Brachytherapy 15 (2016) 30e34

Gynecologic Oncology

Bladder distension improves the dosimetry of organs at risk

during intracavitary cervical high-dose-rate brachytherapy
Grant Harmon, Bonnie Chinsky, Murat Surucu, Matthew Harkenrider, William Small Jr.*
Department of Radiation Oncology, Loyola University Hospital, Maywood, IL

ABSTRACT PURPOSE: To evaluate dose-volume histograms (DVHs) and dose-surface histograms (DSHs) to
analyze bladder distension during cervical brachytherapy.
METHODS: Twenty brachytherapy fractions from five cervical cancer patients were selected. For
each fraction, empty and full (200cc of contrasted saline) bladder simulation CT scans existed, one
of which was used to plan treatment. An alternative plan was then created with the unused scan.
DVH for each fraction was generated for the bladder, rectum, sigmoid colon, and small bowel.
Mean DVH dose, D0.1cc, and D2cc were calculated for each organ at risk. Plans were then exported
to a MATLAB-based program to generate a DSH.
RESULTS: Full bladder plans showed no difference in bladder D2cc or D0.1cc compared with
empty bladder plans; however, bladder mean DVH dose and DSH dose were both significantly
reduced. Full bladder plans showed a significant reduction in small intestine D2cc from 2.81 Gy
to 1.83 Gy and reduction in D0.1cc from 4.07 Gy to 2.57 Gy ( p ! 0.05); similarly, sigmoid D2cc
was significantly reduced from 4.24 Gy to 3.87 Gy ( p ! 0.05) and D0.1cc was reduced from
6.12 Gy to 5.61 Gy ( p ! 0.05) in full bladder plans. Both small intestine and sigmoid also showed
reduced mean DVH and DSH dose in full bladder plans. The rectum showed no significant differ-
ence in D2cc, D0.1cc, mean DVH, or DSH dose between plans.
CONCLUSIONS: Bladder distension during cervical brachytherapy significantly reduced dose in
all DVH and DSH parameters for sigmoid and small intestine with no change in bladder parameters.
It reduces dose to organ at risk, but the correlation to toxicity requires further investigation. 2016
American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.
Keywords: Bladder distension; Cervical cancer; HDR brachytherapy; Dose-surface histogram

