A Template for

Clinical Drawings
in Cancer of the Cervix
Carey B. Shenfield MD
Johannes C.A. Dimopolous MD
Heloisa De Andrade Carvalho MD PhD
Elena F. Fidarova MD
Richard Pötter MD
 Clinical Drawings

• Clinical drawings have traditionally been used to depict the extent

of disease based on clinical examination. Tumour that is visible or
palpable is drawn manually, usually on paper templates.
• With the advent of image-guided brachytherapy in cervical cancer,
an argument can be made to also incorporate disease findings
from imaging examinations into these “clinical drawings”.
• We aim to develop standarized methods for the creation of these
clinical drawings, that would hopefully, eventually, lead to some
level of standardization of clinical drawings across different
physicians, across different centres, across time, and ultimately,
across multiple tumour sites as well.
 Clinical Drawings

• “At Diagnosis” or “At Brachytherapy” should be marked on each

drawing.
• Treatment received to date, including any external beam
radiotherapy (EBRT) delivered to date, should be noted.
• Four different views or planes are illustrated: Specular, Axial,
Coronal, and Sagittal.
• Dotted lines of the vagina represent a virtual division in thirds.
Dotted lines in the parametria represent a border between the
proximal and distal half of the parametria.
• A pink line in the coronal view represents uterine artery.
 Clinical Drawings

• Tumour dimensions: height (h), width (w), and thickness (t)

should be documented. Height, defined on the sagittal view, is
measured along the long axis of the uterus. Thickness, defined
on the sagittal view, is measured perpendicular to the height.
Width, measured on the axial view, represents the greatest
lateral diameter. Vaginal extension of tumour is specified
separately.
• The date of the evaluation should be recorded.
• The drawing should be signed.
 Clinical Drawings
Manual Colour Drawing
• There are three basic options for the drawing of uniform and
reproducible universal clinical drawings.
• A first option utilizes coloured marker pens and a colour legend.
Four different, specific colours are used. In addition, tumour can
be identified as exophytic in nature by changing the border as
outlined in the legend.
• There are certain advantages to coloured marker approach, such
as straightforward and quick implementation, and immediately
recognizable distinctions of different anatomical areas of
involvement. However, the incorporation of up to four specifically
coloured markers into routine clinical practice in clinics and
operating rooms may be a challenge to do consistently. Ensuring
the consistent availability of the markers in multiple work
environments, with multiple caregivers, may not be practical.
 Clinical Drawings
Manual Line Drawing
• A second option uses a legend that requires only a single pen
to convey the same amount of information. Different
anatomical areas of involvement are demonstrated using
simple line patterns, with a specific pattern for each
anatomical site according to the legend. Again, any exophytic
tumour can be delineated with a special border.
• Unlike the colour approach, consistent availability of a pen at
any location or with any caregiver should not be an issue. A
drawback is that the drawings may appear less readily
discernible. However, after a brief learning curve, practioners
should be able to draw and read such drawings with ease.
This approach seems the most practical and reliable, and
could be adopted widely.
 Clinical Drawings
Electronic Drawing

• Finally, a third option involves a computer-based method to create

the clinical drawings. This method involves electronic versions of the
colour or background lines templates, with electronically modifiable
tumour cartoons. The cartoons can be modified for the individual
patient by way of a Powerpoint© type of application, using relatively
simple tools (Figures 3, 4). Clinical drawings can be stored and
transmitted electronically. Drawings for physical medical chart
record-keeping would have to be printed.
 Clinical Drawings
Electronic Drawing
• Advantages of an electronic approach include the consistency and
clarity of the drawings produced. In addition, the electronic format
facilitates the storage, access, and distribution of the drawings.
Electronic templates could be made available on the internet for
clinical use. However, logistical issues such as the availability of a
local computer with the appropriate software, the availability of a
local (colour) printer for generation of hard copies, and the
clinician’s familiarity with the software tools needed, may preclude
this electronic method’s widespread adoption.
 Legends
• Cervical tumour is represented by a red border or structure in the
colour legend, or by a border filled with oblique lines in the
background lines legend.
• Vaginal tumour extension is represented by a green border or
structure in the colour legend, or by a border filled with vertical
lines in the background lines legend.
• Parametrial extension is represented by a blue border or structure
in the colour legend, or by a border filled with horizontal lines in the
background lines legend.
• Rectum or bladder involvement is represented by a yellow border
or structure in the colour legend, or by a border filled with crossed
lines in the background lines legend.
• Tumour is presumed to be infiltrative, and with the exception of
parametrial extension, can be additionally designated as exophytic
using an irregularly shaped border.
 Colour Legend

