REVIEW ARTICLE

Three-Dimensional Dosimetry of the Full and Empty

Bladder in High Dose Rate Vaginal Cuff Brachytherapy
Justyna D. Kobzda, MSc,* Ewa Cikowska-Wozniak, PhD,* Magdalena Michalska, PhD,*
and Roman Makarewicz

Objectives: The objectives of the study were to assess the bladder doses during vaginal cuff
brachytherapy and to examine the effect of bladder filling on normal tissue dosimetry by
means of computed tomography.
Materials and Methods: A total number of 45 women were enrolled in a prospective
clinical trial. Patients were treated with the application of a single-line source vaginal cylinder.
All the patients were asked to consume 400 mL of water 40 minutes before computed to-
mography scans were taken. For each patient, 2 treatment plans were performedVone with
full bladder and the other one when the bladder was emptied. A dose-volume histogram
and the equivalent of 2-Gy dose for full and empty bladder were calculated. Doses to the
bowels in 2 states of the bladder were estimated.
Results: Thirty-five patients received a lower dose to the empty bladder than to the filled
organ. The average dose difference was 0.5 Gy. Ten patients received a lower dose to the
full bladder than to the empty one. However, in this case, the difference amounted only to
0.2 Gy on average. Dose parameters (the maximal dose received by 0.1 cm3 of tissue and
the maximal dose received by 2 cm3 of tissue) were lower in the empty state, but the
volumetric parameters (the percent of bladder volume receiving Q50% of the prescribed
dose and the percent of bladder volume receiving Q80% of the prescribed dose) were higher
in the empty state of the bladder. Doses to the bowels seemed to be higher in the empty
bladder. However, none of the doses exceeded the limitations.
Conclusions: The results have shown that in most cases, the dose to the empty bladder
is lower than when the bladder is full. Simultaneously, the doses to the bowels increase
proportionally in the empty state of the bladder comparing to the full organ. Protection of
the bowels, which are more radiosensitive, suggests treating the patients in the full state of
the bladder. Early and late bowel toxicity should be investigated to establish clear standards
of treatment.
Key Words: Vaginal cuff brachytherapy, HDR brachytherapy

Received September 17, 2013, and in revised form February 18, 2014.
Accepted for publication February 18, 2014.
(Int J Gynecol Cancer 2014;24: 923Y927)

E ndometrial carcinoma is 1 of the most common gyneco-

logic malignancy in Poland. The standard treatment of
oophorectomy with or without the application of lymph node
dissection. The implementation of adjuvant radiation for sur-
endometrial cancer is hysterectomy and bilateral salpingo- gical stage I patients with intermediate risk factors has been

*International Oncotherapy Centre, Poznan; and Chair and Clinic Nicolaus Copernicus University in Torun, Bydgoszcz, Poland.
of Oncology and Brachytherapy, Centre of Oncology in Bydgoszcz, Address correspondence and reprint requests to Justyna D. Kobzda,
Copyright * 2014 by IGCS and ESGO MSc, International Oncotherapy Centre, 28 Czerwca 1956r. 223/229
ISSN: 1048-891X Str. 61-485 Poznan, Poland. E-mail: justyna.kobzda@gmail.com.
DOI: 10.1097/IGC.0000000000000127 The authors declare no conflicts of interest.

International Journal of Gynecological Cancer & Volume 24, Number 5, June 2014 923

Copyright 2014 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited.
Kobzda et al International Journal of Gynecological Cancer & Volume 24, Number 5, June 2014

a controversial subject over the years. However, studies show
that radiation therapy is an effective treatment strategy.1 Ex-
ternal beam radiotherapy has usually been reserved for the
patients with high (915%) recurrence rate, whereas vaginal
brachytherapy has been used in cases with low or medium
recurrence rate.2 Recently, highYdose rate brachytherapy has
replaced lowYdose rate treatment in most centers. The ad-
vantage of this modality is primarily related to the convenience
of an outpatient administrator.
The most common applicators are the vaginal cylinders
with different diameters, adjusted to the size of the vagina. In
some cases, 2 ovoids or a ring applicator can be used to reach
the most upper part of the vagina.3 Recently, a new method
with the application of an intravaginal balloon applicator has
been introduced.4 This technique was developed to keep the
best conformity and dose coverage in accordance with the
anatomy of the patient.
In this study, the vaginal cylinders were used for all
insertions to treat the proximal one third of the vagina (according
to ABS and GEC-ESTRO recommendations5). The high dose
rate (HDR) dose, delivered by iridium 192 source, was pre-
scribed to the depth of 0.5 cm from the cylinder surface.
AIM
The implementation of 3-dimensional (3D) technique
provides the opportunity to record doses to organs at risk.6
The objectives of this study were to assess the bladder tissue
doses during vaginal cuff brachytherapy (VBT), to examine
the effect of bladder filling on normal tissue dosimetry by
means of computed tomography (CT), and to suggest stan-
dards of treatment.
MATERIALS AND METHODS
A total number of 45 women were enrolled in a pro-
spective clinical trial. The choice of patients was done on the
basis of clinical diagnosis (patients with endometrial cancer

FIGURE 1. Dose distribution in empty (A) and full (B) bladder state. Isodose lines: V50, V75, V90,
V100, and V150.

