{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,22]],"date-time":"2025-12-22T07:34:08Z","timestamp":1766388848665,"version":"3.48.0"},"reference-count":30,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2025,12,21]],"date-time":"2025-12-21T00:00:00Z","timestamp":1766275200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>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\u201325.50). Bulboclitoral complex maximum dose (Dmax) was median 49.07 Gy (48.49\u201350.25) and 28.81 Gy (18.14\u201344.61) 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 &lt; 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\u201382.6) and 0%, respectively (p \u2264 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.<\/jats:p>","DOI":"10.3390\/medicina62010014","type":"journal-article","created":{"date-parts":[[2025,12,22]],"date-time":"2025-12-22T07:01:33Z","timestamp":1766386893000},"page":"14","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["The \u201cUndefined and Ignored Normal Tissue\u201d Bulboclitoral Complex in Locally Advanced Cervical Cancer Treated with Definitive Radiochemotherapy: Is It Not the Organ at Risk?"],"prefix":"10.3390","volume":"62","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7928-6264","authenticated-orcid":false,"given":"Kamuran","family":"Ibis","sequence":"first","affiliation":[{"name":"Department of Radiation Oncology, Institute of Oncology, Istanbul University, 34093 Istanbul, T\u00fcrkiye"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-7726-7830","authenticated-orcid":false,"given":"Mahmut Hudai","family":"Aydin","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Institute of Oncology, Istanbul University, 34093 Istanbul, T\u00fcrkiye"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-4710-9708","authenticated-orcid":false,"given":"Korhan","family":"Kokce","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Institute of Oncology, Istanbul University, 34093 Istanbul, T\u00fcrkiye"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-4634-6599","authenticated-orcid":false,"given":"Leyla","family":"Suncak","sequence":"additional","affiliation":[{"name":"Department of Medical Physics, Institute of Oncology, Istanbul University, 34093 Istanbul, T\u00fcrkiye"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-9290-149X","authenticated-orcid":false,"given":"Ozlem Guler","family":"Guniken","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Institute of Oncology, Istanbul University, 34093 Istanbul, T\u00fcrkiye"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1751-8546","authenticated-orcid":false,"given":"Can","family":"Ilgin","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Institute of Oncology, Istanbul University, 34093 Istanbul, T\u00fcrkiye"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-6824-2067","authenticated-orcid":false,"given":"Deniz","family":"Bolukbas","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Institute of Oncology, Istanbul University, 34093 Istanbul, T\u00fcrkiye"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6984-3466","authenticated-orcid":false,"given":"Nezihe Seden","family":"Kucucuk","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Institute of Oncology, Istanbul University, 34093 Istanbul, T\u00fcrkiye"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0563-5964","authenticated-orcid":false,"given":"Inci Kizildag","family":"Yirgin","sequence":"additional","affiliation":[{"name":"Department of Radiology, Institute of Oncology, Istanbul University, 34093 Istanbul, T\u00fcrkiye"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,12,21]]},"reference":[{"key":"ref_1","first-page":"209","article-title":"Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries","volume":"71","author":"Sung","year":"2021","journal-title":"CA Cancer J. Clin."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"649","DOI":"10.1136\/ijgc-2023-004429","article-title":"ESGO\/ESTRO\/ESP guidelines for the management of patients with cervical\u2014Update 2023","volume":"33","author":"Cibula","year":"2023","journal-title":"Int. J. Gynecol. Cancer"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"161","DOI":"10.1016\/j.ijrobp.2020.08.044","article-title":"Persistence of late substantial patient-reported symptoms (LAPERS) after radiochemotherapy including image-guided adaptive brachytherapy for locally advanced cervical cancer: A report from the EMBRACE study","volume":"109","author":"Vittrup","year":"2021","journal-title":"Int. J. Radiat. Oncol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"400","DOI":"10.1016\/j.ijrobp.2021.08.036","article-title":"Impact of vaginal symptoms and hormonal replacement therapy on sexual outcomes after definitive chemoradiatherapy in patients with locally advanced cervical cancer: Results from the EMBRACE-I study","volume":"112","author":"Kirchheiner","year":"2022","journal-title":"Int. J. Radiat. Oncol. Biol. Phys."