Enough and Some to Spare: Improved OAR Sparing with Daily Online Cone Beam Adaptive Radiation Therapy (OnC-ART) of the Cervix

Abstract

The standard of care treatment for locally advanced cervical cancer involves pelvic chemoradiation. During treatment planning, the cervix and uterus contours are expanded by 1.5 to 2 cm margins to account for inter- and intrafractional motion per the consensus guidelines. Daily online cone-beam adaptive radiation therapy (OnC-ART) accounts for interfractional motion, thus significantly reducing CTV to PTV margins. In this study, we compared the dosimetry of standard larger margin plans (IGRT) to 0.5 cm margins for patients treated with daily OnC-ART and hypothesized that daily OnC-ART with reduced margins will have improved dosimetry. A retrospective cohort of 10 patients with cervical cancer (stage IIB - IIIC2) treated with 260 definitive daily fractions of OnC-ART chemoradiation between April 2021 and December 2022 was included. Initial plans were generated with OnC-ART and IGRT CTV to PTV margins as follows: combined cervix, uterus, and GTV (0.5 cm vs. 1.5 cm), combined parametria and vagina (0.5 cm vs. 1 cm), nodal chains (0.5 cm vs. 0.5 cm), and gross nodes (0.5 cm vs. 0.5 cm). The initial IGRT plan was copied to synthetic CTs generated for each fraction in the adaptive workflow containing the daily contours of all targets and OARs. The dosimetry of each IGRT fraction was compared to the dose delivered from each daily OnC-ART fraction. Statistical significance was defined as p < 0.05. When compared with dosimetry from daily IGRT, the daily OnC-ART plans had significantly improved CTV coverage and less hotspots with improvements in D95% (+1.6%), D99% (+2.9%), and Dmax (-0.9%). Bowel bag and bowel loops showed significant improvements in Dmax (-1.4% and - 2.6%), V40 (-6.2% and -5.3%), and V45 (-6.1% and 5.5%). The daily OnC-ART plans had a mean bowel bag V40 of 177.4 cm3. Contrastingly, the mean bowel bag V40 for the large margin IGRT plans was 268.7 cm3. The bladder and rectum also showed significant improvements in Dmax (-1.7% and -1.6%), V40 (-25.2% and -36.0%), and V30 (-9.7% and -17.1%). The daily OnC-ART plans had a mean bladder and rectum V40 of 41.6 cm3 and 18.4 cm3, and the large margin IGRT plans had a mean bladder and rectum V40 of 65.1 cm3 and 40.8 cm3. Bone marrow had a significantly reduced dose with improvements in Dmean (-3.2%), V10 (-2.7%), and V20 (-3.3%). Reduced CTV to PTV margins achievable with daily OnC-ART is shown to not only improve sparing of critical OARs, especially the bladder and rectum, but also improves target coverage compared to larger margins from daily IGRT. The clinical impact of these dosimetric improvements is currently undergoing investigation.