2016 9th International Congress on Image and Signal Processing, BioMedical Engineering and Informatics(CISP-BMEI 2016)

Comparative of Patients with Cervical Cancer Using

3D-CRT and IMRT
Wei Peng , Yuan Zhao*
School of Biomedical Engineering, Hubei University of Science and Technology Xianning, China
*Corresponding author: 362084134@qq.com

Abstract—This paper studied the dosimetry of patients with of cervical cancer are vaginal bleeding and vaginal discharge
cervical cancer using three-dimensional conformal radiotherapy increased.
(3D-CRT) and intensity-modulated radiation therapy (IMRT).
The doses of target areas and the organs at risk (OAR) were In recent years, with the development of radio technology
studied and analyzed in detail, which will give us a base for and promotion, radiation therapies take an important position
clinical choice of cervical cancer radiotherapy technology. in the clinical treatment of cervical cancer [6-8]. Conventional
Twenty cases of cervical cancer patients were selected randomly, radiotherapy will cause varying degrees of impacts to the
aged from 38 to 65 and the median age was 46 years old. The CT patient's rectum, bladder, etc. There are two main types of
images were obtained by CT and transmitted to the Oncentra radiotherapy for cervical cancer: intensity modulated radiation
planning system, delineated in the clinical target volume (CTV), therapy(IMRT)[9-15] and three dimensional conformal
planning target volume (PTV), and organ at risk(bladder, radiotherapy(3D-CRT)[16-20].
rectum, femoral head), and designed respectively 3D-CRT and
IMRT plans. The prescription doses were 46.80Gy, fractionated The purpose of this study is to compare and analyze the
doses were 1.8Gy. The PTV dose volume histograms (DVH) and feasibility and advantages of the 3D-CRT and IMRT in the
isodose curve were used to evaluate the dosimetry of these two treatment of cervical cancer, and attempts to analyze and solve
plans with the differences: (1) the conformity index(CI); (2) the some problems in radiotherapy of cervical cancer.
homogeneity index(HI); (3) the maximum dose of distribute to
the OAR such as bladder, rectum, left and right sides of the II. COMPARISON OF 3D-CRT AND IMRT IN CERVICAL
femoral head; (4) the percentage volume of the bladder, rectum,
CANCER
left and right sides of the femoral head under radiation at
different dose levers. The results indicated that the conformity Twenty cases of cervical cancer patients were randomly
index of IMRT plans was distinctly superior to the 3D-CRT. divided into two groups, A and B, ten cases in each group. The
IMRT plans distinctly reduced the volumes of the rectum, left two groups had no significant differences in age, duration and
and right sides of the femoral head by the high dose levels. IMRT severity of illness, and had comparable, and no patients with
plans had advantages in reducing the high dose area bladder and radiotherapy. A group to do 3D-CRT plan, and B group to do
rectum, femoral head around the radiation volume of a 3D-CRT. IMRT plan. At the same time, the two plans in the conformal
It is concluded that patients with cervical cancer received IMRT index (CI), uniform index (HI) and organs at risk by dose
may diminish the Normal Tissue Complication Probability (Dmax) and endanger organs in different dose of irradiated
(NTCP) and severity. volume percentage were compared and concluded access to
information. In this paper, one case analysis is introduced. The
Keywords- cervical cancer; radiotherapy; three dimensional
conformal; intensity modulation radiationtherapy
total dose received by the patients in this paper was 46.80Gy,
5-6 weeks, /26 times, 1.8Gy/time, 5times / week.
I. INTRODUCTION A. Design of treatment plans.
The high incidence of cervical carcinoma in situ carcinoma Target area and organ at risks: a successive layer to
was 30~35 years old, and invasive carcinoma was 50~55 years delineate the target volume at the CT level, and then developed
old [1]. In recent years, due to the widespread use of cervical a three-dimensional conformal radiotherapy plan and a strong
cytology, cervical cancer and precancerous lesions can be radiation therapy plan, in which CTV delineated by
detected and treated early, the incidence and mortality of radiotherapy physicians. According to the report, the clinical
cervical cancer has been significantly decreased [2-5]. This target volume (CTV) of patients with cervical cancer after
disease seriously affects the life and work of the patients surgery including paravaginal soft tissue, vaginal on one
greatly and harm to women's health. second and stump and pelvic lymph drainage area (including
Early stage cervical cancer has no obvious symptoms and iliac, external iliac and external iliac, presacral lymph node
signs, or only the performance similar to cervicitis. Cervical region and obturator), the range is 4~5 lumbar to the inferior
patients are easy to be missed diagnosis due to normal cervical border of the obturator, and PTV (planning target volume)
appearance Once the symptoms appear, often have been delineated by the physical division obtained in 0.7cm outside
developed to a considerable extent. The main clinical features the CTV in three dimension. Radiation physicians outline the
bladder, rectum and left and right femoral head and other

978-1-5090-3710-0/16/$31.00 ©2016 IEEE 1849

organs. The areas of small intestine include the bowel and
mesenteric tissue. Bladder included the bladder in the filling
state. The rectum is a rectum sigmoid colon to the anus, which
was shown in Fig.1.

