Int. J. Radiation Oncology Biol. Phys., Vol. 67, No. 2, pp.

485– 489, 2007

Copyright © 2007 Elsevier Inc.
Printed in the USA. All rights reserved
0360-3016/07/$–see front matter

doi:10.1016/j.ijrobp.2006.08.067

CLINICAL INVESTIGATION Endometrium

DOSIMETRIC AND TOXICITY COMPARISON BETWEEN PRONE AND

SUPINE POSITION IMRT FOR ENDOMETRIAL CANCER
SUSHIL BERIWAL, M.D.,*† SHEENA K. JAIN, B.S.,† DWIGHT E. HERON, M.D.,*†
REGIANE S. DE ANDRADE, M.D.,* CHYONGHIOU J. LIN, PH.D.,* AND HAYEON KIM, M.S.*†
*Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA;
†
University of Pittsburgh School of Medicine, Pittsburgh, PA

Purpose: To determine the dosimetric and toxicity differences between prone and supine position intensity-
modulate radiotherapy in endometrial cancer patients treated with adjuvant radiotherapy.
Methods: Forty-seven consecutive endometrial cancer patients treated with adjuvant RT were analyzed. Of these,
21 were treated in prone position and 26 in the supine position. Dose–volume histograms for normal tissue
structures and targets were compared between the two groups. Acute and chronic toxicity were also compared
between the cohorts.
Results: The percentage of volume receiving 10, 20, 30, 40, 45, and 50 Gy for small bowel was 89.5%, 69%, 33%,
12.2%, 5%, and 0% in the prone group and 87.5%, 62.7%, 26.4%, 8%, 4.3%, and 0% in the supine group,
respectively. The difference was not statistically significant. The dose–volume histograms for bladder and rectum
were also comparable, except for a slightly greater percentage of volume receiving 10 Gy (1.5%) and 20 Gy (5%)
for the rectum in the prone group. Acute small bowel toxicities were Grade 1 in 7 patients and Grade 2 in 14
patients in the prone group vs. Grade 1 in 6 patients and Grade 2 in 19 patients in the supine group. Chronic
toxicity was Grade 1 in 7 patients and Grade 3 in 1 patient in the prone group and Grade 1 in 5 patients in the
supine group.
Conclusion: These preliminary results suggest that no difference exists in the dose to the normal tissue and
toxicity between prone and supine intensity-modulated radiotherapy for endometrial cancer. Longer follow-up
and more outcome studies are needed to determine whether any differences exist between the two approaches.
© 2007 Elsevier Inc.

Endometrial cancer, Intensity-modulated radiotherapy, Positioning, Toxicity.

INTRODUCTION combination of a prone position with a belly board and

Adjuvant pelvic radiotherapy (RT) is recommended for
patients with intermediate-risk and high-risk adenocarci-
noma of the uterus after surgery to decrease locoregional
recurrence (1–3). The success of this treatment may come at
the cost of an increased risk of small bowel complications.
Various techniques have been used to reduce the volume of
the small bowel in the treatment field and to reduce the dose
to the nontarget volume to decrease the risk of complica-
tions.
Mechanical small bowel displacement techniques, in-
cluding prone positioning with the use of a belly board, have
been among the most effective methods used to reduce the
small bowel dose in conventional pelvic RT (4 –12). Re-
cently, intensity modulation has been shown to effectively
decrease the small bowel dose and radiation toxicity in
gynecologic pelvic RT (13–17).
The purpose of this study was to determine whether the
intensity-modulated RT (IMRT) would further reduce the
radiation dose to the small bowel compared with IMRT in
the supine position. The study also assessed whether any
difference resulted in the development of acute and chronic
toxicities between the two approaches.
METHODS AND MATERIALS
Simulation and contouring
Patients were positioned either prone on the belly board or
supine with a vacuum-evacuated Vac-Lok bag (Med-Tec, Orange
City, IA) for immobilization. A radiopaque, cylindrical, vaginal
marker, SHADOWFORM vaginal marker (IZI, Baltimore, MD),
was inserted to indicate the position of the vaginal apex. All
patients underwent a planning CT scan with oral and i.v. contrast
in the treatment position on a GE Helical CT scanner (GE Medical
Systems, Milwaukee, WI). The clinical target volume (CTV) in-
cluded the internal, external, and common iliac nodes and the
proximal vagina. In patients with disease involving the cervix or

