International Journal of Clinical Oncology

, Volume 12, Issue 6, pp 408–415 | Cite as

Current status of intensity-modulated radiation therapy (IMRT)

  • Kazuo HatanoEmail author
  • Hitoshi Araki
  • Mitsuhiro Sakai
  • Takashi Kodama
  • Naoki Tohyama
  • Tohru Kawachi
  • Masaharu Imazeki
  • Takayuki Shimizu
  • Tsutomu Iwase
  • Minoru Shinozuka
  • Hideyo Ishigaki


External-beam radiation therapy has been one of the treatment options for prostate cancer. The dose response has been observed for a dose range of 64.8–81 Gy. The problem of external-beam RT for prostate cancer is that as the dose increases, adverse effects also increase. Three-dimensional conformal radiation therapy (3D-CRT) has enabled us to treat patients with up to 72–76 Gy to the prostate, with a relatively acceptable risk of late rectal bleeding. Recently, intensity-modulated radiation therapy (IMRT) has been shown to deliver a higher dose to the target with acceptable low rates of rectal and bladder complications. The most important things to keep in mind when using an IMRT technique are that there is a significant trade-off between coverage of the target, avoidance of adjacent critical structures, and the inhomogeneity of the dose within the target. Lastly, even with IMRT, it should be kept in mind that a “perfect” plan that creates completely homogeneous coverage of the target volume and zero or small dose to the adjacent organs at risk is not always obtained. Participating in many treatment planning sessions and arranging the beams and beam weights create the best approach to the best IMRT plan.

Key words

Three-dimensional conformal radiation therapy (3D-CRT) Intensity-modulated radiation therapy (IMRT) Prostate cancer 


