Courtney Williams

DOS 531-501: Clinical Oncology for Medical Dosimetry

April 24, 2022

Clinical Oncology Assignment: Cervical Cancer with Pelvic Node Involvement

Introduction

Cervical cancer is the second most common cancer diagnosed in women worldwide.1 In

the United States, African-American and Hispanic women are more likely to be diagnosed while

Jewish women are the least likely to be diagnosed.2 Common causes of the malignancy include

having multiple sexual partners, sexual intercourse beginning at a young age, and incidence of

sexually transmitted diseases, STDs.2 Human papilloma virus, HPV, is a STD that that has

significant correlation with cervical cancer.2 Other risk factors include oral contraceptives with

estrogen only, smoking, obesity, nulliparity, immunosuppression, hormonal factors, and low

economic status.2 Cervical cancer is typically slow growing and early stage disease is usually

asymptomatic.2 Patients with symptoms can present with abnormal vaginal discharge, pelvic or

back pain, painful urination, hematochezia, or hematuria.2 The most common presenting

symptom is abnormal vaginal bleeding.2 The rate of mortality has gone down due to effective

screening examinations, like the Papanicolaou’s smear, and the development of a vaccine against

HPV.2 Although mortality rates have declined over recent years, cervical cancer is still the third

deadliest malignancy for women.1

In this case a thirty-year-old female patient presented with vaginal bleeding. The patient

has a significant history of cancer in her family including cervical cancer and ovarian cancer.

Imaging indicated a five centimeter tumor with early right parametrial extension and possible
protrusion into the upper vagina. The patient was diagnosed with poorly differentiated squamous

cell carcinoma of the cervix. The FIGO staging was IB3 and the radiologic staging was IIB. The

patient’s initial treatment was 50.4 Gray, Gy, with external beam radiation therapy, EBRT. The

patient also received brachytherapy to 43.5 Gy using tandem and ovoid treatment.

Patient Position

The patient was positioned supine, head-first on the treatment table. A pillow as placed

under the patient’s head for comfort. A vaclok was used for stable leg positioning and daily setup

reproducibility. For typical cervical cancer patient setup legs are straight; however, a knee

sponge was placed under the vaclok to allow for a slight bend of the knees. This was done to

provide patient comfort and did not affect the field borders or impede treatment planning. The

patient was given a blue ring to hold on her chest to keep hands and arms out of the treatment

field. The patient was instructed to have a moderately full bladder for treatment to reduce overall

dose to the bladder.

Table Setup
Target Dose

Utilizing EBRT, the tumor and involved regional lymphatics are typically treated to 45-

50 Gy at 1.8-2 Gy per fraction.3 The primary tumor can be boosted to 80-85 Gy utilizing

intracavitary brachytherapy. 3 In this case, the clinical intent was curative. The patient was treated

with concurrent chemotherapy and radiation therapy. She was prescribed 45 Gy, 2.8 Gy in 25

fractions, for the initial treatment course. The patient was prescribed a boost of 5.4 Gy, 180cGy

in 3 fractions, to the parametrial extension volume. The patient was also treated with tandem and

ovoid brachytherapy using Cesium-137. The first brachytherapy fraction dose was 21.5 Gy and

the second was 22 Gy. The patient also received low dose cisplatin chemotherapy.

Initial treatment (45 Gy)

Initial treatment (45 Gy) plus Boost

Avoidance Structures

The gross tumor volume is within the cervix and uterus. The entire female pelvis was

treated including the regional lymph nodes. The organs at risk include the bladder and rectum.3

Since the regional lymph nodes were also treated the bowel space is considered an additional

critical structure. If periaortic were included the kidneys and spinal cord would be additional

organs at risk.3 The femoral heads were also avoidance structures.

Lymph Nodes

The internal iliac and external iliac nodes were included in the treatment area. The three

most common lymphatic nodes and chains that may be treated include the obturator, internal

iliac, and external iliac.3 The periaortic lymph nodes may also be involved in lymphatic spread

for some cases.3

Anatomical Boundaries / Field Borders

A typical superior field border is located at the L4-L5 vertebral interspace.3 That was the

superior border used for this case. The typical inferior field border is the bottom of the obturator

foramen.3 That was the inferior border used for this case. The typical lateral border is one

centimeter lateral to the pelvic brim.3 The anterior border includes the pubic symphysis.3 The

posterior border typically splits the sacrum.3 For this case the posterior border extended to the

back of sacrum. Multi-leaf collimator leaves are used to block bony and untreated anatomy. The

fields include the whole pelvis and regional lymph nodes. The femoral heads are blocked.

Treatment Techniques

The initial treatment utilized a four-field box technique to provide uniform dose to the

pelvis and regional lymph nodes. The gantry angles were 270, 0, 90, 180. The collimator was set

to 0 degrees for all fields. The couch was at 0 degrees. No wedges were used since field-within-

a-field, FIF, was utilized on all fields. Each field was comprised of two segments. The beam
energy used for all fields was 15MV. The beams were weighted differently to provide uniform

dose distribution. The anteroposterior, AP, field was weighted to deliver 22.53 percent of the

overall dose. The right lateral field was weighted to 22.41 percent. The left lateral field was

weighted to 22.95 percent. The posteroanterior, PA, field was weighted to 32.11 percent. This

created even dose distribution including the ten percent isodose line, IDL, and the fifty percent

IDL. It also kept the maximum dose within the gross tumor volume, GTV. The isocenter is

centered in the treatment field. The isocenter for the parametrial boost is in the center of that

reduced field. The maximum dose for the initial course was 47.85 Gy. The maximum dose for

the boost course, located in the muscular gluteal tissue, was 5.93 Gy. The patient was treated on

an Elekta Linac. The initial course plan was to the isocenter dose point and was normalized to 96

percent to increase periphery dose coverage.

The boost plan utilized an AP/PA technique. The gantry angles were 1, and 179. This was

chosen to limit beam divergence on the midsagittal edge of the field. There was 1 segment for

each field. The beam energy was 15MV. No wedge was used. The collimator and couch were set

to 0 degrees. The AP beam was weighted to 51 percent while the PA beam was weighted to 49

percent. The dose was prescribed to the isocenter for that plan and was normalized to 100

percent. Additional brachytherapy fractions were planned by another dosimetrist.

4-Field Box Technique

DVH / OAR Tolerances

For this case the critical structures were the bladder, bowel space, femoral heads, and rectum.

The bladder received a maximum of 52.83 Gy. The maximum dose tolerance for the bladder is

82 Gy.3 The rectum received a maximum dose of 47.63 Gy. The maximum dose for the rectum is

82 Gy.3 The femoral heads received 42.52 Gy. The maximum dose for the femoral heads is 45

Gy. The bowel space received a maximum of 52.63 Gy. This contour included parts of the large

and small intestine. For the small and large intestines, no more than 20 cubic centimeters, cc,

should receive more than 45 Gy.3

References

1. Williamson CW, Liu HC, Mayadev J, Mell LK. Advances in External Beam Radiation

Therapy and Brachytherapy for Cervical Cancer. Clin Oncol (R Coll Radiol).

2021;33(9):567-578. doi:10.1016/j.clon.2021.06.012

2. Rideaux K. Gynecologic Cancers. In: Principles and Practice of Radiation Therapy. 4th

ed. Mosby Elsevier; 2016:740-741.

3. Vann AM, Dasher BG, Wiggers NH, Chestnut SK. Gynecological Cancers. In: Portal

Design in Radiation Therapy. 3rd ed. Augusta, GA: Phoenix Printing.; 2013:159-166.