Reprint requests to: Sushil Beriwal, M.D., Department of Radiation Conflict of interest: none.
Oncology, Magee-Womens Hospital, University of Pittsburgh Med- Received Aug 1, 2006, and in revised form Aug 28, 2006.
ical Center, 300 Halket St., Pittsburgh, PA 15213. Tel: (412) 641- Accepted for publication Aug 28, 2006.
4600; Fax: (412) 641-1971; E-mail: beriwals@upmc.edu

485
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486 I. J. Radiation Oncology ● Biology ● Physics Volume 67, Number 2, 2007

pelvic lymph nodes, the presacral region to S3 was also included Table 1. Clinicopathologic characteristics
in the CTV. A margin of 1 cm around the lymph node groups was
used. The vaginal CTV included the proximal 4 cm of the vagina Characteristic Group 1 Group 2
and paravaginal tissues. The CTV was expanded by 1 cm to create
Age at study entry (y)
the planning target volume (PTV). The superior border of the 40–49 2 4
pelvic CTV was generally 1 cm below L5-S1, resulting in the PTV 50–59 4 8
being approximately at L5-S1. In 8 patients, the CTV was ex- 60–69 9 6
panded to include the paraaortic lymph nodes to the level of L1. 70–79 3 5
Normal structures were also entered into the planning CT scan and 80–89 3 3
included small bowel, bladder, rectum, and kidneys (if the paraaor- Median 66 62
tic lymph nodes were included). The small bowel may move inside Range 42–83 42–84
the peritoneal cavity. Therefore, we contoured the entire peritoneal Body mass index (kg/m2)
surface from the cul-de-sac to 2 cm above the PTV on the small Median 27.4 30.3
Range 20.8–30.7 20.3–43.4
bowel structure. The small bowel tissue density was changed to a
Stage (n)
Hounsfield unit of 0 for treatment planning to avoid error in the IB 4 6
IMRT dose calculations from the contrast material. IC 9 5
Corrections were not made for bowel or bladder motion (i.e., IIA 1 1
contouring these normal structures from serial CT scans or gener- IIB 2 6
ating a PTV expansion of these structures). No specification of the IIIA 3 3
bladder filling position was done during simulation or treatment. IIIC 2 5
LVSI (n)
Present 13 10
IMRT planning Absent 8 16
Treatment planning was performed using the Eclipse Planning Histologic type (n)
System, version 7.1.59 (Varian Medical Systems, Palo Alto, CA) Endometroid adenocarcinoma 16 19
and treatment was delivered using a Varian 2100C linear acceler- Grade 1 4 3
ator. Dynamic multileaf collimators shaped the fields. The median Grade 2 8 11
Grade 3 4 5
number of 6-MV coplanar fields used was 7 (range, 5– 8). The
Papillary serous 2 4
dose–volume constraints of the target and normal tissues were Carcinosarcoma 3 2
defined for each patient. The typical input parameters for IMRT Clear cell 0 1
planning of the PTV were as follows: ⬍35% of small bowel to Pelvic lymph nodes dissected (n)
receive 35 Gy, with a dose maximum of 50 Gy; ⬍40% of bladder No 4 4
to receive 40 Gy, with a dose maximum of 50 Gy; ⬍40% of the Yes 17 22
rectum to receive 40 Gy, with a dose maximum of 50 Gy; and Median 9 10
⬍35% of each kidney to receive ⱕ16 Gy, with dose maximum of Range 2–41 2–26
45 Gy. The IMRT plans were optimized to minimize the amount
Abbreviation: LVSI ⫽ lymphvascular involvement.
of PTV receiving ⬍95% of the prescribed dose and the amount
receiving ⬎110% of the prescribed dose.
These 8 patients had Stage III disease (Stage IIIC in 7 and Stage
Patient characteristics IIIA in 1). Patients were followed up after treatment with physical
Between April 2001 and February 2005, 47 patients with endo- examinations and cytology every 3 months for the first 2 years and
metrial cancer were treated with adjuvant IMRT and high-dose- every 6 months thereafter. Acute and late toxicities were graded
rate intracavitary brachytherapy. These were nonrandomly treated using the Radiation Therapy Oncology Group scale.
in the supine or prone position at the treating physicians’ discre-
tion. Of the 47 patients, 21 were treated in the prone position Statistical analysis
(Group 1) and 26 in the supine position (Group 2). The patient The Mann-Whitney U test was used for comparison of dose–
characteristics are given in Table 1. All patients had undergone volume histograms for normal structures. The calculation of the
total abdominal hysterectomy with or without pelvic and paraaor- actuarial rate of survival, local control, and toxicity was performed
tic lymph node dissection. The demographics, body mass index, using the Kaplan-Meier method. The chi-square method with
stage, histologic type, and type of surgery were comparable be- Fisher’s exact test was used for univariate analysis.
tween the two groups (Table 1). Seven patients had also received
adjuvant chemotherapy after RT completion (four in Group 1 and
three in Group 2). The indication for adjuvant chemotherapy was RESULTS
Stage III disease in 4 patients and unfavorable histologic features Outcome and toxicities
in 3 patients. The chemotherapy administered was paclitaxel and
The review of IMRT dosimetry showed excellent cover-
carboplatin for six cycles. The external beam radiation dose ad-
ministered was 45–50.4 Gy, and all patients received 10 Gy of
age of the PTV in both groups. The median PTV receiving
high-dose-rate vaginal cuff brachytherapy in two insertions. A 95% of the prescribed dose in Groups 1 (prone) and 2
vaginal cylinder was used for cuff brachytherapy and the upper 3 (supine) was 100% and 98.5%, respectively. The PTV re-
cm of the vagina was treated with the dose prescribed at 0.5 cm ceiving ⬎110% in Groups 1 and 2 was 1.5% and 2.5%,
from the surface of the cylinder. Four patients in each group were respectively. The percentage of volume receiving 10, 20, 30,
treated with an extended field to include the paraaortic region. 40, 45, and 50 Gy for small bowel was 89.5%, 69%, 33%,

