Lisa Spanovich

Comparative Article Analysis Part I: Trade Magazine

There are many differences when viewing a trade journal versus a peer reviewed journal.
The most noticeable of these differences is how visually busy the trade journals looked. Along
the outer edges of the online publication called Radiology Today, there were many
advertisements, click bait, and even Twitter feed. Most of the titles of articles in Radiology
Today seemed to be purposefully written to lure a reader in, as opposed to just stating the facts.
Conversely, when someone publishes a professional article, it is not necessary to add the extra
visual clutter or attention grabbing headlines. Trade publications are typically offered for free
because they are paid for by their advertisers; peer reviewed journals offer no such payments or
honorariums for publishing.1 For this analysis, I decided to take a closer look at a journal article
called Real-Time Radiotherapy, found in the online website of Radiology Today magazine by
Beth W. Orenstein. This article grabbed my attention because I wanted to know more about ways
that radiation therapy treatments can be optimized. This analysis will include a brief description
of the article, along with its strengths and weaknesses.
This article gave a good insight into radiation therapy and the difficulty of seeing
different tissue densities during patients daily pre-treatment imaging. One of the newest
radiation treatment machines that is being developed is an MRI unit combined with a linear
accelerator (MR-Linac). Because MRI is excellent for viewing contrasts in tissues densities, it
can accurately show the progression of the tumor throughout the patients treatment course. The
article explains concepts in regards to this machine, such as the better dose control with this new
technology and also the patient specific response to treatment.2 This means that if the patients
tumor is responding well, the doctor could decide to limit the amount of radiation that he/she
originally planned on giving. This is also helpful for the other end of the spectrum, when a
patients tumor is not shrinking from the treatments, and more radiation should be administered.
This type of technology also revolutionizes the way treatment planning is conducted. The
machine enables patients treatments to be designed on the fly,2 which is not something that is
the norm at most facilities, but it ultimately gives the patient a more specialized treatment. One
of the last things that was discussed in this article was the expense of this new technology versus
the benefits. The MR-Linac is very expensive compared to traditional linear accelerators. And
because of the expense, it is unknown how widely available this variation of a linear accelerator
will be in the future.
I wanted to review this particular article because it relates to my current and future
professions. Even though this new machine may not end up in a center where I work, it is
important to be aware that this type of technology exists. A reason I chose this article for the
journal section of the analysis is the fact that even though the magazine is strictly radiology
based, it is very informative and can educate people who are not familiar with the technology.
The way the information was presented, most people, not in the radiology field, could get an
understanding about what the information entailed. It explained why developing this technology
would be beneficial to patients, how the machine works, what it would be used for, and how the
cost of the machine compares to other treatment machines.
The article gave a good insight as to the direction that new technology is going in, and
how it could change the way radiation therapy is given. I enjoyed reading this article because it
shows what is in the future of my profession. There are, and will probably always be, hurdles to
overcome and it was good to see that there are so many advancements being made that will
greatly help our patients. The article length was fairly short, so it kept the reader engaged. At the
conclusion of the article, it stated that the author was a freelance medical writer and regular
contributor to Radiology Today.2 Even though someone may be very knowledgeable in their
field, there is no proof of validation of the information presented. There were also specific quotes
from a doctor who gave his testimonial on how great it has been since his department has been
using this technology. The reader cannot use one testimonial to decide on the validity of a
product.

References

1. Lenards N. Weege M. Reading and Writing in Radiation Therapy and Medical Dosimetry.
La Crosse, WI: UW-L Medical Dosimetry and Radiation Therapy Program. 2016.
2. Orenstein B. Real-Time Radiotherapy. Radiology Today website.
http://www.radiologytoday.net/archive/rt0117p16.shtml. Accessed 1-30-17.

