Feasibility of dose escalation using intensity-modulated radiotherapy in posthysterectomy cervical carcinoma

Purpose: To evaluate retrospectively the utility of intensity-modulated radiotherapy (IMRT) in reducing the volume of normal tissues receiving radiation at varying dose levels when the female pelvis after hysterectomy is treated to doses of 50.4 Gy and 54 Gy. Methods and Materials: Computed tomography scans from 10 patients who had previously undergone conventional postoperative RT were selected. The clinical tumor volume (vaginal apex and iliac nodes) and organs at risk were contoured. Margins were added to generate the planning tumor volume. The Pinnacle and Corvus planning systems were used to develop conventional and IMRT plans, respectively. Conventional four-field plans were prescribed to deliver 45 Gy (4F_{45 Gy}) or 50.4 Gy; eight-field IMRT plans were prescribed to deliver 50.4 Gy (IMRT_{50.4 Gy}) or 54 Gy (IMRT_{54 Gy}) to the planning tumor volume. All plans were normalized so that ≥97% of the planning tumor volume received the prescribed dose. Student's t test was used to compare the volumes of organs at risk receiving the same doses with different plans. Results: The mean volume of bowel receiving ≥45 Gy was lower with the IMRT_{50.4 Gy} (33% lower) and IMRT _{54 Gy} (18% lower) plans than with the 4F_{45 Gy} plan. The mean volume of rectum receiving ≥45 Gy or ≥50 Gy was also significantly reduced with the IMRT plans despite an escalation of the prescribed dose from 45 Gy with the conventional plans to 54 Gy with IMRT. The mean volume of bladder treated to 45 Gy was the same or slightly lower with the IMRT_{50.4 Gy} and IMRT_{54 Gy} plans compared with the 4F_{45 Gy} plan. Compared with the 4F_{45 Gy} plan, the IMRT_{50.4 Gy} plan resulted in a smaller volume of bowel receiving 35-45 Gy and a larger volume of bowel receiving 50-55 Gy. Compared with the 4F_{45 Gy} plan, the IMRT_{54 Gy} plan resulted in smaller volumes of bowel receiving 45-50 Gy; however, small volumes of bowel received 55-60 Gy with the IMRT plan. Conclusion: Intensity-modulated RT may permit an increase in the radiation dose that can safely be delivered to the central pelvis and pelvic lymph nodes after hysterectomy. However, dose-volume calculations using individual CT scans do not account for internal organ motion. Detailed data concerning the relationships among radiation dose, treatment volume, and treatment effects are lacking, and prospective studies of pelvic IMRT are needed to determine the safety and efficacy of this treatment.