Cervix May be additionally

Vagina defined as:

Parametria Exophytic

Rectum or Bladder
Infiltration
Background Lines Legend

Cervix May be additionally

Vagina defined as:

Parametria Exophytic

Rectum or Bladder
Infiltration
Patient:
Clinical Drawing At Diagnosis
At Brachytherapy
w
EBRT Gy
Infiltrative Exophytic

Cervix

Vagina w = __ _ cm
h = __ _ cm
t = __ _ cm
Parametria
Vagina
Involvement
= _ _ cm
Rectum or
Bladder

dd/mm/yy
/ /

Signature
Patient:
Clinical Drawing At Diagnosis
At Brachytherapy
w EBRT Gy
Infiltrative Exophytic

Cervix

Vagina w = __ _ cm
h = __ _ cm
t = __ _ cm
Parametria
Vagina
Involvement
= _ _ cm
Rectum or
Bladder

dd/mm/yy
/ /

Signature
 Electronic Drawing Tools
The drawings can be created and modified electronically using
common Powerpoint© tools. Click on the individual cartoon to
select it:
 Electronic Drawing Tools
After selecting a cartoon, a right click on the cartoon brings up a
menu. After clicking on the Copy option, a right click of the cursor
on any open area will bring up a second menu, with a Paste option.
Clicking on the Paste option will place a copy of the cartoon, which
can then be dragged and modified to create the drawing:
 Electronic Drawing Tools
You can change the size of the cartoon by placing your mouse
over one of the corner resizing handles that appear as white
circles. The mouse cursor will change to a two-headed arrow.
Dragging the corner handle to resize the picture will retain its
proportions:
 Electronic Drawing Tools

Alternatively, dragging a side handle will change the size

of the cartoon in that direction:
 Electronic Drawing Tools
For finer adjustments to the cartoon, a right click on the cartoon
reveals the Edit Points tool. This tool allows you to modify the
cartoon by adjusting individual points that make up the
perimeter of the cartoon:
 Electronic Drawing Tools
Any individual edit point can be clicked and dragged to fine
tune and individualise the drawing. The cursor takes on the
appearance below when the point is active and moveable:
 Examples of Clinical Drawings

• The different sample drawings reflect different stages,

patterns of growth, and extent of disease. Stages IB to IVA
are illustrated.
• Clinical tumour drawings should depict the disease in
three dimensions and provide a clear view of the
characteristics of the disease. Descriptions are based on
visualisation, palpation, and imaging findings.
• Measurements of tumour dimensions are illustrated.
• For the purposes of illustration, the clinical drawings are
followed by a written description of the drawing.
 w
1.8cm At Brachytherapy
At Diagnosis X
Dose of EBRT Gy
IB1
w = 1.8 cm
h = 2.0 cm
t = 1.5 cm

Vagina: cm

dd/mm/yy
/ /

Signature Case I
 IBI - At Diagnosis

• Cervix: tumour at the posterior and

right lip, from 5 to 10h
• Vagina: not involved
• Parametria: not involved

Case I
 w
0.8cm
At Brachytherapy X
At Diagnosis
Dose of EBRT 45 Gy

IB1
w = 0.8 cm
h = 1.0 cm
t = 0.5 cm

Vagina: cm

dd/mm/yy
/ /

Signature Case I
 IBI - At Brachytherapy

Good response
• Cervix: residual tumour from 7 to 9h
• Vagina: not involved
• Parametria: not involved

Case I
 w
5.8cm
At Diagnosis X At Brachytherapy
Dose of EBRT Gy

IB2
w = 5.8 cm
h = 7.5 cm
t = 5.8 cm

Vagina: cm

dd/mm/yy
/ /

Signature Case II
 IBII - At Diagnosis
• Cervix: large exophytic tumour involving the whole
cervix, and protuding to almost 2/3 of the vagina,
which is not infiltrated. Lateral fornices not
visualised in the specular view, but not infiltrated
at palpation, and MRI
• Vagina: not involved
• Parametria: not involved
Note: since the tumor has a large caudal extension, h (height) has to
be measured along its‘ axis on the sagittal view of MRI, and also on
the coronal view, besides physical exam
Case II
 w
3.2cm
At Diagnosis At Brachytherapy X
Dose of EBRT 41.4 Gy
IB2 - exophytic
w = 3.2 cm
h = 3.6 cm
t = 3.5 cm

