Ca cervix part 2

Presented by Dr Rajendra Patel

Guided by Dr Rajeev Jain sir

Today’s topic
Field placement
Contouring
Planning Steps In cervix Carcinoma
 indication for radiation therapy.
 Positioning and Immobilization.
 Simulation & Tumor Localization (CT based).
 Field Placement.
 Dose, Time, and Fractionation & Calculation.
 Treatment Delivery techniques & verification.
 Follow-up during and after treatment.
Indication of radiotherapy
Definitive treatment for stage I-IIA (resectable) disease with same
efficacy as surgery

Definitive treatment (with CCRT) for stage IIB–IVA

Recommended with CCRT in bulky >4 cm stage IB2-IIA, because of
common need of post-hysterectomy RT and increased complication risk
with combined surgery/RT

Patients with stage IVB disease may receive palliative radiation to the
pelvis for selected indications such as to stop vaginal bleeding, relieve
pain, or alleviate urethral obstruction from extrinsic compression.

Postoperative pelvic radiation is well-established for involved LN,

involved parametrium or involved surgical margins
Indication of EBRT
IB2-IVA (as chances of lymphatic metastasis is high)

When cervical os is not negotiable in early case of IA-

IB1

When IA – IB1 cases prefer to avoid surgery or deemed

inoperable
Chemotherapy
As part of definitive treatment (concurrent with EBRT) for
locally advanced cervical cancer(>IIB)
Stage IB1: concurrent chemotherapy not validated

Adjuvant chemotherapy (following concurrent radiation /

chemotherapy) may reduce the overall recurrence rate
and is currently under investigation

Commonly used for palliation for local, regional or

systemic disease
CCRT data

Overall survival benefit of 10% and progression free

survival benefit across all stages
Chemo radiotherapy has 6% improvement from
radiotherapy in 5 year survival
Weekly Cisplatin at 40 mg/m2 during 5 weeks of pelvic
EBRT with or without chemotherapy during BT is the
current standard of care.
3-weekly cisplatin/5-FU is also validated by level
I evidence.
Meta-analysis results indicate no particular
benefit to cisplatin as compared with other types
of chemotherapy.
Concurrent chemo radiotherapy is beneficial in
early diseases and no statistical benefit in
advance cases
RT technique
EBRT to pelvis ± PA LN irradiation
Integrated with brachytherapy (BT)
Radiation therapy should be completed within 7
weeks
POST OP RT indication
LVSI Stromal Invasion Tumor Size
POSITIVE DEEP 1/3 ANY
POSITIVE MIDDLE 1/3 >2
POSITIVE SUPERFICIAL 1/3 >4
NEGATIVE DEEP OR >5
MIDDLE 1/3
POST
OP
CCRT
indicatio
n
Positioning and immobilisation
supine position supine with arms on the chest, knee
and lower leg immobilisation or alpha cradles to prevent
pelvic rotation, and aligned using orthogonal laser
beams with anterior and lateral tattoos marked with
radio-opaque material for stability
prone position on a belly board, The prone position
aids in shifting small bowel out of the pelvis. In patients
who have had a hysterectomy, small bowel may drop
into the pelvic area
IMRT, due to stability of the pelvis, the supine position
is typically preferred with immobilization devices
surrounding the pelvis to ensure minimal motion during
treatment.
 knee rest
• Relaxes lower back making
pt. more comfortable
• Minimize rotation of pelvis
• Knee rest with indexing
limits superior-inferior and
lateral motion
Prone position on a belly
board
 For obese pt.
 Prevent small bowel toxicity
 Daily reproducibility of
position is questionable
Immobilisation
 Several types of immobilization options
available in radiotherapy
 Needs to be:
 Comfortable

 Reproducible

 Minimal beam attenuating

 Affordable
Immobilization options
Thermoplastics form the basis
for immobilization in
In the pelvis these are difficult
to be used as:-
Lack of bony points for fixation
Continuing abdominal
movements with respiration
Presence of fat pads and folds
RCC Raipur technique- simple supine
positioning with skin markings:-
 Cheap

