47

Limiting dose to the lumbosacral plexus for pelvic-paraaortic cases with VMAT
Elizabeth McGinnis, BS, R.T.(T), Thomas Sutherland, BS, R.T.(R), Michael Wheatley BS,
R.T.(R)(T), Nishele Lenards, PhD, CMD, R.T.(R)(T), FAAMD, Ashley Hunzeker, MS, CMD,
Karen Lang, MS, CMD, R.T.(T), Ashley Fellows, MS, CMD, R.T.(T), Sabrina Zeiler, MS,
CMD, R.T.(T)
Medical Dosimetry Program at the University of Wisconsin-La Crosse, WI
ABSTRACT
The purpose of this study was to demonstrate the use of the lumbosacral plexus (LSP) as
an organ at risk (OAR) in planning of pelvic radiotherapy cases to reduce dose deposited in the
region of the LSP. Previous studies have shown that pelvic cases planned with volumetric
modulated arc therapy (VMAT) can have the unintended consequence of “dose dumping” into
the region of the LSP, increasing the likelihood of patients experiencing radiation induced
lumbosacral plexopathy (RILSP) in higher total dose treatments. Fifteen retrospective patients
from 2 different clinical sites were selected based on the criteria of a primary pelvic diagnosis
that included paraaortic fields treated to a dose of 50 Gy or greater. The LSP was delineated and
the percentage of volume receiving 40 Gy (V40) and 50 Gy (V50) were recorded from the original
plans. The plans were replanned with the use of the LSP in the optimization planning objectives
to attempt to lower the V40 and V50 while maintaining similar dose to targets and other critical
OAR. A statistical analysis demonstrated that the V40 and V50 could be significantly decreased
using the LSP as an OAR and still provide acceptable coverage and similar dose to the other
OAR.

Keywords: lumbosacral plexus (LSP), volumetric modulated arc therapy (VMAT), pelvic
radiotherapy, paraaortic radiotherapy, lumbosacral plexopathy
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Introduction
Today, pelvic cancer radiation cases are widely treated using intensity modulated
radiation therapy (IMRT) or volumetric modulated arc therapy (VMAT). Pelvic cases
utilizing IMRT or VMAT techniques often involve large treatment volumes encompassing nodal
chains to include the paraaortic nodes. A significant advantage of IMRT/VMAT treatment
planning in pelvic cases is better dose conformity and target coverage while sparing dose to
normal healthy tissue.1 In addition to radiation therapy, patients often receive concomitant
chemotherapy, making the pelvic nerves radiosensitive in rectal, anal, lymphoma, and
gynecological malignancies. The increased sensitivity to pelvic nerves, such as the lumbosacral
plexus (LSP), can lead to radiation-induced injuries in doses as low as 40-60 Gy.2,3,4 The
incidence of severe radiation complications can potentially be decreased by delineating the LSP
as an organ at risk (OAR). The complexity of the LSP anatomy and the degree of radiation-
induced injury that may occur emphasizes the importance of defining the structural anatomy in
the LSP region.
The LSP, originating from the L1-L4 nerve roots, is a delicate network of nerve roots that
are formed to supply motor and sensory innervations to the lower extremities.5 Anatomically
located between the 12th thoracic vertebrae and the 4th sacral vertebrae. The LSP is divided into 2
parts: the lumbar plexus and the sacral plexus. The lumbar plexus exists between the 12th
thoracic vertebral body and the 4th lumbar vertebral body. The lumbar plexus lies adjacent to the
lumbar spine and behind the psoas major muscle in the retroperitoneum where it innervates the
lower abdomen, as well as the anterior and medial parts of the lower extremities. A network of
short and major nerves supplies the pelvis, extending through to the hip muscles. The smallest
part of the 4th lumbar nerve subdivides to join the 5th lumbar nerve to create the sacral plexus that
innervates the dorsal half.4 The sacral plexus exists from the 4th lumbar vertebral body to the 4th
sacral vertebral body, where it rests on the piriform muscle. Short motor nerve branches extend
through the hip to the muscles, and 5 major nerves supply the remaining dorsal half of the lower
limbs.4 With the structural anatomy of the LSP defined, a standardized method of contouring was
sought by various researchers.
