on last GTV
slice (-6.98cm here).

Scroll down unIl you
see the anal verge and
again note the
coordinate (-12.98cm
here).

The difference is ~6cm,
which was the distance
noted on exam (which is
be<er than imaging!).
Measure distance GTV to anal verge
(OpIon 2)

Orient yourself in 3D using

the CROSSHAIRS in…
green (coronal), blue (axial),
red (sagi<al)
 Try using the measuring tool
From this paIent’s
Assessment, we know that
on exam the tumor is
located 6cm from anal
verge…let’s double check
where we are at on
SAGITTAL!

TIP: In the SAGITTAL view,
use the measuring tool to
check the verIcal extent of
your contour.
 NOTICE: lymph nodes!*
How do you know if
it’s a lymph node or a
vessel?
1.  Use MRI overlay
2.  Scroll up and
down: nodes will
be rounded
Enlarged structures that
perirectal disappear then
lymph node reappear
3.  Contour the
vessels before
contouring the
GTV

*NOTE: These sub-cenEmeter perirectal nodes are contoured in the GTV to show you they
are in the standard CTV. These DO NOT need to be contoured unless grossly enlarged.
Step 2: Review anatomy of pelvic vessels
(which will define lymph nodes at risk!)

In eContour:

1.  Turn off all
contours
EXCEPT
“Anatomy”
2.  Contours
start where
aorta and
IVC branch
3.  Scroll
inferiorly,
following
branches
Axial view of vessels
 Can you follow these vessels on CT?

Lymph nodes sit

1.  Now turn off on vessels (just
ALL contours can’t see them
2.  Start at when not
abdominal enlarged).
aorta
3.  Scroll inferiorly, This is why we
following contour vessels in
branches nodal CTV

Aorta (artery) or IVC (vein) à Common Iliacs (R and L) à Internal iliac (go posterior/in front
of sacrum) and External Iliacs (go anterior…become inguinal/femoral when exit pelvis)
 Use anatomy contours

Confirm your findings by individually turning on the contours for each structure
 Step 3: Contour your CTV
These are the consensus CTVs for anorectal cancer

RTOG Anorectal contouring atlas

In rectal cancer, external iliac nodes (CTVB) and inguinal nodes (CTVC) are not at risk of tumor
spread*, so we will only contour CTVA
(*FYI The anal canal drains to the inguinal nodes, which is why they are treated in anal cancer)
 Caudal (inferior) extent of CTV
(Muscles and connecIve Issue of pelvic floor are be<er visualized with MRI)

1.  CTV should

extend at least to
the pelvic floor,
even if upper
rectal cancer
Pelvic floor
2.  Extend to a Levator ani
minimum of 2cm
caudad to GTV

Mesorectum
(peri-rectal)
 CTV in low pelvis

Scrolling through the CT images, moving superiorly

 CTV in low pelvis

Posterior and
lateral margins:
Extend to lateral Anterior margin:
pelvic muscles or Extend into
bone prostate/seminal
vesicles in a male
(vagina for female)
 CTV in mid-pelvis

CTVA covers:
Rectum Anterior margin:
Mesorectum Extend 1 cm into
Internal iliac vessels posterior
Presacral space bladder wall

Mesorectum Prsacral
(peri-rectal)
 Moving superiorly in CTV

Include internal iliac

arteries and veins
DO NOT include
NOTICE: posterior muscle or bone
border of CTV abuts
external iliac vessels
(which we do NOT
include unless T4
tumor invading
prostate or vaginal
anteriorly)

Lymph node Presacral

 Cephalad (superior) extent of CTV

ConInue contour
up to where the
common iliacs
bifurcate OR L5/S1
interspace*

*Rad onc is amid a transiIon away from bony anatomy to guide contours (instead contouring
sok Issue), but it sIll pervades in many ways – including pelvic nodal upper borders (ie L5/S1).
 Step 4: Add a CTV Boost volume

Extend CTV to cover

SequenIal boost
enIre mesorectum
means addiIonal
and presacral region
treatments to give
at level of GTV, with
higher dose to
a minimum 2cm
smaller volume
margin on GTV
cephalad and caudad

But how do I do
this?? Next slide…
 Add margin for CTV Boost
1.  Start with 2cm margin
from GTV using “Margin
for Structure” à

2.  If enIre mesorectum and

presacral area is not included
in this 2cm expansion, use
brush/pen to expand contour
(next slide)

3.  “Crop” contour that extends

outside CTV (next slide)
 EdiIng CTV Boost
CTV Boost
CTV (incl nodes)
Now we have 2 problems:
1.  The enIre
mesorectum is not
included in our
volume
–  SOLUTION: Use pen/
brush to expand the
volume (final CTV
Boost in dark green)

2.  The contour extends

outside CTV (and into
bone!)
–  SOLUTION (next slide)
Current CTV Boost structure shown in RED
 EdiIng CTV Boost

“Crop” contour that

extends outside CTV à




NOTE: SomeImes you will want to crop
with an addiIonal margin (ie 0.3cm
margin PTV to skin in H&N)
 Step 5: Add a margin for PTV
7-10mm margin on
CTV is usually
sufficient to account
for pelvic moIon

CTV+7mm = PTV à

We’ve done this

before …
Add a margin
for PTV

NOTE: all margins same

“Margin for structure”

REPEAT this step for CTV boost

 Sagi<al Coronal

Always check your final volumes in sagi<al and coronal views to make
sure you have contoured a volume that makes sense in 3 dimensions!

BONUS: You can compare your volumes to “bony anatomy” blocks (next slide)
Images reproduced from:
h<ps://www.astro.org/uploadedFiles/_MAIN_SITE/Affiliate/ARRO/Resident_Resources/EducaIonal_Resources/ARROcase/Content_Pieces/ARROContourRectal.pdf
 FOR FUN:
Draw blocks/MLCs!
You will need to go to “External Beam Planning” in
your treatment planning system

eContour à “Pearls” tab describes borders for 3D
conformal blocks

NOTE: classic borders for a 3-field beam
arrangement were based on BONY ANATOMY. With
CT simulaIon, we can contour areas at risk, and
decrease our margins. However, fancy treatment
planning (with IMRT) did not improve outcomes on
RTOG 0822 (which is DIFFERENT from anal cancer).

The margin from PTV to “block edge” (meaning, the
shape of you MLCs) is suggested to be about 7mm
because the dose at the end of the field is ~50%
(requires some build-up in Issue to get to 100%
prescripIon dose).
 References
•  RTOG contouring atlas for anorectal:
–  h<ps://www.rtog.org/CoreLab/ContouringAtlases/Anorectal.aspx
–  NOTE: this was created for BOTH anal and rectal cancer, which are treated
quite differently, so pay a<enIon!
–  PublicaIon validaIng the above atlas: Myerson et al. IJROBP 2009:
h<p://www.ncbi.nlm.nih.gov/pubmed/19117696
•  RTOG protocol
–  RTOG 0822 actually showed no difference between IMRT and 3D-CRT. This
could sIll be a reference to guide contouring and placement of 3D blocks per
the 3D-CRT arm.
–  h<ps://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?
study=0822
•  ARROContour: CAUTION! not peer-reviewed, but a resident presentaIon
created by ARRO (ASTRO’s Resident Commi<ee)
–  h<ps://www.astro.org/uploadedFiles/_MAIN_SITE/Affiliate/ARRO/
Resident_Resources/EducaIonal_Resources/ARROcase/Content_Pieces/
ARROContourRectal.pdf