 Reproducible
 Ease of use and comfortable for patient.
Vacloc
CT SIMULATION
 CT scanning is recommended for data acquisition.
 Patients are usually scanned in supine position, arms overhead ,
knees immobilised with knee rest
 For obese pts. prone belly board may be used
CT scan is obtained from
T10-T11 interspace to upper
third of femur,
slice thickness may vary
from 3-5 mm depending upon
institutional protocol
These images are
transferred to treatment
planning system (TPS) and
contouring is done
NPO since 6am
Oral contrast – 30 ml of iohexal mixed with 2 liter of water
should be given over 2 hour prior to simulation CT
IV contrast push – iohexal - 2ml/kg body wt at the time of
CT scan
Rectal contrast – iohexal 20 ml + 300ml NS at the time of
scan
Vaginal contrast with swab at distal end of growth
 Bladder Protocol for Simulation
 In pelvic malignancies bladder filling status has largely been the
matter of debate.
 George et al.,[1] and Pinkawa et al.,[2] recommended a full bladder
for treatment of gynecological malignancies, as the dose-volume-
load to bladder and cranially displaced sigmoid colon/small bowel
loops can be reduced significantly.
 However; Pinkawa in another study[3] found that bladder wall
displacements are reduced significantly (P < 0.01) at superior and
anterior border while treating empty bladder compared to full bladder
and also there is less variability in bladder volume in an empty
bladder state.
 the ideal bladder filling status has not been ensured by any study so
far.
 The bladder protocols may vary from institution however most
institute follow a consistent bladder filling protocol of voiding urine 15
min prior to both imaging and treatment
Image registration
Technique by which the coordinates of identical points in
two imaging sets are determined and a set of
transformations determined to map the coordinates the
one image to another
Uses of image registration – study organ motion (4 D CT)
Assess tumour extent (PET/MRI fusion)
Assess changes in organ and tumour volumes over
time(adaptive RT)
Types of transformations-
Rigid – translation and rotations
Deformable – for motion studies
 Plain X ray simulation(2D)
AP and lateral simulator films are taken.
Standard field borders decided using bony anatomical
landmarks.
Fudicial marker placed at different border with anatomical
landmark and check x-ray done
 Field border for AP-PA fields
 Superior – L4-L5 interspace <IIB(except bulky ds)
 To cover common illiac LN for >IIB : L3-L4 interspace
 Lateral – 1.5-2 cm from pelvic brim
 Inferior – lower border of obturator foramen or 2-3 cm inferior
to distal extent of growth/ with large disease this can extend up
to ischial tuberosity.
 When the tumour involves the distal half of the vagina, the
portals should be modified to cover the inguinal lymph nodes
because of the increased probability of metastases
Inguinal LN in AP PA Field

AP-PA field is extended laterally till Anterior superior

iliac spine used with a to cover the inguinal lymph
node
 Lateral fields/four fields technique
Posterior border - 0.5 cm posterior to the anterior
border of the S2-S3 vertebral junction
When uterosacral ligament is involved whole sacrum
anterior border on the lateral field should be set at a
vertical line anterior to the pubic symphysis, since the
external iliac lymph nodes must be covered or 2cm
anterior to GTV-P
Superior and inferior border same as AP-PA fields
 Extended Pelvic nodal fields
 overdose the kidneys, spinal cord, and small bowel Dose
escalation to Para-aortic nodes to approximately >45 Gy is not
feasible.
 superior border - covers the renal hilum, often at the T12-L1
interspace,
 Inferior borders - cover the obturator foramen, unless there is
distal vaginal or inguinal node involvement.
 Anterior border - rests 2 cm in front of the vertebral body or
enlarged nodes as contoured,
 Posterior - the border bisects the mid-vertebral body.
 The pelvic portion mimics that described for the four-field
pelvic setup.
 Lateral border: width (in general, 8 to 10 cm) can be
determined by CT scan
 Para-aortic field: 2 field vs. 4 field
AP-PA treatments to the para aortic nodal chain may
overdose the kidneys, spinal cord, and small bowel.
The spinal cord dose (T12 to L2–3) should be kept to <45
Gy
This can be done by interposing a 2-cm-wide 5 HVL
shield on the posterior portal (usually after 40-Gy tumour
dose) or using lateral ports and limiting the kidney dose
to <18 Gy
The use of four fields, is implemented as an alternative to
AP-PA alone as a way to reduce some of the dose to the
anterior small bowel, kidney S.C
 Shielding of A-P fields

Individualised shielding is
employed in the anterior
beam to superior corners
to exclude small bowel.