Vagina: cm

dd/mm/yy
/ /

Signature Case II
 IBII - At Brachytherapy

Good response:
• Cervix: residual tumour still involving the
whole cervix, with practically no extension to
vaginal space. Fornices well visualised, and
with no disease
• Vagina: not involved
• Parametria: not involved

Case II
 w

At Diagnosis X
3.8cm
At Brachytherapy
Dose of EBRT Gy
IIA
w = 3.8 cm
h = 2.5 cm
t = 4.0 cm

Vagina: 1.5 cm

dd/mm/yy
/ /

Note: extension of vaginal involvement is specified Case III

Signature separately, and should not be included in h
 IIA - At Diagnosis

• Cervix: tumour involving cervix from 2 to 12h.

External os not visualized
• Vagina: involvement of right, and posterior
fornices, from 5 to 11h, to a maximum
extension of 1.5 cm
• Parametria: not involved

Case III
 w

At Diagnosis
0.5cm At Brachytherapy X
Dose of EBRT 45 Gy
IIA
w = 1.0 cm
h = 1.0 cm
t = 1.0 cm

Vagina: 0.3 cm

dd/mm/yy
/ /

Signature Note: the small extension of vaginal involvement can be measured Case III
only on clinical exam. In this case, it can be included in w.
 IIA - At Brachytherapy

Good response:
• Cervix: residual tumour at right/posterior
lip, from 7 to 8h
• Vagina: only a small extension to the right
fornix, contiguous with residual tumour
• Parametria: not involved

Case III
 w At Brachytherapy
At Diagnosis X Dose of EBRT Gy
4.5cm

IIB
w = 4.5 cm
h = 5.0 cm
t = 4.2 cm
Vagina: 2 cm

dd/mm/yy
/ /

Signature Case IV
 IIB - At Diagnosis

• Cervix: exophytic and infiltrative tumour involving

almost the whole cervix, preserving only a small
portion of the left anterior lip, with bulky endocervical
extension
• Vagina: exophytic lesion involving right and posterior
fornices, with 2 cm extension
• Parametria: proximal infiltration of right parametrium

Case IV
 At Brachytherapy X
At Diagnosis w
1.7cm
Dose of EBRT 45 Gy

IIB
w = 2.0 cm
h = 2.0 cm
t = 1.5 cm
Vagina: cm

dd/mm/yy
/ /

Signature Case IV
 IIB - At Brachytherapy

Good response:
• Cervix: residual non exophytic tumour, in
the right/posterior lip, from 5 to 10h
• Vagina: not involved
• Parametria: not involved

Case IV
At Diagnosis X w
At Brachytherapy
7.5cm Dose of EBT Gy

IIIA

w = 7.5 cm
h = 4.7 cm
t = 4.8 cm

Vagina: 7 cm

5cm

dd/mm/yy 4cm
from urethra
/ / 2cm
from urethra

Signature
Case V
 IIIA - At Diagnosis

• Cervix: exophytic tumour involving the

whole cervix
• Vagina*: anterior (lower third, 7 cm), and
right lateral (middle third, 5 cm) walls
• Parametria: distal involvement of the right;
proximal of the left

*Note: lateral vaginal involvement does not reach lower 1/3.

Largest dimension should be reported, in this case, at the anterior
wall. Additional measurements from the urethral os help to better
understand tumour, and treatment. Case V
At Diagnosis w At Brachytherapy X
6.0cm Dose of EBRT 45 Gy
IIIA
Anterior
vaginal wall

w = 6.0 cm
h = 4.0 cm
t = 4.5 cm

Vagina: 4 cm

dd/mm/yy
/ /

Signature
Case V
 IIIA - At Brachytherapy

Partial or Bad response:

• Cervix: partial regression of the tumour,
mainly the exophytic component. Left
posterior lip not involved
• Vagina: anterior wall with disease extending
for 4 cm
• Parametria: small regression but still distal
involvement at right; proximal at left

