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. 2025 Jun 12;9(2):96-107.
doi: 10.1002/pro6.70019. eCollection 2025 Jun.

Dosimetric and hematological toxicity analyses of bone marrow-sparing intensity-modulated radiation therapy for patients with cervical cancer treated with extended-field radiation therapy

Jia-Nan Wang  1 , Xi Yu  1 , Li-Na Gu  1 , Dong-Mei Liu  1 , Qiu-Yue Su  1 , Jing-Qi Xia  1 , Wei-Kang Yun  2 , Xin Li  2 , Xue-Yuan Hu  2 , Shan-Shan Yang  1 , De-Yang Yu  2
Affiliations

Dosimetric and hematological toxicity analyses of bone marrow-sparing intensity-modulated radiation therapy for patients with cervical cancer treated with extended-field radiation therapy

Jia-Nan Wang et al. Precis Radiat Oncol. .

Abstract

Objective: This study aimed to assess the dosimetric parameters and hematological toxicity (HT) associated with bone marrow-sparing (BMS) intensity-modulated radiation therapy (IMRT) in patients diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage IIIC cervical cancer undergoing extended-field radiation therapy (EFRT).

Methods: Patients with cervical cancer presenting with common iliac or para-aortic lymph node metastases require EFRT, which often results in grade 3 HT. Therefore, we retrospectively analyzed data of 84 patients with FIGO stage IIIC cervical cancer who underwent concurrent chemoradiotherapy (EFRT, brachytherapy, and weekly cisplatin 40 mg/m2) at Harbin Medical University Cancer Hospital, including 40 who received BMS-IMRT and 44 who received normal IMRT. Dose-volume histogram (DVH) parameters and estimated treatment times were compared. We also compared acute HT between the normal and BMS groups.

Results: Dosimetric analysis demonstrated that BMS-IMRT significantly reduced the mean volume of bone marrow receiving ≥10, ≥20, ≥30, and ≥40 Gy without affecting the target coverage of planning target volume and sparing the organs at risk. Within the BMS-IMRT group, 37.5% of the patients developed grade ≥3 HT, with an increase in HT (HT3+ = 61.4%) in patients receiving normal-IMRT (P = 0.029).

Conclusions: For patients with cervical cancer treated with EFRT, BMS-IMRT represents a feasible treatment approach that may mitigate HT and facilitate the uninterrupted administration of concurrent chemoradiotherapy.

Keywords: bone marrow sparing; cervical cancer; extended‐field  radiation therapy; hematological toxicity; intensity‐modulated radiation therapy.

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Conflict of interest statement

All authors declare no potential conflicts of interest.

Figures

FIGURE 1
FIGURE 1
(A) Distribution of most functional bone marrow in the radiation field of conventional EFRT in cervical cancer; (B) Typical figures showing contours for bone marrow cavity in EFRT of LS (orange) and OC (purple). (C) Typical dose distributions of the four plans in cervical cancer: normal‐VMAT, BMS‐VMAT, normal‐TOMO, and BMS‐VMAT plans. EFRT, extended‐field radiation therapy; LS, lumbosacral spine; OC, os coxae; VMAT, volume‐modulated arc therapy; BMS, bone marrow sparing; TOMO, helical tomotherapy.
FIGURE 2
FIGURE 2
The histogram shows the difference in dosimetric parameters of PTV and OARs among the two BMS‐IMRT (VMAT and TOMO) and two normal IMRT plans (VMAT and TOMO): (A) conformity index (CI) and (B) homogeneity index (HI) for planning target volume (PTV) and planning gross target volume (PGTV); Dose–volume parameters and comparisons of (C) BM and (D) other OARs. ***P<0.001, ****P<0.0001. ns: P > 0.05, no statistical significance. PTV, planning target volume; OAR, organs at risk, BMS‐IMRT, bone marrow‐sparing intensity‐modulated radiation therapy; VMAT, volume‐modulated arc therapy; TOMO, helical tomotherapy.
FIGURE 3
FIGURE 3
(A) Dose–volume histograms (DVHs) of PTV, PGTV, and bone marrow in different plans. (B) Comparison of treatment time among different plans. (C) Multivariate logistic regression analyses of clinicopathological variables associated with grade 3 or 4 acute hematological toxicity. ****P < 0.0001. ns: P > 0.05, no statistical significance.
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