# The “Undefined and Ignored Normal Tissue” Bulboclitoral Complex in Locally Advanced Cervical Cancer Treated with Definitive Radiochemotherapy: Is It Not the Organ at Risk?

## TL;DR

This study shows that the bulboclitoral complex, important for female sexual health, is often overlooked in cervical cancer radiotherapy and can be protected by adjusting treatment plans.

## Contribution

The study introduces the concept of contouring the bulboclitoral complex as an organ at risk in cervical cancer radiotherapy.

## Key findings

- Contouring the BCC as an organ at risk significantly reduced its maximum radiation dose.
- The percentage of BCC volume receiving 45 Gy was nearly eliminated with the new treatment plan.
- The BCC is currently undefined in radiotherapy guidelines for gynecological cancers.

## Abstract

Background and Objectives: The bulboclitoral complex (BCC) is an essential organ for female sexual health. However, it is not defined as an organ at risk in any guideline defining target volumes in radiotherapy of gynecological cancers, and there is no information about dose constraint. Materials and Methods: Simulation computed tomography scans of 20 patients diagnosed with locally advanced cervical cancer were used retrospectively. The volumetric modulated arc therapy treatment plan with a total dose of 45 Gy in 25 fractions was created using the planning target volume (PTV)-standard, which was created without considering the BCC, and the PTV-BCC spared, which were contoured and included in the optimization. Bulboclitoral complex doses in PTV-standard and PTV-BCC spared plans were compared using the paired simple t test. Results: Median BCC volume was 17.6 cm3 (11.20–25.50). Bulboclitoral complex maximum dose (Dmax) was median 49.07 Gy (48.49–50.25) and 28.81 Gy (18.14–44.61) in the PTV-standard and PTV-BCC spared plans, respectively, and the BCC Dmax was statistically significantly lower in the PTV-BCC spared plan (p < 0.001). When comparing BCC percentage of volume receiving 45 Gy (V45), the median values for PTV-standard and PTV-BCC spared plans were 37.5% (13.3–82.6) and 0%, respectively (p ≤ 0.001). Conclusions: The bulboclitoral complex can be dosimetrically protected from radiation by contouring and optimizing it as an organ at risk in the radiotherapy plan. The clinical effects of protecting the BCC from radiation as an organ at risk on sexual health need to be investigated.