Shielding to the inferior

corners to protect femoral
heads may mask the
external iliac nodes and
should be used carefully.
 Shielding of lateral fields

Lateral beams have

shielding to sacral nerve
roots posteriorly.
For simulation of para-
aortic nodal beams,
intravenous contrast is
required to localise
kidneys for shielding
 Midline shielding
Depending on brachytherapy dose administered, midline
shielding with rectangular or specially designed blocks
has been traditionally use for a portion of EBRT dose
delivered with the AP-PA ports
Midline blocks may be individualized, based on the
point A isodose line or a rectangular block of
approximately 4-cm width.
However, in the era of 3D brachytherapy planning, the
use of a midline block has been questioned because it
may result in tumor underdosing while still
contributing significant dose to the bladder, sigmoid,
and rectum
Midline Shielding in AP-PA Portals
and Use of a Parametrial Boost
for patients with persistent disease after approx. 45-50 Gy
EBRT to pelvis midline shield can be used to boost
parametria or nodes
When parametrial tumor persists, 50 to 60 Gy may be
delivered to the parametria, with reduced AP-PA portals
In the modern era, the use of highly conformal boosts with
3D planning, IMRT & HDR 3D brachytherapy have
replaced conventional technique
Also midline block may not be beneficial in patients
receiving 3D image planned brachytherapy with adequate
optimization of dose to the tumour and away from the
normal tissues.
TWO FIELD
 Heterogeneous dose
distribution
 Parametrium under dosed
 More skin reaction
 Useful when lower part of
vagina involved
FOUR FIELD
 Homogeneous box shaped
dose distribution
 Whole target vol. Including
parametrium gets adequate
dose
 Skin reaction are decreased
 Treatment time more
Dose distribution 2 field vs 4 field
BEAM ENERGY

Because of the thickness of the pelvis, high-energy

photon beams (6 MV or higher) are especially suited for
this treatment.
They decrease the dose of radiation delivered to the
peripheral normal tissues (particularly bladder and
rectum)
provide a more homogeneous dose distribution in the
central pelvis.
avoid subcutaneous fibrosis
 Dose & fractionation
Primary radiotherapy

40-44 Gray to whole Pelvis followed by midline

shielding up to 50 Gy in 25 daily fractions of 2 Gy
given in 5 weeks followed by Intracavitary
brachytherapy.

Persistent /bulky parametrial tumour: boost up to 60

Gy
Dose & fractionation
Adjuvant radiotherapy
50Gy/25 # or 45 Gy in 25 daily fractions of 2 or 1.8 Gy
given in 5 weeks.
50.4 Gy in 28 daily fractions of 1.8 Gy in 5 1⁄2 weeks if
macroscopic residual disease.
Para-aortic node radiotherapy
Adjuvant radiotherapy:45 Gy in 25 daily fractions of 1.8 Gy
given in 5 weeks.
Palliative treatment
Whole pelvis or para-aortic nodes
20–30 Gy in 5–10 daily fractions given in 1–2 weeks.
8 Gy in 1 fraction for haemostasis.
Target Volume delineation
 Contouring
Several contouring guidelines available for CTV
 Taylor et al pelvic nodal delineation (CT based)
 Toita et al for CTV delineation in intact cervix EBRT (CT based)
 Lim et al for CTV delineation in intact cervix IMRT (MRI based)
 Small et al for CTV delineation in post operative IMRT (CT based)
 PGI literature review & guidelines for delineation of CTV for intact carcinoma
cervix (CT based)
 Guidelines for organ at risk
 Pelvic Normal Tissue Contouring Guidelines for Radiation Therapy: A Radiation
Therapy Oncology Group Consensus Panel Atlas (CT based)
Beadle et al found that mean maximum changes in the center of the
cervix : superior–inferior 2.1, anterior–posterior 1.6, and right–left
lateral 0.82
Mean maximum changes in the perimeter of the cervix were
superior 2.3 and inferior 1.3, anterior 1.7 and posterior 1.8, and 0.76
and 0.94 cm in the right and left
STAGE WISE LN % POSITIVE
Stage Pelvic LN % Paraaortic LN %
IA1 0.5 0
IA2 4.8 <1
IB 15.9 2.2
IIA 24.5 11
IIB 31.4 19
III 44.8 30
IVA 55 40
LN INVOLVEMENT OF DIF GROUP BY –
BENEDETTI PACINI P. STUDY
LN % IB-IIA >= IIB
OBTURATOR (SUPERFICIAL) 86% 92%
OBTURATOR (DEEP) 7% 5%
PARAMETRIAL 15% 16%
EXTERNAL ILLIAC 29% 21%
PRESACRAL 7% 3%
COMMON ILLIAC(SUPERFICIAL) 28% 29%

