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Absolute Clinical Radiation Oncology Review pp 1–28Cite as

General Principles of Radiation Oncology

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Abstract

This chapter discusses the general management and thought process used by radiation oncologists. Several broad and basic principles of radiation oncology are discussed.

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Author information

Authors and Affiliations

  1. Penn State Cancer Institute, Hershey, PA, USA

    Nicholas G. Zaorsky

  2. Mayo Clinic, Jacksonville, FL, USA

    Daniel M. Trifiletti

  3. University of Chicago, Chicago, IL, USA

    Daniel W. Golden

Authors
  1. Nicholas G. Zaorsky
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  2. Daniel M. Trifiletti
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  3. Daniel W. Golden
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Corresponding author

Correspondence to Nicholas G. Zaorsky .

Editor information

Editors and Affiliations

  1. Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA

    Daniel M. Trifiletti

  2. Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA

    Nicholas G. Zaorsky

Dose Constraints

Dose Constraints

  • Daniel M. Trifiletti,
  • Nicholas G. Zaorsky &
  • Daniel W. Golden 

  1. Mayo Clinic, Jacksonville, FL, USA

    Daniel M. Trifiletti

  2. Penn State Cancer Institute, Hershey, PA, USA

    Nicholas G. Zaorsky

  3. University of Chicago, Chicago, IL, USA

    Daniel W. Golden

QUANTEC Dose Constraints

Critical structure

Volume

Dose/volume

Max dose

Toxicity rate

Toxicity endpoint

Brain

  

<60 Gy

<3%

Symptomatic necrosis

Brain

  

72 Gy

5%

Symptomatic necrosis

Brain

  

90 Gy

10%

Symptomatic necrosis

Brain stem

  

<54 Gy

<5%

Neuropathy or necrosis

Brain stem

D1–10 cc

<= 59 Gy

 

<5%

Neuropathy or necrosis

Brain stem

  

<64 Gy

<5%

Neuropathy or necrosis

Optic nerve/chiasm

  

<55 Gy

<3%

Optic neuropathy

Optic nerve/chiasm

  

55–60 Gy

3–7%

Optic neuropathy

Optic nerve/chiasm

  

>60 Gy

>7–20%

Optic neuropathy

Spinal cord

  

50 Gy

0.2%

Myelopathy

Spinal cord

  

60 Gy

6%

Myelopathy

Spinal cord

  

69 Gy

50%

Myelopathy

Cochlea

Mean

<=45 Gy

 

<30%

Sensory-neural hearing loss

Parotid, bilateral

Mean

<=25 Gy

 

<20%

Long-term salivary function <25%

Parotid, bilateral

Mean

<=39 Gy

 

<50%

Long-term salivary function <25%

Parotid, unilateral

Mean

<=20 Gy

 

<20%

Long-term salivary function <25%

Pharyngeal constrictors

Mean

<=50 Gy

 

<20%

Symptomatic dysphagia and aspiration

Larynx

  

<66 Gy

<20%

Vocal dysfunction

Larynx

Mean

<50 Gy

 

<30%

Aspiration

Larynx

Mean

<44 Gy

 

<20%

Edema

Larynx

V50

<27%

 

<20%

Edema

Lung

V20

<=30%

 

<20%

Symptomatic pneumonitis

Lung

Mean

7 Gy

 

5%

Symptomatic pneumonitis

Lung

Mean

13 Gy

 

10%

Symptomatic pneumonitis

Lung

Mean

20 Gy

 

20%

Symptomatic pneumonitis

Lung

Mean

24 Gy

 

30%

Symptomatic pneumonitis

Lung

Mean

27 Gy

 

40%

Symptomatic pneumonitis

Esophagus

Mean

<34 Gy

 

5–20%

Grade 3+ esophagitis

Esophagus

V35

<50%

 

<30%

Grade 2+ esophagitis

Esophagus

V50

<40%

 

<30%

Grade 2+ esophagitis

Esophagus

V70

<20%

 

<30%

Grade 2+ esophagitis

Heart (Pericardium)

Mean

<26 Gy

 

<15%

Pericarditis

Heart (Pericardium)

V30

<46%

 

<15%

Pericarditis

Heart

V25

<10%

 

<1%

Long-term cardiac mortality

Liver

Mean

<30–32 Gy

 

