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Karol Wynn
Clinical Lab 2
April 5, 2015

RTOG-0418A Phase II Study of Intensity Modulated Radiation Therapy (IMRT) to the

Pelvis +/-Chemotherapy for Post-operative Patients with either Endometrial or Cervical
Carcinoma

RTOG-0418 is a trial designed to evaluate the treatment of post-operative cervical and

endometrial cancer with or without the use of Cisplatinum based chemotherapy with the addition
of IMRT. The IMRT plan includes the treatment of the pelvic nodal volumes and the primary
vaginal and paravaginal target volumes. The patients are treated after hysterectomy. The use of
radiotherapy in the past included a four field box or a 3DC technique to a dose of 45Gy in 25fx
or 50.4Gy in 28fx. The data has shown significant acute and late side effects to the small bowel
and pelvic contents using these techniques. The goal of the study is to decrease normal tissue
complications while delivering 50.4Gy/28fx to the targeted volumes. The data sets used in this
lab is a postoperative cervical cancer patient scanned with and without a full bladder. The patient
is immobilized using a VacLoc bag placed under the upper abdomen to the feet. The two scans
are fused by the dosimetrist for the delineation of the ITV. The target volumes including the
vessels are outlined and expanded by the physician. All critical structures are contoured by the
dosimetrist following the RTOG contouring atlas for female pelvis and this protocol. The Eclipse
TPS is utilized with the Varian TrueBeam Accelerator. The full bladder CT scan is used for
planning. Beam energy is 10MV. The specifics of the planning procedure and outcomes are
defined below.
Target Volumes:
1. PTVn: PTVn is the CTVn expanded 7mm. CTVn is the lower common iliac nodes,
internal iliac nodes, external iliac nodes to the level of the superior femoral heads,
presacral nodes to the level of S3 and the obturator nodes stopping volumes at the upper
third of the obturator fossa. The CTVn excludes the boney pelvis, small bowel and
iliopsoas muscle adjacent to noncancerous nodal volumes. The PTVns superior extent is
the top of L5.

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2. PTVp: PTVp is the ITV expanded 7mm. The ITV is defined by the fusion of full and
empty bladder CTs. The ITV volumes include the vagina and paravaginal tissues on both
scans. The lateral margin of the PTVp is to the obturator muscle and the inferior margin
extends to the upper third of the symphysis pubis. These volumes are variable and
dependent on preoperative diagnostic studies and physical exam.

Figure 1: Frontal CT_FULL BLADDER: PTVn is the blue volume encompassing the CTVn in
orange. The fuschia volume is the vessels. PTVp is the red outlined volume encompassing the
lighter green ITV.

Figure 2: Sagittal CT_FULL BLADDER, PTVn is the blue volume encompassing the CTVn
in orange. The fuschia volume is the vessels. PTVp is the red outlined volume encompassing the
lighter green ITV.

Organs at Risk (OR):

1. Bladder: Volumes are outlined on all CT slices from the bladder base to its superior
extent.
2. Rectum: Volumes begin at anal verge and continue superiorly until the volume changes
its round shape and the sigmoid begins.
3. Femoral Heads: The bilateral femoral head volume begins superiorly at the ball of the
femur and includes the ischial tuberosity. The inferior extent is the end of the
tuberosities.
4. Small Bowel: All loops of small bowel and the surrounding peritoneum to the abdominal
wall to account for bowel movement. Superior extent is 2.1cm above PTVn.
5. Sacrum: All sacral volumes on CT slices. (not an OR, but outlines are required)

Figure 3: Bladder is outlined in yellow, bilateral femoral heads in fuchsia, and light
blue/periwinkle is the small bowel volume. The solid fuchsia volume is the vessels.

Figure 3: Bladder is outlined in yellow while the light blue/periwinkle is the small bowel
volume. The rectum is solid brown and the sacrum is olive.

Figure 4: Bladder is outlined in yellow and light blue/periwinkle is the small bowel volume. The
rectum is solid brown and the sacrum is olive.

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Treatment Planning Objectives and Constraints:
1. PTVn and PTVp are to receive 50.4Gy in 28fx.
2. PTV dose objectives are a minimum coverage of 90% to between 95% and 98% of the
PTV volumes. The maximum dose limit is <5% of PTVs to receive over 115% of
50.4Gy.
3. Bladder constraint is <35% to receive 45Gy.
4. Rectal constraint is <60% to receive 30Gy.
5. Small Bowel constraint is < 30% to receive 40Gy.
6. Femoral Head constraint is 15% to receive 30Gy.
Planning Technique and Beam Arrangement:
1. VMAT planning is utilized with heterogeneity corrections applied.
2. Beam arrangement is three, 358 arcs. Two clockwise arcs beginning at 181 and ending
at 179 and one counterclockwise arc beginning at 179 and ending at 181.

Figure 5: VMAT arcs beginning at CW- 181 to 178 , returning CCW and final arc CW.

Figure 6: AP and Right Lateral DRRs at isocenter.

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Plan Outcome: Initially, two 358 VMAT arcs are optimized. The plan objectives are defined to
the combined PTVn and PTVp volumes. The PTVn has a lower limit of 100% at 5195cGy and
an upper limit of 5250cGy. The PTVp has an upper limit of 5250cGy and a lower limit of 100%
at 5195cGy. In addition, an upper and lower objective is set on the ITV. An optimization
volume for bladder, rectum and, small bowel are made by cropping these structures from
PTV_comb with an additional 2mm separation. These volumes are named Rectum_Opti,
Bladder_Opti, and Bowel_Opti. A maximum dose of 5040cGy is set to the Rectum_Opti and
additional constraints are added to achieve the protocol objectives. These constraints are a rough
ratio of structure volume to cropped volume and the structures respective dose limits. The
normal tissue optimizer (NTO) is set to automatic with a priority of 95. Target and OR priorities
are shown in Figures 8 and 9. The plan optimization is run several times with critical structure
constraints adjusted after DVH review. A third CW arc is added after several attempts to lower
the hotspot below 110% and aid in the coverage of the targets. The plan is normalized to deliver
97% to 100% of PTV_comb. The plan meets all PTV objectives and critical structure dose
limits (see Tables 1&2.) Isodose distributions are displayed in Figures 10 and 11. Final DVH
results are seen in Figure 12.

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Figure 7: Optimization values and priorities.

Figure 8: Optimization values and priorities continued.

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Figure 9: Three Plane isodose distributions. Red bold line is 5040cGy (100%) and yellow bold
line is 4788cGy (95%).

Figure 10: Color Wash from max dose to 20% of 50.4Gy.

Table 1: Target Objectives and Results

Targets
ITV
PTVp or PTV Vagina 50.4
PTVn or PTV nodal
Max Dose

Desired Objectives
90% at 95% to 98%
90% at 95% to 98%
90% at 95% to 98%
< 5% of PTVs >115%

Achieved Objectives
97% at 100%
97% at 100%
97% at 100%
108.5% = 54.7Gy

Table 2: Critical Structure Constraints and Results

Organs at Risk
Bladder
Rectum

Desired Objectives
< 35% 45Gy
< 60% 30Gy

Achieved Objectives
35% at 38.9Gy
60% at 23.9Gy

Small_Bowel
Femoral Heads

< 30% 40Gy

15% 30Gy

30% at 34.4Gy
15% at 26.1Gy

Red: PTVp
Blue: PTVn

Rectum

Bladder

Femoral Heads

Small Bowel

Figure 11: DVH showing critical structures and target volumes.

Green: ITV