Research Article

Evaluation of Multimodality Imaging Based Treatment Volume Determination for Vulvar Squamous Cell Carcinoma (VSCC)

Selcuk Demiral*, Omer Sager, Ferrat Dincoglan and Murat Beyzadeoglu

Department of Radiation Oncology; University of Health Sciences, Gulhane Medical Faculty, Ankara, Turkey

Submission: March 19, 2024; Published: April 22, 2024

*Corresponding Address: Selcuk Demiral, University of Health Sciences, Gulhane Medical Faculty, Department of Radiation Oncology, Gn. Tevfik Saglam Cad, Etlik, Kecioren, Ankara / Turkey, Email: drs.demiral@hotmail.com

How to cite this article: Selcuk Demiral*, Omer Sager, Ferrat Dincoglan and Murat Beyzadeoglu. Evaluation of Multimodality Imaging Based Treatment Volume Determination for Vulvar Squamous Cell Carcinoma (VSCC). Canc Therapy & Oncol Int J. 2024; 26(4): 556193. DOI:10.19080/CTOIJ.2024.26.556193

Abstract

Objective: Although accounting for a relatively smaller proportion of all cancers worldwide, vulvar squamous cell carcinoma (VSCC) presents a health concern among women. While surgery may play a critical role for successful management of VSCC, irradiation may serve as a complementary or alternative therapeutic strategy in certain circumstances. In this study, we aimed at evaluating treatment volume determination for VSCC with comparative assessment of CT and MRI.

Materials and methods: Ultimate endpoint of this study has been about treatment volume determination for VSCC with comparative assessment of CT and MRI. All included patients have been referred for RT at Department of Radiation Oncology at Gulhane Medical Faculty, University of Health Sciences for VSCC. We carried out a comparative analysis of treatment volume determination by CT simulation images for radiation treatment planning and with Magnetic Resonance Imaging (MRI).

Results: As the critical result of this study, we found that CT and MRI defined treatment volume determination resulted in differences. Within this context, fusion of CT and MRI was used for ground truth treatment volume definition.

Conclusion: In the current study, we found that CT and MRI defined treatment volume determination resulted in differences. Taking this into account, fusion of CT and MRI was utilized for ground truth treatment volume definition. These results may have implications for increased adoption of multimodality imaging for treatment volume determination of VSCC, however, validation in prospective clinical studies may be required.

Keywords: Vulvar squamous cell carcinoma /VSCC); Radiation therapy (RT); Target definition, Computed Tomography (CT); Magnetic Resonance Imaging (MRI)

Abbreviations: RT: Radiation Therapy; CT: Computed Tomography; MRI: Magnetic Resonance Imaging; VSCC: Vulvar Squamous Cell Carcinoma; EBRT: External Beam Radiation Therapy; SBRT: Stereotactic Body Radiation Therapy; IMRT: Intensity Modulated RT; ART: Adaptive RT (ART; LINAC: Linear Accelerator; AAPM: American Association of Physicists in Medicine; ICRU: International Commission on Radiation Units and Measurements

Introduction

Although accounting for a relatively smaller proportion of all cancers worldwide, vulvar squamous cell carcinoma (VSCC) presents a health concern among women [1-7]. Disease course typically depends on stage at diagnosis, and both the disease and treatment strategies utilized for management may deteriorate patients’ quality of life. Surgical interventions, radiation therapy (RT), and systemic agents may be used for VSCC management [2-7]. In terms of irradiation, several forms including external beam radiation therapy (EBRT), Stereotactic Body Radiation Therapy (SBRT), and brachytherapy may be used according to patient, disease, and treatment characteristics. As a matter of fact, utilization of higher irradiation doses may contribute to improved local control outcomes for VSCC, however, toxicity profile of radiation delivery should be considered to avoid excessive radiation induced toxicity. Clearly, recent years have witnessed several advances in technology in the millenium era. Molecular imaging methods, Image Guided RT (IGRT), automatic segmentation techniques, Intensity Modulated RT (IMRT), stereotactic RT, and adaptive RT (ART) have been introduced for optimal radiotherapeutic management of patients [8-49]. Indeed, improved treatment results may solely be achieved through close collaboration among related disciplines for cancer management. Tumor boards may obviously contribute to bringing together surgical oncologists, radiation oncologists, medical oncologists, imaging and other relevant specialists to discuss about patient, tumor, and treatment characteristics. While surgery may play a critical role for successful management of VSCC, irradiation may serve as a complementary or alternative therapeutic strategy in certain circumstances. In this study, we aimed at evaluating treatment volume determination for VSCC with comparative assessment of CT and MRI.