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  1. 1.
    IMRT CWG2001Intensity-Modulated radiotherapy. Current status and issues of interestInt J Radiat Oncol Biol Phys51880914CrossRefGoogle Scholar
  2. 2.
    Brahme, A 1988Optimization of stationary and moving beam radiation therapy techniquesRadiother Oncol12129140PubMedCrossRefGoogle Scholar
  3. 3.
    Kitamura, Y, Shirato, H, Sepenwoolde, Y,  et al. 2002Three-dimensional intrafractional movement of prostate cancer measured during real-time tumor tracking radiotherapy in supine and prone treatment positionsInt J Radiat Oncol Biol Phys5311171123PubMedCrossRefGoogle Scholar
  4. 4.
    Bayley, AJ, Catton, CN, Haycocks, T,  et al. 2004A randomized trial of supine vs prone positioning in patients undergoing escalated dose conformal radiotherapy for prostate cancerRadiother Oncol703744PubMedCrossRefGoogle Scholar
  5. 5.
    Crook, JM, Raymond, Y, Salhani, D,  et al. 1995Prostate motion during standard radiotherapy as assessed by fiducial markersRadiother Oncol373542PubMedCrossRefGoogle Scholar
  6. 6.
    Rudat, V, Schraube, P, Oetzel, D,  et al. 1996Combined error of patient positioning variability and prostate motion uncertainty in 3D conformal radiotherapy of localized prostate cancerInt J Radiat Oncol Biol Phys3510271034PubMedCrossRefGoogle Scholar
  7. 7.
    Zelefsky, MJ, Crean, D, Mageras, GS,  et al. 1999Quantification and predictors of prostate position variability in 50 patients evaluated with multiple CT scans during conformal radiotherapyRadiother Oncol50225234PubMedCrossRefGoogle Scholar
  8. 8.
    Vigneault, E, Pouliot, J, Laverdiere, J,  et al. 1997Electronic portal imaging device detection of radioopaque markers for the evaluation of prostate position during megavoltage irradiation: a clinical studyInt J Radiat Oncol Biol Phys37205212PubMedCrossRefGoogle Scholar
  9. 9.
    Teh, BS, Mcgary, JE, Dong, L,  et al. 2002The use of rectal balloon during the delivery of intensity modulated radiotherapy (IMRT) for prostate cancer: more than just a prostate gland immobilization device?Cancer J8476483PubMedCrossRefGoogle Scholar
  10. 10.
    Ciernik, IF, Baumert, BG, Egli, P,  et al. 2002On-line correction of beam portals in the treatment of prostate cancer using an endorectal balloon deviceRadiother Oncol653945PubMedCrossRefGoogle Scholar
  11. 11.
    van Lin, EN, Van der Vight, LP, Witjes, JA,  et al. 2005The effect of an endorectal balloon and off-line correction on the interfraction systematic and random prostate position variations: a comparative studyInt J Radiat Oncol Biol Phys61278288PubMedCrossRefGoogle Scholar
  12. 12.
    Shimizu, S, Shirato, H, Mitamura, K,  et al. 2000Use of an implanted marker and real-time tracking of the marker for the positioning of prostate and bladder cancersInt J Radiat Oncol Biol Phys4815911597PubMedCrossRefGoogle Scholar
  13. 13.
    Serago, CF, Chungbin, SJ, Buskirk, SJ,  et al. 2002Initial experience with ultrasound localizaion for positioning prostate cancer patients for external beam radiotherapyInt J Radiat Oncol Biol Phys5311301138PubMedCrossRefGoogle Scholar
  14. 14.
    Kupelian, P, Willoughby, T, Mahadevan, A,  et al. 2007Multi-institutional clinical experience with the Calypso System in localization and continuous, real-time monitoring of the prostate gland during external radiotherapyInt J Radiat Oncol Biol Phys6710881098PubMedGoogle Scholar
  15. 15.
    Partin, AW, Mangold, LA, Lamm, DM,  et al. 2001Contemporary update of prostate cancer staging nomograms (Partin Tables) for the new millenniumUrology58843848PubMedCrossRefGoogle Scholar
  16. 16.
    D'Amico, AV, Renshaw, AA, Cote, K,  et al. 2004Impact of the percentage of positive prostate cores on prostate cancer specific mortality for patients with low or favorable intermediate-risk diseaseJ Clin Oncol2237263732PubMedCrossRefGoogle Scholar
  17. 17.
    Lieberfarb, ME, Schultz, D, Whittington, R,  et al. 2002Using PSA, biopsy Gleason score, clinical stage, and the percentage of positvie biopsies to identify optimal candidates for prostate-only radiation therapyInt J Radiat Oncol Biol Phys53898903PubMedCrossRefGoogle Scholar
  18. 18.
    Kestin, L, Goldstein, N, Vicini, F,  et al. 2002Treatment of prostate cancer with radiotherapy: should the entire seminal vesicles be included in the clinical target volume?Int J Radiat Oncol Biol Phys54686697PubMedCrossRefGoogle Scholar
  19. 19.
    Teh, BS, Bastasch, MD, Wheeler, TM,  et al. 2003IMRT for prostate cancer: defining target volume based on correlated pathologic volume of diseaseInt J Radiat Oncol Biol Phys56184191PubMedCrossRefGoogle Scholar
  20. 20.
    Beard, CJ, Chen, MH, Cote, K,  et al. 2004Perineural invasion is associated with increased relapse after external beam radiotherapy for men with low-risk prostate cancer and may be a marker for occult, high-grade cancerInt J Radiat Oncol Biol Phys581924PubMedCrossRefGoogle Scholar
  21. 21.
    Roach, M,III, DeSilvio, M, Lawton, C,  et al. 2003Phase III trial comparing whole-pelvic versus prostate-only radiotherapy and neoadjuvant versus adjuvant combined androgen suppression: Radiation Therapy Oncology Group 9413J Clin Oncol2119041911PubMedCrossRefGoogle Scholar
  22. 22.
    Pirzkall, A, Carol, MP, Pickett, B,  et al. 2002The effect of beam energy and number of fields on photon-based IMRT for deep-seated targetsInt J Radiat Oncol Biol Phys53434442PubMedCrossRefGoogle Scholar
  23. 23.
    Pollack, A, Zagars, GK, Starkshcall, G,  et al. 2002Prostate cancer radiation dose response: results of the M. D. Anderson phase III randomized trialInt J Radiat Oncol Biol Phys5310971105PubMedCrossRefGoogle Scholar
  24. 24.
