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Treatment Planning Considerations for Shoulder Osteoarthritis: An Introduction into Low

Dose Radiotherapy for Large Joints
Madeleine Booth M.S., R.T.(R)(T), Joseph M. Bryant, M.S., Meshan C. Curry M.S., R.T.(R)(T),
Nishele Lenards, PhD, CMD, R.T.(R)(T), FAAMD, Ashley Hunzeker, M.S., CMD
University of Wisconsin-La Crosse Medical Dosimetry Program
Introduction
Osteoarthritis (OA) is a common disease that causes inflammation and degeneration of
joint tissue. In 2017, the Centers for Disease Control (CDC) stated that 23%, or 54 million
people in the United States had been diagnosed with the disease.1 Due to the aging population
and genetic predispositions, the incidence rate of osteoarthritis is expected to increase. 2
Conventional medical treatment options may not be beneficial to some patients. Some research
has shown that even after standard of care treatment, 25% of patients either have no response, or
lose their response over time.3 The use of low dose radiotherapy (LDRT) is a common treatment
option for osteoarthritis in Germany. Clinical results demonstrate that LDRT can alleviate the
painful symptoms caused by degenerative diseases like OA and that the results of this treatment
are improved when compared to conventional treatment methods.2
Currently, there is an alternative treatment method in use that incorporates radiation,
known as radiosynoviorthesis. This is the process of injecting radiocolloid-emitting beta particles
into the joint space.6 These injected radiopharmaceuticals are phagocytized by the macrophages
in the synovial membrane.7 These macrophages are the cause of the inflammatory response that
results in pain felt by individuals who suffer from arthritis. However, this method can take up to
6 months for patients to notice the effects of the treatment.6,7 Similarly, LDRT affects the
inflammatory response to arthritic joint conditions and reduces pain.8,9 Currently, patients are
treated for osteoarthritis of the shoulder with a dose of 300 cGy in 6 fractions (fx). While there
are currently no multinational guidelines for treating shoulder osteoarthritis with radiation, this
dose is based on the 2018 German Society for Radiation Oncology (DEGRO) recommendation
and prior research.3,5 Lower dosages of LDRT, such as 50 cGy per fraction, have been shown to
have equivalent treatment outcomes when compared to higher dosages. A randomized clinical
trial by Ott et al.5 demonstrated that a single fraction of lower dose LDRT (50 cGy) provided
equivalent therapeutic benefit when compared to a single fraction at a dose of 100 cGy.2,3.
However, the prescribed radiation dose is determined by the radiation oncologist and is patient
specific.
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Osteoarthritis is a painful, degenerative disease that affects the tissues of the joint spaces,
such as the shoulder. Conventional medical treatment options, such as corticosteroid injections,
are not always sufficient to alleviate the symptoms from this disease. Low dose radiotherapy is a
newer treatment option for patients with shoulder osteoarthritis and has shown positive
outcomes. However, the problem is that there is a paucity of literature about treatment planning
considerations for this new treatment option. The purpose of this case study is to provide an
overview of treatment planning techniques and considerations for shoulder osteoarthritis.
Treatment techniques for shoulder LDRT, such as treatment field borders, current dosages, beam
arrangements, and appropriate beam energy, are discussed. Additionally, any special
considerations for shoulder radiotherapy are highlighted in detail.
Case Description
Patient Selection and Setup
An eligibility criterion was determined for patients to receive LDRT for OA. The
inclusion criteria were completion of a prior course of curative radiation therapy and chronic
osteoarthritis that had not been alleviated with traditional methods. The simulation process
included a planning CT scan with the patient in a reproducible and comfortable position. For
LDRT to the shoulder joint, the patient was setup on a Q-fix wing board, headrest level of 3,
with an immobilization Vac-lok to keep the patient’s upper body and shoulders flush with
minimum variation for daily treatment. A knee sponge was provided for comfort and the
patient’s feet were banded. The patient’s head was also turned away from the treatment area to
ensure precise delivery to only the clinical target volume (CTV) and planning target volume
(PTV).
Anatomical Contouring
The anatomical contours that were delineated included target structures and organs at
risk. The CTV for the shoulder included the joint space and all articular surfaces in the treatment
field. The medical dosimetrist or radiation oncologist contoured the PTV (Figure 1). A planning
target volume (PTV) margin of 0.8 cm was added to ensure coverage of the CTV. The OAR that
were of interest included the ipsilateral lung and spinal cord. Protection of these OAR was
especially important to reduce the likelihood of a secondary malignancy and injury. To ensure
that the OAR was not included in the treatment area, daily kilovoltage (KV-KV) setup films
were performed, as well as megavoltage (MV) port films on the 1st day of treatment.
Treatment Planning
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The treatment planning process consisted of the development of a 3-dimensional