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 3D Dosimetry of Bladder in
International Journal of Gynecological Cancer & Volume 24, Number 5, June 2014 HDR Brachytherapy

after surgery with all FIGO stages). Patients were treated with Differences between the volumes of full and empty blad-
the application of a single-line source vaginal cylinder ap- der calculated in the treatment planning system were significant
plicator to deliver a dose of 6 Gy per fraction at the depth of (Table 2). The mean volume of the full bladder was approxi-
0.5 cm from the applicator surface. The total dose was 24 Gy mately 3.5 times bigger comparing to the empty organ.
in 4 fractions when brachytherapy alone was used or 18 Gy For evaluation reasons, the following values were taken
in 3 fractions when brachytherapy was combined with external into account for both full and empty bladder: percent of
beam irradiation. Qualification for brachytherapy as monother- bladder volume receiving greater than or equal to 50% of the
apy or adjuvant therapy with external beam radiotherapy (EBRT) prescribed dose (V50), percent of bladder volume receiving
was done on the basis of FIGO stage after surgery, grading, greater than or equal to 80% of the prescribed dose (V80),
information about lymph nodes, and other prognostic factors. D0.1 cc, and D2 cc. To show insignificant differences in the
The cylindersdiameters varied within the range of 2.5 to 3.5 cm. doses to the rectum, the approximation for the values of the
The widest cylinder that the patient could tolerate was inserted doses to the rectum are estimated more precisely comparing
to ensure the optimal coverage of treatment volume. to the rest of the data.
All the patients were asked to apply Laxantia 1 day before The evaluation of the bladder showed differences in
every fraction to provide a minimal filling and at the same doses between empty bladder (EB) and full bladder (FB). The
time possibly maximal stability of the rectum and bowels. The outcome presented in Table 2 describes the average values
imaging protocol was standardized, and CT scans with full gathered from all the results. From the outcomes, 2 groups
and empty bladder were performed on the same day for each have been distinguished. In the first group, 35 patients re-
patient. The position of the patient at the time of CT imaging ceived a lower dose to EB than to FB. In all these cases, the
and treatment delivery was the same (patient lying on the difference reached 0.5 Gy on average. In the second group, 10
back with knees bent). To provide a sufficient filling of the patients received a lower dose to FB than to EB. However, the
bladder, patients were asked to consume 400 mL of water difference amounted only to 0.2 Gy on average. D0.1 cc rep-
40 minutes before the CT scans were taken. No contrast was resents the maximal dose received by the organ in accordance
used to visualize the bladder during imaging. After perform- with GEC-ESTRO recommendations.5 The evaluation of this
ing the first set of CT scans, the patients were asked to empty parameter showed again the higher values for FB in most cases.
the bladder, and CT imaging was repeated. For the rectum and bowels (including the sigmoid), only
Both sets of CT images were transferred to the 3D D2 cc was taken into account. The goal of this evaluation was
Flexiplan Planning System (Nucletron, An Electa Company, to verify if these organs change their position significantly
Veenendaal, the Netherlands). The bladder, rectum, bowels, and because of the different filling of the bladder. The results
clinical target volume (CTV) were contoured in 3 dimen- showed only slight differences in the doses to the rectum
sions by 1 physician and checked by another. For preserving
the same conditions in all cases, the contouring protocol was TABLE 1. Patients characteristics
standardized, and the following rules were set in place: the blad-
der was delineated in the empty and full state as a whole organ; Characteristics No. Patients
the rectum and bowels (including the sigmoid) were contoured
within the whole length of the cylinder and 2 cm above it. Age
A dose volume histogram was generated. The volumes e60 26
of the bladder receiving at least 100% or more, 90% or more, 960 19
80% or more, and 50% or more of the dose were reported FIGO stage
(a dose distribution for exemplary patient is shown in Fig. 1).
IA 11
Measurements of the maximal dose received by 2 cm3 of
tissue (D2 cc, a factor which has been correlated with the IB 22
risk of late adverse effects) and the maximal dose received by II 8
0.1 cm3 of tissue (D0.1 cc, a representation of maximal dose III-IV 4
received by the organ) for the bladder were recorded ac- Tumor grade
cording to GEC-ESTRO recommendations. For the rectum G1 19
and bowels (small bowels and sigmoid), D2 cc was calculated.
All dosimetric parameters were summed, and the mean G2 22
values were calculated. The differences in bladder volume in G3 4
the full and empty state were compared using the t test. Treatment schedule
45 Gy/50.4Gy EBRT + 18 Gy BT 36
24 Gy BT only 9
RESULTS
Cylinder diameter, cm
A cylinder size of 2.5 cm was used in 4 cases, 3.0 cm in
23 cases and 3.5 cm in 18 patients. All patients received 6 Gy 2.5 4
per fraction to the upper one third of the vagina (the active 3 23
length of the cylinder was 3 cm). Patients characteristics by 3.5 18
means of age, FIGO stage (2009), and tumor grade are shown BT, brachytherapy; EBRT, external beam radiotherapy.
in Table 1.