Comparative Article Analysis Part II: Peer-Reviewed Journal

The peer reviewed article that I chose for this analysis is from the Medical Dosimetry
publication, called Role of belly board device in the age of intensity modulated radiotherapy
for pelvic radiation. I chose this article because I was intrigued to see what the results of the
study would be when determining if the belly board is still a valuable setup device in
radiation oncology. One of the obvious reasons that I knew this is a research article is
because it was organized according to the recommended list of subsections for a research
article. Another reason, unlike the magazine journal, is it does not have pictures and
advertisements to grab your attention. This is strictly an informative paper. I mentioned
previously in the magazine journal analysis that mainstream individuals could potentially
pick up the magazine and comprehend it; but for a peer-reviewed journal, that is not the case.
Peer reviewed journals are very specific to a topic/study, and unless you are familiar with that
topic/study, the article may not be fully understood. In this section, an analysis will be given
to describe its research, and the strengths and weaknesses of the article.
This article brought up the issue of small bowel toxicity and how it is a limiting factor for
radiation treatment for pelvic malignancies (including the rectum, cervix, and prostate).1 A
small study was conducted with 11 patients with rectal cancer, and each patients treatment
was planned using 3D conformal and IMRT techniques, and they were also simulated supine
and prone (using a belly board device). The article made sure to explain that the supine scans
were obtained from the diagnostic scans, so that no additional radiation was given to scan the
patient in the supine position. The study was to ultimately decide whether or not belly boards
are still a necessary setup device when there is a more targeted type of radiation treatments
available (IMRT).
The study concluded that rectal treatment in the prone position yielded the best results
(lower bowel dose). Of both treatment positions, IMRT was able to spare more of the bowel.
After reading through this article, I was impressed by how intricate they conducted their
studies in regards to the different techniques. For example, they measured the
anterior/posterior and lateral separations of the patients to see how much of their tissue was
rearranged when the patient was in the supine versus prone positions. They included scans
that showed how the bowel was displaced when the patient was in the supine versus prone
treatment position. I was not surprised with the results of the study. Utilizing a belly board
device lets gravity to the work of helping to move healthy tissue out of the area to be treated.
Similarly, IMRT does the same; it limits the bowel dose, so it would only make sense that a
prone IMRT plan would yield the best results.
The sampling of 11 patients seemed to be a good amount for this study. Of the 11
patients, 2 were female. At first glance, 11 participates doesnt seem like a large enough
sample of people, but this study is to determine the best position for treatment, and even
though anatomy differs from person to person, it should be fairly consistent across the board.
Even though this study generated factual evidence, I do have to say that sometimes a
particular position may not be tolerated by the patient. In previous experiences with patients
who received IMRT treatments while in the prone position, they are less stable and have
more room for movement when lying on their stomachs. A treatment plan might look great
on the computer, but if the patient is unable to hold still during their IMRT treatment, the
patient is not receiving an accurate treatment.

References

1. Estabrook. Neil C. et al. Role of belly board device in the age of intensity modulated
radiotherapy for pelvic radiation. Medical Dosimetry, Volume 41, Issue 4, 300-304.
http://www.meddos.org/article/S0958-3947(16)30059-0/fulltext. Accessed 1-30-17.
modify the MRI in a special way so the electrons wouldn't be affected by its magnetic field. The
linear accelerator is mounted on a rotating gantry so that the treatment beam can pass directly
through the body of the MRI, enabling the patient to be imaged and treated simultaneously.
Another issue was stopping leaks that create noise and interfere with the MR images. To solve
this problem, ViewRay researchers took a cue from the military, which has learned how to hide
airplanes from radar, says Jim Dempsey, PhD, ViewRay's founder and chief scientific officer.
Stealth aircraft are coated in carbon, which absorbs microwaves. Copper reflects microwaves. In its
patented technology, "we use layers of copper and carbon shielding to meet up and absorb any
leaking radiofrequency interference," Dempsey says.
Personalized Therapy
The MRI-guided linear accelerator can be used to treat all types of cancer at almost all locations,
says Ben J. Slotman, MD, PhD, a professor and chairman of the department of radiation oncology
at Vrije University Medical Center in Amsterdam. "We have the MRIdian system in use for six
months now and have focused on patients with tumors in the pancreas, liver, adrenal gland,
kidney, prostate, rectum, lung, and breast. In all these cases, we use stereotactic or
hypofractionated treatment. However, if we have free time slots available, we also use it for some
other indications."
The MR-linear accelerator combination could solve several challenges that radiation oncologists
currently face. One of the huge challenges is not being able to predict when a healthy organ
exhibits severe toxicities from radiation, Christodouleas says. "One reason is that human beings
are different in the way they are sensitive to radiation," he says. Some patients are just more
sensitive than others. "Another reason is that we really don't know what dose normal tissues have
gotten over the course of treatment. We don't have good ways of tracking that." One of the major
benefits of having superior soft tissue imaging during treatment "is that it can help us target and
track the cumulative dose to both tumor and healthy tissues over the course of therapy," he says.
The combination system also allows radiation oncology to be tailored to the patient's tumor. "The
way most radiation treatment works is you create a plan in advance, and you deliver that exact
same plan without changing it," says Michael F. Bassetti, MD, PhD, a radiation oncologist at the
University of Wisconsin's Carbone Cancer Center in Madison, one of the first centers to treat with
ViewRay's low-field system, beginning in 2014.
"[The MR-linear accelerator] allows the potential to adjust the treatment as you go along based on
response. It really offers potential useful information about the patient's individual cancer biology
and the ability to personalize the treatment" vs one-size-fits-all treatments, he says. "With good
quality imaging on a daily basis, we can actually watch the response as it is happening during their
treatment course and make adjustments, if we want," Bassetti says.
In the future, MR-linear accelerator systems may allow oncologists to decide whether a patient
benefits from further treatment based on the in-treatment imaging response. "For example, some
patients may have such a good response that they may not need surgery, while poor responders
might need more aggressive surgery or chemotherapy as a follow-up," he says.
Better Dose Control
While the MR-linear accelerators can be used for most tumors, those using it find it is most helpful
for tumors in locations that can change from day to day because of movement of nearby organs.
Good examples are tumors of the lung, which can move with each breath, and
tumors of the abdomen that can be affected by how full the patient's bowel or
bladder are. Today, Slotman says, physicians are able to control around 90% of
early-stage lung cancers with stereotactic ablative radiotherapy. With the MRIdian
Linac, the radiation oncologists could push their success rate even higher because
they can see the lung tumor as it moves up and down with each breath. Knowing
where the tumor is during treatment means they can deliver the radiation only
when it is in the target field, he says.

