Case I Cervix sufficient response residual parametrial involvementunfavourable

Case I: Cervix sufficient response -residual parametrial involvementunfavourable topography • H. R. 44 years old patient with FIGO Stage IIB, SCC, G 2 cervical carcinoma – Post laparoscopic lymph node staging(0/19) – Involvement of both parametria (right distal, left proximal) and middle vagina – Ectocervical tumor growth – Treatment strategy: 45 Gy EBT+ 4 x 7 Gy HDR-BT – Response: good

Findings prior therapy: Involvement of both parametria (right=distal, left=proximal) Invasion of anterior upper vagina MRI axial sagittal coronal

Infiltrative At Diagnosis Cervix w Vagina Parametria w = _7_ _ cm h = _5_ _ cm t = _5_ _ cm h t vaginal involvement = 4 cm

Tumour extension: MRI sagittal axial Diagnosis coronal Volume Width Thickness Height 82 cm³ 5. 9 cm 4. 9 cm 5. 7 cm

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Findings at brachytherapy: Proximal residual involvement of both parametria Hardening of the anterior upper vagina

At Brachytherapy Hardening w =3 cm h =3 cm t =3 cm h t Vaginal involvement =1 cm w

Tumour extension: MRI sagittal axial coronal 2 cm cm 1 3. 4. 5 cm Brachytherapy Volume Width Thickness Height 13. 5 cm³ 4. 5 cm 2 cm 3. 1 cm

Tumour response: Findings prior therapy: Involvement of both parametria (right=distal, left=proximal) Invasion of anterior middle vagina Findings at the time of Brachytherapy: Proximal residual involvement of both parametria Hardening of the anterior fornix Volume Width Thickness Height Diagnosis 82 cm³ 5. 9 cm 4. 9 cm 5. 7 cm Brachytherapy 13. 5 cm³ 4. 5 cm 2 cm 3. 1 cm

Contouring cervix large insufficient response • GTV: macroscopic tumour extension at time of brachytherapy… High signal intensity mass(es) (FSE, T 2) in cervix/corpus, parametria, vagina, bladder and rectum • HR-CTV: includes gtv, whole cervix, and presumed extracervical tumour extension. Pathologic residual tissue(s) as defined by palpable indurations and/or grey zones in parametria, uterine corpus, vagina or rectum and bladder are included in HR-CTV. No safety margin are added. • IR-CTV: encompasses the HR-CTV different safety margins are added according to the treatment strategy, tumour size and tumour regression. In any case a minimal safety margin of 5 to 15 mm have to be added. Extensive disease: Good remission: HR-CTV and the initial tumour extension

IR CTV HR CTV GTV

GTV Tumor at time of diagnosis. GTV IR CTV HR CTV

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