COMMON ILLIAC (DEEP) 7% 13%

Normal organ
Anorectum - Inferiorly from the anal verge as marked with
a radiopaque marker at the time of simulation. Contouring
ends superiorly before the rectum loses its round shape in
the axial plane and connects anteriorly with the sigmoid.
The AnoRectum is used with the Sigmoid and Bowel Bag.
Sigmoid - Bowel continuing where the AnoRectum contour
ended. Stops prior to connecting to the ascending colon
laterally. Contoured when a brachytherapy applicator rests
in the uterus. Any sigmoid adjacent or above the uterus or a
brachytherapy applicator should be contoured.
 Bowel bag
 Inferiorly from the most inferior small or large bowel loop, or above the
Rectum (GU) or AnoRectum (GYN), whichever is most inferior. If when
following the bowel loop rule the Rectum or AnoRectum is present in that
axial slice, it should be included as part of the bag; otherwise it should be
excluded.

 Tips: Contour the abdominal contents excluding muscle and bones. Contour
every other slice when the contour is not changing rapidly, and interpolate
and edit as necessary. Finally, subtract any overlapping non-GI normal
structures. If the TPS does not allow subtraction leave as is.

 Stop contouring the BowelBag, SmallBowel, and Colon 1 cm above PTV for
most coplanar beam plans, but the choice will depend on the treatment
technique. Stop these PTVs at distances much greater than 1 cm for non-
coplanar beam plans depending on the beam angle and path. Tomotherapy
plans will require stopping from 1 to 5 cm above the PTV, depending on the
selected field size, which is often 2.5 cm.
Bladder - Inferiorly from its
base, and superiorly to the
dome.
Femoral head - The
proximal femur inferiorly
from the lowest level of the
ischial tuberosities (right or
left) and superiorly to the
top of the ball of the femur,
including the trochanters.
Femur head
 CTV COMPONENTS
GTV Entire GTV – intermediate/high signal seen on T2
weighted MR images

CERVIX Entire cervix if not already included in GTV contour

UTERUS Entire uterus

PARAMETRUIM Entire parametrium including ovaries; include entire
mesorectum if US ligament involved

Min or no vaginal involvement –include upper half

Upper vaginal involvement – include upper 2/3 vagina

VAGINA
Extensive vaginal involvement – include entire vagina
Parametrium contouring guideline CTV P2
 To delineate the parametrium , connective tissue extending from the
cervix to the pelvic wall are included, along with the visible linear
structures that run laterally (e.g. vessels, nerves and fibrous
structures)
 Cranial border : defined at the level where the true pelvis begins.
Contours should stop once loops of bowel are seen next to the
uterus (Lim/Toita et al.)
 Anteriorly: contouring is done up to the level of posterior border of
bladder in the central region, while, in periphery it extends till the
anterior end of lateral pelvic bony wall.
 Posteriorly: parametrium is contoured only till the anterior part
(semicircular) of mesorectal fascia. In case of significant parametrial
invasion(IIIB)/uterosacral ligament involvement, include entire
mesorectum.(Lim et al.(RTOG)/PGI Guidelines).
 Laterally, the parametrium is contoured till the lateral pelvic wall,
upto the medial edge of internal obturator muscle.
 Caudal border of parametrium is taken at the pelvic floor.
Final PTV: The ITV margin given over CTV P1 for uterine
motion is added to the total PTV and this is taken as the total
target volume (final PTV) to be treated.
 SUMMARY OF GUIDELINES FOR DELINEATING NODAL REGION