The system is also ideal for treating tumors such as those found on the pancreas
that are close to critical sensitive structures, Bassetti says. The pancreas lies in very
close proximity to the small intestine, stomach, kidneys, and spinal cord. Many
patients' tumors are adjacent to organs, such as the intestine or stomach, that
cannot tolerate high doses of radiation, Bassetti says. "So the doses of radiation we
would like to deliver are limited by our ability to avoid that dose to critical or
adjacent organs. If we can see what we're doing, while we're doing it, we
understand what we're delivering to that organ."

The combination system also could lead to higher radiation dosing, if it is needed,
for a number of reasons. One reason is physicians don't have to be concerned about
delivering such high doses to healthy tissue because they can clearly see when it is
and isn't in the way, Brown says. "I'm much more comfortable giving a very high
dose of radiation to a tumor if I can see the intestine right next to it and know it isn't
moving into the field," Bassetti agrees.

Treatment Response and Planning

Also, if physicians can image the patient during treatment, as opposed to before
and after, they can see how well the treatment is working as they are delivering it.
They might need to step up the dose if the tumor isn't responding, or they could
perhaps lower the dose or number of treatments if they see it's responding well
after only a few of the planned courses. In most cases, radiation oncologists have to
wait three months or more after treatment to reimage their patients and see how
well they responded.

In the future, Brown says, physicians will be able to use MRI diffusion weighted
imaging to determine the effectiveness of the treatment as they are delivering it.
"There are many things MR sequences can show you," he explains, "and one will tell
you about the diffusion of water in tissue. That can tell you how densely packed the
tissues are at the cellular level. If water is able to diffuse more readily between
cells, that's a sign that there's tissue death. That's something we wouldn't be able
to pick up before."

Researchers at UCLA reported in the March 2016 issue of Medical Physics on their
pilot study using ViewRay's MRI-guided radiotherapy system to perform a
longitudinal diffusion MRI strategy for assessing patient response to radiotherapy.
They concluded that such an approach may enable response-guided adaptive
radiotherapy, but more research is needed.

Eventually, Christodouleas says, researchers hope to automate the best sequences

for different types of tumors and treatments based on experience with the
combination machine. MR imaging should help, for example, to identify organs and
their parts. With that information, "we may find that you need one sequence for a
pancreatic tumor that's up against the duodenum and another for a tumor that's
midpancreas and not constantly up against the bowel," he says. "It's not a question
of whether it can be done with the MR images. It's really just a matter of putting
these sequences together. In a CT world, you're still just getting the one parameter,
and you simply can't solve these problems."

