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Utilizing Bladder Scanners in Radiation Therapy for Cervical

Cancer
MaryKate Janita
The Ohio State University
July 30th, 2017
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Introduction
New technology continues to develop in the world of Radiation Oncology. These
developments come from new studies and information that may be discovered year to year. For
instance, when organs such as the bladder and rectum are in treatment fields, the placement of
them can differ, which is vital for treatment depending on whether they are full or empty.
Research over the years has suggested it is best to treat pelvic patients with prostate, endometrial,
or cervical cancer, with a full bladder and empty rectum to keep organs as close to the same
location every day for a more accurate treatment and reduced dose to those areas. With the
development of cone-beam computed technology, the bladder and rectum are analyzed before
treatment to see if they meet the requirements. If patients have not met the full/empty
requirements, they are then taken off the treatment table and given directions to meet those
requirements, such as drink more water. This can be time consuming and lead to repeat CBCT
images, overall increasing patient radiation dose. Portable bladder scanners, an ultrasound
device, can easily read an individual's bladder by producing an image or reading in milliliters the
volume of the bladder. By implementing the use of a bladder scanner into a patient’s treatment
plan, it could potentially save the patient from extra exposure to radiation as well as cut down on
treatment times. Past research on implementing bladder scanners pretreatment, have focused
mainly on prostate patients. Also, most research conducted has studied treatment plans that used
2D imaging. The lack of this topic relating to 3D imaging may be due to it being a newer
technique. The following research will explore IMRT treatments for female cervical cancer as
well as using 3D imaging prior to treatment to line up the patient. It will also explore radiation
dose absorbed by patients during CBCT images, accuracy of bladder scanners, and the benefits
of a full bladder during treatment.

Hypothesis
Implementing the use portable bladder scanners to check for bladder volume will prevent
extra radiation exposure and increased treatment time from repeat CBCTs. This hypothesis may
be correct because often patients have difficulty adequately filling their bladder and must be
imaged multiple times until it is at the volume used to plan their treatment. Bladder scanners are
nonionizing and in place use sound waves to give an accurate reading of the volume of an
individual’s bladder. The critical predication is that bladder scanners read the bladder volume
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accurately and will cut down on extra radiation given to the patient as well as save time from
having to take repeat images.

Literature Review
To reduce dose to healthy tissue and side effects in cervical cancer patients receiving
radiation therapy, intensity-modulated radiation therapy (IMRT) is used. With this treatment,
tighter margins are used and therefore it is important that the majority of dose is within the
planned tumor volume (PTV). With tighter margins, everyday patient setup is vital so that the
internal anatomy matches the location that it was in when the patient’s treatment plan was
produced. Full bladder and empty rectum volumes can help with limiting movement of the uterus
as well as reduce dose to organs at risk. Ahmad1 conducted research on bladder-filling change
throughout treatments of 13 cervical cancer patients and the displacement of the cervix-uterus. In
addition to various CT scans at different bladder volumes, ultrasounds were also taking of the
bladder.1(341) All patients were treated in the prone position with external beam radiation therapy
(EBRT) to doses of 46-50 Gy and were asked to drink 500mL of water prior to treatment.1 In
addition, each patient had 2-6 fiducial markers implanted in the fornixes of the vagina to be able
to evaluate points of interest (PoI) and the tip of the uterus (ToU).1(p341) Overall, the results of
this study found that there was a large variation between patients in the extent of motion due to
changes in the bladder volume, some had very little, while others had up to 65 mm in a single
direction.1(p343)

Buchali2 conducted research to determine to what extent filling status of the bladder
during external beam irradiation effects organ movement. In this study, 29 female patients with
cervical or endometrial cancer were scanned in CT with an empty and full bladder, which
averaged at 190mL.2(p30) Treatment plans were then generated by one physician and physicist, to
avoid differences, to compare the dose distributions to the uterus, bladder, and rectum. The
results for an empty to full bladder were as followed; corpus uteri difference of 7mm upward,
4mm posterior, cervix difference of 4mm upward, half of bladder decrease in dose from 94%-
84%, two-thirds of bladder decrease in dose from 78% to 61%.2(p31-33) Overall, this research
found small but significant reductions in doses delivered to the organs at risk.2(p33) This research
is significant to mention because it shows the importance of the correct volume for a full bladder.
Although patients in this protocol did not have a completely full bladder, 190mL was enough to
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help reduce the dose given to the bladder and rectum and reduce movement of the uterus. Chan et
al4 also studied the movement of the uterus/cervix during radiation therapy and reported that for
every 10-ml decrease in the bladder volume, the uterine canal moved 8 mm inferiorly, the uterine
fundus 18 mm inferiorly, and the cervical os 3 mm anteriorly. Therefore, with both studies, it
could be assumed the more bladder volume, the less movement and dose to organs at risk.

