A study to evaluate the adequacy of pelvic lymph node coverage in carcinoma cervix patients in Indian population by conventional four field box technique using computerized tomography simulation based pelvic lymph node contouring

Tanmoy Ghosh, Joydeep Basu


Background: Traditionally pelvic External Beam Radiotherapy is delivered with four field box technique in carcinoma cervix patients. The primary aim of this prospective observational study is to determine the adequacy of pelvic lymph nodal coverage by conventional Four Field Box Technique with the help of pelvic lymph node contouring by CT simulation.

Methods: Between January 2013 and August 2015 sixty patients with biopsy proven Carcinoma Cervix were enrolled in this study. Of these fifty-three patients were available for final analysis. CT simulation based Pelvic lymph node contouring was done for each patient. Then two External Beam Radiotherapy plans were generated, one contoured based and the other based on bony landmark based Four Field Box Technique. The number of patients whose contoured lymph nodes lies partly outside the field borders of the bony landmark-based plan and also its extent was determined. D90 of various groups of pelvic lymph nodes obtained from both the plans were compared using ‘paired sample t - test’.

Results: It was seen that with Four Field Box Technique there is inadequate coverage of common iliac lymph nodes in 34/53 patients. The difference between the mean D90 of common iliac lymph nodes in two sets of plans was found to be statistically significant.

Conclusions: Pelvic field planning should be individualized. CT simulation-based radiotherapy planning should be done for each individual patient to adequately cover the nodal microscopic disease.


CT simulation, Four field box technique, Pelvic lymph node contouring

Full Text:



Anderson JR, Genadry R. Anatomy and Embryology. In: Berek, Jonathan S. eds. Berek and Novak's Gynecology, 14th Ed. Lippincott Williams and Wilkins; 2007:75-128.

Portaluri M, Bambace S, Perez C, Angone G. A three-dimensional definition of nodal spaces on the basis of CT images showing enlarged nodes for pelvic radiotherapy. Inter J Rad Oncol Biol Phys. 2005 Nov 15;63(4):1101-7.

Taylor A, Rockall AG, Reznek RH, Powell ME. Mapping pelvic lymph nodes: guidelines for delineation in intensity-modulated radiotherapy. Inter J Radiation Oncol Biol Phys. 2005 Dec 1;63(5):1604-12.

Patient Selection and Preparation Strategies. In: “ACR Manual on Contrast Media” Version 8, 2012; 5-12.

Uchida M, Edamitsu O, Chang Y, Nishimura H, Hayabuchi N. Dynamic study of the liver with helical scanning: determination of hepatic contrast enhancement in routine studies. Nihon Igaku Hoshasen Gakkai zasshi. Nippon Acta Radiol. 1996 Jun;56(7):502-6.

Heiken JP, Brink JA, McClennan BL, Sagel SS, Crowe TM, Gaines MV. Dynamic incremental CT: effect of volume and concentration of contrast material and patient weight on hepatic enhancement. Radiol. 1995 May;195(2):353-7.

Small Jr W, Mell LK, Anderson P, Creutzberg C, De Los Santos J, Gaffney D, et al. Consensus guidelines for delineation of clinical target volume for intensity-modulated pelvic radiotherapy in postoperative treatment of endometrial and cervical cancer. Inter J Radia Oncol Biol Phys. 2008 Jun 1;71(2):428-34.

Eifel PJ, Winter K, Morris M, Levenback C, Grigsby PW, Cooper J, et al. Pelvic irradiation with concurrent chemotherapy versus pelvic and para-aortic irradiation for high-risk cervical cancer: an update of radiation therapy oncology group trial (RTOG) 90-01. J Clin Oncol. 2004;22(5):872-80.

Pearcey R, Brundage M, Drouin P, Jeffrey J, Johnston D, Lukka H, et al. Phase III trial comparing radical radiotherapy with and without cisplatin chemotherapy in patients with advanced squamous cell cancer of the cervix. J Clin Oncol. 2002;20(4):966-72.

Bonin SR, Lanciano RM, Corn BW, Hogan WM, Hartz WH, Hanks GE. Bony landmarks are not an adequate substitute for lymphangiography in defining pelvic lymph node location for the treatment of cervical cancer with radiotherapy. Inter J Radi Oncol BiolPhys. 1996 Jan 1;34(1):167-72.

Finlay MH, Ackerman I, Tirona RG, Hamilton P, Barbera L, Thomas G. Use of CT simulation for treatment of cervical cancer to assess the adequacy of lymph node coverage of conventional pelvic fields based on bony landmarks. Inter J Radi Oncol Biol Phys. 2006 Jan 1;64(1):205-9.

Zhang X, Yu H. Evaluation of pelvic lymph node coverage of conventional radiotherapy fields based on bony landmarks in Chinese cervical cancer patients using CT simulation. J Zhejiang Uni Science B. 2009 Sep 1;10(9):683-8.

Zunino S, Rosato O, Lucino S, Jauregui E, Rossi L, Venencia D. Anatomic study of the pelvis in carcinoma of the uterine cervix as related to the box technique. Inter J Radi Oncol Biol Phys. 1999 Apr 1;44(1):53-9.

McAlpine J, Schlaerth JB, Lim P, Chen D, Eisenkop SM, Spirtos NM. Radiation fields in gynecologic oncology: correlation of soft tissue (surgical) to radiologic landmarks. Gynecol Oncol. 2004 Jan 1;92(1):25-30.