An assessment of interfractional uterine and cervical motion: Implications for radiotherapy target volume definition in gynaecological cancer

Abstract

Purpose To assess interfractional movement of the uterus and cervix in patients with gynaecological cancer to aid selection of the internal margin for radiotherapy target volumes. Methods and materials Thirty-three patients with gynaecological cancer had an MRI scan performed on two consecutive days. The two sets of T2-weighted axial images were co-registered, and the uterus and cervix outlined on each scan. Points were identified on the anterior uterine body (Point U), posterior cervix (Point C) and upper vagina (Point V). The displacement of each point in the antero-posterior (AP), supero-inferior (SI) and lateral directions between the two scans was measured. The changes in point position and uterine body angle were correlated with bladder volume and rectal diameter. Results The mean difference (±1SD) in Point U position was 7 mm (±9.0) in the AP direction, 7.1 mm (±6.8) SI and 0.8 mm (±1.3) laterally. Mean Point C displacement was 4.1 mm (±4.4) SI, 2.7 mm (±2.8) AP, 0.3 (±0.8) laterally, and Point V was 2.6 mm (±3.0) AP and 0.3 mm (±1.0) laterally. There was correlation for uterine SI movement in relation to bladder filling, and for cervical and vaginal AP movement in relation to rectal filling. Conclusion Large movements of the uterus can occur, particularly in the superior–inferior and anterior–posterior directions, but cervical displacement is less marked. Rectal filling may affect cervical position, while bladder filling has more impact on uterine body position, highlighting the need for specific instructions on bladder and rectal filling for treatment. We propose an asymmetrical margin with CTV–PTV expansion of the uterus, cervix and upper vagina of 15 mm AP, 15 mm SI and 7 mm laterally and expansion of the nodal regions and parametria by 7 mm in all directions.