Figure 3 Multi leaf collimator and PTV conformal

Figure 1 Target area and organs at risk B. Comparison of treatment plans

For 3D-CRT, the field angle directions are 0 degree, 90
For the 3D-CRT plan, the radiotherapy fields were set to be degree, 180 degree and 270 degree; for IMRT, the field angle
4 with 0°, 90°, 180°and 270°. The fields were shown in directions are 0 degree, 50 degree, 100 degree, 150 degree, 210
Fig. 2. The selections of the fields were based on the protection degree, 260 degree and 310 degree.
of the OARs, such as bladder, rectum, and femoral head. The two plans in the conformal index (CI), uniform index
According to the intensity of the X-ray and the angles of the (HI) and organs at risk by dose (Dmax) and endanger organs in
fields, we can achieve two results. Firstly, the main irritation different dose of irradiated volume percentage were compared
dose were distributed in the target volume homogeneously, and concluded.
with little dose distributed in the normal tissues. Secondly the
irritation dose distribution conformal with the target volume. The conformal index of patients were obtained and shown
in Tab.1. There were statistically significant differences in the
conformal index of the two kinds of irradiation technology
(p<0.05). The conformal degree of IMRT was significantly
better than that of 3D-CRT.

Table 1 Comparison of conformal index

3D-CRT（ x±s） IMRT（ x±s） p

CI 0.38±0.10 0.87±0.12 0.000

The uniform index of patients were obtained and shown in

Tab.2. There was no significant difference in the uniformity
index of the two kinds of irradiation technology (p>0.05). The
uniformity of IMRT is similar to 3D-CRT. The dose of hot
point of IMRT is 50.98Gy and cold point is 45.78Gy, the
average dose in PTV is 47.19Gy. The dose of hot point of 3D-
CRT is 51.36Gy and cold point is 44.94Gy, the average dose in
Figure 2 Radiotherapy fields in 3D-CRT plan PTV is 47.51Gy.
The PTV conformal were performed by the multi leaf
Table 2 Comparison of uniform index
collimator (MLC) which were shown in Fig.3.
3D-CRT（ x ± s） IMRT（ x ± s ） p
HI 1.09±0.10 1.15±0.14 0.199

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 III. RESULT AND DISCUSSION significant difference between the highest dose of 3D-CRT and
IMRT (P>0.05). The largest amount of rectal, left and right
A. Results femoral head of IMRT were 46.89Gy, 45.72Gy, 43.52Gy.
The Dose-volume Histogram(DVH) were performed for They were all significantly lower than that of 3D-CRT with
3D-CRT and IMRT in Fig. 4 and Fig. 5, respectively. DVH can 49.36Gy, 50.69Gy, 48.21Gy. The highest exposure dose was
summarize the dose distributions of target volume and organs statistically significant (p<0.05). The Mean percent volume of
at risk in one figure in detail. The principle, the volume dose of OARs in 3D-CRT and IMRT were shown in Tab. 4.
target should exceed 95%, and the volume dose of organ at risk
should less than 5%. The differences of target and organ at risk Table 3 Comparison of the distribution of the OAR under different irradiation
patterns
were shown in detail with different color. It is obviously that
the dose volume of CTV exceed 95% in the dose of 4600cGy, Maximum dose(Gy)
which satisfied the prescription dose for both 3D-CRT and OAR p
3D-CRT( x ± s ) IMRT( x ± s )
IMRT plans. The dose of cord in 3D-CRT was much smaller bladder 50.79±1.50 49.93±3.45 0.070
than that in IMRT. The dose of bladder in 3D-CRT was similar rectum 49.36±1.72 46.89±4.42 0.004
with IMRT. However, the best advantages of IMRT was that left femoral
50.69±2.47 45.72±5.32 0.012
the doses of the left and right femoral head were much smaller head
right femoral
than that in 3D-CRT. It is indicated that the IMRT plans can head
48.21±1.90 43.52±2.35 0.023
protected the femoral head much better.