Case V
At Diagnosis X w At Brachytherapy
9.0cm
Dose of EBRT Gy

IIIB
w = 9.0 cm
h = 6.0 cm
t = 5.0 cm
Vagina: 5 cm

dd/mm/yy
/ /

Signature Note: vagina and parametria not included in h

Case VI
 IIIB - At Diagnosis

• Cervix: large exophytic tumour preserving only a

small part of posterior lip, with cranial infiltration
of the whole cervix Case VI

• Vagina: right lateral wall with exophytic lesion

involving almost 2/3 of the vagina (5 cm)
• Parametria: right with distal infiltration; left to
pelvic wall

Case VI
At Diagnosis w
At Brachytherapy X
6.8cm Dose of EBRT 50.4 Gy

IIIB
w = 6.8 cm
h = 4.2 cm
t = 4.5 cm
Vagina: 5 cm

dd/mm/yy
/ /

Signature Note: parametria not included in h. Case VI

 IIIB - At Brachytherapy
Bad response:
• Cervix: tumour infiltrating anterior lip, with
persistence of the extensive endocervical
component
• Vagina: not involved
• Parametria: partial tumour regression, with
right and left distal infiltration, not reaching
pelvic wall

Case VI
At Diagnosis X w At Brachytherapy
8.0cm Dose of EBT Gy

IVA - Bladder

w = 8.0 cm
h = 6.0 cm
t = 6.5 cm
Vagina: 5 cm

dd/mm/yy
/ /

Signature Case VII

 IVA - At Diagnosis

• Cervix: extensive exophytic tumour

• Vagina: fornices completely involved by disease,
exophytic in the anterior wall until middle 1/3 (5
cm). Paracolpus partially infiltrated bilaterally
• Parametria: right infiltrated to pelvic wall; left
distal
• Bladder: invasion of the posterior wall

Case VII
At Diagnosis w At Brachytherapy X
7.0cm Dose of EBRT 45 Gy

IVA - Bladder

w = 7.0 cm
h = 5.0 cm
t = 5.0 cm
Vagina: 2.5 cm

dd/mm/yy
/ /

Signature Case VII

 IVA - At Brachytherapy
Poor response:
• Cervix: exophytic tumour in the anterior lip.
External os visible
• Vagina: exophytic lesion in the anterior fornix
with 2.5 cm extension. Lateral and posterior
fornices with no visible disease, but with bulging
due to cervical tumour extension
• Parametria: distal infiltration at right, minimal
proximal infiltration at left
• Bladder: persistence of posterior bladder wall
invasion at MRI
Case VII
At Diagnosis X w
At Brachytherapy
6.0cm
Dose of EBRT Gy
IVA - Rectum

w = 6.0 cm
h = 5.5 cm
t = 6.0 cm
Vagina: cm

dd/mm/yy
/ /

Signature
Case VIII
 IVA - At Diagnosis

• Cervix: extensive infiltrative tumour of

the cervix, and endocervix
• Vagina: bulging of right fornix by tumour.
Mucosa not infiltrated
• Parametria: right half infiltrated; left to
proximal third
• Rectum: involvement of anterior wall

Case VIII
At Diagnosis w
At Brachytherapy X
5.0cm
Dose of EBRT 45 Gy
IVA - Rectum

w = 5.0 cm
h = 5.0 cm
t = 5.0 cm
Vagina: cm

dd/mm/yy
/ /

Signature Case VIII

 IVA - At Brachytherapy

Poor response:
• Cervix: persistence of infiltrative tumour of
the cervix, and endocervix
• Vagina: bulging of right fornix by tumour.
Mucosa not infiltrated
• Parametria: proximal infiltration of right and
left
• Rectum: not involved clinically or on MRI

Case VIII
 Special Case
• To Illustrate a bulky cervical tumour where the
tumour bulges towards the vaginal, bladder and
rectal walls, but these structures are not involved.
At Diagnosis X w At Brachytherapy
5.8cm Dose of EBRT Gy

IB2 - Bulky

w = 5.8 cm
h = 6.4 cm
t = 6.0 cm
Vagina: cm

dd/mm/yy
/ /

Signature Case IX
 IBII - At Diagnosis

• Cervix: infiltrative bulky tumour

involving the whole cervix
• Vagina: not involved
• Parametria: not involved
• Bladder and rectum: not involved
*Note: tumour volume pushes the parametria laterally. At physical exam it
may feel involved, but this can be better judged by MRI
Case IX