Carcinoma Vulva Planning Meet : 09/22/18

1. Ca Vulva : 3DCRT Planning
(Photon-electron) Field matching
and IMRT

2. PATIENT’S DETAILS
• Name : Bimla Devi
• Age/sex : 45 yrs/F
• Diagnosis : Ca Vulva, Stage II (lower 3rd vagina involved)
• Treatment: NACRT f/b assessment for surgery

3. 3DCRT PLANNING
• Planning CT :
• oral contrast
• Intermediate bladder protocol
• Frog leg position
• Hands over chest
• Fiducials just above the
greater trochanter
• IV contrast
• Customised bolus of 0.5 cm
thickness for the vulvar region
at simulation
• Images taken from L1 to mid
thigh with slice thickness of 3
mm

4. CONTOURING
• Target Volume
1. Entire Vulva
2. B/L Inguinofemoral nodes
3. Pelvic lymph nodes
Consensus recommendations for radiotherapy contouring and
treatment of vulvar carcinoma
David K. Gaffney

5. CTV TUMOR

6. CTV NODAL

7. CTV INGUINAL NODE

8. CTV TOTAL

9. CTV TOTAL PTV

10. OAR(RECTUM)

11. 3DCRT Planning
 Wide anterior and Wide Posterior Field

12. Wide anterior field and Wide posterior field

14. FEMORAL HEAD Dmax 56 GY

15. 3DCRT Planning
3 methods
1. Wide anterior field, narrow posterior field, anterior electron
field
2. Narrow anterior and Narrow posterior field and anterior
electron field
3. Wide anterior, Narrow posterior, and anterior inguinal photon
fields

16. 1st : WIDE anterior and NARROW
posterior field without electron field

18. 1st : WIDE anterior and NARROW posterior field
and anterior electron field

19. 2. Narrow anterior and narrow posterior field
with anterior electron

20. 3rd : Wide anterior, narrow posterior and
photon field for inguinal

23. Challenges with 3DCRT technique
• Abutting photon-electron fields at the groin result in significant
hotspots and dose inhomogeneity at the match line, which
contribute to patient morbidity
• The depth of inguinal node necessitates the use of high energy
electron that result in severe skin reaction
• The irradiation of large volumes of normal tissue, especially
small bowel exposes patients to treatment related toxicities and
limits the total deliverable dose

24. IMRT : VMAT
• Dose Constraints
• Small bowel : V45 < 195 cc
• Rectum : V50 < 50%
• Bladder : Dmax < 65 Gy
• Femoral heads : <15 % to receive > 35 Gy

27. 3DCRT Vs IMRT
• PTV coverage
• Conformity index
• Dose homogeneity index
• OAR dose : DVH

28. 3DCRT
• Conformity index (RTOG) 0.90
• Homogenity index (ICRU 83) 0.33
IMRT
0.96
0.18
PTV COVERAGE

29. 3DCRT Vs IMRT
3DCRT IMRT
OAR Max Mean Max Mean
B/l femoral 56.1 50.2 46.2 35.1
Rectum 54.7 50.8 46.5 44.2
Bladder 55.2 52.3 44.7 40.6
Bowel 50.2 46.2 44.9 40.12

30. Thank you