Clinical experiences with online adaptive radiotherapy of vulvar carcinoma

Figures & data

Figure 1. Adaptive treatment and subsequent data collection workflow.

Table 1. Patient demographics.

Patient No	Age	Primary disease/recurrence	FIGO stage	No. of lymph node metastases	Operation T site^a	Radiation field including vulva	Radiation field including uni- or bilateral groin
1	85	Primary	IIIA1	1	R0	No	Yes, unilateral
2	83	Primary	IIIA	2	R0	No	Yes, unilateral
3	80	Primary	IVB	22	R1	Yes	Yes, unilateral
4	63	Primary	IIIA (ii)	1	R0	No	Yes, bilateral
5	84	Recurrence	IIIB	1	R1	Yes	No
6	71	Recurrence	IB	1	R0	Yes	Yes, unilateral
7	43	Fourth recurrence	–	0	Inoperable	Yes	No
8	59	Primary	IIIA	1	R0	No	Yes, unilateral
9	54	Primary	IB	0	R1	Yes	No
10	46	Primary	IB	1	R1	Yes	Yes, unilateral
11	82	Primary	IIIC	3 + perinodal	R1	Yes	Yes, bilateral
12	57	Primary	II	0	Inoperable	Yes	Yes, bilateral
13	71	Third recurrence	IIIa	3	Inoperable	No	Yes, unilateral
14	63	Primary	IB	0	R1	Yes	No
15	56	Recurrence	IB	1	R0	No	Yes, unilateral
16	70	Primary	IIIA	1	R0	No	Yes, unilateral
17	79	Primary	IIIA	1	R0	No	Yes, unilateral
18	70	Primary	IIIA	1	R0	No	Yes, unilateral
19	58	Primary	IB	0	R1	Yes	No
20	75	Primary	IIIA	1	R0	No	Yes, bilateral

^aR0 = free margin, R1= not sufficient margin.

Figure 2. Distribution of chosen adapted plans for patient 1–20. Reasons for not choosing an adapted plan is also shown for each patient. Patient 1 was the pilot patient and was only treated with the adaptive workflow for the last 8 fractions. Patient 1–3 wasn't included in the daily registration and reasons are therefore unknown.

Figure 3. Example of vulvar carcinoma patient with anatomical change due to lymphocele and the direct consequence in dose coverage. A) Reference plan, B) Daily CBCT using scheduled plan, C) Daily CBCT using adapted plan. Isodose levels 95%, 90%, 80% and 50% are visualized. CTV and PTV contours are shown in pink and blue, respectively.

Figure 4. Normalized dose to reference plan for scheduled plans, adapted plans and verification plans for bladder (mean dose), rectum (mean dose), CTV (D95%) & PTV (D95%) respectively for patients 1–20. Dashed lines indicate reference dose. The figure excludes 2 upper outliers on bladder scheduled and adapted, 1 upper outlier on bladder verification, 1 upper outlier on rectum adapted and verification, and 2 and 3 lower outliers on CTV and PTV scheduled respectively, to improve visualization.

Table 2. Average CBCT slice edits [%] (and range) of bladder, rectum, and CTV contour for patient 4-20.

Patient number	Bladder	Rectum	CTV
4	16.4 (0–50)	4.30 (0–18.2)	3.02 (0–11.8)
5	0.62 (0–10.7)	0.55 (0–11.1)	22.8 (0–50)
6	1.13 (0–13.2)	0 (0)	9.43 (0–34.5)
7	3.61 (0–17.1)	1.76 (0–20)	3.15 (0–17.4)
8	75.3 (0–100)	55.2 (0–100)	38.2 (0–100)
9	36.8 (0–95.2)	4.0 (0–33.3)	0.34 (0–5.88)
10	15.8 (0–48.8)	7.62 (0–28.6)	22.7 (0–100)
11	6.45 (0–45-2)	1.93 (0–28.6)	13.5 (0–81.0)
12	19.3 (0–100)	2.45 (0–21.1)	26.3 (0–100)
13	27.8 (0–55.6)	17.4 (0–37.5)	35.9 (5.33-100)
14	28.7 (0–60)	19.0 (0–44.4)	2.05 (0–29.49
15	35.7 (0–69)	22.2 (5-50)	8.70 (0–100)
16	45.3 (0–100)	13.2 (0–28.6)	11.3 (0–100)
17	47.4 (17.2-100)	22.2 (0–100)	17.6 (0–64.2)
18	41.8 (0–100)	27.7 (10–100)	21.0 (0–100)
19	26.4 (0–66.7)	5.80 (0–19.6)	9.66 (0–100)
20	34.3 (0–75)	7.52 (0–30.3)	40.9 (0–100)

Figure 5. Correlation between proportion of recontoured slices and the time for adaptation for patient 4–20. Each data point represents mean number of slices needed recontouring (bladder, rectum, CTV or total) for each patient. Red lines describe linear fit.

Data availability statement

Corresponding author can be contacted for access to data and will provide data upon reasonable request. However, this requires that the ethical and data protection regulations allow sharing of the requested data.