Another potential advantage is shortening time to treatment, especially when

radiation therapy is being used for palliative care, Bassetti says. Now, patients have
to come to radiology for a CT scan to plan their treatment. "We send them away or
back to the hospital floor while we plan the radiation," he says. "With this system,
you can plan on the fly entirely, so we can bring them down for one single visit,
potentially." It not only is more convenient for the patient but also allows them to
get the pain relief they need sooner, he says.
 Costs vs Benefits
While combining MR and linear accelerators has many advantages, it also has some
disadvantages. One disadvantage to the MRI-linear accelerator is that it is likely more expensive
than regular radiotherapy. Radiotherapy is incredibly low-cost compared with chemotherapy or
surgery or other techniques used for cancer treatment, Brown says. Radiotherapy has benefitted
from efficiencies that continue to lower its cost, he says. "Using the MR-linac will likely be more
expensive," Brown says. Reimbursement could also be an issue. "One of the things we will be
looking at is enhanced reimbursement for the MR-linac. We believe, if it brings value to the health
care system, our users should be reimbursed accordingly," he says.
Time also could be a disadvantage. A regular session using the MR-linac shouldn't take any longer
than a session with a conventional linear accelerator, Brown says. However, using diffusion
weighted imaging to determine tumor response could add some time to treatment sessions.
Typically, radiation sessions last 15 to 20 minutes. Diffusion weighted imaging may add five to 10
minutes. "So you're not really talking about a significant amount of time, especially compared to the
potential benefit," Brown says.
In addition, some patients have metal implants and cannot get MRIs, Bassetti says. Also, there's
this: While MR is nonionizing and there's no safety concern for exposing patients to any
unnecessary radiation, a strong magnet requires that proper safety procedures be put in place.
Elekta uses a 1.5T MR imaging system from Philips similar to that used in its diagnostic systems.
Those familiar with the MRI-linear accelerator machines don't believe they will ever be the standard
treatment for all cancers, but Slotman believes that if cost weren't an issue, more patients would
be treated with them. "I believe that 15% to 25% of patients who are treated with radiotherapy will
have a definite benefit of MR-guided radiotherapy," he says. "If costs were not an issue, this could
easily be 80% to 90%."
Because it's more expensive, it won't be used for cases that don't require it, Brown agrees. "It
would make sense to treat those cases on the less expensive technology that is still of high
quality." However, Brown says, it's all about "seeing," and "seeing" what the radiation oncologists
are doing as the treatment happens can make all the difference.
"This has the potential to improve the efficacy of radiation therapy," Dempsey agrees, and that can
be life-changing for some patients.
Beth W. Orenstein, of Northampton, Pennsylvania, is a freelance medical writer and regular
Radiology
contributor to Today
.

Great Valley Publishing Co., Inc.,

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 Medical Dosimetry 41 (2016)30
30

Medical Dosimetry
journal homepage:www.meddos.or

Role of belly board device in the age of intensity modulated

radiotherapy for pelvic irradiation

Neil C. Estabrook, M.D.,n Gregory K. Bartlett, B.S., C.M.D.,n Julia J. Compton, M.D.,n
Higinia R. Cardenes, M.D., Ph.D.,n and Indra J. Das, Ph.D., F.A.C.R., F.A.S.T.R.O.n, *

Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN; and Department of Radiation Oncology, New York University Langone
Medical Center, New York, NY

ARTICLEINF Introduction
O
ABSTRACT
Article history: Small bowel dose often represents a limiting factor for radiation treatment of pelvic malignancies. To reduce
Received 16 February 2016 small bowel toxicity, a belly board device (BBD) with a prone position is often recommended. Intensity
Received in revised form modulated radiotherapy (IMRT) could reduce dose to small bowel based on the desired dosevolume constraints.
15 July 2016
We investigated the efficacy of BBD in conjunction with IMRT. A total of 11 consecutive patients with the
Accepted 20 July 2016
diagnosis of rectal cancer, who were candidates for definitive therapy, were selected. Patients were immobilized
with BBD in prone position for simulation and treatment. Supine position computed tomography (CT) data were
either acquired at the same time or during a diagnostic scan, and if existed was used. Target volumes (TV) as
Keywords:
IMRT well as organs at risk (OAR) were delineated in both studies. Three-dimensional conformal treatment (3DCRT)
Belly board device and IMRT plans were made for both scans. Thus for each patient, 4 plans were generated. Statistical analysis was
Rectal cancer conducted for maximum, minimum, and mean dose to each structure. When comparing the normalized mean
Small bowel toxicity Gross TV dose for the different plans, there was no statistical difference found between the planning types. There
was a significant difference in small bowel sparing when using prone position on BBD comparing 3DCRT and
IMRT plans, favoring IMRT with a 29.6% reduction in dose (p 0.007). There was also a statistically
significant difference in small bowel sparing when comparing supine position IMRT to prone-BBD IMRT
favoring prone-BBD IMRT with a reduction of 30.3% (p 0.002). For rectal cancer when small bowel could be
a limiting factor, prone position using BBD along with IMRT provides the best sparing. We conclude that
whenever a dose escalation in rectal cancer is desired where small bowel could be limiting factor, IMRT in
conjunction with BBD should be selected.
& 2016 American Association of Medical Dosimetrists.