The three dimensional conformal and intensity modulated

radiation therapy plan of cervical cancer was the same as that
of PTV, we got the following results:
(1) The fitness of IMRT was better than 3D-CRT, and the
difference was statistically significant (p<0.01), and the degree
of fit of IMRT was better than that of 3D-CRT;
(2) The dose distribution uniformity of the two plans was
similar, and the difference was not statistically significant
(p>0.05), and the uniformity of IMRT was similar to that of
3D-CRT;
(3) The highest exposure dose comparison results: There
was no statistically significant difference between the two
plans for the highest dose of bladder. 3D-CRT and IMRT had
no significant difference in the dose of bladder. And in the
rectum, left and right femoral head maximum dose aspects,
Figure 4 DVH for 3D-CRT IMRT rectum, left and right femoral head maximum dose
respectively 46.89Gy, 45.72Gy, 43.52Gy, were significantly
lower than that of 3D-CRT 49.36Gy, 50.69Gy, 48.21Gy (p<
0.05).
(4) Different dose level irradiation volume comparison
results: at the 40Gy level and above, IMRT of the bladder and
rectum, left femoral head with 3D-CRT were reduced by
46.59%, 29.70%, 18.25%, 18.81%, whose difference was
statistically significant (p<0.01); at the 30Gy level, IMRT of
the bladder and rectum, left and right femoral head compared
with 3D-CRT. By 30.72%, 16.51%, 11.50%, 17.83% of the
volume, whose difference was statistically significant (p<0.01);
the two planned irradiation volume was no significant
difference between 20Gy and 10Gy level; left femoral head
10Gy exposure level in the IMRT program has more volume
than 3D-CRT, and IMRT in high dose area in the bladder,
rectum and left and right femoral head protection is superior to
3D-CRT. Therefore, it is expected to reduce the incidence of
Figure 5 DVH for IMRT complications (NTCP) and severity of OAR radiation therapy
in patients with cervical cancer.

The doses of organ at risk for 3D-CRT and IMRT were Table 4 Mean percent volume of OARs in 3D-CRT and IMRT
shown in Tab.3. According to the highest dose of OAR Volume Dose（Gy）
OAR(bladder, rectum, femoral head), there was no statistically

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 had obvious advantages in 3D-CRT, and the advantages of low
3D-CRT ( x ± s ) IMRT ( x ± s )
dose area is not significant.
≥10 100±4.13 98.41±2.57
≥20 94.82±8.13 87.90±5.26 Although IMRT is the best choice for the treatment of
bladder
≥30 87.36±10.44 56.64±22.91 cervical cancer nowadays, however, IMRT is not perfect.
≥40 82.47±12.00 35.88±17.62 Theoretically, the sub-fields will increase the IMRT security
≥10 86.02±19.24 85.67±18.45 problems and unforeseen complications. Due to the increase of
≥20 83.57±20.05 78.84±20.12 the monitor units (MU) in linacs, 374.50±21.10 for IMRT,
rectum
≥30 76.44±20.76 59.93±23.52 278.19±14.05 for 3D-CRT, the irradiation time prolonged,
≥40 68.36±21.17 38.66±23.39 which will lead to the activation of the linear accelerator
≥10 94.47±12.00 96.83±16.89 collimator. The patients and staff will exposed in the radiation
Left ≥20 86.49±22.84 64.82±20.89 environment more frequently, and affect the health. The main
femora
l head ≥30 43.25±23.14 31.75±25.90 purpose of IMRT in the treatment of cervical cancer is not to
≥40 26.83±12.15 8.58±17.42 improve the target dose, but to protect the surrounding normal
≥10 96.23±13.41 98.83±15.68 tissue. There are still many problems to be solved, such as
Right
femora
≥20 84.61±19.38 67.10±23.27 reasonable range of PTV; the function of the design plan; setup
l head ≥30 46.25±21.57 28.42±21.27 error in the implementation of the plan; the necessity of two-
≥40 28.09±13.60 9.28±18.34 way plan; long-term observation and follow-up of internal
organs caused by the motion error and the curative effect.
This study selected 20 cases of cervical cancer. The 3D-
CRT and IMRT plans were performed for all the patients. The
prescription dose is 46.80Gy with fractionated dose 1.8Gy. The
highest dose of the bladder in two plans have no significant IV. ACKNOWLEDGEMENT
difference (p>0.05). For IMRT, the rectum and left and right This work was supported by type B project of Department
femoral head were significantly lower than the maximum dose of Education of Hubei Province (B2015086) and youth project
of 3D-CRT (p<0.05), which showed the advantages of IMRT of Hubei University of Science and Technology (ky14083).
in the protection of rectum and femoral head. The main reason
of the reduction of the rectum and femoral head came from the
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