Yi et al2 and Min et al6 published a standardized method of contouring the LSP. Yi et
al2 established a standardized method of contouring the LSP by identifying soft tissue and bony
landmarks on CT images only. Conversely, Min et al6 delineated a generalized LSP region to
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account for the area where the LSP is not visible on CT imaging.6,7 Though these methodologies
varied, the contouring approaches gave researchers the means to do comparable dose correlation
studies to establish preliminary dosimetric parameters for the LSP that could help reduce
complications like radiation induced lumbosacral plexopathy (RILSP), a neurological
impairment of the peripheral nervous system in the LSP that is a sequela from radiation therapy.8
Tunio et al4 sought to correlate dose to the LSP and RILSP in 50 cervical cancer patients
treated with IMRT and intracavitary high-dose rate (HDR) brachytherapy between 2007-2012.
At a 5-year follow up, 4 patients (8%) had developed grade 2/3 RILSP. Using anatomy manuals
and the Yi et al2 LSP contour protocol, Tunio et al4 established quantifiable data to correlate the
dose to LSP that could cause RILSP but cited limitations of a small sample size and relatively
short period of follow up. The dosimetric values calculated by Tunio et al4 suggested a
correlation between dose to the LSP and RILSP. The study revealed a reduced risk of RILSP
when: the mean dose was lower than 45 Gy, the percentage of LSP volume receiving 40 Gy
(V40) was lower than 55%, the volume receiving 50 Gy (V50) was lower than 30%, and the
volume receiving 55 Gy (V55) was lower than 5%.4 Though Tunio et al4 was able to find a
correlation between dose to the LSP and RILSP, the incidence of RILSP may be underestimated
due to the time frame of when symptoms start to appear.
The occurrence of RILSP is widely underreported even though patient symptoms are
often debilitating and severely affect the quality of life. Radiation-induced lumbosacral
plexopathy has a wide range of onset, from 1-3 months to years following treatment.2,3,5 A major
consideration of the underreporting is that radiation oncologists are not involved in long-term
follow-up care, thereby reducing the number of diagnoses of RILSP.2 Typically, symptoms are
reported to the patient’s primary care physician and can be difficult to diagnose due to
comorbidities and complexity with differential diagnoses. Although reported cases are rare,
published data suggests that the reported frequency of RILSP in gynecological malignancies
ranges from 1.3% to 6.67%, with reporting clinical symptoms of varying degrees of bilateral
limb weakness, numbness, paralysis, and possibly urinary and fecal incontinence.3,4-6 While the
primary goal of radiation treatments is to irradiate the tumor volume to yield loco-regional
control while sparing normal surrounding tissues to minimize side effects and complications, this
is only achievable with the discerning knowledge of tumoricidal doses and tolerance doses to
normal tissues.6 With cases of RILSP still being reported, it is worth evaluating the effectiveness
 50

of reducing dose to the LSP by using a delineated LSP structure in the pelvic-paraaortic
treatment planning process.
The problem is that the LSP is not a standard delineated OAR for pelvic-paraaortic
irradiation resulting in no dose tracking during VMAT treatment planning and potentially higher
volumes receiving 40 Gy (V40) and 50 Gy (V50). Previous researchers suggested that further
quantitative analysis must be conducted with a larger cohort sample to establish a correlation
between the absence of delineating the LSP as an OAR and “dose-dumping” into the LSP
region.4,6 The purpose of this study was to delineate the LSP as an OAR to lower the volumetric
constraints in VMAT planned pelvic cases while maintaining acceptable target coverage. It was
hypothesized that researchers would be able to (H1A) lower the V40 to the LSP and (H2A) lower
the V50 to the LSP while maintaining acceptable target coverage.
Methods and Materials
Patient Selection and Setup
Patient data were collected retrospectively and included 30 patients from 2 separate
institutions. Fifteen patients were simulated using a GE Discovery RT scanner to obtain the
pelvic scan with 2 mm slice thickness, and 15 patients were simulated using a Philips Brilliance
CT scanner to obtain a pelvic scan with 3 mm slice thickness. Each patient was positioned head-
first supine with their legs in a custom Vaclok bag and arms positioned on their chest. Three
setup tattoos, an anteroposterior midline tattoo and 2 lateral tattoos were given during the
simulation. The scans were exported to Eclipse treatment planning system (version 13.6 and 15).