to reduce the dose to small bowel as much as possible which may

Small bowel toxicity is a limiting factor for radiation treatment of
pelvic malignancies (rectum, cervix, and prostate). It becomes
extremely critical for dose escalation studies in an attempt to improve
radiation outcome. Typically 40 to 45 Gy is accepted as the tolerance
be difficult owing to anatomical position of the target volume,
cm3 of the contoured peritoneal cavity receives Z 45 Gy.3,4 It is,
therefore, generally recommended especially in pelvic malignancies.
Before the intensity modulated radiation therapy (IMRT) era, most
of the small bowel sparing was performed by surgical placement of

dose for small bowel.1-3 Acute small bowel injury has been described tissue expanders, slings, or meshes to move the mobile loops of the
with a threshold dose for grade 3 or greater toxicity when a volume of organ out of the treatment fields.5 Noninvasive approaches have been
120 cm3 of individually contoured loops receive Z 15 Gy or when 195 used as well based on employing gastrointestinal contrast during
treatment planning, patient positioning, abdominal compression, and bladder filling.6,7 Another noninvasive method commonly used with 3-
dimensional conformal radi-
position without BBD. For 3DCRT, 4-field box technique was used, whereas for
IMRT, 5 to 7 field step-and-shoot IMRT was used. Thus for each patient, 4
Reprint requests to Indra J. Das, Ph.D., F.A.C.R., F.A.S.T.R.O., Department of optimized treatment plans were generated as follows: Prone-BBD 3DCRT, Prone-
Radiation Oncology, New York University Langone Medical Center, 160 E, 34th St, BBD IMRT, Supine 3DCRT, and Supine IMRT. Gross target volume (GTV),
New York, NY 10016. clinical target volume, and planning target volume (PTV) as well OARs including
E-mail: indra.das@nyumc.org the small bowel, bladder, and femoral heads/necks were delineated in all 4 plans.
In each case, small bowel and target volume were maintained to be identical
(Table 1). Dose prescription and OAR tolerance doses were optimized in each
http://dx.doi.org/10.1016/j.meddos.2016.07.002
case without any bias of the treatment option selection. The optimization
0958-3947/Copyright 2016 American Association of Medical Dosimetrists constraints for PTV coverage were 100% to 95% volume. For small bowel, a
ation therapy (3DCRT) is a belly board device (BBD) in a prone maximum of 50 Gy was allowed; however, additional constraints of 5, 100, and
position.8-12 This simple device allows mobile, small bowel to fall 150 cm3, to a dose less than 45, 40, and 35 Gy, respectively, were maintained.
Patient's body dimensional analysis was performed at the isocenter plane of
N.C. Estabrook et al. / Medical Dosimetry 41 (2016) 300304 301 the
superiorly and anteriorly away from pelvic treatment fields when a pelvic fields to account for possible changes in anterior-posterior and lateral
dimensions of the pelvis for both the prone and supine patient setups. Patients had
patient is positioned in a prone position with the anterior abdomen
different prescribed dose, therefore, doses were normalized for comparison
placed in a cut out in the board. In fact, the American College of purposes between plans. Statistical analyses were conducted for maximum,
Radiology accreditation program guidelines strongly recommend minimum, and mean normalized dose to the GTV, PTV, and small bowel,
the use of BBD in prone position for all rectal malignancies, where respectively, using 2-tail paired analysis. The homogeneity index (HI) was
small bowel could be a limiting factor in delivering appropriate
radiation dose.13 The BBD has been reported by
various investigators to perform well dosimetrically.9,14,15 It is a simple
device which, as demonstrated pictorially in Fig. 1, allows for a great
amount of small bowel displacement away from the pelvis.
With IMRT, where dose optimization can be performed on
each organ of interest especially organs at risk (OAR), the question
can be raised whether or not prone positioning and BBD are still
needed to spare small bowel when offering neoadjuvant treatment
for unresected rectal cancer. Beriwal et al.16 provide some insights
for treating gynecologic malignancies and showed that the use of
prone position in IMRT gains no advantage for sparing small
bowel, which seems contradictory to the general views and several
publications,14,15,17 as optimization should accomplish dose
constraint objectives and reduce dose to OARs. This is clearly
shown in a systematic review of the literature of BBD use 15 that
concluded the use of a prone BBD with either 3DCRT or IMRT
yielding better sparing of small bowel in pelvic radiation fields
and might give the lowest gastrointestinal treatment related
morbidity. Owing to such a contradiction, it was felt necessary to
evaluate this topic again.
The efficacy of BBD in conjunction with IMRT in the
neoadjuvant treatment of rectal cancer is investigated in this study,
specifically to evaluate sparing small bowel and thus possibly
reducing radiation toxicity. In this study, we make a direct
comparison of 4 different possible setup/treatment modalities.
They are: 3DCRT and IMRT treatments with a prone-BBD and
without a BBD in a supine position.