Introduction Brachytherapy offers several advantages compared with

EBRT alone. Because the radiation source is placed imme-
Carcinoma of the cervix is a disease that affects millions
diately proximate to the target volume, brachytherapy de-
of women worldwide. With O500,000 new cervical cancer
livers a very high dose of radiation to the target while
cases diagnosed each year, cervical cancer ranks as the
minimizing dose to organs at risk (OAR). Brachytherapy
third most frequent cancer in women globally (1). A com-
can be delivered with high dose rate (HDR), low dose rate,
bination of external beam radiation therapy (EBRT) and
or pulsed dose rate. The combination of HDR brachyther-
brachytherapy with concurrent chemotherapy has become
apy and EBRT in treatment has been shown to increase
the standard of care in the treatment and management of
overall survival in multiple types of cancer (4e6).
locally advanced cervical cancer (2, 3).
When treating cervical cancer with HDR brachytherapy,
the main OAR for radiation exposure are the bladder,
rectum, sigmoid colon, and small bowel. Studies have
Received 6 July 2015; received in revised form 8 September 2015;
accepted 23 September 2015.
demonstrated that the total radiation dose to bladder and
Financial disclosure: This project was supported by The Student rectum is directly correlated with late complications, which
Training in Approaches to Research (STAR) Program of Loyola University can include hemorrhagic cystitis, hydronephrosis, rectal
Medical School. bleeding, or bowel obstructions (7e9). Consequently, an
* Corresponding author. Department of Radiation Oncology, Loyola optimal treatment plan delivers the desired prescription
University Hospital, 2160 South 1st Ave, Room 2932, Maywood, IL
60153. Tel.: 1-708-216-2559.
dose to the target organ while minimizing dose delivered
E-mail address: wmsmall@lumc.edu (W. Small). to the OAR.
1538-4721/$ - see front matter 2016 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.brachy.2015.09.009
 G. Harmon et al. / Brachytherapy 15 (2016) 30e34
The shape and position of organs within the pelvis can
greatly affect the radiation dose distribution. The volume
of the urinary bladder plays a large role in this, as distension
of the bladder can affect the surface area exposed to radia-
tion as well as the position of the small bowel and sigmoid
colon. Because there is no national guideline on bladder vol-
ume during treatment, it usually comes down to institutional
preference. Previous studies have shown no difference in
minimum dose to the maximally irradiated D2cc of the
bladder, sigmoid colon, and rectum when comparing full
and empty bladder plans (10). However, for thin-walled hol-
low organs such as the bladder, the surface area irradiated
may give a more accurate measure of biological effect than
full volume irradiated (11). This study aims to evaluate both
dose-volume histograms (DVHs) and dose-surface histo-
grams (DSHs) of OAR to analyze the dosimetric effect of
bladder distension during brachytherapy of the cervix.
Methods
Five patients that received intracavitary cervical HDR
brachytherapy at Loyola University Health System were
retrospectively analyzed under Institutional Review Board
approval. The patients had varying stages of pathologically
confirmed cervical cancer, ranging from Stage IIA to IVA.
These patients were treated with EBRT to the whole pelvis
with a prescription dose of 45 Gy in 25 fractions. Concur-
rent cisplatin chemotherapy was used in combination with
radiation.
Each patient received 3e5 fractions of intracavitary
brachytherapy at a prescription dose of 5.5e6.0 Gy/fraction
to Point A via tandem and ovoid applicators. A total of 20
fractions were analyzed. For each fraction, there existed
two computed tomography (CT) scans with the applicator
in place: a CT with a Foley catheter continuously evacu-
ating the empty bladder, and a CT with instillation of
200cc of contrasted saline filling the bladder with a
clamped Foley. During the treatment planning process, both
scans were examined and one was selected based on the
clinical judgment of the treating physician. This CT was
then used to create a treatment plan using Varian BrachyVi-
sion version 6.5 (Varian Medical Systems, Lincolnshire, IL)
treatment planning system.
Retrospectively, the unused CT scan was used to create
an alternate treatment plan, thus yielding both an empty
bladder plan and a full bladder plan for each fraction. All
applicators on the scan were identified on axial, sagittal,
and coronal planes; Point A and Point B were both identi-
fied to ensure comparable prescription dose delivery be-
tween clinically used plans and research plans. Identical
source dwell positions and times used in clinical plans were
copied to the research plans.
Contours of OAR were delineated according to Radia-
tion Therapy Oncology Group Atlas Guidelines (12).
The outer wall of the bladder was contoured inferiorly
31
from the base and superiorly to the dome of the structure.
The rectum was contoured inferiorly from the anal verge
and ended superiorly to the rectosigmoid junction. The
sigmoid was delineated inferiorly at the rectosigmoid
junction and superiorly before it conjoined with the de-
scending colon anterolaterally. The small intestine was
contoured by individual bowel loops beginning at the most
inferior loop and ending superiorly at the axial cut at
which the sigmoid terminated to ensure consistency be-
tween plans. In addition to organ delineation, both bladder
and rectal International Commission on Radiation Units
(ICRU) points were inserted. The ICRU bladder point
was inserted at the most posterior point of the Foley cath-
eter balloon. The ICRU rectal point was inserted 0.5 cm
posterior to the vaginal wall at the axial level of the base
of the tandem. Two medical physicists (BC and MS) and
an attending physician (WS) reviewed retrospective
research plans for contour delineation, applicator, and
ICRU point identification.
DVHs were generated for each plan, which provided the
mean DVH dose, D0.1cc, and D2cc (minimum dose to the maxi-
mally irradiated 0.1cc and 2cc, respectively) for each OAR.
After this analysis was completed, all plans were exported in
Digital Imaging and Communications in Medicine (DICOM)
format into MATLAB-based Computational Environment for
Radiation Research (Advanced Radiotherapy Treatment Plan-
ning Group, New York, NY) software. This software was used
to obtain the DSH mean dose value for each OAR.
For statistical analysis, a Wilcoxon signed-rank test was
chosen to directly compare differences between OAR dose
parameters in full bladder and empty bladder treatment
plan pairs.
Results
Figures 1 and 2 describe the D0.1cc and D2cc for OAR
with empty and full bladder plans. There were no
Fig. 1. Minimum dose to the maximally irradiated 0.1cc volume (D0.1cc) of
each organ at risk during HDR brachytherapy of the cervix. Bars are
comparing continuously evacuated (empty) bladder treatments and 200cc
saline-filled (full) bladder treatments. Columns depict mean values; error
bars depict standard deviation. Statistical significance ( p ! 0.05) according
to Wilcoxon signed-rank test is signified using (*). HDR 5 high dose rate.
32 G. Harmon et al. / Brachytherapy 15 (2016) 30e34

dose and mean DSH dose were reduced to the bladder, sig-
moid, and small intestine with the full bladder plans. There
were no differences in DVH dose or DSH dose to the
rectum.