<5%

RILD (in normal liver function)

Liver

Mean

<42 Gy

 

<50%

RILD (in normal liver function)

Liver

Mean

<28 Gy

 

<5%

RILD (in Child-Pugh A or HCC)

Liver

Mean

<36 Gy

 

<50%

RILD (in Child-Pugh A or HCC)

Kidney, bilateral

Mean

<15–18 Gy

 

<5%

Clinical dysfunction

Kidney, bilateral

Mean

<28 Gy

 

<50%

Clinical dysfunction

Kidney, bilateral

V12

<55%

 

<5%

Clinical dysfunction

Kidney, bilateral

V20

<32%

 

<5%

Clinical dysfunction

Kidney, bilateral

V23

<30%

 

<5%

Clinical dysfunction

Kidney, bilateral

V28

<20%

 

<5%

Clinical dysfunction

Stomach

D100

<45 Gy

 

<7%

Ulceration

Small bowel (individual loops)

V15

<120 cc

 

<10%

Grade 3+ toxicity

Small bowel (peritoneal cavity)

V45

<195 cc

 

<10%

Grade 3+ toxicity

Rectum

V50

<50%

 

<10%

Grade 3+ toxicity

Rectum

V60

<35%

 

<10%

Grade 3+ toxicity

Rectum

V65

<25%

 

<10%

Grade 3+ toxicity

Rectum

V70

<20%

 

<10%

Grade 3+ toxicity

Rectum

V75

<15%

 

<10%

Grade 3+ toxicity

Bladder (bladder cancer)

  

<65

<6%

Grade 3+ toxicity

Bladder (prostate cancer)

V65

<50%

  

Grade 3+ toxicity

Bladder (prostate cancer)

V70

<35%

  

Grade 3+ toxicity

Bladder (prostate cancer)

V75

<25%

  

Grade 3+ toxicity

Bladder (prostate cancer)

V80

<15%

  

Grade 3+ toxicity

Penile bulb

Mean dose to 95% gland

<50 Gy

 

<35%

Severe erectile dysfunction

Penile bulb

D90

<50 Gy

 

<35%

Severe erectile dysfunction

Penile bulb

D60–70

<70 Gy

 

<55%

Severe erectile dysfunction

Site

Organ at risk

Dose constraint 1

Dose constraint 2

Dose constraint 3

Notes

Pediatrics

Long bone

V40 < 64%

Mean < 37 Gy

Max 59 Gy

 

Pediatrics

Kidney

V10 < 80%

   

Pediatrics

Flat bone

Minimize V35

   

Pediatrics

VB

V18 all or none

  

18 Gy over entirety if receiving any RT; this will prevent scoliosis

Pediatrics

Skin/lymphedema

   

Keep longitudinal 2–3 cm strip of extremity to <15 Gy

Pediatrics

Soft tissue (to prevent RT-induced sarcoma)

V60

   

CNS

Cauda equina

0.03 cc < 16 Gy

5 cc < 14 Gy

  

CNS (SRS)

Brain stem

0.5 cc < 10 Gy

   

CNS (SRS)

Optic nerves/Chiasm

0.2 cc < 8 Gy

   

CNS (SRS)

Spinal cord

0.35 cc < 10 Gy

Max 18 Gy / 3 fx (RTOG 0236, 0618)

 

Kilpatrick (2010) [1]

H&N

Mandible

0.1 cc < 70 Gy

   

H&N

Temporal Lobe

0.03 cc < 68 Gy

1 cc < 58 Gy

  

H&N/Lung

Brachial Plexus

0.1 cc < 66 Gy

   

H&N

Brainstem

0.1 cc < 55 Gy

   

H&N

Optic Nerves/Chiasm

0.1 cc < 55 Gy

   

H&N

Spinal cord (+ 3 mm)

0.1 cc < 50 Gy

  

PRV

H&N

Uninvolved constrictor

Mean < 45 Gy

   

H&N

Contralateral SMG

Mean < 39 Gy

   

H&N

GSL

Mean < 35 Gy

   

H&N

Cochlea [2]

Mean < 35 Gy

<12–14 Gy/1 fx

 

For mean < 45 Gy, risk of hearing loss <30%.

