{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,28]],"date-time":"2026-02-28T19:38:02Z","timestamp":1772307482561,"version":"3.50.1"},"reference-count":27,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2025,8,1]],"date-time":"2025-08-01T00:00:00Z","timestamp":1754006400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Life"],"abstract":"<jats:p>Purpose: To present the findings of our preliminary experience using daily image-guided radiotherapy (IGRT) supported by implanted fiducial markers (FMs) in the radiotherapy of the vaginal cuff, in a cohort of post-surgery endometrial cancer patients. Methods: Patients with vaginal cuff cancer requiring adjuvant radiation with external beams were enrolled. Five patients underwent radiation therapy targeting the pelvic disease and positive lymph nodes, with doses of 50.4 Gy in twenty-eight fractions and a subsequent stereotactic boost on the vaginal vault at a dose of 5 Gy in a single fraction. One patient was administered 30 Gy in five fractions to the vaginal vault. These patients underwent external beam RT following the implantation of three 0.40 \u00d7 10 mm gold fiducial markers (FMs). Our IGRT strategy involved real-time 2D kV image-based monitoring of the fiducial markers during the treatment delivery as a surrogate of the vaginal cuff. To explore the potential role of FMs throughout the treatment process, we analyzed cine movies of the 2D kV-triggered images during delivery, as well as the image registration between pre- and post-treatment CBCT scans and the planning CT (pCT). Each CBCT used to trigger fraction delivery was segmented to define the rectum, bladder, and vaginal cuff. We calculated a standard metric to assess the similarity among the images (Dice index). Results: All the patients completed radiotherapy and experienced good tolerance without any reported acute or long-term toxicity. We did not observe any loss of FMs during or before treatment. A total of twenty CBCTs were analyzed across ten fractions. The observed trend showed a relatively emptier bladder compared to the simulation phase, with the bladder filling during the delivery. This resulted in a final median Dice similarity coefficient (DSC) of 0.90, indicating strong performance. The rectum reproducibility revealed greater variability, negatively affecting the quality of the delivery. Only in two patients, FMs showed intrafractional shift &gt; 5 mm, probably associated with considerable rectal volume changes. Target coverage was preserved due to a safe CTV-to-PTV margin (10 mm). Conclusions: In our preliminary study, CBCT in combination with the use of fiducial markers to guide the delivery proved to be a feasible method for IGRT both before and during the treatment of post-operative gynecological cancer. In particular, this approach seems to be promising in selected patients to facilitate the use of SBRT instead of BRT (brachytherapy), thanks to margin reduction and adaptive strategies to optimize dose delivery while minimizing toxicity. A larger sample of patients is needed to confirm our results.<\/jats:p>","DOI":"10.3390\/life15081218","type":"journal-article","created":{"date-parts":[[2025,8,1]],"date-time":"2025-08-01T08:51:41Z","timestamp":1754038301000},"page":"1218","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Single-Center Preliminary Experience Treating Endometrial Cancer Patients with Fiducial Markers"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0009-0003-8308-929X","authenticated-orcid":false,"given":"Francesca","family":"Titone","sequence":"first","affiliation":[{"name":"Radiation Oncology Unit, Department of Oncology, \u201cSanta Maria della Misericordia\u201d University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Eugenia","family":"Moretti","sequence":"additional","affiliation":[{"name":"Medical Physics Unit, Department of Oncology, \u201cSanta Maria della Misericordia\u201d University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8098-9204","authenticated-orcid":false,"given":"Alice","family":"Poli","sequence":"additional","affiliation":[{"name":"Clinic of Obstetrics and Gynecology, \u201cSanta Maria della Misericordia\u201d University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy"},{"name":"Department of Medicine, University of Udine, 33100 Udine, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marika","family":"Guernieri","sequence":"additional","affiliation":[{"name":"Medical Physics Unit, Department of Oncology, \u201cSanta Maria della Misericordia\u201d University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sarah","family":"Bassi","sequence":"additional","affiliation":[{"name":"Medical Physics Unit, Department of Oncology, \u201cSanta Maria della Misericordia\u201d University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Claudio","family":"Foti","sequence":"additional","affiliation":[{"name":"Medical Physics Unit, Department of Oncology, \u201cSanta Maria della Misericordia\u201d University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8257-0618","authenticated-orcid":false,"given":"Martina","family":"Arcieri","sequence":"additional","affiliation":[{"name":"Clinic of Obstetrics and Gynecology, \u201cSanta Maria della Misericordia\u201d University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy"},{"name":"Department of Biomedical, Dental, Morphological and Functional Imaging Science, University of Messina, 98125 Messina, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2521-1088","authenticated-orcid":false,"given":"Gianluca","family":"Vullo","sequence":"additional","affiliation":[{"name":"Radiation Oncology Unit, Department of Oncology, \u201cSanta Maria della Misericordia\u201d University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Giuseppe","family":"Facondo","sequence":"additional","affiliation":[{"name":"Radiation Oncology Unit, Department of Oncology, \u201cSanta Maria della Misericordia\u201d University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marco","family":"Trov\u00f2","sequence":"additional","affiliation":[{"name":"Radiation Oncology Unit, Department of Oncology, \u201cSanta Maria della Misericordia\u201d University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2461-6777","authenticated-orcid":false,"given":"Pantaleo","family":"Greco","sequence":"additional","affiliation":[{"name":"Department of Medical Sciences, Obstetrics and Gynecology Unit, University of Ferrara, 44121 Ferrara, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0529-201X","authenticated-orcid":false,"given":"Gabriella","family":"Macchia","sequence":"additional","affiliation":[{"name":"Radiation Oncology Unit, Responsible Research Hospital, 86100 Campobasso, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2424-2691","authenticated-orcid":false,"given":"Giuseppe","family":"Vizzielli","sequence":"additional","affiliation":[{"name":"Clinic of Obstetrics and Gynecology, \u201cSanta Maria della Misericordia\u201d University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy"},{"name":"Department of Medicine, University of Udine, 33100 Udine, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7848-0329","authenticated-orcid":false,"given":"Stefano","family":"Restaino","sequence":"additional","affiliation":[{"name":"Clinic of Obstetrics and Gynecology, \u201cSanta Maria della Misericordia\u201d University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy"},{"name":"PhD School in Biomedical Sciences, Gender Medicine, Child and Women Health, University of Sassari, 07100 Sassari, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,8,1]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1136\/ijgc-2020-002230","article-title":"ESGO\/ESTRO\/ESP guidelines for the management of patients with endometrial carcinoma","volume":"31","author":"Concin","year":"2021","journal-title":"Int. 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Management for Cervical Cancer Patients: A Comparison of the Guidelines from the International Scientific Societies (ESGO-NCCN-ASCO-AIOM-FIGO-BGCS-SEOM-ESMO-JSGO). Cancers, 16.","DOI":"10.3390\/cancers16142541"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.radonc.2021.01.039","article-title":"Impact of a fiducial marker based ART strategy on margins in postoperative IMRT of gynecological tumors","volume":"158","author":"Buijs","year":"2021","journal-title":"Radiother. Oncol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"256","DOI":"10.1016\/j.ijrobp.2010.08.024","article-title":"Vaginal motion and bladder and rectal volumes during pelvic intensity-modulated radiation therapy after hysterectomy","volume":"82","author":"Jhingran","year":"2012","journal-title":"Int. J. Radiat. Oncol. Biol. 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