LYMPH NODE RECOMMENDED MARGIN

GROUP
COMMON ILIAC 7 mm margin around vessel. Extend
posterior and lateral borders to psoas and
vetebral body
Cranial - L4-L5 intersection
Caudal - bifurcation of common ililac artery
EXTERNAL ILIAC 7 mm margin around vessel. Extend anterior
border by further 10 mm anterolaterally to
include lateral external iliac nodes
Cranial - bifurcation of Common iliac A
Caudal - superior aspect of femoral head
where it becomes femoral artery
Nodal CTV
INTERNAL ILIAC 7 mm margin around vessel. Extend lateral
borders to pelvic side wall
Cranial - bifurcation of common iliac artery
into internal artery along its branches
(obturator, hypogastric)
Caudal - paravaginal tissue at the level of
vaginal cuff
OBTURATOR Join external and internal iliac regions with a 17
mm wide strip along the pelvic side wall

PRE SACRAL Subaortic : 10 mm strip over anterior sacrum

Mesorectum : cover entire mesorectum space
Sacral foramina are not included in CTV
 Common iliac - 7 mm margin around vessel. Extend posterior and
lateral borders to psoas and vetebral body
 EXTERNAL
ILIAC
 7 mm margin
around
vessel.
Extend
anterior
border by
further 10
mm
anterolaterall
y to include
lateral
external iliac
nodes
 INTERNAL
ILIAC
 7 mm margin
around
vessel.
Extend
lateral
borders to
pelvic side
wall
 PRE SACRAL
 Subaortic : 10 mm strip over anterior sacrum
 Mesorectum : cover entire mesorectum space
 OBTURATOR
 Join external and internal iliac regions with a 17 mm wide strip along
the pelvic side wall
 Total CTV
CTV N and the CTV P are
combined and named as total
CTV
PTV: 10 mm over total CTV
ITV Margin:The uterine motion
is accounted for by giving an
ITV margin on the uterus
An asymmetrical margin with
ITV expansion of 15 mm
antero-posteriorly, 15mm
supero-inferiorly and 7 mm
laterally, is taken from the
uterus (CTV P1)
Axial slice showing different margins given over
CTV 2 (blue) and total CTV (light green)
Axial slice showing final PTV (red)
Post operated CTV
CTV-T comprises the surgical tumour bed including the
vaginal vault and parametrial tissues.
Vaginal cuff and 3 cm of vagina inferior to the cuff.
CTV-T is delineated using preoperative CT and MRI,
operative diagrams and histological findings to include
sites at high risk of recurrence.
Parametrial/Paravaginal tissue From the vaginal cuff to
the medial edge of the internal obturator muscle/ischial
ramus on each side.
Presacral lymph nodes Lymph node region anterior to
S1and S2 region.
Thank you
PGI guidelines
CTV nodal (CTV 1)
 1. Start contouring iliac vessels from aortic bifurcation down till the
appearance of femoral head
 2. Uniformly, pelvic blood vessels are given a margin of 7mm
however; the upper border is maintained at aortic bifurcation
 3. The contour is extended around common iliac vessels posteriorly
and laterally so as to include connective tissue between iliopsoas
muscles and lateral surface of vertebral body
 4. No additional 10mm anterolateral extension is given around
external iliac vessels along the iliopsoas muscle
Fig 1 An atlas of clinical target volume for pelvic lymph
nodes for uterine cervical cancer (a-h), vessels (yellow),
CTV 1 (red)
5. To cover obturator nodes, a strip 17 mm wide is created medial
to the pelvic sidewall, by joining the contour of external iliac vessels
with internal iliac vessels.
Contouring of obturator nodes with 17 mm brush is continued lower
down along pelvic side wall, till superior part of obturator foramen
6. The posterior margin of CTV 1 contour over internal iliac vessels
lies along anterior edge of piriformis muscle
7. Pre-sacral region is covered by connecting the volumes on each
side of pelvis with a 10-mm strip over the anterior sacrum starting
from aortic bifurcation till S2-S3 junction. Sacral foramina are not
included in CTV 1
8. All visible nodes (contoured as GTV N) are given a margin of
10mm to create CTV node and are included in CTV 1
9. Muscle and bone are excluded from CTV 1.
CTV primary (CTV 2 and CTV 3)
CTV [Figure 2] primary for intact carcinoma cervix consists of
gross tumor volume of the primary tumor (GTV primary), uterine
cervix, uterine corpus, parametrium, vagina and ovaries.
Definitions for each component structure of the CTV primary
Uterus (CTV 2) contoured along with the gross disease (GTV
primary) as a single structure, the uterus (CTV 2) [Figure 2a-d].
Vagina - paravaginal tissue is included along with the vaginal wall.
In cases with minimal or no vaginal wall involvement, the
contouring is stopped four slices above the lower border of
obturator foramen, so that when 1.5 cm ITV (internal target
volume) margin is given over the uterus, the lower border does not
extend beyond the lower border of obturator foramen.
Fig 2 CTV for primary for uterine cervical cancer, (a-d) represent
delineation of CTV 2 (pink), (e-i) represent delineation of CTV 3(red),
where 2 f shows parametrial contouring for cervix cancer stage II B, and
2 g shows parametrial contouring for bulky stage III B, and (j) represents
Total CTV (red)
Parametrium (CTV 3)
To delineate the parametrium [Figure 2e-i], connective
tissue extending from the cervix to the pelvic wall are
included, along with the visible linear structures that run
laterally (e.g. vessels, nerves and fibrous structures).
Cranial border of parametrium is defined at the level
where the true pelvis begins.
Anteriorly - contouring is done up to the level of
posterior border of bladder in the central region, while, in
periphery it extends till the anterior end of lateral pelvic
bony wall, as the parametrium is attached till here.
Parametrium cont.
Posteriorly - the parametrial contouring is different in two
different sets of patients.
In patients with (FIGO) stage III B or greater disease, or who
have clinical or radiological evidence of involvement of
uterosacral ligaments, or have extensive nodal involvement,
the parametrial volumes would extend up to the rectal contour to
include the entire mesorectum and uterosacral ligaments within
the parametrium [Figure 2 g].
In all other patients who do not have the advanced disease, the
posterior boundary of parametrium is contoured only till the
anterior part (semicircular) of mesorectal fascia [Figure 2 f].
Laterally - till the lateral pelvic wall, upto the medial edge of
internal obturator muscle.
Caudal border - medial border of levator ani or at the pelvic
floor.
 The CTV primary finally includes the uterus (CTV 2) and the
parametrium (CTV 3). Ovaries visible on CT are included within the
CTV primary.

