There are three main volumes in radiation therapy planning.

The GTV is the position and

extent of the gross tumour e.g. what can be seen, palpated or imaged. This plan does not
include a GTV because the radiation oncologist may have not included it in the volumes.
The second volume is the clinical target volume (CTV), this volume includes an additional
margin for microscopic spread of the disease. The CTV in this plan does not include a GTV
but includes a tampon inserted into the vagina soaked with contrast to help define the
structure’s borders. It also includes majority of rectum and small portions of the small bowel.
It also encompasses the involved nodes, the common, external and internal iliac, and
presacral nodes. The CTV must be adequately treated to achieve curative treatment.
The third volume is the planning target volume (PTV). This volume accounts for the effects
of organ and patient movements (internal variation) and inaccuracies in beam and patient
setup (external variation). It also ensures that the dose is being delivered to the CTV. The
PTV on this plan is a large irregular oval shape that encompasses the CTV with a , large
portions of the rectum, vagina, tampon, entire uterus and posterior aspects of the bladder and
surrounding soft tissue(Barrett, 2009).

Critical Structures
The Organs at risk in this plan include the skin, urinary bladder, rectum and femoral heads
and vagina.
The dose prescription assigned for the patient is 45Gy which is under dose tolerance for
endpoint reactions for the organs at risk, therefore the skin, rectum urinary bladder, femoral
heads and vagina are unlikely to experience any endpoint reactions. It is also important to
note the patient is having concurrent chemotherapy over the course of the treatment. The
chemotherapy drug cisplatin is a known radio-sensitizer that may cause the acute side effects
of radiation therapy to occur earlier and be more severe.

Vagina
The vagina is located in the PTV so will receive 95% of the prescribed dose. The patient is
likely to experience the acute side effects of vaginal adhesions and vaginitis, both these side
effects can cause pain which can make sexual intercourse uncomfortable and difficult. This
can lead to sexual intimacy problems between the patient and their partner.
Long term the vagina may remain dry and can get tighter and shorter. This can be prevented
having regular intercourse or using a device called a vaginal dilator which will maintain the
vaginal vault size.

Rectum
Approximately 95% of the rectum is located within the PTV so will receive 95% of the
prescribed dose. This patient’s rectum also has a lot of gas/air in their rectum which will
cause less absorption of dose causing it to be distributed outside the rectum as seen on the
plan. This patient will likely experience the acute reactions of proctitis and tenesmus that
occur at 25-30Gy.

Urinary bladder
The urinary bladder will receive 26Gy to 100% of its structure. This is over the dose
tolerance, so the patient will develop cystitis. Cystitis may affect patient’s quality of life if
not managed. Frequency of urinating during the night (Nocturia) may increase which may
result in disturb your sleeping habits. Disturbance in your sleeping habits could mean sleep
deprivation for the patient and contribute to the patient’s fatigue. Cystitis could also affect the
patient’s social life as she won’t be able to drink alcohol at social gatherings. Alcohol is a
known diuretic and is likely to exacerbate the side effects of cystitis.

Femoral Heads
The femoral heads will not develop endpoint reactions because the dose prescription of 45Gy
is under the dose tolerance for the endpoint reaction of osteoradionecrosis which occurs at
50Gy when given to 10% of the volume.

Pretty good Raymond but you forgot small bowel! – the structure that you prioritised in
your plan (I hope) and skin, particularly in skin folds and natal cleft. You also need to think
globally about the patient and impact of enteritis and side effects from chemo –
nausea/vomiting/diarrhea and how that might affect weight, nutrition management and
fatigue. Not to mention she still has brachy to come. Good use of the tables and some
referencing. Please use these comments to help you consider the patient more holistically
in the clinically and your next written task.
 Table 1. Critical Structures, Dose Tolerances and Endpoint Reactions
Critical Acute Side Endpoint Reactions Dose Dose Structures
structure effects/Dose Tolerances receiving
Tolerances
Skin - Temporary alopecia - Gangrene 55Gy to Skin receiving
(10-15Gy) - Necrosis 100cm2 9-12 Gy
- Erythema (20Gy) - Ulceration
- Dry desquamation
(30Gy)
- Moist desquamation
(40Gy)

Urinary - Cystitis (25Gy) <65Gy to 100% of

Bladder whole organ structure
<6 % chance receiving 31 Gy
of grade 3 late
RTOG
Rectum - Proctitis (25-30 Gy) - Necrosis V50 < 50% 50% of the
- Tenesmus - Fistula V60< 35% structure
receiving 50Gy
Femoral - Osteoradionecrosis 50Gy < 50% Both Femoral
Heads heads receiving
<13Gy
Adapted from:(Emami et al., 1991), (Washington & Leaver, 2016)(Milano, Constine, & Okunieff, 2007)
Bibliography
Barrett, A. (2009). Practical Radiotherapy Planning Fourth Edition. (J. Dobbs & T. Roques,
Eds.). London: CRC Press,.

Emami, B., Lyman, J., Brown, A., Coia, L., Goitein, M., Munzenrider, J. E., … Wesson, M.
(1991). Tolerance of normal tissue to therapeutic irradiation. International Journal of
Radiation Oncology, Biology and Physics, 21(1). https://doi.org/10.1016/0360-
3016(91)90171-Y

Milano, M. T., Constine, L. S., & Okunieff, P. (2007). Normal Tissue Tolerance Dose
Metrics for Radiation Therapy of Major Organs. Seminars in Radiation Oncology, 17(2),
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Washington, C. M., & Leaver, D. T. (2016). Principles and practice of radiation therapy.
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