Clinical and Translational Oncology

, Volume 18, Issue 5, pp 480–488 | Cite as

Clinical target volume in postoperative radiotherapy for gastric cancer: identification of major difficulties and controversies

  • J. SochaEmail author
  • G. Wołąkiewicz
  • E. Wasilewska-Teśluk
  • P. Janiga
  • T. Kondraciuk
  • A. Majewska
  • K. Olearski
  • L. Kępka
Research Article



To identify the main difficulties in postoperative clinical target volume (CTV) delineation in gastric cancer (GC).


Before and after a training course, 20 radiation oncology residents were asked to delineate the CTV for the postoperative GC case on four computed tomography scans: dome of the diaphragm, anterior abdominal wall, duodenal stump and porta hepatis level, and to determine the lower CTV border. CTV volume was reconstructed from requested planar contours. Area of intersection (AI) for each requested scan and volume of intersection (VI), defined as the overlap of delineated area/volume with respective reference area (RA)/reference volume (RV) proposed by the senior radiation oncologist, were computed. The degree of agreement between the reference and participants’ contours was quantified using the Concordance Index (CI): AI/RA × 100 % or VI/RV × 100 %. The lower CTV border was analyzed separately. Pre- and post-training CIs were compared. A questionnaire investigated the difficulties with contouring.


Mean CI value was the lowest for the dome of the diaphragm (24 % pre-training, 35 % post-training) and for the duodenal stump (49 % pre-training, 61 % post-training). Mean CI for the CTV volume was 49 % pre-training and 59 % post-training, p = 0.39. Mean distance from the reference to the participants’ lower CTV borders was 2.73 cm pre-training and 2.0 cm post-training, p = 0.71. In a questionnaire, 75 % of respondents indicated the elective nodal area as the main difficulty.


Delineation of the dome of the diaphragm and the duodenal stump, as yet not recognized as the source of variation, should be addressed in the international consensus guidelines and clarified.


Adjuvant radiotherapy Gastric cancer Interobserver variation Radiotherapy planning Volume delineation 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

12094_2015_1396_MOESM1_ESM.tif (33.2 mb)
Supplementary material 1 (TIFF 33984 kb)
12094_2015_1396_MOESM2_ESM.tif (33.2 mb)
Supplementary material 2 (TIFF 33984 kb)


  1. 1.
    Macdonald JS, Smalley SR, Benedetti J, Hundahl SA, Estes NC, Stemmermann GN, et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med. 2001;345:725–30.CrossRefPubMedGoogle Scholar
  2. 2.
    Smalley SR, Gunderson L, Tepper J, Martenson JA Jr, Minsky B, Willett C, et al. Gastric surgical adjuvant radiotherapy consensus report: rationale and treatment implementation. Int J Radiat Oncol Biol Phys. 2002;52:283–93.CrossRefPubMedGoogle Scholar
  3. 3.
    Tepper JE, Gunderson LL. Radiation treatment parameters in the adjuvant postoperative therapy of gastric cancer. Semin Radiat Oncol. 2002;12:187–95.CrossRefPubMedGoogle Scholar
  4. 4.
    Jansen EPM, Nijkamp J, Gubanski M, Lind PA, Verheij M. Interobserver variation of clinical target volume delineation in gastric cancer. Int J Radiat Oncol Biol Phys. 2010;77:1166–70.CrossRefPubMedGoogle Scholar
  5. 5.
    Moretones C, León D, Navarro A, Santacruz O, Boladeras AM, Macià M, et al. Interobserver variability in target volume delineation in postoperative radiochemotherapy for gastric cancer. A pilot prospective study. Clin Transl Oncol. 2012;14:132–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Japanese Gastric Cancer Association. Japanese Classification of Gastric Carcinoma—2nd English edition. Gastric Cancer. 1998;1:10–24.CrossRefPubMedGoogle Scholar
  7. 7.
    Ausili Cefaro G, Perez CA, Genovesi D, Vinciguerra A (eds). A guide for delineation of lymph nodal clinical target volume in radiation therapy, Il Pensiero Scientifico Editore; 2008.Google Scholar
  8. 8.
    Lee NY, Lu JJ. Target volume delineation and field setup: a practical guide for conformal and intensity-modulated radiation therapy. Berlin: Springer; 2013.CrossRefGoogle Scholar
  9. 9.
    Barrett A, Dobbs J, Morris S, Roques T. Oesophagus and stomach. In: Barrett A, Dobbs J, Morris S, Roques T, editors. Practical radiotherapy planning, 4th ed. London: Hodder Arnold Publication; 2009.Google Scholar
  10. 10.
    Czito BG, Palta M, Willet CG. Stomach cancer. In: Perez C, Brady L, editors. Principles and practice of radiation oncology. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013.Google Scholar
  11. 11.
    Matzinger O, Gerber E, Bernstein Z, Maingon P, Haustermans K, Bosset JF, et al. EORTC-ROG expert opinion: radiotherapy volume and treatment guidelines for neoadjuvant radiation of adenocarcinomas of the gastroesophageal junction and the stomach. Radiother Oncol. 2009;92:164–75.CrossRefPubMedGoogle Scholar
  12. 12.
    Yoon HI, Chang JS, Lim JS, Noh SH, Hyung WJ, An JY, et al. Defining the target volume for post-operative radiotherapy after D2 dissection in gastric cancer by CT-based vessel-guided delineation. Radiother Oncol. 2013;108:72–7.CrossRefPubMedGoogle Scholar
  13. 13.
    Chung HT, Shakespeare TP, Wynne CJ, Lu JJ, Mukherjee RK, Back MF. Evaluation of a radiotherapy protocol based on INT0116 for completely resected gastric adenocarcinoma. Int J Radiat Oncol Biol Phys. 2004;59:1446–53.CrossRefPubMedGoogle Scholar

Copyright information

© Federación de Sociedades Españolas de Oncología (FESEO) 2015

Authors and Affiliations

  • J. Socha
    • 1
    Email author
  • G. Wołąkiewicz
    • 2
  • E. Wasilewska-Teśluk
    • 2
  • P. Janiga
    • 3
  • T. Kondraciuk
    • 4
  • A. Majewska
    • 5
  • K. Olearski
    • 6
  • L. Kępka
    • 2
  1. 1.Radiotherapy DepartmentRegional Oncology CenterCzestochowaPoland
  2. 2.Radiotherapy DepartmentIndependent Public Health Care Facility of the Ministry of the Interior and Warmian & Mazurian Oncology CentreOlsztynPoland
  3. 3.Radiotherapy DepartmentGreater Poland Cancer CenterPoznanPoland
  4. 4.Radiotherapy DepartmentSubcarpathian Cancer CenterBrzozowPoland
  5. 5.Radiotherapy DepartmentWest Pomeranian Oncology CenterSzczecinPoland
  6. 6.Radiotherapy DepartmentRegional Oncology CenterTarnówPoland

Personalised recommendations