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 IMRT for endometrial cancer ● S. BERIWAL et al. 487

Table 2. Comparison of dosimetry between groups

Group 1 (n ⫽ 21) Group 2 (n ⫽ 26)

Dosimetry Mean Median Range Mean Median Range p

Bladder
V10 99.50 100 93–100 99.20 100.0 89.5–100 0.567
V20 96.00 100 60–100 92.50 98.0 51.3–100 0.132
V30 79.50 85 29.2–100 71.10 76.5 30–100 0.154
V40 36.30 30 6.2–99 34.80 34.0 8–99 0.864
V45 19.80 13 1–80 17.70 14.0 1.5–92 0.607
V50 6.74 0 0–48 6.48 0.0 0–80 0.746
Rectum
V10 98.90 100 88–100 95.10 98.5 76–100 0.006
V20 95.70 100 61.8–100 89.00 95.0 68–100 0.019
V30 70.40 72 21.6–98 68.30 70.0 26.2–100 0.732
V40 24.00 13 2–94 25.30 20.0 7–58 0.314
V45 10.40 2.5 0–46 9.67 3.5 0–30 0.428
V50 3.13 0 0–16.7 2.47 0.0 0–20 0.756
Small bowel
V10 82.40 89.5 19.5–98 86.82 87.5 60–96 0.969
V20 62.30 69 15.4–85 61.60 62.7 36.9–87 0.806
V30 33.60 33 3.4–59 33.10 26.4 15–73 0.814
V40 12.90 12.2 0–25.7 12.60 8.0 3–46 0.549
V45 5.80 5 0–17.2 6.04 4.3 0.7–29 0.755
V50 1.43 0 0–9.5 1.16 0.0 0–9 0.806
PTV95 (%) 98.8 100.00 87–100 97.00 98.50 93–100 0.065
PTV110 (%) 6.00 1.50 0–45 9.90 2.50 0–45 0.325
PTV120 (%) 1.00 0.00 0–10 0.90 0.00 0–8 0.959

Abbreviations: V10 through V50 ⫽ percentage of volume receiving 10 Gy through 50 Gy, respectively; PTV95, PTV110, PTV120 ⫽
planning target volume receiving 95%, 110%, and 120% of prescribed dose, respectively.

