Vulva Plan Comparison

Cortney Cashner
Patient Information
• Age: 83 years old
• Diagnosis: invasive squamous
cell carcinoma of the left vulva (4.5cm)
with involvement of the urethra and distal
vagina

• Patient not a candidate for pathological

lymph node evaluation, surgical resection,
or chemotherapy
• Patient with multiple comorbidities, not a
candidate for radiosensitizing cisplatin,
and physician approximate chance of
complete pathologic response = 60%
• Treatment to include nodes because
involvement is likely
 • Patient headfirst supine
• Lower body in Vac-Lock bag with legs slightly frogged
• Triangular sponge under knees under vac-lock
Simulation Procedure • Holding O-ring on chest

• MRI obtained after CT-sim for better localization of soft-tissue structures and lymph nodes
Planning Treatment • AP and Lt Lat DRRs demonstrating the PTV
•
Volume PTV includes CTV, external iliac nodes, internal iliac nodes, and inguinal nodes + 1 cm margin.
Radiation Therapy
Prescription
• The physician's prescription for
the patient was 180 cGy for 25
fractions for a total of 45 Gy to the
PTV.

• There was an additional boost of

180 cGy for 12 fractions for a total
of 21.6 Gy to the boost PTV which
was the vulva with 1 cm margin.
Organs at Risk

• Organs near the vulva include:

• Bladder (Light Yellow)
• Rectum (Red)
• Bowel (White)
• Left femoral head (Dark
Yellow)
• Right femoral head (Light
green)
 *Notice patient's adipose
3D Plan tissue sliding to the patient's
left.*
 • 4 field-box: AP, Lt Lat, PA, Rt Lat
3D Planning Technique • MLC margin 1cm
• Control points: 2 for the Lt Lat and 1 for the Rt Lat
Segments
 *Notice less dose to normal
3D Plan tissue.*
DVH 3D
• Triangles = plan 2, with more conformal MLC
pattern
• Squares = plan1, with less conformal MLC
pattern

• White = Bowel
• Magenta = Lt Femur
• Red = Rectum
• Green = Rt Femur
• Aqua = PTV
• Light Yellow = Bladder

• Normalization: 100% of dose covers 95% of

PTV
• Max Dose: 4947.6cGy (109.9%) 4940.7cGy
(109.8%)
 OAR Tables 3D
Organs at Risk (OAR) Desired Planning Objective Planning Objective Outcome
Bladder V4500cGy ≤ 35% (RTOG 0724) 37.8%

Bowel V4500cGy≤ 30% (RTOG 0921) 16.3%

Rectum V4500cGy≤ 60% (RTOG 0724) 45%

Rectum V4500cGy ≤ 30-50% (RTOG 0822) 45%

Rt & Lt Femoral Head V4500cGy ≤ 20% (RTOG 0822) Rt: 50.13%, Lt: 74.04%

Rt & Lt Femoral Head D0.1cc ≤ 5000cGy (RTOG 0822) Rt: 4924.5cGy, Lt: 4864.9cGy

A combination of RTOG protocols is used for our 3D pelvis dose constraints.

 • For this patient, flash was not required to obtain optimal coverage of the vulva.
IMRT Planning • No external disease
• Self-bolus by adipose tissue
Technique • Physician sees desquamation without flash
• 3 arcs, 30-degree collimator rotation with complementary angles, 0.5 cm MLC margin
• Aperture shape controller = high
PTV Expansion If Flash is • The red structure is the "PTV_plan"
• PTV_plan = PTV + 1.5 cm circumferential PTV, - 3 mm from skin surface
Required
 • BEV on the left demonstrates lack of flash when not using PTV_plan
PTV Expansion • BEV on the right demonstrates flash after utilizing PTV_plan
 *Notice how much more

IMRT Plan conformal isodose lines are in

the IMRT plan than in the 3D
plan.*
 • PTV upper 4550 priority 260, 4500 lower 120 priority
Optimization •
•
3 bowel uppers and a mean
2 rectum uppers
•
Values •
1 bladder mean
1 upper on each femoral head
• Normal tissue objective 175
DVH IMRT

• White = Bowel
• Magenta = Lt Femur
• Red = Rectum
• Green = Rt Femur
• Aqua = PTV
• Light Yellow = Bladder

• Normalization: 100% of dose covers 95% of

PTV
• Max Dose: 4931.6cGy (109.6%)
 OAR Tables IMRT
Organs at Risk (OAR) Desired Planning Objective Planning Objective Outcome
Bladder V4000cGy ≤ 40-55% 12.67%

Bladder V4500cGy ≤ 15-30% 4.04%

Bladder Max ≤ 5000cGy 4858.5cGy

Rectum V6000cGy ≤ 15-20% 0%

Rectum V4500cGy ≤ 30-50% 16.52%

Bowel V3500cGy ≤ 180-230cc 195.13cc

Bowel V4000cGy ≤ 100-130cc 120.81cc

Bowel V4500cGy ≤ 65-90cc 52.72cc

Bowel Max ≤ 5000cGy 4882.4cGy

Rt & Lt Femoral Head V4000cGy ≤ 40-65% Rt: 6.63%, Lt: 4.74%

Rt & Lt Femoral Head V4500cGy ≤ 25-40% Rt: 0.56%, Lt: 0.13%

Rt & Lt Femoral Head Max ≤ 5000cGy Rt: 4618.1cGy, Lt: 4858.5cGy

Dose constraints from RTOG0822 phase II.

Hong T, Moughan J, Garofalo M, et al. NRG oncology radiation therapy oncology group 0822: A phase II study of preoperative chemoradiotherapy utilizing intensity modulated radiation therapy (IMRT) in
combination with capecitabine and oxaliplatin for patients with locally advanced rectal cancer.Int J Radiat Oncol Bio Phys. 2015; 93(1):29-36. Doi: 10.1016/j.ijrobp.2015.05.005
 • Each plan is normalized to 100% of dose covering 95%
of the PTV

Plan Evaluation • Each plan's overall maximum dose is under 110% of 45

Gy
• Each plan's hot spot is in an acceptable location, within
the PTV
Plan Evaluation

• Triangles = 3D
• Squares = VMAT

• White = Bowel
• Magenta = Lt Femur
• Red = Rectum
• Green = Rt Femur
• Aqua = PTV
• Light Yellow = Bladder

• Normalization: 100% of dose covers 95% of

PTV
• Max Dose: 4947.6cGy (109.9%) 4940.7cGy
(109.8%)
 • IMRT plan is the better plan because:
• Lower OAR doses
Conclusion • Lower integral dose
• More conformal isodose lines