Materials and Methods

Our clinic has long been treating a high patient population from several places from Turkey and abroad. Using state of the art irradiation techniques, several benign and malignant tumors were irradiated at our tertiary cancer center. The primary endpoint of this study has been about treatment volume determination for VSCC with comparative assessment of CT and MRI. All included patients have been referred for RT at Department of Radiation Oncology at Gulhane Medical Faculty, University of Health Sciences for VSCC. We carried out a comparative analysis of treatment volume determination by CT simulation images for radiation treatment planning and with Magnetic Resonance Imaging (MRI). CT simulations of the patients have been executed at CT-simulator (GE Lightspeed RT, GE Healthcare, Chalfont St. Giles, UK) available at our department. Also, MRI of patients have been acquired and used for comparative analysis. A Linear Accelerator (LINAC) with the capability of sophisticated IGRT techniques was utilized for irradiation. After rigid patient immobilization, planning CT images were acquired at CT-simulator for radiation treatment planning. Thereafter, acquired RT planning images were sent to the delineation workstation by use of the network. Treatment volumes and surrounding critical structures were defined on these images and structure sets were generated. Also, target definition was also performed on MRI for comparison. All patients were treated by using state of the art RT techniques at the Department of Radiation Oncology at Gulhane Medical Faculty, University of Health Sciences.

Results

Our study was primarily designed for assessment of treatment volume determination for VSCC with comparative evaluation of CT and MRI. Irradiation procedures were performed at our Radiation Oncology Department of Gulhane Medical Faculty at University of Health Sciences, Ankara. Before treatment, all included patients were individually assessed by a multidisciplinary team of experts from surgical oncology, radiation oncology, and medical oncology.

We have considered the reports by American Association of Physicists in Medicine (AAPM) and International Commission on Radiation Units and Measurements (ICRU) for accurate radiation treatment planning. Radiation physicists took part in generation of radiation treatment plans by considering the relevant critical organ dose constraints by meticulous consideration of contemporary guidelines and clinical experience. Also, the published international guidelines and consensus recommendations for RT contouring and treatment of vulvar carcinoma were considered [7]. Tissue heterogeneity, electron density, CT number and HU values in CT images were also considered by radiation physicists for accurate radiation treatment planning. Primary objective of radiation treatment planning was to achieve optimal treatment volume coverage without violation of critical organ dose constraints. IGRT techniques including kilovoltage cone beam CT and electronic digital portal imaging were utilized, and radiation treatment has been performed by Synergy (Elekta, UK) LINAC. As the critical result of this study, we found that CT and MRI defined treatment volume determination resulted in differences. Within this context, fusion of CT and MRI was used for ground truth treatment volume definition.