As mentioned, bladder scanners can measure the volume of a bladder using ultrasound
technology. They have different settings to accommodate for certain types of patients whether
they are male, female, or female with a hysterectomy, and they come in many different sizes.
One difference between most other ultrasound technology and bladder scanners is that any
trained individual can operate them. However, for the use of a bladder scanner to be beneficial in
a clinical setting, it would need to be accurate for various bladder volumes. Byun3 investigated
the accuracy of a portable bladder scanner (BS) compared to a 2D conventional ultrasound
(CUB) at different bladder volumes. In this study, 65 subject’s bladder volumes were measured
after drinking 100, 200, 300, and 400 mL; each volume was scanned three times with each
device and then compared to the catheterized volume. The overall results found that the portable
BS was just as accurate if not more accurate than the CUS.3(p688) This research helps demonstrate
that portable bladder scanners would be able to give accurate readings for patients with different
bladder volumes.

Bladder scanner volumes are also comparably accurate to the volume of a bladder in a
CBCT. CBCTs are a three-dimensional imaging modality that allows soft-tissue visualization,
which helps improve the accuracy of treatments.7 This is especially useful for patients who must
follow a full bladder protocol for treatment. In centers where CBCT imaging is not available, in
order to know if a bladder scanner could replace the effectiveness of CBCT, the two must be
compared. In a study done by Ung et al, fourteen prostate cancer patients were enrolled in a
study comparing BS, CT, and CBCT volumes.7(p381) It is important to note that as the study went
on, the differences between the three measured volumes had a mean percentage difference of -
6.2% to 19.7% perhaps due to the therapists becoming more experienced using the bladder
scanners. However, the overall results were within a 20% range of each other, which is
reasonable enough for it to be used as a screening tool to detect large differences.7(p381) They
also discovered implementing a pretreatment bladder scan roughly added one minute to the total
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treatment time. This study not only helped show that there is accuracy between the different
modalities, but also the significance of having experienced operators using the bladder scanner.

Departments where CBCT is available to visualize the bladder could run into issues such
as having to reimage the patient multiple times due to the patient’s inability to prepare the proper
bladder volume. In cases like this, utilizing a bladder scanner would be beneficial prior to CBCT
to save the patient from extra radiation exposure. There are many different protocols for kv-
CBCT that can affect the overall dose such as kvp, mas, imager distance from source, and depth.
Hyer et al6 studied organs and the effective dose from cone-beam CT systems. In this study, they
created a human-like phantom and scanned three sites, the head, chest, and pelvis, and evaluated
the dose to organs in each site. For the pelvis scan, they used the manufacture installed protocol
for prostates (see table 1).6 The overall doses to organ in the pelvis from the Varian OBI CBCT
system can be found on table 5.6 The total the organs received was roughly 129.5mGy or an
effective dose of 4.34 msV.6 The total organ dose was calculated by adding all of the dose from
each organ and tissue together. Limitations of this study include the male makeup of the
phantom, therefore dose to female reproductive organs could not be assessed. Also, the phantom
is not identical to a human, therefore doses will not be as accurate. Most cervical cancer is
treated anywhere from 4500cGy-5400cGy8 to prevent damage to heathy tissue. According to this
study, roughly 12.95cGy was received from a pelvis CBCT. Therefore, at roughly 18-25
treatments, and one CBCT per treatment, the radiation dose to the patient can quickly increase
especially with bladder filling difficulties.

With each organ having a specific max dose, also known as an organs TD 5/5, it is vital
that we do not exceed this max dose during treatment. Implementing bladder scanners could help
reduce dose as well as decrease the overall side effects patients may receive. Some of these side
effects are acute cystitis, dysuria, bladder irritation, diarrhea, bleeding, pain, and dermatisis.8 The
presented research helps prove that bladder scanners could easily be used as an accurate
screening tool prior to pretreatment of cervix cancer. It would additionally cut down on treatment
times due to repeat CBCT images and additional radiation exposure to the patients.
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Methods

First for the experiment, use a female pelvis phantom with different bladder volumes to
create a baseline for the bladder scan results and CT. This will allow the researcher to come up
with a range for the bladder volumes to know when a bladder is acceptable for treatment. This
will also help the issue of having many different volumes based off just physician
opinion/preference. To also help with this issue, it would be best to use patients from a single
physician. The human bladder can hold around 600mL of urine, however the urge to urinate can
occur around 150mL.5 From this information, an educated assumed range could be 200-350mL
(this information will be confirmed from the bladder scan and then comparing it to CT to be sure
the bladder is full enough). After both the bladder scan and CT, patients would be asked to void
so we could have yet another measurement for the urine volume. Subjects for this experiment
should be all be female, without hysterectomy to prevent variables, and diagnosed with cervix
cancer undergoing radiation treatments. For this experiment, the independent variable will be the
bladder scan, the dependent variable will be total effectiveness of the bladder scan. The total
effectiveness will be measured by the amount of time treatment takes as well as the number of
cone-beams taken for each treatment. The experimental group will receive bladder scans before
each treatment as well as a conebeams, however the control group will only receive conebeams
on treatment days. Refer to figure 6.0 for clarification. For both groups, they will be asked to
start drinking 600mL (20oz) of water an hour before treatment. For the experimental group,
before their treatment their bladder will be scanned using a portable bladder scanner to save on
space in the treatment room. Since best results are done laying down, the patient will be laying
on treatment table for this scan. Operators of bladder scanner needs to be sufficiently trained
before the experiment. The patient should be scanned in the lower pelvis, several inches under
the umbilicus. If the scan reads within the acceptable range, therapists will continue with setup
and imaging. If bladder volume is not acceptable on cone-beam or if bladder volume is not in
acceptable range, patient should be instructed to drink more water to be treated properly. For the
control group, bladder volume will only be measured by CBCT. Again, if required volume is not
met, patients will be instructed to drink more before treatment. The time of each treatment and
the number of conebeams taken should be recorded for both groups. All patients should be
treated in a supine position, with a lower vacloc bag as an immobilization device. At the end of
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the study, the number of conebeams for each group should be evaluated, as well as the accuracy
between the conebeams and bladder scanner for the experimental group.

