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Clinical Oncology Paper

Ariana Redmond

DOS 531 Clinical Oncology for Medical Dosimetrists

University of Wisconsin La-Crosse

Introduction

A 63-year-old female patient had a routine Pap smear with abnormal and human

papilloma virus (HPV) positive results. Cervical biopsies revealed moderately to poorly

differentiated squamous cell carcinoma (SSC). A pelvic exam and MRI showed a posterior

cervical lesion roughly 1.7cm at greatest dimension. Pathology revealed a FIGO stage IB1

human papilloma virus (HPV) related squamous cell carcinoma (SCC) of the exocervix. It is

moderately differentiated with lymph-vascular space invasion (LVSI+) and middle 1/3 cervical

stromal invasion.

Patient Position

The patient is positioned in the supine, head-first position. She has an uniedexed ‘F’ headrest

for comfort and is holding onto a ring with her hands on her chest, to keep her hands out of the

treatment field, which extends to mid-L4. Her lower body is immobilized with a vacloc bag with

a small knee-sponge indexed under. The purpose of the vaclok and knee-sponge help immobilize

the patient and provide better reproducibility of daily setup. The knee sponge helps create a more
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reproducible pelvic pitch. She was simulated with a full bladder to increase the distance between

the treatment field and the small bowel and the bladder. This helps minimize dose to these

structures.

Target Dose

The patient underwent a radical hysterectomy and is prescribed 4500cGy of external

beam radiation therapy (EBRT) in 25fx (180cGy/fx) to the whole pelvis with concurrent

cisplatin chemotherapy. Following EBRT, the patient will receive a brachytherapy boost. Figure

1 displays the patient's treatment prescription.

Surgery is the main course of treatment for stage IB1 cervical cancer. Post-op

chemoradiation and brachytherapy boost is recommended for patients at high-risk of recurrent

disease. High-risk patients are those with positive margins or lymph nodes, or those with

parametrial extension.1 This patient has negative margins, however, she has middle 1/3 cervical

stromal invasion and is LVSI+, indicating the need for chemoradiation. The American Society of

Radiation Oncology currently suggests high-risk patients receive whole pelvic radiation therapy

to a dose of 4500-5040cGy in fractions of 180cGy. Cisplatin is administered once a week during

radiation to enhance the treatment's effects.1

Figure 1: Patient’s prescribe treat

Avoidance Structures
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Avoidance structures are organs at risk that are contoured onto the patient’s planning CT

scan. These structures include the bladder, bone marrow, small and large bowel, femoral heads,

kidneys, liver, rectum, the spinal cord and a spinal cord 5mm planning risk volume (PRV).

Planning objectives help dosimetrists create treatment plans. They tell us the allowable dose to

critical structures. Exceeding tolerance dose to these structures can result in contraindications

that are specific to each organ. Exceeding dose to the bowel and rectum can result in ulcerations,

obstructions, perforations and fistulas. The bladder can result in symptomatic bladder contracture

and loss. Increased dose to femoral heads, kidneys, liver and spinal cord can cause necrosis,

nephritis, liver failure, and myelitis, respectively.2 Below you can see the contoured OAR and

PTV (figure 2), and both the OSU (figure 3) and QUANTEC (figure 4) dose constraints2. The

OSU dose constraints differ slightly from the QUANTEC dose constraints.

Figure 2: Contoured PTV and OAR

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Figure 3: Ohio State postop GYN dose constraints

Figure 4: QUANTEC dose constraints2

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Lymph Node Involvement

Involved nodal chains in the treatment field include the common iliac, internal iliac,

external iliac and perirectal nodes. See figure 5 below for visual representation of the nodal PTV

with labeled lymph nodes.

Figure 5: Contoured PTVn with lymph nodes labeled

Anatomical Boundaries

The anatomical boundaries for whole pelvis irradiation of post-op cervical cancer treated

with 3DCRT four-field box are as follows. Superiorly, to L4/5 and inferiorly below the obturator

foramen. Laterally include 2 cm beyond the pelvic brim. Anteriorly, the field should extend 1 cm

anterior to the pubic symphysis and posteriorly to the S2/3 interspace unless there is posterior

extension into the rectum, in which the entire sacrum should be included.3

This patient was treated utilizing VMAT technique, so these borders are adapted slightly.

There are 2 different PTV structures drawn, a primary (PTVp) and nodal (PTVn), these can be

seen in figure 6. The PTVp encompasses the main site of disease and is located at the inferior

portion of the field. The PTVn includes the involved lymph node chains including the common,

internal and external iliac, and perirectal nodes. The PTVp and PTVn are combined to form a
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PTV total (figure 7). This PTV has the same treatment borders as the 3DCRT four-field box

besides the superior extent of the volume which extends to mid L4.

