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The Use of Rectal Balloon During the Delivery of Intensity Modulated Radiotherapy (IMRT) for Prostate Cancer: More Than Just a Prostate Gland Immobilization Device?

Teh, Bin S. MD; McGary, John E. PhD; Dong, Lei PhDa; Mai, Wei-Yuan MD; Carpenter, L. Steve MD; Lu, Hsin H. MD; Chiu, J. Kam MD; Woo, Shiao Y. MD, FACR; Grant, Walter H. PhD; Butler, E. Brian MD


PURPOSE The purpose of this study was to investigate the role of a rectal balloon for prostate immobilization and rectal toxicity reduction in patients receiving dose-escalated intensity-modulated radiotherapy for prostate cancer.

PATIENTS AND METHODS Patients with localized prostate cancer who were undergoing intensity-modulated radiotherapy were treated in a prone position, immobilized with a customized Vac-Lok bag (MED-TEC, Orange City, IA). A rectal balloon with 100 cc of air was used to immobilize the prostate. The prostate displacements were measured using computed tomography (CT)-CT fusion on 10 patients who received radioactive seed implant before intensity-modulated radiotherapy. They were scanned twice weekly during 5 weeks of intensity-modulated radiotherapy, and breathing studies were also performed. Rectal toxicity was evaluated by use of Radiation Therapy Oncology Group scoring in 100 patients. They were treated to a mean dose of 76 Gy over 35 fractions (2.17-Gy fraction size). Dose-volume histogram of the rectum was assessed. A film phantom was constructed to simulate the 4-cm diameter air cavity that was created by the rectal balloon. Kodak XV2 films (Rochester NY) were used to measure and compare dose distribution with and without the air cavity. A fraction of 1.25 Gy was delivered to the phantom at isocenter with 15-MV photons by use of the NOMOS Peacock system and the MIMiC treatment delivery system (Sewickley, PA).

RESULTS The anterior-posterior and lateral prostate displacements were minimal, on the order of measurement uncertainty (∼1 mm). The standard deviation of superior-inferior displacement was 1.78 mm. Breathing studies showed no organ displacement during normal breathing when the rectal balloon was in place. The rectal toxicity profile was very favorable: 83% (83/100) patients had no rectal complaint, and 11% and 6% had grade 1 and 2 toxicity, respectively. Dose-volume histogram analysis revealed that in all of the patients, no more than 25% of the rectum received 70 Gy or greater. As visualized by film dosimetry, the dose at air-tissue interface was approximately 15% lower than that without an air cavity. The dose built up rapidly so that at 1 and 2 mm, the differential was approximately 8% and 5%, respectively. The dosimetric coverage at the depth of the posterior prostate wall was essentially equal, with or without the air cavity.

DISCUSSION The use of a rectal balloon during intensity-modulated radiotherapy significantly reduces prostate motion. Prostate immobilization thus allows a safer and smaller planning target volume margin. It has also helped spare the anterior rectal wall (by its dosimetric effects) and reduced the rectal volume that received high-dose radiation (by rectal wall distension). All these factors may have further contributed to the decreased rectal toxicity achieved by intensity-modulated radiotherapy, despite dose escalation and higher-than-conventional fraction size.

Department of Radiology/Section of Radiation Oncology, Baylor College of Medicine, The Methodist Hospital, Houston, Texas.

Reprint requests: Dr. Bin S. Teh, The Methodist Hospital, 6565Fannin, MS 121-B, Houston, TX 77030.

aDr. Lei Dong's current affiliation is University of Texas M.D. Anderson Cancer Center, Houston, TX.

Dr. Teh received the 2002 American Radium Society (ARS) Young Oncologist Travel Grant Award in “Radiation Oncology” for this work.

No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this article.

Presented at the 84th Annual Meeting of the American Radium Society, Las Croabas, Puerto Rico, April 27–May 1, 2002.

Received on June 28, 2002; accepted for publication August 1, 2002.

© 2002 Lippincott Williams & Wilkins, Inc.