The inclusion criteria involved patients who received paraaortic pelvic irradiation with VMAT
technique to a total dose greater than 45 Gy. Patients without paraaortic nodal involvement or a
treatment technique other than VMAT were excluded from the study.
Contours
The CT scan was used for the contouring of the LSP, bladder, small bowel, and rectum
OAR and delineating of the target volumes for treatment planning. The target volumes were
delineated by the radiation oncologist. The LSP was delineated by the radiation oncologist or
radiation oncology resident based on the standardized method as defined by Yi et al.2
Treatment Planning
For the retrospective study, all patients were planned with an inverse planning VMAT
technique on the Eclipse treatment planning system. The retrospective plan maintained identical
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beam parameters with the initial plan, utilizing 6 MV or 10 MV beam energies. The objective for
the replans was to keep the dose to the secondary OAR (bladder, small bowel, and rectum)
within 3% of the original plans while maintaining acceptable coverage to the target volumes. All
planning objectives remained the same to collect accurate data of measured dose to the LSP in
plan comparison.
Plan Comparison
The dose to the LSP was compared between the retrospective plans and the original
treatment plan. The V40 and V50 for the LSP were analyzed and recorded for each plan. In the
initial plan, dose was optimized to the bladder, small bowel and rectum using Quantitative
Analysis of Normal Tissue Effects in the Clinic (QUANTEC) recommendations and every
attempt was made to reproduce the doses in the replan. The target volumes were also analyzed to
ensure comparable coverage in the presence of the delineated LSP.
Statistical Analysis
A one-sided Wilcoxon signed rank test was performed to compare the LSP V40 and V50
distributions for the original plan and the replan. With a family-wise error rate of 5% for
each volume measure, a Bonferroni correction was applied to control the type 1 error rate for
multiple testing. Statistical analysis was performed using R (R Core Team, 2020). A Wilcoxon
signed rank test was used rather than a paired t-test due to right skewness and outliers observed
in the samples of paired differences.9 The statistical correlation was not dependent on the volume
(cm3) of the LSP.
Results
LSP V40
A quantitative analysis showed a significant decrease in the LSP V40 in the replan
compared to the original plan, with a mean decrease of 6.7%. The V40 mean to the LSP in the
replan was 58.5%, whereas the initial plan yielded a mean V40 of 65.18% (Figure 1). The
difference in LSP V40 is illustrated in the boxplots with a reference line at 0 for comparison
(Figure 2). The positive values indicated the dose in the original plan was greater compared
to the replan. Because the LSP V40 was significantly lower for the replan V40 and acceptable
target coverage was maintained, the null hypothesis (H10) was rejected (P < 0.0005).
LSP V50
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The decreased mean in LSP V50 yielded less significant differences in the replan
compared to the original plan, however, the maximum dose difference was - 20.9% (Table 1).
The decreased mean in LSP V50 was - 3.02% with a V50 mean of 11% to the LSP in the replan
(Figure 1). The difference in LSP V50 is also illustrated in the boxplots with a reference line at 0
for comparison (Figure 2). The positive values indicate the dose in the original plan is greater
than for the replan.9 Using the Wilcoxon rank test to perform the statistical analysis, it was
observed that the V50 was significantly decreased in the replan with the LSP contoured.9 There
was sufficient evidence to conclude that LSP V50 was lower with the replan than with the
original plan while maintaining acceptable target coverage (P < 0.0005), therefore the null
hypothesis (H20) was rejected at α = 0.05.9
Secondary OAR
To acknowledge any possibility of inadvertent dose distribution into nearby normal
structures to spare dose to the LSP, the goal during the replanning phase was to keep the dose to
the bladder, small bowel, and rectum within 3% of the original planned treatments while
maintaining acceptable coverage to the target volumes. As demonstrated by the graphical display
of the DVH (Figure 1), the replans maintained clinically acceptable coverage to the target
volume while meeting normal tissue constraints to the bladder, small bowel, and rectum with the
addition of the delineated LSP. A plan comparison of the dosimetric constraint values of the
OAR demonstrated that 26/30 plans (86%) met the 3% OAR variance constraint. The remaining
4/30 plans (14%) yielded a maximum of 5% variance to the OAR in comparison to the initial
plans.
