| Inclusion criteria |
-
•
Cervical cancer with squamous, adenosquamous or adenocarcinoma histology
-
•
Stage IA-IIA
-
•
Stage IIB with <5 cm in width in MR scan
-
•
Stage IIIC1 patients are allowed as long as the following is met: no common iliac node, <3 cm in the largest dimension, <3 pathologic nodes and primary with stage IA-IIB (IIB <5 cm in width)
|
|
|
| Radiotherapy |
| Simulation |
-
•
CT Scan (full and empty bladder) fused with MR scan OR MR Scan (full and empty bladder) fused with CT Scan. If available, fusion with FDG PET-CT is allowed. Bone fusion between scans
-
•
Preparation: Drinking protocol- empty bladder followed by 400 mL of water before scan. Rectum should be empty with diameter <4 cm in the AP diameter
|
| Contours and Field |
-
•
Contour CTVLR as per EMBRACE 2 protocol [11] in different scan sets. Ensure that a 5 mm is provided around the CTVHR towards the bladder and rectum and that contours are expanded inferiorly by 2 cm to cover the uninvolved vagina.
-
•
Generate a primary internal target volume, ITVp, by combining contours from the various image-sets (CTVLR contoured on empty- and full-bladder CT and MR scans)
-
•
Generate an elective nodal clinical target volume, CTVn by contouring nodes as follows:
-
o
IA-IB2 AND no suspicious nodes: CTVn - Obturator, External and Internal illiacs and Presacral
-
o
IB3-IIB OR positive pelvic node: Nodes as specified above + common illiacs until aorta bifurcation
-
•
GTVHighDose = suspicious or cancerous pelvic lymph nodes
-
•
Contour OAR:
-
o
Bladder: Whole organ including bladder neck
-
o
Rectum: from ano-rectal sphincter to recto-sigmoid junction
-
o
Sigmoid: from recto-sigmoid junction to left iliac fossa
-
o
Bowel: outer contour of bowel loops including the mesentery in a single contour
-
o
Femurs: Right and left femoral heads
-
o
Bone Marrow: Pelvic bones as a surrogate
|
| Planning |
-
•
VMAT preferably (or IMRT)
-
•
ITVLowDose = ITVp + CTVn
-
•
PTVLowDose = ITVLowDose + 5 mm isotropic expansion
-
•
PTVHighDose = GTVHighDose + 5 mm isotropic expansion
-
•
Refer to Table 2 for suggested dose constraints
|
| Dose-prescription |
|
| Treatment delivery |
-
•
Image verification: Perform daily CBCT and align to bone anatomy
-
•
Assess necessary shifts: Automatic correction if <1 cm of translation. If translation larger ≥1 cm or 4 degrees of rotation, repeat patient setup and CBCT.
-
•
Assess soft tissues: Verify rectal diameter and bladder filling. Inspect bowel position in regards to PTVLowDose and PTVHighDose. Verify if cervix and uterus are within PTVLowDose volume.
-
•
Troubleshooting: Consider removing patient from bed and waiting longer or offering more fluid if bladder is empty or bowel significantly intruding PTV space. Empty rectum if full (AP diameter >6 cm) or if this is significantly pushing the vagina and cervix anteriorly
|
| Chemotherapy |
|
