Vulvar Plan Comparison

Presented by: Joseph Bryant

DOS 772: Clinical Internship II
Patient Information
75 years old
Stage IB Multifocal Squamous Cell Carcinoma of the Vulva, Bilateral Groin
- (HPV associated)
- Inguinal lymph nodes/local at-risk lymphatics included
Wide Local Excision revealed many tumors, with the largest being 0.5 cm across with a
1.5 cm depth of invasion
- Negative margins
- Partial bilateral vulvectomy
Vulva and at-risk lymphatics included in treatment field
Simulation Method and Setup
SBRT Board with VacLok bag

Supine, Sponge and Pillow under head–Hands on chest

Rolled bubble wrap in crease/folds in groin area to prevent/reduce skin irritation

Frog-leg Position (heels touching)

Full Bladder
Treatment Prescription
4500 cGy delivered in 25 fractions
● 180 cGy per fraction

Treated 5 days per week

IMRT/VMAT with image guidance

6 MV energy

Patient to arrive with a full bladder

PTV Margins

CTV (red) + 0.7 cm PTV (light

green)

CTV/PTV was cropped inside

body

Margin kept to external border to

ensure superficial aspect received
sufficient coverage
Surrounding OAR
Bladder – Blue

Bowel – Yellow

Left Femoral Head – Purple

Right Femoral Head – Pink

Rectum – Brown

Sigmoid – Green
Volumetric Modulated Arc Therapy (VMAT) Technique
Image

Plan Parameters

2 Arcs –
● A0: 255 - 105 CW
● B0: 105 - 255 CCW

30 and 265 degree collimator rotation

No couch rotation
VMAT Plan
Dmax: 114.5%
- Dmax in CTV/PTC in
vulva

Normalization: 100% of
prescribed dose covers 95%
of Target Structure
3D Conformal Technique
Plan Parameters

4 Fields -
● A0: 0 Degrees (6x)

● A1- 0 Degrees (10x)

● B0: 280 Degrees (10x)

○ 45 degree wedge

● C0: 80 Degrees (10x)

○ 45 degree wedge

*All beams had a 90 degree collimator rotation.

3D Plan
Dmax: 127.4%

- Hot spot just outside PTV on anterior nodal volume

Normalization: 100% of prescribed dose covers of 95% of Target Structure

VMAT Plan Outcome
Organ at Risk (OAR) Desired Planning Objective Planning Objective Outcome

Bladder D50% ≤ 3500 cGy 1635 cGy

D35% ≤ 4000 cGy 1766 cGy

Bowel D45% ≤ 3420 cGy 264 cGy

Max ≤ 5000 cGy 4046 cGy

Left Femoral Head D50% ≤ 3000 cGy 1455 cGy

Right Femoral Head D50% ≤ 3000 cGy 1386 cGy

Rectum D50% ≤ 5000 cGy 1182 cGy

Sigmoid D50% ≤ 4500 cGy 286 cGy

3D Plan Outcome
Organ at Risk (OAR) Desired Planning Objective Planning Objective Outcome

Bladder D50% ≤ 3500 cGy 1477 cGy

D35% ≤ 4000 cGy 1494 cGy

Bowel D45% ≤ 3420 cGy 291 cGy

Max ≤ 5000 cGy 5321 cGy

Left Femoral Head D50% ≤ 3000 cGy 3574 cGy

Right Femoral Head D50% ≤ 3000 cGy 3572 cGy

Rectum D50% ≤ 5000 cGy 418 cGy

Sigmoid D50% ≤ 4500 cGy 185 cGy

Comparison - 95% Isodose Coverage
VMAT 3D
Comparison - 95% Isodose Coverage
VMAT 3D
Comparison - 95% Isodose Coverage
VMAT 3D
Comparison - 80% Isodose Coverage
VMAT 3D
Comparison - 80% Isodose Coverage
VMAT 3D
Comparison - 80% Isodose Coverage
VMAT 3D
Comparison - 50% Isodose Coverage
VMAT 3D
Comparison - 50% Isodose Coverage
VMAT 3D
Comparison - 50% Isodose Coverage
VMAT 3D
 CTV
PTV
Rectum

VMAT Bladder
Sigmoid
DVH

Bowel L Femoral R Femoral

Head Head

CTV
PTV
Bladder
3D R Femoral
DVH Head

Rectum
L Femoral
Head
Sigmoid Bowel
Mean Dose Comparison
VMAT 3D

CTV 102.3% 115.3%

Bladder 36.6% 30.4%

Bowel 11.1% 16.6%

Left Femoral Head 33.5% 79.3%

Right Femoral Head 34.5% 79.3%

Rectum 27.1% 27.4%

Sigmoid 9.1% 4.1%

Conclusion
- Both plans were normalized to ensure adequate coverage of the PTV/CTV

- VMAT provided much better coverage, and conformality than 3D, when
compared without normalization

- VMAT did a better job at sparing OAR

- VMAT led to a reduced overall volume of the body exposed to low dose
radiation

- 3D planning does provide a setup with more margin for error, but with
daily CBCT/KV image guidance, the benefits of VMAT far outweigh this
concern.