Discussion

While accounting for a relatively smaller proportion of all cancers worldwide, VSCC presents a health concern among women [1-7]. Disease course typically depends on stage at diagnosis, and both the disease and treatment strategies utilized for management may deteriorate patients’ quality of life. Surgical interventions, RT, and systemic agents may be used for VSCC management [2- 7]. In terms of irradiation, several forms including EBRT, SBRT, and brachytherapy may be used according to patient, disease, and treatment characteristics. As a matter of fact, utilization of higher irradiation doses may contribute to improved local control outcomes for VSCC, however, toxicity profile of radiation delivery should be taken into account to avoid excessive radiation induced toxicity. Clearly, recent years have witnessed several advances in technology in the millenium era. Molecular imaging methods, IGRT, automatic segmentation techniques, IMRT, stereotactic RT, and ART have been introduced for optimal radiotherapeutic management of patients [8-49]. Indeed, improved treatment results may solely be achieved through close collaboration among related disciplines for cancer management. Tumor boards may obviously contribute to bringing together surgical oncologists, radiation oncologists, medical oncologists, imaging and other relevant specialists to discuss about patient, tumor, and treatment characteristics. While surgery may play a critical role for successful management of VSCC, irradiation may serve as a complementary or alternative therapeutic strategy in certain circumstances. In this study, we aimed at evaluating treatment volume determination for VSCC with comparative assessment of CT and MRI.

Our clinic has long been treating a high patient population from several places from Turkey and abroad. Using state of the art irradiation techniques, several benign and malignant tumors were irradiated at our tertiary cancer center. Primary endpoint of this study was about treatment volume determination for VSCC with comparative assessment of CT and MRI. All included patients have been referred for RT at Department of Radiation Oncology at Gulhane Medical Faculty, University of Health Sciences for VSCC. We carried out a comparative analysis of treatment volume determination by CT simulation images for radiation treatment planning and with MRI. CT simulations of the patients have been executed at CT-simulator (GE Lightspeed RT, GE Healthcare, Chalfont St. Giles, UK) available at our department. Also, MRI of patients have been acquired and used for comparative analysis.

A LINAC with the capability of sophisticated IGRT techniques was utilized for irradiation. After rigid patient immobilization, planning CT images were acquired at CT-simulator for radiation treatment planning. Thereafter, acquired RT planning images were sent to the delineation workstation by use of the network. Treatment volumes and surrounding critical structures were defined on these images and structure sets were generated. Also, target definition was also performed on MRI for comparison. All patients were treated by using state of the art RT techniques at the Department of Radiation Oncology at Gulhane Medical Faculty, University of Health Sciences.

Our study was primarily designed for assessment of treatment volume determination for VSCC with comparative evaluation of CT and MRI. Irradiation procedures were performed at our Radiation Oncology Department of Gulhane Medical Faculty at University of Health Sciences, Ankara. Before treatment, all included patients were individually assessed by a multidisciplinary team of experts from surgical oncology, radiation oncology, and medical oncology. We have taken into account the reports by AAPM and ICRU for accurate radiation treatment planning. Radiation physicists took part in generation of radiation treatment plans by considering the relevant critical organ dose constraints by meticulous consideration of contemporary guidelines and clinical experience. Also, the published international guidelines and consensus recommendations for RT contouring and treatment of vulvar carcinoma were considered [7]. Tissue heterogeneity, electron density, CT number and HU values in CT images were also considered by radiation physicists for accurate radiation treatment planning. Primary objective of radiation treatment planning was to achieve optimal treatment volume coverage without violation of critical organ dose constraints. IGRT techniques including kilovoltage cone beam CT and electronic digital portal imaging were utilized, and radiation treatment has been performed by Synergy (Elekta, UK) LINAC. As the critical result of this study, we found that CT and MRI defined treatment volume determination resulted in differences. Within this context, fusion of CT and MRI was used for ground truth treatment volume definition.

From the perspective of radiation oncology, optimal treatment volume determination and normal tissue sparing may be considered among the critical components of optimal radiotherapeutic management. While determination of larger treatment volumes might result in excessive radiation induced toxicity, definition of smaller treatment volumes may lead to treatment failures. Adaptive RT strategies and multimodality imaging-based target definition have been suggested for achieving improved outcomes [50-104]. In the current study, we found that CT and MRI defined treatment volume determination resulted in differences. Taking this into account, fusion of CT and MRI was utilized for ground truth treatment volume definition. These results may have implications for increased adoption of multimodality imaging for treatment volume determination of VSCC, however, validation in prospective clinical studies may be required.

