Dosimetric comparison of sequential intensity-modulated radiation therapy (IMRT) and simultaneous integrated boost IMRT for lymph node-positive cervical cancer

Introduction:Nodal boost is being increasingly employed to escalate the dose to involved nodes in node-positive cervical cancer. The study aimed to compare the dosimetric differences between sequential boost intensity-modulated radiation therapy (SeB-IMRT) and simultaneous integrated boost IMRT (SIB-IMRT) in terms of target coverage and organs-at-risk (OARs) with special emphasis on the effect of nodal shrinkage and anatomical change of normal tissues during radiotherapy.Methods:Two computed tomography (CT) datasets (of phase I and phase II) of 40 patients of node-positive cervical cancer treated with SeB-IMRT [planning target volume (PTV) 45/25] followed by SeB to residual nodes (PTV 12 center dot 6/7) were utilised. SIB-IMRT1 plan consisted of PTV pelvis and para-aortic nodal region (PTV 45/25) and SIB to gross nodes (PTV 55/25). In order to account for the change in nodal and normal tissue topography during treatment, a third plan (SIB-IMRT2) was generated by utilising the SIB-IMRT1 plan for 44 Gy in 20 fractions and reproducing the plan on the second CT dataset for 11 Gy in 5 fractions. Dosimetric parameters of the three plans were compared using the Friedman test with Bonferroni correction.Results:We observed that the doses to OARs (bowel, rectum and bladder) were significantly higher in SeB-IMRT plan as compared to the SIB-IMRT plans. V40 Gy of bowel for SeB-IMRT, SIB-IMRT1 and SIB-IMRT2 plans were 354 center dot 8 cc, 271 cc and 321 center dot 8 cc, respectively (p = 0 center dot 001), whereas V30 Gy were 687 center dot 8 cc, 635 center dot 5 cc and 680 cc, respectively (p = 0 center dot 001). The target coverage was marginally better in SeB-IMRT plan as compared to SIB-IMRT1 and SIB-IMRT2 plans (V95% = 99 center dot 2 versus 97 center dot 7 versus 97 center dot 9, respectively, p = 0 center dot 000)Conclusion:SIB-IMRT led to better sparing of OARs, especially bowel. However, the magnitude of benefit decreases if the change in nodal and normal tissue topography during radiotherapy is not considered implying the need for frequent image guidance when SIB-IMRT is planned for node-positive cervical cancer.