Figure 6.0

Female Patients
to drink 600mL
of water

Control Group Experimental


Group

Bladder Scan kvCBCT

kvCBCT Treatment

Treatment
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Possible Results

Predictions for the results of this experiment will be that overall, using a bladder scanner
prior to imaging will cut down on treatment time and the number of CBCT images, which
supports the hypothesis. More specifically, I predict that patients in the control group will have a
harder time filling their bladder to the acceptable volume as treatment goes on due to side
effects, resulting in having to take more images. If the hypothesis is proven wrong, I would
expect this to be due to increased time treatment times due to therapists struggling to operate the
bladder scanner in a timely fashion. I would not expect that utilizing the bladder scanner would
result in more images having to be taken, unless the original full bladder ranges from scanning
the phantom were inaccurate. Overall, from this experiment, I believe results will support my
hypothesis. While it may not be necessary to utilize bladder scanning for all patients, it would be
a useful tool to use for patients that struggle at the beginning or even throughout their entire
treatments to prep and maintain a full bladder.
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Figures and Tables


Table 1
Scan Site XVI OBI
Head Chest Pelvis Head Chest Pelvis

kV Collimator S20 M20 M10 - -


kV Filtera F0 F1 F1 Full bow- Half bow- Half bow-
tie tie tie
kVp 100 120 120 100 110 125
mA 10 40 64 20 20 80
ms/projection 10 40 40 20 20 13
# of Projections 361 643 643 360 655 655
Total mAs 36.1 1028.8 1646.1 145 262 680
Meaured HVL (mm 5.9 8.9 8.9 5.4 5.7 6.4
Al)
Acquisition Angleb 350°- 273°- 273°- 88°-292° 88°-92° 88°-92°
190° 269° 269°
cw cw cw cw/ccw cw/ccw cw/ccw
Acquisition Time
Axial Field of View 27 41 41 25 45 45
(cm)
Long. Field of View 26 26 12.5 18 16 16
(cm)
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Table 5
Tissue/Organ Measured Organ Doses (mGy)
Pelvis Scan
Lung 0.01
Liver 0.28
Stomach 0.30
Colon 3.26
Bladder 15.30
Gonads (testes) 34.61
Bone marrow (whole body) 1.14
Bone marrow (irradiated site) 5.77
Bone surface (whole body) 1.14
Bone surface (irradiated site) 5.77
Skin (whole body) 3.05
Skin (irradiated site) 27.77
Remainder Organs:
Heart 0.08
Spleen 0.28
Adrenals 0.34
Gall bladder 0.52
Kidneys 0.59
Pancreas 0.52
Small intestine 1.72
Prostate 27.25
Effective dose (msV) 4.34
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References Cited
1
Ahmad R. Radiotherapy and oncology: Increasing treatment accuracy for cervical cancer
patients using correlations between bladder-filling change and cervix-uterus
displacements: proof of principle. Elsevier; 2011;98:340.
2
Buchali A. Radiotherapy and oncology: Impact of the filling status of the bladder and rectum on
their integral dose distribution and the movement of the uterus in the treatment planning
of gynecological cancer. Elsevier; 1999;52:29.
3
Byun S. Accuracy of bladder volume determinations by ultrasonography: are they accurate over
entire bladder volume range? Elsevier; 2003;62:656.
4
Chan P, Dinniwell R, Haider M.A, et al. Inter- and intra-fractional tumor and organ movement
in patients with cervical cancer undergoing radiotherapy: A cinematic-MRI point-of-
interest study. International Journal of Radiation Oncology, Biology, and Physics.
2008;70:1507–1515.
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Hole J. Human Aantomy and Physiology. 2nd ed. Dubuque, IA: Wm. C. Brown Company
Publishers; 1981.
6
Hyer, D. E., Serago, C. F., Kim, S, et al. An organ and effective dose study of XVI and OBI
cone-beam CT systems. Journal of Applied Clinical Medical Physics. 2015;11:181–197.
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Ung K, White R, Mathlum M, Mak-Hau V, Lynch R. Comparison study of portable bladder
scanner versus cone-beam CT scan for measuring bladder volumes in post-prostatectomy
patients undergoing radiotherapy. Journal Of Medical Imaging And Radiation
2014;58(3):377-383.
8
Washington M, Leaver D. Gynecologic Cancers. 4th ed. St. Louis, MO: Elsevier Mosby; 2016.
740-744.