Discussion
Previous research correlated the unintentional dose to the LSP as a risk factor for RILSP
when the LSP is not considered during treatment planning.2,3,4,5,8 In the current study, the
researchers delineated and reduced dose to the LSP, while not compromising treatment planning
objectives. Clinically acceptable planning target volume (PTV) coverage was maintained, and
the dose was not inadvertently distributed to other nearby OAR, consistent with the Tunio et al4
research. Consideration of the delineated LSP in treatment planning would potentially reduce the
risk of radiation induced complications as suggested from previous research. 2,3,4,5,8
Researchers in the current study evaluated the literature to validate findings that
correlated with a delineated LSP used in planning optimization with reduced risk of
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complications. Vinciguerra et al5 and Delanian et al8 discussed the occurrence of RILSP
symptoms and the correlation of dosimetric volumes of the LSP. Neurotoxicity may present
earlier in high-dose radiation therapy with moderate volumes of the LSP receiving higher dose
levels, and late occurrence of radiation induced symptoms may also present with a larger volume
of the LSP receiving moderate dose levels. Researchers in the current study used similar dose
levels and volumes to the pelvic-paraaortic region stressing the importance of reducing the
volume of irradiation to the nerves.5,8 In accordance with As Low As Reasonably Achievable
(ALARA) principles, the current study contributes data to support that a delineated LSP as an
OAR lowers volumetric constraints and maintains acceptable target coverage.5,8
Conclusion
The problem is that the LSP is not a standard delineated OAR for pelvic-paraaortic
irradiation resulting in no dose tracking during VMAT treatment planning and potentially higher
V40 and V50. The purpose of this retrospective study was to delineate the LSP as an OAR to
lower the volumetric constraints in VMAT planned pelvic cases while maintaining acceptable
target coverage. The use of quantitative statistical analysis demonstrated that the delineation of
the LSP as an OAR resulted in lower mean V40 and V50 in VMAT planned pelvic cases while
maintaining acceptable target coverage. Researchers demonstrated that, if delineated, the LSP
V40 and V50 can be significantly reduced in treatment planning
The limitations of this study included the small sample size collected from only 2
radiation oncology centers and the use of 1 treatment planning system. Future research should
include VMAT treatment planning to the pelvis with consideration to the LSP as an OAR in a
larger sample size across multiple treatment institutions. Collecting data from multiple treatment
institutions may account for interobserver variability in contouring and treatment planning.
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Acknowledgments
The researchers would like to acknowledge Dr. David Reineke, at the University of Wisconsin-
La Crosse Statistical Consulting Center, for his assistance in statistical analysis for this research
project. Any errors in statistics or interpretation of data are the sole responsibility of the authors.
 55

References
1. Deng, X., Han, C., Chen, S., Xie, C., Yi, J., Zhou, Y., Zheng, X., Deng, Z. and Jin, X.
Dosimetric benefits of intensity‐modulated radiotherapy and volumetric‐modulated arc
therapy in the treatment of postoperative cervical cancer patients. J Appl Clin Med Phys. 18:
25-31. http://doi.org/10.1002/acm2.12003
2. Yi S, Mak W, Yang C, et al. Development of a standardized method for contouring
the lumbosacral plexus: A preliminary dosimetric analysis of this organ at risk among 15
patients treated with intensity-modulated radiotherapy for lower gastrointestinal cancers and
the incidence of radiation-induced lumbosacral plexopathy. Int J Radiat Oncol Biol Phys.