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Kobzda et al International Journal of Gynecological Cancer & Volume 24, Number 5, June 2014

TABLE 2. Mean dosimetric values in full and empty bladder state

Mean Dosimetric Values
According to Bladder
Filling (VBT Only) Full Bladder Empty Bladder P
3
Mean volume (range), cm 229.7 (53.4Y663.4) 65.3 (28.4Y379.0) G0.05
V50 (range), % 10.1 (3.1Y22.3) 17.7 (3.7Y33.9) G0.05
V80 (range), % 1.5 (0Y5.2) 3.6 (0Y11.3) G0.05
Physical dose for a EQD2 for a Physical dose for a EQD2 for a
single fraction, Gy single fraction, Gy single fraction, Gy single fraction, Gy
D0.1 cc (range), Gy 6.4 (5.0Y8.8) 12 (8.0Y20.8) 6.0 (4.5Y7.6) 10.8 (6.8Y16.1) G0.05
D2 cc (range), Gy 4.9 (3.9Y5.9) 7.7 (5.4Y10.5) 4.6 (3.1Y5.6) 7.0 (3.8Y9.6) G0.05
D2 cc for rectum (range), Gy 3.60 (2.5Y5.6) 4.75 (2.7Y9.5) 3.55 (2.4Y5.3) 4.65 (2.6Y8.9) 0.41
D2 cc for bowels (range), Gy 4.1 (1.3Y5.7) 5.8 (1.1Y9.9) 4.6 (2.5Y7.3) 7.0 (2.8Y15.0) G0.05

(3.60 Gy for FB and 3.55 for EB on average). For bowels, we
achieved an average difference of 0.5 Gy (4.1 Gy for FB and
4.6 Gy for EB).
As a representation of biological dose received by the
bladder, rectum, and bowels, the equivalent of 2-Gy dose
(EQD2) was calculated (>/A = 3). The limitations for OARs
follow again the GEC-ESTRO recommendationsVless than
90 Gy for bladder and less than 75 Gy for the rectum and
bowels in the whole treatment (EBRT + BT).5 The total EQD2
(EBRT + BT) calculated for full and empty bladder is shown
in Table 3. We protectively assumed that a bladder receives a
full prescribed dose from EBRT in 3D technique (for 45 Gy/25
fractions: EQD2, 43.2 Gy; for 50.4 Gy/28 fractions: EQD2,
48.4 Gy). The mean dose for the bowels was estimated after
the evaluation of 15 EBRT plans and amounted 25 Gy (for
25 fractions: EQD2, 20 Gy; for 28 fractions: EQD2, 22.4 Gy).
DISCUSSION
Vaginal cuff brachytherapy is a simple outpatient pro-
cedure, which consists in the application of a highYdose rate
brachytherapy method. This radiotherapy technique allows for
the minimization of the rate of toxicity. In a large retrospective
study made by Horowitz et al,7 highYdose rate brachytherapy
was yielded to 164 surgically staged patients with stage IA,
IB, and II (FIGO 2009) to provide excellent rates of local
control. Their overall failure was 8.4% with only 3 pelvic or
vaginal failures (1.8%). Similar results were obtained by other
authors.8 They emphasized an extremely low risk rate of toxicity.
Moreover, the randomized trial comparing vaginal brachytherapy
alone to pelvic irradiation (PORTEC 2) published in 2010
proved that brachytherapy is effective in ensuring vaginal
control and should be a treatment of choice for patients with
endometrial carcinoma of high-intermediate risk.2 Most data
in the literature on HDR brachytherapy show a very favorable
rate (0%Y1%) of significant complications (Alektiar et al10).
These low rates of toxicity were obtained as a result of close
attention paid to total doses, fraction doses, length of vagina
treated, and references points. The optimal state of bladder
filling was rarely taken into account.
Our data show that for the bladder, the empty state is
slightly more advantageous. However, this organ is consid-
ered the most radioresistant from all the OARs in this area.
Doses to the rectum did not show any significant dif-
ferences (Table 2), which brings to the conclusion that the
states of the bladder did not affect the position of this organ.
Bowels are the most unstable organ for dosimetric eval-
uation because of their constant peristaltic movements. This
makes it impossible to define a clear location of the bowels
within the time between CT simulation and treatment. There-
fore, a dosimetric evaluation of the bowels should be read as
an estimation. However, few regularities have been observed.
In most cases, the position of the bowels differed in full and
empty state of the bladder, which was clearly observed on the