Discussion
This study aimed to evaluate the effect of bladder disten-
sion on radiation dosage to OAR during brachytherapy of
the cervix. The observed results show that distending the
bladder causes a reduction in dose of the sigmoid, colon,
and small intestine in all parameters evaluated. This is
likely due the bladder pushing these organs superiorly
Fig. 2. Minimum dose to the maximally irradiated (D2cc) of each organ at and away from the applicator, thus lowering the dose
risk during HDR brachytherapy of the cervix. Bars are comparing contin-
received (Fig. 3). The bladder itself showed no difference
uously evacuated (empty) bladder treatments and 200cc saline-filled (full)
bladder treatments. Columns depict mean values; error bars depict standard in D0.1cc or D2cc received but had lower mean dose to the
deviation. Statistical significance ( p ! 0.05) according to Wilcoxon organ as a whole. Decreased mean DVH and DSH doses
signed-rank test is signified using (*). HDR 5 high dose rate. are expected given the increased volume of the filled
bladder. The majority of the organ was in a more anterior
significant differences noted for the bladder or rectum position from the tandem, yielding the reduced mean dose.
D0.1cc and D2cc between plans. The D0.1cc of the sigmoid The rectum showed an increased ICRU point dose in the
was 6.12 Gy vs. 5.61 Gy ( p 5 0.04) with empty and full full bladder plans, although the D0.1cc and D2.0cc were not
plans, respectively. The D2cc of the sigmoid was 4.24 Gy different, limiting the clinical implications.
vs. 3.87 Gy ( p ! 0.001). The D0.1cc of the small intestine The DSH data demonstrated the same outcomes as the
was 4.07 Gy vs. 2.57 Gy ( p 5 0.003) with full and empty DVHs. This further solidifies the viability of the results,
plans, respectively. The D2cc of the small intestine was as it indicates the specified organs are receiving reduced
2.81 Gy vs. 1.84 Gy ( p ! 0.001). doses with bladder distension when measured by both sur-
Table 1 shows the ICRU point doses, mean DVH dose, face area and volume.
mean DSH dose, and ICRU point differences to OAR be- As the greatest benefits are seen by the small intestine,
tween plans. There were no differences in bladder ICRU distending the bladder during intracavitary brachytherapy
point dose, but the rectum ICRU point dose increased from should especially be considered in patients with pre-
3.54 Gy to 4.10 ( p 5 0.04) with bladder filling. Mean DVH existing gastrointestinal conditions. Some of the most com-
mon side effects seen after treatment are bowel symptoms.
Table 1 Morris et al. (2) showed that in a trial of 193 women treated
Bladder and rectum ICRU points and mean radiation dose according to the with radiotherapy for cervical cancer, 26 individuals (13%)
dose-volume histogram and dose-surface histogram of each organ at risk had chronic (O6 months) bowel side effects after the treat-
during HDR brachytherapy of the cervix
ment. Sparing the gastrointestinal tract as much radiation as
Empty bladder Full bladder possible may alleviate some of the gastrointestinal distress
Organ at risk treatment (200 cc) treatment p-Value
found in these patients.
Bladder Comparable studies have been performed in the past
ICRU dose 5.16 (2.11) 5.02 (2.03) 0.20 with results consistent with those seen in this experiment.
Mean DVH dose 2.35 (0.34) 1.90 (0.26) !0.001
Mean DSH dose 2.74 (0.32) 2.00 (0.22) !0.001 A prospective study by Kim et al. (13) showed that patients
Rectum who received 180cc of sterile water in the bladder during
ICRU dose 3.54 (0.93) 4.10 (0.98) !0.001 treatment had a significant reduction in D2cc to the small
Mean DVH dose 1.73 (0.23) 1.74 (0.26) 0.94 bowel, according to three-dimensionalevolume dose data.
Mean DSH dose 1.71 (0.24) 1.73 (0.24) 0.68
In addition, the study showed bladder distension had a sig-
Sigmoid
Mean DVH dose 1.69 (0.30) 1.48 (0.37) !0.001 nificant decrease in the D50% to the small bowel (dose
Mean DSH dose 1.67 (0.32) 1.46 (0.36) !0.001 received by 50% of the volume of the organ) (13).
Small intestine Similarly, a study by Cengiz et al. (14) showed that in 10
Mean DVH Dose 1.16 (0.41) 0.75 (0.32) !0.001 women that underwent brachytherapy of the cervix, bladder
Mean DSH Dose 1.20 (0.34) 0.73 (0.25) !0.001
fullness significantly affected dose to small intestine and
ICRU 5 International Commission on Radiation Units; HDR 5 high bladder. The small intestine showed a reduced median
dose rate; DVH 5 dose-volume histogram; DSH 5 dose-surface histogram.
maximal dose, whereas the bladder showed significantly
Note. The Table is comparing continuously evacuated (empty) bladder
treatments and 200cc saline-filled (full) bladder treatments. Numbers in lower doses to the larger volumes of the bladder. However,
parentheses depict standard deviation. Statistically significant differences the analysis also showed reduced dose maximum to the
( p ! 0.05) according to paired t test are bolded. rectum, which differs from our study.
 G. Harmon et al. / Brachytherapy 15 (2016) 30e34 33

Fig. 3. (a) Three-dimensional representation of the empty bladder scan. (b) Three-dimensional representation of the full bladder scan. (c) Sagittal CT slice of
empty bladder scan. (d) Sagittal CT slice of full bladder scan. All scans acquired from the same patient. Yellow 5 bladder. Brown 5 rectum.
Navy 5 sigmoid. Orange 5 small intestine. Cyan 5 550-cGy isodose. Green points 5 applicator dwell points. CT, computed tomography (For interpretation
of the references to color in this figure legend, the reader is referred to the Web version of this article.)

It is important to consider that for bladder distension to References

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Conclusions
The combination of the volumetric dose analysis and the
surface doses on hollow organs indicates that distending the
bladder improves dosimetric end points for the sigmoid co-
lon and small bowel while performing brachytherapy of the
cervix. The analysis also showed that bladder distension
had no significant effect on D2cc to the bladder or rectum.
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