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1146","DOI":"10.1097\/IGC.0000000000000207","article-title":"A systematic review of quality of life and sexual function of patients with cervical cancer after treatment","volume":"24","author":"Ye","year":"2014","journal-title":"Int. J. Genecol Cancer"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1717","DOI":"10.1097\/IGC.0b013e3182a80a65","article-title":"Self-reported sexual, bowel and bladder f\u0131nction in cervical cancer patients following different treatment modalities: Longitudinal prospective cohort study","volume":"23","author":"Pieterse","year":"2013","journal-title":"Int. J. Gynecol. Cancer"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1638","DOI":"10.1016\/j.ejca.2011.11.014","article-title":"Five-year quality of life of endometrial cancer patients treated in the randomised Post Operative Radiation Therapy in Endometrial Cancer (PORTEC-2) trial and comparison with norm data","volume":"48","author":"Nour","year":"2012","journal-title":"Eur. J. Cancer"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Seguin, L., Touzani, R., Bouhnik, A.D., Charif, A.B., Marino, P., Bendiane, M.K., Gon-\u00e7alves, A., Gravis, G., and Mancini, J. (2020). Deterioration of sexual health in cancer survivors five years after diagnosis: Data from the French National Prospective VICAN Survey. Cancers, 12.","DOI":"10.3390\/cancers12113453"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"20201139","DOI":"10.1259\/bjr.20201139","article-title":"A first radiotherapy application of functional bulboclitoris anatomy, a novel female sexual organ at risk, and organ sparing fea-sibility study","volume":"94","author":"Marshall","year":"2021","journal-title":"Br. J. Radiol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1189","DOI":"10.1097\/01.ju.0000173639.38898.cd","article-title":"Anatomy of the clitoris","volume":"174","author":"Sanjeevean","year":"2005","journal-title":"J. Urol."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Di Marino, V., and Lepidi, H. (2014). Anatomic Study of the Clitoris and the Bulboclitoral Organ, Springer International Publishing. [1st ed.].","DOI":"10.1007\/978-3-319-04894-9"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1007\/s10508-020-01638-6","article-title":"A brief history of the clitoris","volume":"49","author":"Charlier","year":"2020","journal-title":"Arch. Sex. Behav."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"20150032","DOI":"10.1259\/bjr.20150032","article-title":"Proposed genitalia con-touring guidelines in anal cancer intensity modulated radiotherapy","volume":"88","author":"Brooks","year":"2015","journal-title":"Br. J. Radiol."},{"key":"ref_14","first-page":"353","article-title":"Female erectile tissues and sexual dysfunction after pelvic radiotherapy: A scoping review","volume":"72","author":"Marshall","year":"2022","journal-title":"CA Cancer J. Clin."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"333","DOI":"10.1016\/j.ijrobp.2005.09.028","article-title":"Conformity index: A review","volume":"64","author":"Feuvret","year":"2006","journal-title":"Int. J. Radiat. Oncol. Biol. Phys."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"338","DOI":"10.1080\/0284186X.2017.1400684","article-title":"Radiotherapy for cervical cancer\u2014Impact on the vaginal epithelium and sexual function","volume":"57","author":"Bergmark","year":"2018","journal-title":"Acta Oncol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1088","DOI":"10.1016\/j.ijrobp.2015.12.363","article-title":"Health-related quality of life in locally advanced cervical cancer patients after definitive chemoradiation therapy in-cluding image-guided adaptive brachytherapy: An analysis from the EMBRACE Study","volume":"94","author":"Kirchheiner","year":"2016","journal-title":"Int. J. Radiat. Oncol. Biol. Phys."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"S51","DOI":"10.1016\/j.ijrobp.2019.06.483","article-title":"Sexual activity and vaginal functioning in patients with locally advanced cervical cancer following definitive radiochemotherapy and image-guided adaptive brachytherapy (EMBRACE study)","volume":"105","author":"Kirchheiner","year":"2019","journal-title":"Int. J. Radiat. Oncol. Biol. Phys."