H&N

Oral cavity

Mean < 30–40 Gy

   

H&N

Lacrimal gland

Mean < 34 Gy

   

H&N

Combination parotid [3]

Mean < 25 Gy

   

H&N

Contralateral parotid

Mean < 20 Gy

   

GI

Small bowel/Stomach

1 cc < 60 Gy

V50 < 2%

  

GI

Duodenum

2 cc < 55 Gy

   

GI

Liver

V30 < 60%

Mean < 25 Gy

  

GI (SBRT)

Liver

700 cc < 21 Gy

   

GI (SBRT)

Duodenum

V15 < 9cc/1 fx

V20 < 3cc/1 fx

Dmax <23 Gy

  

Murphy (2010) [4]

GI

Kidney [3]

    

GI

Kidney

V18 < 66%

   

GI

Bladder

V40 < 35%

  

Same as prostate

GI

Femoral heads

1 cc < 45 Gy

V40 < 35%

  

GI

Heart

V40 < 100%

V50 < 33%

  

GI

Lung

V5 < 50%

V20 < 20%

Mean < 12 Gy

 

Thoracic

Lung (−PTV)

V5 < 60%

V20 < 30%

Mean < 18 Gy

Lung V5 not associated with toxicity per secondary analysis of RTOG 0617 [5]

Thoracic

Lung [3]

   

<20% risk of pneumonitis

Thoracic

Contra lung after EPP [6]

V20 < 7%

  

Rice (2007) [6]

Thoracic

Heart

V45 < 2/3

V50 < 25%

V60 < 30%

RTOG 0617

Thoracic

Heart

V30 < 50%

V45 < 35%

 

RTOG 1308

Thoracic

Heart

    

Thoracic

Esophagus

V60 < 30%

Mean < 34 Gy

  

Thoracic

Spinal cord

0.1 cc < 45 Gy

  

Max dose 54 Gy has <1% RT myelopathy per QUANTEC

Breast

Heart

V30 < 1%

Mean < 4 Gy

 

NSABP B51

Breast

Lung

V20 < 15%

   

Breast

Breast

0.03 cc < 115%

  

NSABP B51

GU

Bladder

V40 < 50%

V65 < 25%

  

GU

Femoral heads

V50 < 10%

   

GU

Rectum

V40 < 35%

V65 < 17%

  

GU

Rectum

V50 < 3cc (50 Gy SBRT)

V24 < 35% of rectal wall circumference

 

Kim (2014). Using 45–50 Gy/5 fractions for prostate cancer [7]

GU

Penile bulb

    

GU

Kidney

    

GU (HDR)

Bladder

V75 < 1 cc

   

GU (HDR)

Rectum

V100 < 1 cc

   

GU (HDR)

Urethra

V125 < 1 cc

V150 = 0 cc

  

GYN

Rectum

V40 < 60%

  

RTOG 0724 (postop cervix)

GYN

Rectum

V40 < 80%

  

RTOG 1203 (cervix + endometrial)

GYN

Bowel space (SB, colon, sigmoid)

V40 < 30%

  

RTOG 0724, RTOG 1203

GYN

Bladder

V45 < 35%

  

RTOG 0724, RTOG 1203

GYN

Bone marrow

V10 < 90%

V40 < 37%

 

RTOG 1203

GYN

Bladder pt

<75 Gy, <80% of dose,

D2cc < 90 Gy

  

GYN

Rectal pt

<70 Gy, <70% of dose

D2cc < 75 Gy

  

GYN

Sigmoid

 

D2cc <75 Gy

  

GYN

Small bowel

D2cc < 60 Gy

V55 < 15 cc

 

Verma (2014) [8]

Gyn (HDR)

Rectum/Sigmoid

2cc < 75 Gy

  

D2cc = the minimum dose to the maximally irradiated 2cc

Gyn (HDR)

Bladder

2cc < 90 Gy

   

Gyn (HDR)

Upper vagina

Point <120 Gy

   

Gyn (HDR)

Lower vagina

Point <90 Gy

   
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Zaorsky, N.G., Trifiletti, D.M., Golden, D.W. (2019). General Principles of Radiation Oncology. In: Trifiletti, D., Zaorsky, N. (eds) Absolute Clinical Radiation Oncology Review. Springer, Cham. https://doi.org/10.1007/978-3-319-96809-4_1

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