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72. Demiral S, Beyzadeoglu M, Dincoglan F, Sager O (2020) Evaluation of Radiosurgery Target Volume Definition for Tectal Gliomas with Incorporation of Magnetic Resonance Imaging (MRI): An Original Article. Biomed J Sci & Tech Res (BJSTR) 27: 20543-20547.
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78. Sager O, Dincoglan F, Demiral S, Beyzadeoglu M (2021) Radiation Therapy (RT) target determination for irradiation of bone metastases with soft tissue component: Impact of multimodality imaging. J Surg Surgical Res 7: 42-46.
79. Sager O, Dincoglan F, Demiral S, Beyzadeoglu M (2021) Evaluation of Changes in Tumor Volume Following Upfront Chemotherapy for Locally Advanced Non-Small Cell Lung Cancer (NSCLC). Glob J Cancer Ther 7: 31-34.
80. Sager O, Demiral S, Dincoglan F, Beyzadeoglu M (2021) Assessment of posterior fossa target definition by multimodality imaging for patients with medulloblastoma. J Surg Surgical Res 7: 37-41.
81. Dincoglan F, Sager O, Demiral S, Beyzadeoglu M (2021) Assessment of the role of multimodality imaging for treatment volume definition of intracranial ependymal tumors: An original article. Glob J Cancer Ther 7: 43-45.
82. Beyzadeoglu M, Demiral S, Dincoglan F, Sager O (2022) Assessment of Target Definition for Extramedullary Soft Tissue Plasmacytoma: Use of Multımodalıty Imaging for Improved Targetıng Accuracy. Canc Therapy & Oncol Int J 22(4): 556095.
83. Dincoglan F, Sager O, Demiral S, Beyzadeoglu M (2022) Target Volume Determination for Recurrent Uterine Carcinosarcoma: An Original Research Article Revisiting the Utility of Multimodality Imaging. Canc Therapy & Oncol Int J 22(3): 556090.
84. Demiral S, Sager O, Dincoglan F, Beyzadeoglu M (2022) Reappraisal of Computed Tomography (CT) And Magnetic Resonance Imaging (MRI) Based Target Definition for Radiotherapeutic Management of Recurrent Anal Squamous Cell Carcinoma (ASCC): An Original Article. Canc Therapy & Oncol Int J 22(2): 556085.
85. Demiral S, Dincoglan F, Sager O, Beyzadeoglu M (2022) An Original Article for Assessment of Multimodality Imaging Based Precise Radiation Therapy (Rt) in the Management of Recurrent Pancreatic Cancers. Canc Therapy & Oncol Int J 22(1): 556078.
86. Sager O, Demiral S, Dincoglan F, Beyzadeoglu M (2022) Assessment of Target Volume Definition for Precise Radiotherapeutic Management of Locally Recurrent Biliary Tract Cancers: An Original Research Article. Biomed J Sci & Tech Res 46(1): 37054-37059.
87. Sager O, Demiral S, Dincoglan F, Beyzadeoglu M. (2022) Radiation Therapy (RT) Target Volume Determination for Locally Advanced Pyriform Sinus Carcinoma: An Original Research Article Revisiting the Role of Multimodality Imaging. Biomed J Sci & Tech Res 45(1): 36155-36160.
88. Demiral S, Sager O, Dincoglan F, Beyzadeoglu M (2022) Improved Target Volume Definition for Radiotherapeutic Management of Parotid Gland Cancers by use of Multimodality Imaging: An Original Article. Canc Therapy & Oncol Int J 21(3): 556062.
89. Beyzadeoglu M, Sager O, Demiral S, Dincoglan F (2022) Reappraisal of multimodality imaging for improved Radiation Therapy (RT) target volume determination of recurrent Oral Squamous Cell Carcinoma (OSCC): An original article. J Surg Surgical Res 8(1): 4-8.