Figure 6: PTVn and PTVp

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Figure 7: PTV Total with border labels

Treatment Technique

This patient will receive both external beam radiation therapy (EBRT) and brachytherapy

for her cervical SCC. For EBRT, she is receiving volumetric modulated arc therapy (VMAT) to

a dose of 4500cGy in 25 fractions. Plans utilizing VMAT technique allow for increased

conformity and dose modulation compared to 3D conformal radiation therapy (3DCRT). In

doing so, lower dose is delivered to surrounding critical structures, reducing the acute and late

side effects.2

Her treatment has three different 10x, 356-degree arcs. Three arcs are needed because of

the length of the PTV (about 21 cm). Field size and MLC travel limitations would prevent the
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entire PTV from being covered in a 2-field treatment plan. Her PTV is central in her body, full

arcs ensure full volume coverage and helps ensure an even dose distribution. The maximum

energy that can be used for IMRT/VMAT is 10x due to potential neutron production for plans

with energies greater than 10x. An energy of 10x is beneficial for this patient due to its

penetrating power. The PTV is deep within the patient, a 6x beam may not offer as much PTV

coverage as a 10x beam. An additional benefit of a 10x beam over 6x is increased skin sparing

because dmax is deeper. The patient’s plan summary can be seen in figure 8.

The first arc rotates clockwise from 183 to 179 degrees with the collimator turned 90

degrees. Figure 9 displays a BEV of the field. This 14.8 x 23.8 cm field encompasses the

superior 2/3 of the PTV. The second arc also has a collimator angle of 90 degrees and rotates

counterclockwise from 177 to 181 degrees (Figure 10). This field is 15 x 23.8 cm and

encompasses the inferior 2/3 of the PTV. The third field has a 0-degree collimator angle and

treats clockwise from 182-178 degrees (Figure 11). The field size of 17 x 22.4 cm encompasses

the entire length of the PTV.

Several optimization structures were created to help shape the isodose lines and create a

high-quality treatment plan. Figure 12 shows the isodose distribution at isocenter in the axial,

coronal and sagittal views. Critical structures that overlap with the PTV create conflicts during

optimization because we push dose to the PTV while trying to limit dose to OAR. To prevent

these conflicts, avoidance structures are created for PTV overlapping structures. Figure 13

demonstrates a slice where the bladder and rectum overlap with the PTV. Figure 14 shows the

same slice, but with the avoidance structures. The bladder is cropped 5 mm and the rectum 3 mm

from the PTV to help create distance for dose falloff. In the optimizer, dose constraints are

utilized on the avoidance structures rather than the original, overlapping structures. Other

structures that these were made for include the bone marrow and the bowel.
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Other optimization structures created to help shape isodose lines include a 100% and

50% ring, and anterior, middle and posterior avoidance structures. The 100% ring (figure 15) is 1

cm thick and is cropped 2 mm away from the PTV. The purpose of this structure is to control

where the 100% isodose line is and to keep it tight to the PTV and highly conformal, the 50%

ring has a similar role except it is for the 50% isodose line. As you can see in figure 16, the

optimizer followed the 100% ring objected well as there is not much 100% dose (yellow)

extending into the ring. The anterior avoidance structure (figure 17) carves out dose in the

anterior portion of the body. We want to avoid additional dose in this region because this is

where anterior structures such as the bowel and bladder are located. Figure 18 shows the isodose

lines following the path of the anterior avoid structure at isocenter.

Figure 8: Patient treatment plan summary

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Figure 9: Field 1 BEV collimator 90

Figure 10: Field 2 BEV collimator 90

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Figure 11: Field 3 BEV collimator 0

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Figure 12: Isodose lines at isocenter in the axial, coronal and sagittal views
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Figure 13: Axial slice showing where the bladder and rectum overlap with the PTV

Figure 14: The same axial CT slice as figure 13, with bladder and rectum optimization structures

created.
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Figure 15: 100% isodose ring cropped 2 mm from the PTV and is 1 cm thick

Figure 16: Yellow 100% isodose line and the 100% isodose ring
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Figure 17: Purple anterior avoidance structure at isocenter

Figure 18: Isodose lines following anterior avoidance structure at isocenter

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DVH

Figure 19 shows a DVH with absolute dose of the PTV and OAR. The hot spot of this

plan is 110.1% with a conformity index of 1.04. All target and OAR dose constraints, besides the

bowel space and bone marrow were met for this plan. The bowel space constraint (V4500cGy ≤

150-250 cc) was not met (V4500cGy = 337.944 cc) due to a significant amount of bowel within

the pelvis. The bone marrow had 2 constraints that were not met including the mean ≤ 1500-

2000cGy which was 2537,6cgy and V1000 ≤ 75-90% which was 85.577%. These objectives not

being met can also likely be attributed to the large about of bone marrow that overlaps with the

PTV, as seen in figure 20. The left kidney easily met dose constraints due to the distance

between the structure and the PTV. All other structures had doses that were less than the dose

limit range but were closer than the left kidney.

Figure 19: DVH displaying absolute dose of PTV total and OAR
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Figure 20: Bone marrow overlapping with PTV at isocenter

References
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1. Chino J, Annunziata CM, Beriwal S, et al. Radiation Therapy for Cervical Cancer:

Executive Summary of an ASTRO Clinical Practice Guideline. Pract Radiat Oncol.

2020;10(4):220-234. doi:10.1016/j.prro.2020.04.002

2. Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic irradiation.

Int J Radiat Oncol Biol Phys. 1991;21(1):109-122. doi:10.1016/0360-3016(91)90171-y

3. Tsuchida K, Murakami N, Kato T, et al. Postoperative pelvic intensity-modulated

radiation therapy reduced the incidence of late gastrointestinal complications for uterine

cervical cancer patients. J Radiat Res. 2019;60(5):650-657. doi:10.1093/jrr/rrz041