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1016\/j.radonc.2021.12.034","article-title":"Dose-effect relationship between vaginal dose points and vaginal stenosis in cervical cancer: An EMBRACE-I sub-study","volume":"168","author":"Westerveld","year":"2022","journal-title":"Radiother. Oncol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"428","DOI":"10.1016\/j.ijrobp.2007.09.042","article-title":"Consensus guidelines for delineation of clinical target volume for intensity modulated pelvic radiotherapy in postoperative treat-ment of endometrial and cervical cancer","volume":"71","author":"Small","year":"2008","journal-title":"Int. J. Radiat. Oncol. Biol. Phys."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"348","DOI":"10.1016\/j.ijrobp.2009.10.075","article-title":"Consensus guidelines for delinea-tion of clinical target volume for intensity modulated pelvic radiotherapy for the definitive treatment of cervical cancer","volume":"79","author":"Lim","year":"2011","journal-title":"Int. J. Radiat. Oncol. Biol. Phys."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"e353","DOI":"10.1016\/j.ijrobp.2012.01.023","article-title":"Pelvic normal tissue contouring guidelines for radiation therapy: A Radiation Therapy Oncology Group consensus panel atlas","volume":"83","author":"Gay","year":"2012","journal-title":"Int. J. Radiat. Oncol. Biol. Phys."},{"key":"ref_23","unstructured":"(2025, July 20). Available online: https:\/\/www.embracestudy.dk\/UserUpload\/PublicDocuments\/Docs\/EMBRACE_II_title_page_and_total_protocol_v15_151015.pdf."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"ICRU (2013). ICRU REPORT 89: Prescribing, recording, and reporting brachytherapy for cancer of the cervix. J. ICRU, 13, 1\u2013258.","DOI":"10.1093\/jicru\/ndw042"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1191","DOI":"10.1016\/j.ijrobp.2016.02.043","article-title":"Consensus recommendations for radiation therapy contouring and treatment of vulvar carcinoma","volume":"95","author":"Gaffney","year":"2016","journal-title":"Int. J. Radiat. Oncol. Biol. Phys."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"413","DOI":"10.1016\/j.ijrobp.2020.08.061","article-title":"NRG Oncology\/RTOG consensus guidelines for delineation of clinical target volume for intensity modulated pelvic radiation therapy in postoperative treatment of endometrial and cervical cancer: An update","volume":"109","author":"Small","year":"2021","journal-title":"Int. J. Radiat. Oncol. Biol. Phys."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"36","DOI":"10.1016\/j.radonc.2019.11.005","article-title":"Recommendations from gynaecological (GYN) GEC-ESTRO working group\u2014ACROP: Target concept for image-guided adaptive brachy-therapy in primary vaginal cancer","volume":"145","author":"Schmid","year":"2020","journal-title":"Radiother. Oncol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"S77","DOI":"10.1016\/j.brachy.2023.06.127","article-title":"Eval-uation of radiation dose to the bulboclitoris in patients receiving interstitial brachytherapy for gynecologic cancers involving the lower vagina","volume":"22","author":"Venkatesh","year":"2023","journal-title":"Brachytherapy"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"171","DOI":"10.1016\/j.prro.2024.11.004","article-title":"Consensus guidelines for definition of clinical target volumes for intensity modulated radiation therapy for intact cervical cancer: An update","volume":"15","author":"Fields","year":"2025","journal-title":"Pract. Radiat. Oncol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"123","DOI":"10.1016\/j.ygyno.2023.01.005","article-title":"Vaginal changes, sexual functioning and distress of women with locally advanced cervical cancer treated in the EMBRACE vaginal morbidity substudy","volume":"170","author":"Suvaal","year":"2023","journal-title":"Gynecol. Oncol."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/1\/14\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,22]],"date-time":"2025-12-22T07:29:16Z","timestamp":1766388556000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/1\/14"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12,21]]},"references-count":30,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,1]]}},"alternative-id":["medicina62010014"],"URL":"https:\/\/doi.org\/10.3390\/medicina62010014","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12,21]]}}}