90. Dincoglan F, Sager O, Demiral S, Beyzadeoglu M (2022) Multimodality imaging-based treatment volume definition for recurrent Rhabdomyosarcomas of the head and neck region: An original article. J Surg Surgical Res 8(2): 013-018.
91. Dincoglan F, Demiral S, Sager O, Beyzadeoglu M (2022) Appraisal of Target Definition for Management of Paraspinal Ewing Tumors with Modern Radiation Therapy (RT): An Original Article. Biomed J Sci & Tech Res 44(4): 35691-35696.
92. Beyzadeoglu M, Sager O, Demiral S, Dincoglan F (2022) Assessment of Target Volume Definition for Contemporary Radiotherapeutic Management of Retroperitoneal Sarcoma: An Original Article. Biomed J Sci & Tech Res 44(5): 35883-35887.
93. Dincoglan F, Sager O, Demiral S, Beyzadeoglu M (2023) Appraisal of Target Definition for Anaplastic Thyroid Carcinoma (ATC): An Original Article Addressing the Utility of Multimodality Imaging. Canc Therapy & Oncol Int J 24(4): 556143.
94. Demiral S, Dincoglan F, Sager O, Beyzadeoglu M (2023) Reappraisal of Treatment Volume Determination for Parametrial Boosting in Patients with Locally Advanced Cervical Cancer. Canc Therapy & Oncol Int J 24(5): 556148.
95. Demiral S, Sager O, Dincoglan F, Beyzadeoglu M (2023) Tumor Size Changes after Neoadjuvant Systemic Therapy for Advanced Oropharyngeal Squamous Cell Carcinoma. Canc Therapy & Oncol Int J 24(5): 556147.
96. Demiral S, Dincoglan F, Sager O, Beyzadeoglu M (2023) Assessment of Changes in Tumor Volume Following Chemotherapy for Nodular Sclerosıng Hodgkin Lymphoma (NSHL). Canc Therapy & Oncol Int J 24(5): 556146.
97. Sager O, Demiral S, Dincoglan F, Beyzadeoglu M (2023) Evaluation of Volumetric Changes in Transglottic Laryngeal Cancers After Induction Chemotherapy. Biomed J Sci & Tech Res 51(4): 43026-43031.
98. Dincoglan F, Sager O, Demiral S, Beyzadeoglu M (2023) An Original Research Article for Evaluation of Changes in Tumor Size After Neoadjuvant Chemotherapy in Borderline Resectable Pancreatic Ductal Adenocarcinoma. Biomed J Sci & Tech Res 52(1): 43253-43255.
99. Sager O, Dincoglan F, Demiral S, Beyzadeoglu M (2023) Assessment of Tumor Size Changes After Neoadjuvant Chemotherapy in Locally Advanced Esophageal Cancer: An Original Article. Biomed J Sci & Tech Res 52(2): 43491-43493.
100. Beyzadeoglu M, Demiral S, Dincoglan F, Sager O (2023) Evaluation of Target Definition for Radiotherapeutic Management of Recurrent Merkel Cell Carcinoma (MCC). Canc Therapy & Oncol Int J 24(2): 556133.
101. Dincoglan F, Demiral S, Sager O, Beyzadeoglu M (2023) Reappraisal of Treatment Volume Determination for Recurrent Gastroesophageal Junction Carcinoma (GJC). Biomed J Sci & Tech Res 50(5): 42061-42066.
102. Beyzadeoglu M, Dincoglan F, Demiral S, Sager O (2023) An Original Article Revisiting the Utility of Multimodality Imagıng for Refıned Target Volume Determinatıon Of Recurrent Kidney Carcinoma. Canc Therapy & Oncol Int J 23(5): 556122.
103. Beyzadeoglu M, Demiral S, Dincoglan F, Sager O (2023) Appraisal of Target Definition for Recurrent Cancers of the Supralottic Larynx. Biomed J Sci & Tech Res 50 (5): 42131-42136.
104. Beyzadeoglu M, Demiral S, Dincoglan F, Sager O (2024) Reappraisal of Target Definition for Sacrococcygeal Chordoma: Comparative Assessment with Computed Tomography (CT) and Magnetic Resonance Imaging (MRI. Biomed J Sci & Tech Res 55(1): 46686-46692.