12.2%, 5%, and 0% in Group 1 and 87.5%, 62.7%, 26.4%, 8%, multiple adhesions secondary to previous pelvic surgery,
4.3%, and 0% in Group 2, respectively (Table 2). These was treated with extended-field RT. The patient developed
differences were not statistically significant. Similarly, the a small bowel obstruction 12 months after treatment. She
dose–volume histograms for bladder and rectum were also
comparable, except for a slightly greater percentage of Table 3. Comparison of doses to absolute volumes of critical organs
volume receiving 10 Gy (1.5%) and 20 Gy (5%) for the
Volume (cm3)
rectum in the prone group, a statistically significant differ-
ence. To decrease the impact of the way the normal struc- Group 1 Group 2 p
tures are drawn on the planning CT scan, the absolute
volume of the normal structures receiving a dose of 10, 20, Small bowel
V10 1408 1064 0.093
30, 45, and 50 Gy were evaluated for the small bowel, V20 1080 821 0.085
rectum, and bladder and compared between the two groups. V30 620 438 0.161
The absolute volume of an organ receiving the defined dose V40 196.4 115.5 0.181
was comparable between the two groups, with no statisti- V45 70.8 45.1 0.375
cally significant differences (Table 3). V50 0 0 0.786
Rectum
Acute and chronic morbidity was compared between the V10 128 140.2 0.889
two groups. The median follow-up was 19 months (range, V20 128 121.9 0.661
6 – 40 months) in Group 1 and 20 months (range, 6 –52 V30 110 77.6 0.585
months) in Group 2. The treatment was well tolerated in V40 23 30.6 0.556
both groups, with a low incidence of morbidities. Acute V45 2.4 6.4 0.441
V50 0 0 0.689
small bowel toxicity was Grade 1 in 7 patients and Grade 2 Bladder
in 14 patients in Group 1 and was Grade 1 in 6 patients and V10 94.4 109.3 0.252
Grade 2 in 19 patients in Group 2. Similarly, chronic small V20 79.8 106.6 0.252
bowel toxicity was Grade 1 in 7 patients and Grade 3 in 1 V30 66.1 75.8 0.398
patient in Group 1 and Grade 1 in 5 patients in Group 2 V40 26 40.1 0.341
V45 6.9 18 0.352
(Table 4). This difference in toxicity was not statistically V50 0 0 0.804
significant. One patient in Group 1 (prone) had Grade 3
small bowel toxicity. This patient, who had a history of Abbreviations as in Table 2.

