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Small bowel protection in IMRT for rectal cancer

A dosimetric study on supine vs. prone position

Dünndarmschonung bei der IMRT des Rektumkarzinoms

Dosimetrische Studie zur Bauch- und Rückenlagerung

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Abstract

Background

This treatment planning study analyzes dose coverage and dose to organs at risk (OAR) in intensity-modulated radiotherapy (IMRT) of rectal cancer and compares prone vs. supine positioning as well as the effect of dose optimization for the small bowel (SB) by additional dose constraints in the inverse planning process.

Patients and methods

Based on the CT datasets of ten male patients in both prone and supine position, a total of four different IMRT plans were created for each patient. OAR were defined as the SB, bladder, and femoral heads. In half of the plans, two additional SB cost functions were used in the inverse planning process.

Results

There was a statistically significant dose reduction for the SB in prone position of up to 41% in the high and intermediate dose region, compared with the supine position. Furthermore, the femoral heads showed a significant dose reduction in prone position in the low dose region. Regarding the additional active SB constraints, the dose in the high dose region of the SB was significantly reduced by up to 14% with the additional cost functions. There were no significant differences in the dose distribution of the planning target volume (PTV) and the bladder.

Conclusion

Prone positioning can significantly reduce dose to the SB in IMRT for rectal cancer and therefore should not only be used in 3D conformal radiotherapy but also in IMRT of rectal cancer. Further protection of the SB can be achieved by additional dose constraints in inverse planning without jeopardizing the homogeneity of the PTV.

Zusammenfassung

Hintergrund

Diese Planungsstudie analysiert die Dosisverteilung im Zielvolumen und in den Risikoorganen („organs at risk“, OAR) bei der intensitätsmodulierten Strahlentherapie („intensity-modulated radiotherapy“, IMRT) des Rektumkarzinoms und vergleicht hierbei Bauch- und Rückenlagerung sowie die Effekte der Dosisoptimierung für den Dünndarm (DD) durch zusätzliche Dosiseinschränkungen bei der inversen Planung.

Material und Methode

Anhand der Computertomographien (CT) zur Bestrahlungsplanung von 10 männlichen Patienten in Bauch- und in Rückenlage wurden für jeden einzelnen Patienten jeweils 4 verschiedene IMRT-Pläne erstellt. Als OAR wurden DD, Blase sowie die Femurköpfe definiert. In der Hälfte der Fälle wurden in der inversen Planung 2 zusätzliche Optimierungsbedingungen für den DD verwendet.

Ergebnisse

In Bauchlagerung zeigte sich für den DD eine statistisch signifikante Dosisreduktion bis zu 41 % im mittleren und hohen Dosisbereich, verglichen mit der Rückenlagerung. Die Femurköpfe wiesen darüber hinaus in Bauchlagerung eine signifikante Dosisreduktion im Niedrigdosisbereich auf. Durch die zusätzlichen Optimierungsbedingungen bei der inversen Planung wurde für den DD eine weitere signifikante Dosisreduktion im Hochdosisbereich von bis zu 14 % erreicht. Die Dosisverteilung im Planungszielvolumen (PTV, „planning target volume“) und in der Blase wies keine signifikanten Unterschiede auf.

Schlussfolgerung

Die Bauchlagerung ermöglicht eine signifikante Dosisreduktion im DD bei der IMRT des Rektumkarzinoms und sollte daher nicht nur bei der 3D-konformalen Strahlentherapie, sondern auch bei der IMRT des Rektumkarzinoms eingesetzt werden. Eine weitere Reduktion der Dünndarmbelastung kann, ohne Gefährdung der Homogenität im PTV, durch zusätzliche Dosiseinschränkungen bei der inversen Planung erreicht werden.

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Acknowledgements

The authors thank Dr. Negin Sedaghat (Westmead and Nepean Hospitals, University of Sydney, Teaching Hospitals, Australia) for revising the manuscript.

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Authors and Affiliations

  1. Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1–3, 68135, Mannheim, Germany

    Julia Koeck M.D., Katharina Kromer, Kerstin Siebenlist, Sabine Mai M.D., Jens Fleckenstein Ph.D. & Frederik Wenz M.D.

  2. Unita Operativa di Radioterapia, Dipartimento di Oncologia, Az. Ospedaliero-Universitaria di Modena, Modena, Italy

    Frank Lohr M.D.

  3. Department of Internal Medicine, GRN Clinic Weinheim, Weinheim, Germany

    Tobias Baack M.D.

  4. Department of Biomathematics and Medical Statistics, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany

    Sylvia Büttner

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  1. Julia Koeck M.D.
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  2. Katharina Kromer
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Correspondence to Julia Koeck M.D..

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Conflict of interest

J. Koeck, K. Kromer, T. Baack, K. Siebenlist, S. Büttner, and F. Wenz declare that they have no competing interests. F. Lohr has travel grants, research support, and teaching honoraria from Elekta AB (Stockholm, Sweden) and IBA (Schwarzenbruck, Germany) as well as board membership from C‑Rad (Uppsala, Sweden) to declare. S. Mai has travel costs from Elekta AB (Stockholm, Sweden) to declare. J. Fleckenstein has teaching honoraria and travel costs from Elekta AB (Stockholm, Sweden) to declare.

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J. Koeck and K. Kromer contributed equally to the manuscript.

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Koeck, J., Kromer, K., Lohr, F. et al. Small bowel protection in IMRT for rectal cancer. Strahlenther Onkol 193, 578–588 (2017). https://doi.org/10.1007/s00066-017-1107-z

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