Methods and Materials

In total, 11 patients with the diagnosis of rectal cancer were selected under
Institutional Review Board exempt status. All the patients were preoperative with
intact rectums with a plan to go on for an appropriate surgery after neoadjuvant
therapy. Patient characteristics are provided in Table 1. Patients were immobilized
with BBD in the prone position for computed tomography (CT) simulation. No
specific bladder filling instructions were given. Scout radiographs were acquired
before CT scans for localization with maximum extent of the small bowel sparing.
If patients had diagnostic CT scans before simulation, it was used for planning to
limit the radiation exposure and inconvenience to the patient. These scans were
imported into our treatment planning system (Eclipse version 11.3, Varian
Medical system, Palo Alto, CA) for image fusion and treatment planning with
analytical anisotropic algorithm (AAA) for inhomogeneity correction. All
contours were drawn by the senior physicians listed in this study with more than
20 years of experience.
Treatment plans were generated with 3DCRT and IMRT planning techniques
in both sets of CT scans, that is, in prone position on the BBD and in the supine
 When comparing the mean GTV normalized dose with the
302 N.C. Estabrook et al. / Medical Dosimetry 41 (2016) 300304
Fig. 1. Simulation of a patient in a prone position without (a) 3D view (b) and different plans, there was no statistical difference found between
associated DRR (c) with belly board device, indicating small bowel movements.
Color contours: yellowsmall bowel, tealCTV, redbladder, greenoverlap of
CTV and bladder, and blueoverlap of small bowel and bladder are shown. Adapted
from Das et al.[9]
Table 1
Patient statistics and volume information
Patient Age Sex GTV (cm3) GTV (cm3) Small bowel Small bowel
number volume (cm3) volume (cm
Supine Prone Supine Prone

1 71 M 203.2 204.3 449.3 442.7

2 50 M 211.2 187.8 1330.7 1325.1
3 59 M 499.7 504.9 1630.5 1627.0
4 61 M 256.3 271.6 758.5 792.1
5 61 M 91.6 94.0 2781.0 3077.8
6 47 M 171.7 173.1 954.1 937.7
7 40 M 243.3 249.1 527.8 528.5
8 53 F 83.0 78.5 2109.8 2102.7
9 68 F 334.4 327.3 735.3 729.8
10 75 M 178.1 179.4 2100.2 2092.2
11 57 M 122.2 124.9 417.7 411.1
calculated using the average of the maximum, minimum, and mean GTV dose for
each of the 4 setups as follows:18

Homogeneity index HI Dose GTVDosemaxGTVDosemeanGTVmin

1

Results

With the use of the prone-BBD, the anterior-posterior and lateral

separations were reduced on an average by 2.5 1.9 cm and 0.6 1.7
cm compared to supine positioning, respectively, indicating that small
bowel shifted with rearrangement of tissue depending on setup (Fig.
1). Such separation changes are not dosimetrically significant and
hence, not evaluated further. Target coverage to prescribed dose with
3DCRT and IMRT was nearly the same, with nearly identical HI
calculated between the 4 different treatment plans for each patient.
The range of HIs was from 0.13 to 0.17 when comparing the averages
of each of the types. Ideally, for any planning type's, HI should be
near zero with the maximum target dose equal to the minimum dose,
which was achieved in our study (Eq. (1)). There were a few
exceptions to this when evaluating the individual patient plans in
which the maximum dose was slightly higher (4 3% of the
prescription dose) using IMRT in both supine and prone positions
owing to the optimization criterion and where an exact solution could
not be found. Mean dose to GTV and PTV were within 2% of the
prescribed dose in all 4 plans for each patient (data not shown).
Totally, 5 comparisons were made between our 4 different
clinical setups to evaluate for statistically significant differences in
both mean doses to the GTV and to small bowel. The 5
comparisons were as follows:

(1) Supine 3DCRT vs Supine IMRT

(2) Prone-BDD 3DCRT vs Supine IMRT
(3) Prone-BBD 3DCRT vs Prone-BBD IMRT
(4) Supine IMRT vs Prone-BBD IMRT
(5) Supine 3DCRT vs Prone-BDD 3DCRT
Fig. 2. DVH comparisons (A) supine 3DCRT vs supine IMRT, (B) 3DCRT vs IMRT both prone with belly board device, and (C) IMRT plans comparing supine and prone with
belly board device. DVH dose-volume histograms; 3D 3-dimensional conformal radiation therapy; GTV gross tumor volume; IMRT intensity modulated radiation
therapy; PTV planning target volume.
N.C. Estabrook et al. / Medical Dosimetry 41 (2016) 300304
 Fig. 3. Linear correlation plots of patients in rank order of increasing small bowel mean dose for 3DCRT plans in both supine and prone belly board device positioning. There
was no significant difference in small bowel dose between positioning techniques. 3D or 3DCRT 3-dimensional conformal radiation therapy; P prone; S supine.

Fig. 4. Linear correlation plots of patients in rank order of increasing small bowel mean dose for IMRT plans in both supine and prone belly board device positioning. There
was a significant difference in small bowel dose favoring prone belly board positioning. IMRT Intensity Modulated Radiation Therapy; P prone; S supine.

planning types (Fig. 2). There was a significant difference in the small bowel sparing when using prone position on BBD comparing 3DCRT
and IMRT plans, favoring IMRT, with a 29.6% reduction in dose (p 0.007) (Figs. 2B and 3). There was also a statistically significant
difference in small bowel sparing when comparing supine IMRT to prone-BBD IMRT favoring IMRT with a BBD setup with a reduction in
small bowel dose of 30.3% (p 0.002) (Figs. 2C and 4). No other statistically significant differences in mean small bowel dose were found
between other treatment planning positions (Figs. 2A and 5).
The 3DCRT with supine position had the highest mean small bowel dose of all treatment options. When comparing small bowel mean dose
between the 4 potential treatment options, prone-BBD with IMRT gave the lowest dose with a 34% relative reduction compared with a
baseline of 3DCRT with a patient in a supine position. This was better than the small bowel mean dose achieved with Prone-BBD with 3DCRT
(5% relative dose reduction from baseline) or Supine with IMRT (6% relative dose reductions from baseline) as shown in Table 2 summarizing
dosage and statistical analysis.

Discussion

The dosimetric comparisons made in this study between 2 different treatment setup options for treating rectal cancer (supine and prone on
a BBD) and between 2 different treatment planning modalities (3DCRT and IMRT) show 2 combinations that lowered mean dose to small
bowel with a statistical significance. Those were using IMRT with a patient in the prone position on a BBD over 3DCRT on a BBD and using
IMRT on a BBD over IMRT in a supine position (Figs. 3 and 4). Even though prone setup seems to
Fig. 5. Linear correlation plots of patients in rank order of increasing small bowel mean dose for prone belly board 3DCRT plans compared with patients planned with IMRT in a
supine position. There was a significant difference in small bowel dose favoring supine IMRT plans. 3D or 3DCRT 3-dimensional conformal radiation therapy; IMRT
intensity modulated radiation therapy; P prone; S supine.