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488 I. J. Radiation Oncology ● Biology
Table 4. Comparison of gastrointestinal toxicities
between groups
Gastrointestinal
morbidity Group 1 Group 2
Acute
Grade 1 7 (33) 6 (23)
Grade 2 14 (67) 19 (73)
Chronic
Grade 1 7 (33) 5 (27)
Grade 2 0 (0) 0 (0)
Grade 3 1 (4.7) 0 (0)
was treated with surgical resection and had no complica-
tions thereafter. No patient in either group with pelvic
IMRT only developed any Grade 2 or worse toxicity. On
univariate analysis, none of the small bowel dosimetric
variables predicted for an increased risk of either acute or
late gastrointestinal morbidity. Similarly, no patient in ei-
ther group had chronic Grade 2 or worse bladder toxicity.
Two patients in Group 1 and four in Group 2 had Grade 1
bladder toxicity, not a statistically significant difference
between the two groups. No patient in either group had
pelvic, paraaortic, or vaginal recurrence.
DISCUSSION
Adjuvant pelvic RT is recommended for patients with
intermediate- and high-risk adenocarcinoma of the uterus
after surgery to decrease locoregional recurrence (1–3). The
standard RT techniques used to treat the pelvis after hys-
terectomy for carcinoma of the uterine corpus involve either
two or four fields. In these techniques, the cup-shaped tissue
volume produced by the pelvic floor and iliac lymph nodes
can only be irradiated by treatment of the entire pelvic
contents to the prescribed dose. Because conventional RT
techniques have not allowed for significant dose conforma-
tion, much effort has traditionally been directed toward
reducing the volume of irradiated small bowel by separating
it from the target region. Prone positioning with a custom-
ized belly board has been among the most common strate-
gies used to displace the small bowel from the pelvic
radiation ports and has been highly effective in pelvic RT
(4 –12). Small bowel volume reduction within the pelvic
treatment ports of 54 –70% has been achieved using this
technique compared with supine positioning (6 – 8).
Intensity-modulated RT is a new conformal RT technique
that can deliver a high radiation dose to an irregular CTV,
with relative sparing of adjacent normal tissues (18). Nu-
merous dosimetric and toxicity studies have demonstrated
the superiority of IMRT in whole pelvis treatment compared
with three-dimensional conformal planning. In our initial
comparative study, we found that the mean volume of small
bowel, rectum, and bladder receiving doses ⬎30 Gy was
reduced with IMRT by 52%, 66%, and 36%, respectively
(17). Similarly Mundt et al. (15, 16), found that the small
bowel volume treated to the prescription dose was reduced
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● Physics Volume 67, Number 2, 2007
by a factor of two using IMRT. In addition, the volume of
rectum and bladder was reduced by 23%. Almost all these
studies have used the supine position for immobilization for
p IMRT. No consensus has been reached on the treatment
position for pelvic IMRT. In a survey of the Gynecologic
IMRT Working Group, completed by 27 members (18 in the
0.52
0.52 United States, 4 in Europe, 3 in Asia, and 2 in Canada),
46%, 15%, and 39% recommended the supine position,
0.75 prone position, or either position, respectively (19). The
— present study investigated whether the combined effect of
0.44 small bowel displacement using the prone position and
IMRT would be better than the supine position with IMRT
in terms of small bowel dosimetry and toxicity.
One dosimetric study by Adli et al. (20) compared the
supine vs. prone position for pelvic IMRT using limited arc
and extended arc techniques. With the limited arc technique,
prone positioning significantly decreased the irradiated small
bowel volume at the 25–50-Gy dose level compared with
supine positioning. Small bowel volumes receiving ⱖ45 Gy
decreased from 19% to 12.5% (p ⫽ 0.005) with prone posi-
tioning. With the extended arc technique, the decrease in
irradiated small bowel volume was less marked, but remained
detectable at the 35– 45-Gy dose level. Small bowel volumes
receiving ⱖ45 Gy decreased from 13.6% to 10.1% (p ⫽ 0.03)
with prone positioning. The effect of prone positioning on the
large bowel and bladder was variable. Large bowel volumes
receiving ⱖ45 Gy increased with prone positioning from
16.5% to 20.6% (p ⫽ 0.02) in the limited arc technique and
was unaffected in the extended arc technique. In contrast, our
study did not show any difference in dosimetry. Our study was
different from their study in a number of factors. We used the
technique of sliding-window IMRT in contrast to the arc tech-
nique used by Adli et al. (20). The difference in technique may
have accounted for the different results. Second, the nonrandom-
ized nature of our study might have introduced minor imbalances
between the two groups. Although the individual effects of minor
imbalances might be small, when considered together, the imbal-
ances might have a larger impact that could have negated any
positive impact of the prone position.
Furthermore, in the study by Adli et al. (20), the dosi-
metric benefits seen with the prone position were very
small. Also, the setup uncertainties with the prone position
are greater than those with the supine position. The thor-
ough volume analysis related to setup reproducibility is not
available for the prone position. It may require a larger
margin for PTV expansion which could decrease any small
incremental benefit seen with prone positioning. Further-
more, the investigators commented that whether this incre-
mental improvement of small bowel sparing seen was clin-
ically significant for the ultimate reduction of small bowel
complications in gynecologic RT remains to be determined.
We evaluated the clinical toxicity differences between the
two groups and did not see any significant difference. This
could have resulted from the sample size being too small or
the short follow-up period.
In our study, even though we used a customized belly
board for prone positioning, we did not look at the specific
 IMRT for endometrial cancer
position of the belly board opening with respect to the
anatomy. In a study by Koelbl et al. (12) comparing differ-
ent positions of the lower border of the opening found that
if the lower border was near the lumbosacral junction, the
volume of small bowel irradiated was the lowest. Similarly,
other investigators have reported a decreased small bowel
dose with individualized, nonstandardized positioning of
the belly board opening with respect to the compression
device (5, 6). In a small study of individualized small bowel
displacement system-assisted IMRT for cervical cancer,
investigators found that it significantly reduced the small
bowel volume within the pelvic radiation field (21). This
difference in positioning in the prone position may be the
reason we did not see any difference in dosimetry between
the two approaches.
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● S. BERIWAL et al. 489
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