Mapping pelvic lymph nodes: Guidelines for delineation in intensity-modulated radiotherapy

Purpose: To establish guidelines for delineating the clinical target volume for pelvic nodal irradiation by mapping the location of lymph nodes in relation to the pelvic anatomy. Methods and Materials: Twenty patients with gynecologic malignancies underwent magnetic resonance imaging with administration of iron oxide particles. All visible lymph nodes were outlined. Five clinical target volumes were generated for each patient using modified margins of 3, 5, 7, 10, and 15 mm around the iliac vessels. The nodal contours were then overlaid and individual nodes analyzed for coverage. The volume of normal tissue within each clinical target volume and planning target volume was also measured to aid selection of the margin that could provide maximal nodal, but minimal normal tissue, coverage. Results: In total, 1216 nodal contours were evaluated. The nodal coverage was 56%, 76%, 88%, 94%, and 99% using vessel margins of 3, 5, 7, 10, and 15 mm, respectively. The mean volume of bowel within the planning target volume was 146.9 cm3 with a 7-mm margin, 190 cm3 with a 10-mm margin, and 266 cm3 with a 15-mm margin. Minor modification to the 7-mm margin ensured 99% coverage of the pelvic nodes. Conclusion: Blood vessels with a modified 7-mm margin offer a good surrogate target for pelvic lymph nodes. By making appropriate adjustments, coverage of specific nodal groups may be increased and the volume of normal tissue irradiated decreased. On the basis of these findings, recommended guidelines for outlining pelvic nodes have been produced. Purpose: To establish guidelines for delineating the clinical target volume for pelvic nodal irradiation by mapping the location of lymph nodes in relation to the pelvic anatomy. Methods and Materials: Twenty patients with gynecologic malignancies underwent magnetic resonance imaging with administration of iron oxide particles. All visible lymph nodes were outlined. Five clinical target volumes were generated for each patient using modified margins of 3, 5, 7, 10, and 15 mm around the iliac vessels. The nodal contours were then overlaid and individual nodes analyzed for coverage. The volume of normal tissue within each clinical target volume and planning target volume was also measured to aid selection of the margin that could provide maximal nodal, but minimal normal tissue, coverage. Results: In total, 1216 nodal contours were evaluated. The nodal coverage was 56%, 76%, 88%, 94%, and 99% using vessel margins of 3, 5, 7, 10, and 15 mm, respectively. The mean volume of bowel within the planning target volume was 146.9 cm3 with a 7-mm margin, 190 cm3 with a 10-mm margin, and 266 cm3 with a 15-mm margin. Minor modification to the 7-mm margin ensured 99% coverage of the pelvic nodes. Conclusion: Blood vessels with a modified 7-mm margin offer a good surrogate target for pelvic lymph nodes. By making appropriate adjustments, coverage of specific nodal groups may be increased and the volume of normal tissue irradiated decreased. On the basis of these findings, recommended guidelines for outlining pelvic nodes have been produced.