 The Internal target volume (ITV) margin

 The uterine motion is accounted for by giving an ITV margin [Figure
3] on the uterus.
 An asymmetrical margin with CTV 2 – ITV expansion of 15 mm
antero-posteriorly, 15mm superoinferiorly and 7 mm laterally, is taken
from the uterus
Total target volume CTV 1 and the CTV primary are combined and
named as total CTV [Figure 2j], which is further given a margin of 10 mm
all around for the total PTV [Figure 3] to account for setup errors.
The ITV margin given over CTV 2 for uterine motion is added to the total
PTV and this is taken as the total target volume (final PTV) to be treated
[Figure 4].
Thus, in the final PTV, the margin from the uterine surface remains same
as given for ITV, i.e., 15mm in both anteroposterior and superior-inferior
direction.
The final PTV is manually or automatically trimmed up to 3mm from the
skin surface, if necessary to spare skin, provided that the CTV is still
included entirely within the PTV.
Figure 5a-e represent the digitally reconstructed radiographs of CTV 1,
CTV 2, CTV 3, total CTV and final PTV.
 Total CTV
CTV N and the CTV P are
combined and named as total
CTV
PTV: 10 mm over total CTV
ITV Margin:The uterine motion
is accounted for by giving an
ITV margin on the uterus
An asymmetrical margin with
ITV expansion of 15 mm
antero-posteriorly, 15mm
supero-inferiorly and 7 mm
laterally, is taken from the
uterus (CTV P1)