TABLE 3. Total EQD2 for full and empty bladder (calculated for EBRT + BT or BT alone)
EQD2 for Bladder EQD2 for Bowels
Total Dose (EBRT + BT) (>/A = 3), Gy (>/A = 3), Gy
45 Gy EBRT + 18 Gy BT (mean dose for D2 cc of FB + range) 66.4 (59.3Y74.7) 37.5 (23.4Y49.8)
45 Gy EBRT + 18 Gy BT (mean dose for D2 cc of EB + range) 64.2 (54.5Y72.1) 41.0 (28.3Y65.1)
50.4 Gy EBRT + 18 Gy BT (mean dose for D2 cc of FB + range) 71.6 (64.5Y79.9) 39.9 (25.8Y52.2)
50.4 Gy EBRT + 18 Gy BT (mean dose for EB + range) 69.4 (59.7Y77.3) 43.4 (30.7Y67.5)
24 Gy BT only (mean dose for D2 cc of FB + range) 31 (21.5Y42) 23.3 (4.5Y39.7)
24 Gy BT only (mean dose for D2 cc of EB + range) 28 (15.1Y38.5) 28 (11.0Y38.5)

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International Journal of Gynecological Cancer & Volume 24, Number 5, June 2014
CT scans. The more the bladder was filled, the further the
bowels were pushed aside from the cylinder. The dosimetric
data show (Table 2) that the dose to the bowels in the empty
state of the bladder was higher comparing to the full state
(0.5 Gy of average difference). Thus, the full state of the
bladder was more favorable for the bowels, which are more
radiosensitive and should be better protected. However, looking
at EQD2 (Table 3), we see that none of the doses exceeded
the recommended limitations.5
To our knowledge, there were 2 clinical studies exam-
ining the influence of organs filling with regard to the risk of
toxicity. Among them, 1 of the first was the study of Hoskin
et al,9 which examined the effect of bladder filling published
in 2000. They found that the instillation of 100 mL of water
into the bladder decreased the amount of small bowel in
the field without significantly increasing the mean maxi-
mal bladder dose.
The volume and surface area of the bladder were in-
vestigated by Stewart et al.8 They proved that D2 cc, V50,
volume of the bladder receiving 70% or more of the dose,
and the surface area of bladder receiving 50% or more of
the dose significantly predicted for the difference between
an empty and a full bladder. The second conclusion deducted
from this study was that an empty bladder did result in the
nearest point of bowel being significantly closer to the vaginal
vault than when bladder was full. In our study, the volumetric
doses (V50 and V80) were higher in the empty organ. Hence,
a bigger area of the whole organ (the wall and its inner filling)
in the empty state of the bladder received 50% and 80%
of prescribed dose. However, in this case, the irradiation has
an important effect only on the wall of the organ, and the doses
to its filling can be ignored. Thus, we do not expect a sub-
stantial impact of the higher values of these parameters on
the response of the bladder. Nevertheless, a clearer interpre-
tation of this finding may be given after the evaluation of
the patients follow-up.
CONCLUSIONS
The results of this study have shown that in most cases,
the dose to the empty bladder is lower than when the bladder
is full. Simultaneously, the doses to the bowels increase pro-
portionally in the empty state of the bladder comparing to the
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3D Dosimetry of Bladder in
HDR Brachytherapy
full organ. Protection of the bowels, which are more radio-
sensitive, suggests treating the patients in the full state of
the bladder. However, early and late bowel toxicity should
be investigated to establish clear standards of treatment. To
control and evaluate the dose to OAR, CT-based VBT should
be used. The outcomes confirm the other studies.
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