2012;84(2):376-382. http://doi.org/10.1016/j.ijrobp.2011.11.074
3. Klimek M, Kosobucki R, Łuczyńska E, Bieda T, Urbański K. Radiotherapy-induced
lumbosacral plexopathy in a patient with cervical cancer: A case report and literature
review. Contemp Oncol (Pozn). 2012;16(2):194-196. http://doi.org/10.5114/wo.2012.28805
4. Tunio M, Al Asiri M, Bayoumi Y, et al. Lumbosacral plexus delineation, dose distribution,
and its correlation with radiation-induced lumbosacral plexopathy in cervical cancer
patients. Onco Targets Ther. 2015;8:21-27. http://doi.org/10.2147/OTT.S71086
5. Vinciguerra C, Nardone V, Sicurelli F, Guida C, Cappabianca S. Lumbosacral plexopathy in
pelvic radiotherapy: An association not to be neglected; A systematic
review. Arch Neurosci.  2019;6(4):1-6. http://doi.org/10.5812/ans.86686
6. Min M, Roos D, Keating E, et al. External validation of the lumbosacral plexus-contouring
protocol developed by Yi et al. (IJROBP 2012; 84: 376-82) for pelvic malignancies. J Med
Imaging Radiat Oncol. 2014;58(1):117-124. http://doi.org/10.111/1754-9485.12106 
7. Bourhafour I, Benoulaid M, El Kacemi H, El Majjaoui S, Kebdani T, Benjaafar N. Lumbosacral
plexopathy: A rare long-term complication of concomitant chemo-radiation for
cervical cancer. Gynecol Oncol Res Pract. 2015;2(12):1-4. http://doi.org/10.1186/s40661-015-
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8. Delanian S, Lefaix J, Pradat P. Radiation-induced neuropathy in cancer survivors.
Radiat Oncol. 2012;105(3):273-282. http://doi.org/10.1016/j.radonc.2012.10.012
9. R Core Team (2020). R: A language and environment for statistical computing. R Foundation
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 56

Figures

Figure 1. The dose-volume histogram (DVH) displayed in centigray (cGy) for a patient plan that
demonstrates decrease in dose to volume of lumbosacral plexus (LSP) in the replan with a LSP
contour compared to the original plan.
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Figure 2. Side-by-side boxplots of difference in V40 and V50 between original plan and
replan. Boxplots shown have medians that are significantly greater than 0, showing that the dose
for the replan is lower than for the original plan.9
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Tables

Table 1. The contoured LSP volume plan comparison data shows original and replan V40 and
V50 with dose-volume differences.
LSP Original Plan LSP –
Volume Original Plan LSP (%) Replan LSP (%) Replan LSP Difference in
(cm )
3
Volume (%)
V40 V50 V40 V50 V40 V50
133.0 63.00 0.10 55.80 0.00 -7.20 -0.10
110.6 69.70 6.30 41.10 4.80 -28.6 -1.50
134.3 83.10 0.00 79.30 0.00 -3.80 0.00
94.9 82.10 0.30 76.40 0.00 -5.70 -0.30
85.6 69.10 34.50 53.40 13.60 -15.7 -20.9
94.5 77.10 8.50 67.40 7.80 -9.70 -0.70
102.3 73.70 0.00 68.70 0.00 -5.00 0.00
112.6 81.80 60.80 73.70 43.90 -8.10 -16.9
106.5 51.30 6.70 47.90 1.60 -3.40 -5.10
119.0 75.90 68.20 73.80 61.50 -2.10 -6.70
90.7 60.30 45.70 48.90 31.50 -11.40 -14.2
108.1 56.70 31.30 47.40 23.50 -9.30 -7.80
88.4 53.50 0.00 51.70 0.00 -1.80 0.00
104.6 51.30 26.50 46.10 26.10 -5.20 -0.40
112.3 61.50 51.90 60.20 50.10 -1.30 -1.80
112 62.00 1.40 59.00 1.00 -3.00 -0.40
142.3 82.90 29.20 73.30 25.70 -9.60 -3.50
117.1 82.00 21.00 77.00 18.50 -5.00 -2.50
89.4 65.45 11.06 54.10 7.95 -11.35 -3.11
115.6 63.25 1.35 57.84 0.01 -5.41 -1.34
119.9 72.65 0.00 69.96 0.00 -2.69 0.00
111.0 34.84 0.00 28.50 0.00 -6.34 0.00
99.2 52.49 3.97 44.53 1.34 -7.96 -2.63
118.7 57.49 0.00 54.47 0.00 -3.02 0.00
139.3 71.13 0.00 66.10 0.00 -5.03 0.00
107.6 66.12 3.84 62.86 3.73 -3.26 -0.11
108.9 67.78 7.87 57.87 4.95 -9.91 -2.92
106.7 48.07 0.19 42.97 0.00 -5.1 -0.19
96.0 49.46 0.00 48.32 0.00 -1.14 0.00
121.3 69.59 0.00 66.51 0.00 -3.08 0.00
Mean 65.18 14.02 58.50 11.00 -6.67 -3.02
LSP = lumbosacral plexus