provide sparing in 3DCRT as well as in IMRT, it is very difficult to know where IMRT optimization or device is a critical factor and requires
additional study, if needed to understand.
Several investigators have provided positive results for the use of IMRT in pelvic irradiation for gynecologic and prostate cancers. 14,15,17,19-21
However, opposite findings were also reported indicating no gains in using prone IMRT for sparing small bowel in gynecologic malignancies. 16
This point is not universally accepted and a systematic review of the literature of BBD use concluded that use of a prone BBD with either 3DCRT
or IMRT yields the best decrease in small bowel volume in pelvic radiation fields, which might give the lowest gastrointestinal treatment related
morbidity.15 This article highlighted a single piece of literature, where the question of small bowel dose was investigated using prone positioning
with IMRT planning with or without a BBD in the treatment of preoperative rectal cancer. The authors of this article concluded that IMRT with a
BBD gave a greater reduction in irradiated small bowel volume than simply using IMRT in a flat prone position.22
Prone positioning for some patients can be difficult to tolerate,9 but it does provide significant sparing of small bowel. When patients are
unable to tolerate prone position, an IMRT technique could reduce dose to small bowel based on the desired dosevolume constraints with proper
optimization. Here we made comparisons of 5 different combinations of prone vs supine setups with either 3DCRT or IMRT treatment plans for
patients with rectal cancer to evaluate target coverage and small bowel sparing. With any of the combinations, our data suggest adequate coverage
of target volume with no statistically significant coverage differences between plans. Fig. 2 shows representative dose-volume histograms from
our dataset indicating adequate target volume coverage.
Although our data show a statistically significant change in small bowel sparing for 2 comparisons, both of those being with IMRT in a prone
position with BBD compared to others techniques, the data surprisingly did not show a small bowel dose advantage when comparing 3DCRT in a
supine vs a prone-BBD position (Fig. 5). The advantage of small bowel using a BBD has been previously documented in the literature when
comparing 3DCRT setups.10,12,15,23 However, patient numbers have been small in individual series looking not only at rectal cancer but also other
pelvic malignancies (i.e., gynecological). This has led us to hypothesize about the reason for the findings from our data in this specific
 comparison. Most likely, it is because of too small of a sample size in our study. Another contributing factor might be that rectal cancer can be
found anywhere along the length of the organ from the anal verge in the distal pelvis to the sigmoid near the abdomen. Therefore, the primary
lesion could potentially be much
304 N.C. Estabrook et al. / Medical Dosimetry 41 (2016) 300304

Table 2
Normalized dose to target and small bowel for the different setup and planning techniques
Supine-3DCRTa Supine-IMRTb Prone BBDc-3DCRT Prone BBD-IMRT

d
GTV mean (normalized dose)
1.017 1.022 1.013 1.023
GTV standard deviation 0.022 0.021 0.027 0.022
Homogeneity index 0.16 0.13 0.17 0.15
Small bowel mean 0.328 0.310 0.307 0.216
Small bowel standard deviation 0.175 0.192 0.138 0.121
Small bowel mean % difference (baseline is Supine-3DCRT) (%) 0.0 5.5 6.4 34.1
a
3D conformal radiation therapy.
b Intensity modulated radiation therapy.
c
Belly board device. d Gross tumor volume.

closer to the small bowel than with a low-lying pelvic primary such as prostate or cervical cancer. When we analyzed our data for small bowel
dose in primary tumor size and location for distance from the anal verge, we could find no correlation (data not shown). This might indicate that
positioning on BBD is critical and other measures such as oral contrast and bladder filling are keys to sparing small bowel with this technique
when using 3DCRT. For our cohort of patients, we had no systematic requirements for either of these items during simulation and treatment
planning. Irrespective of positioning with 3DCRT planning, our data do support a small bowel dose advantage for IMRT, although not for supine
IMRT compared with 3DCRT on BBD where there was no small bowel dose difference in this particular comparison.
This analysis is the first, we know of, for rectal cancer that makes multiple comparisons between patient setup and treatment planning type.
Our data indicate that additional sparing of small bowel is achieved when IMRT is used in prone position with BBD compared with either both
3DCRT in a prone-BBD position or IMRT in supine position. When we considered the baseline for small bowel dose as a case with a supine
position and treated with 3DCRT, a small bowel dose reduction of 34% was achieved with using IMRT and prone-BBD (Table 2).
One could extend this study with volumetric modulated arc therapy (VMAT); however, the findings may remain identical. There are extensive
literature comparing IMRT and VMAT in many disease sites. Based on dose-volume constraints, one achieves the identical dosimetric coverage.
The only advantage with VMAT is lower monitor units, and thus shorter treatment. Hence, we did not provide additional study with VMAT rather
stayed with IMRT.

Conclusions

For rectal cancer when small bowel could be a limiting factor, BBD in prone position provides a superior treatment option. The prone position
using the BBD along with IMRT provides the best sparing of the small bowel. We conclude that whenever a dose escalation in rectal cancer is
desired where small bowel could be limiting factor, IMRT in conjunction with BBD should be selected.

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