    Shipley, WU, Verhey, LJ, Munzenrider, JE,  et al. 1995Advanced prostate cancer: the results of a randomized comparative trial of high dose irradiation boosting with conformal protons compared with conventional irradiation using photons aloneInt J Radiat Oncol Biol Phys32312PubMedCrossRefGoogle Scholar
  25. 25.
    Lee, WR, Hanks, GE, Hanlon, AL,  et al. 1996Lateral rectal shielding reduces late morbidity following high-dose three-dimensional conformal radiation therapy for clinically localized prostate cancer: further evidence for a significant dose effectInt J Radiat Oncol Biol Phys35251257PubMedCrossRefGoogle Scholar
  26. 26.
    Zelefsky, MJ, Cowen, D, Fuks, Z,  et al. 1999Long-term tolerance of high dose three-dimensional conformal radiotherapy in patients with localized prostate carcinomaCancer8524602468PubMedCrossRefGoogle Scholar
  27. 27.
    Kupelian, PA, Reddy, CA, Carlson, TP,  et al. 2002Preliminary observations on biochemical relapse-free survival rates after short-course intensity-modulated radiotherapy (70 Gy at 2.5 Gy/fraction) for localized prostate cancerInt J Radiat Oncol Biol Phys53904912PubMedCrossRefGoogle Scholar
  28. 28.
    Fiorino, C, Sanguineti, G, Cozzarini, C,  et al. 2003Rectal dose-volume constraints in high-dose radiotherapy of localized prostate cancerInt J Radiat Oncol Biol Phys57953962PubMedCrossRefGoogle Scholar
  29. 29.
    Boersma, LJ, van den Brink, M, Bruce, AM,  et al. 1998Estimation of the incidence of late bladder and rectum complicaitons after high-dose (70–78 GY) conformal radiotherapy for prostate cancer, using dose-volume histogramsInt J Radiat Oncol Biol Phys418392PubMedCrossRefGoogle Scholar
  30. 30.
    Zelefsky, MJ, Fuks, Z, Chan, H,  et al. 2003Ten-year results of dose escalation with three-dimensional conformal radiotherapy for patients with clinically localized prostate cancerInt J Radiat Oncol Biol Phys57S149150Google Scholar
  31. 31.
    Peeters, STH, Heemsbergen, WD, Koper, PCM,  et al. 2006Dose-Response in radiotherapy for localized prostate cancer: results of the Dutch multicenter randomized phase III trial comparing 68 Gy of radiotherapy with 78 GyJ Clin Oncol2419901996PubMedCrossRefGoogle Scholar
  32. 32.
    Zelefsky, MJ, Fuks, Z, Hunt, M,  et al. 2002High-dose intensity modulated radiation therapy for prostate cancer: early toxicity and biochemical outcomes in 772 patientsInt J Radiat Oncol Biol Phys5311111116PubMedCrossRefGoogle Scholar
  33. 33.
    Zelefsky, MJ, Chan, H, Hunt, M,  et al. 2006Long-term outcome of high dose intensity modulated radiation therapy for patients with clinically localized prostate cancerJ Urol17614151419PubMedCrossRefGoogle Scholar
  34. 34.
    De Meerleer, GO, Fonteyne, VH, Vakaet, L,  et al. 2007Intensity modulated radiation therapy for prostate cancer: late morbidity and results on biochemical controlRadiother Oncol82160166PubMedCrossRefGoogle Scholar
  35. 35.
    van der Kogel, AJ, Jarrett, KA, Paciotti, MA,  et al. 1988Radiation tolerance of the rat rectum to fractionated X-rays and pi-mesonsRadiother Oncol12225232PubMedCrossRefGoogle Scholar
  36. 36.
    Deore, SM, Shrivastava, SK, Supe, SJ,  et al. 1993Alpha/beta value and importance of dose per fraction for the late rectal and recto-sigmoid complicationsStrahlenther Onkol169521526PubMedGoogle Scholar
  37. 37.
    Gasinska, A, Dubray, B, Hill, SA,  et al. 1993Early and late injuries in mouse rectum after fractionated X-rays and neutron irradiationRadiother Oncol26244253PubMedCrossRefGoogle Scholar
  38. 38.
    Brenner, DJ 2004Fractionation and late rectal toxicityInt J Radiat Oncol Biol Phys6010131015PubMedCrossRefGoogle Scholar
  39. 39.
    Pollack, A, Hanlon, AL, Horwitz, EM,  et al. 2006Dosimetry and preliminary acute toxicity in the first 100 men treated for prostate cancer on a randomized hypofractionated dose escalation trialInt J Radiat Oncol Biol Phys64518526PubMedCrossRefGoogle Scholar
  40. 40.
    Kupelian, PA, Thakkar, VV, Khuntia, D,  et al. 2005Hypofractionated intensity-modulated radiotherapy (70 Gy at 2.5 Gy per fraction) for localized prostate cancer: long-term outcomesInt J Radiat Oncol Biol Phys6314631468PubMedCrossRefGoogle Scholar
  41. 41.
    Kitamura, Y, Shirato, H, Shinohara, N,  et al. 2003Reduction in acute morbidity using hypofractionated intensity-modulated radiation therapy assisted with a fluoroscopic real-time tumor-tracking system for prostate cancer: preliminary results of a phase I/II studyCancer J9268276PubMedGoogle Scholar
  42. 42.
    Kry, SF, Salehpour, M, Followill, DS,  et al. 2005The calculated risk of fatal secondary malignancies from intensity-modulated radiation therapyInt J Radiat Oncol Biol Phys6211951203PubMedCrossRefGoogle Scholar
  43. 43.
    Hall, EJ, Phil, D 2006Intensity-modulated radiation therapy, protons, and the risk of second cancersInt J Radiat Oncol Biol Phys6517PubMedCrossRefGoogle Scholar
  44. 44.
    van Lin, EN, Futterer, JJ, Heijmink, SW,  et al. 2006IMRT boost dose planning on dominant intraprostatic lesions: gold marker-based three-dimensional fusion of CT with dynamic contrast enhanced and 1H-spectroscopic MRIInt J Radiat Oncol Biol Phys65291303PubMedCrossRefGoogle Scholar

Copyright information

© The Japan Society of Clinical Oncology 2007

Authors and Affiliations

  • Kazuo Hatano
    • 1
    Email author
  • Hitoshi Araki
    • 1
  • Mitsuhiro Sakai
    • 1
  • Takashi Kodama
    • 1
  • Naoki Tohyama
    • 1
  • Tohru Kawachi
    • 1
  • Masaharu Imazeki
    • 1
  • Takayuki Shimizu
    • 1
  • Tsutomu Iwase
    • 1
  • Minoru Shinozuka
    • 1
  • Hideyo Ishigaki
    • 1
  1. 1.Division of Radiation OncologyChiba Cancer CenterChibaJapan

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