Elsevier

Radiotherapy and Oncology

Volume 93, Issue 2, November 2009, Pages 153-167
Radiotherapy and Oncology

Systematic review
Dose–volume effects for normal tissues in external radiotherapy: Pelvis

https://doi.org/10.1016/j.radonc.2009.08.004Get rights and content

Abstract

A great deal of quantitative information regarding the dose–volume relationships of pelvic organs at risk has been collected and analysed over the last 10 years. The need to improve our knowledge in the modelling of late and acute toxicity has become increasingly important, due to the rapidly increasing use of inverse-planned intensity-modulated radiotherapy (IMRT) and the consequent need of a quantitative assessment of dose–volume or biological-based cost functions. This comprehensive review concerns most organs at risk involved in planning optimisation for prostate and other types of pelvic cancer. The rectum is the most investigated organ: the largest studies on dose–volume modelling of rectal toxicity show quite consistent results, suggesting that sufficiently reliable dose–volume/EUD-based constraints can be safely applied in most clinical situations. Quantitative data on bladder, bowel, sexual organs and pelvic bone marrow are more lacking but are rapidly emerging; however, for these organs, further investigation on large groups of patients is necessary.

Section snippets

Late bleeding: dose–volume relationships

Due to both the large number of patients with prostate cancer and the impact of rectal bleeding on the quality of life of long-surviving patients, rectal bleeding has been extensively investigated and reported in the recent literature. Fortunately, there is quite good consistency among the various studies dealing with this topic. A number of reasons may be cited to explain this success: the large data-sets available from several prospective trials; the relative simplicity/consistency along with

Dose–volume effects

Clinical experience suggests the evidence of a dose effect for whole bladder irradiation; Emami et al.[111] estimated a tolerance dose of 65 Gy in order to maintain severe urinary toxicity below 5% and of 80 Gy to keep bladder injury probability below 50%.

In their review, Marks et al.[112] found that the majority of the bladder can be irradiated to approximately 30–50 Gy, and that global injury is infrequent if the maximum bladder dose is <60–65 Gy. If small volumes of the bladder receive 60–65 Gy,

Acute bowel toxicity: dose–volume relationships

It is common knowledge for any radiation oncologist that for a number of malignancies (gynecological, rectum and prostate) the irradiation of large volumes of the bowel to doses around 45–50 Gy (1.8–2 Gy/fr) during whole pelvis irradiation (WPRT) with two- to four-field techniques is associated with moderate/severe acute GI toxicity (primarily diarrhoea) in a significant fraction of patients, and furthermore that the probability and the severity of these effects increase with the field width [121]

Erectile dysfunction: dose–volume relationships

Due to the growing proportion of potent patients before radiotherapy of prostate cancer and the widespread availability of anti-impotence drugs, the exclusion of structures potentially involved in penile erection (bulb of the penis, neurovascular bundles, crura, corpora cavernosa) from the irradiated volume is a very sensitive and controversial topic. Recently, some studies have reported a correlation between the dose received by penile structures (mostly the penile bulb) and sexual function

Femoral heads and pelvic bones

A possible, but uncommon, late side effect of radiotherapy to the pelvic area is damage to the pelvic bones: fine, hair-line cracks known as pelvic insufficiency fractures may occur. Sacral insufficiency fractures, fractures of the pubic rami and femoral neck may complicate pelvic radiation therapy. Less common effects of pelvic irradiation include acetabular protrusion and avascular necrosis of the femoral head.

Femoral head dose constraints are not well established. The early work of Emami et

Hematological toxicity

Pelvic bones contribute significantly to the production of blood components: around 50% of the bone marrow of an adult man is distributed in the pelvic region [185]. The irradiation of the pelvic nodes with large fields is known to have an impact on the white blood cell count as well as other hematological parameters such as hemoglobin and platelet count, especially in combined chemo-radiation treatments (as for gynecological and anal cancer); field dimension, dose and age have been found to be

Final remarks: predictive tools for radiation toxicity?

The prediction of radio-induced toxicity is a very complex task: late radiation injury is related to both dosimetric factors and clinical risk factors, as well as, at least in part, the patient’s genetic make-up. Interestingly, very limited attention has been devoted to the development of clinical instruments for predicting EBRT side effects; nevertheless, a reliable prediction of potential toxicities could help clinicians in optimising treatment planning, and patients in choosing responsibly

Acknowledgements

Fondazione Mozino is gratefully acknowledged for its support to the Prostate Program of the Istituto Nazionale Tumori. We would like to express our gratitude to T. Magnani for her kind assistance.

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