treatment plan for the left shoulder by the medical dosimetrist. The treatment fields employed
were parallel opposed obliques with multi-leaf collimation (MLC) for adequate blocking of
normal tissue (Figure 2). The right anterior oblique (RAO) had a gantry angle of 350° and a
collimator angle of 30°. The left posterior oblique (LPO) had a gantry angle of 170° and a
collimator angle of 330°. A couch angle of 0° was utilized for both fields. The energies selected
were 6 MV for the RAO and 10 MV for the LPO. The radiation dose prescribed for the shoulder
joint was 300 cGy in 6 fractions. The constraints used for the OAR are those recommended by
the Radiation Therapy Oncology Group (RTOG) for conventional fractionation. Specifically, the
ipsilateral lung should receive less than or equal to 20 Gy and the spinal cord should receive less
than or equal to 45 Gy.
Plan Analysis and Evaluation
The initial patient treated with this radiation prescription successfully completed
treatment with no side effects, other than mild fatigue. The patient’s total PTV coverage was
acceptable to the radiation oncologist, and the OAR doses were within acceptance of the RTOG
guidelines (Table 1). The patient’s follow up documents detailed successful relief of OA
symptoms and increased functionality in most daily activities.
Conclusion
Low dose radiotherapy for OA has the potential to be incorporated into the workflow for
medical dosimetrists. Other large joints that have successfully received LDRT with minimum
side effects are the hip joint, bilateral sacroiliac joint (SI) joints, and bilateral knee joints (Table
2). Limited research has been completed on the possibility of re-treatment of these areas for
those dealing with OA symptoms. Future investigation on the potential of this approach, any
associated risks, and physician concerns is recommended.
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References

1. Abdus-Salam AA, Olabumuyi AA, Jimoh MA, Folorunso SA, Orekoya AA. The role of
radiation treatment in the management of inflammatory musculoskeletal conditions: a
revisit. Radiat Oncol J. 2020;38(3):151-161. http://doi.org/10.3857/roj.2020.00178
2. Weissmann T, Rückert M, Putz F, et al. Low-dose radiotherapy of osteoarthritis: from
biological findings to clinical effects-challenges for future studies. Strahlenther Onkol.
2023;10.1007/s00066-022-02038-6. http://doi.org/10.1007/s00066-022-02038-6
3. Donaubauer A-J, Zhou J-G, Ott OJ, et al. Low dose radiation therapy, particularly with
0.5 Gy, improves pain in degenerative joint disease of the fingers: results of a
retrospective analysis. Int J of Mol Sci. 2020;21(16):5854.
http://doi.org/10.3390/ijms21165854
4. Ehlich H, Kresnik E, Klett R, Freudenberg LS, Kampen WU. Intra-articular treatment of
digital osteoarthritis by radiosynoviorthesis-clinical outcome in long-term follow-up. Clin
Nucl Med. 2022;47(11):943-947. http://doi:10.1097/rul.0000000000004322
5. Ott, O.J., Micke, O., Mücke, R. et al. Low-dose radiotherapy: mayday, mayday. we’ve
been hit! Strahlenther Onkol. 2019;195:285–288. http://doi.org/10.1007/s00066-018-
1412-1
6. Dove APH, Cmelak A, Darrow K, et al. The use of low-dose radiation therapy in
osteoarthritis: a review. Int J Radiat Oncol Biol Phys. 2022;114(2):203-220.
http://doi.org/10.1016/j.ijrobp.2022.04.029
7. Kampen WU, Boddenberg-Pätzold B, Fischer M, et al. The EANM guideline for
radiosynoviorthesis. Eur J Nucl Med Mol Imaging. 2022;49(2):681-708.
http://doi.org/10.1007/s00259-021-05541-7
8. Rühle A, Tkotsch E, Mravlag R, et al. Low-dose radiotherapy for painful osteoarthritis of
the elderly: a multicenter analysis of 970 patients with 1185 treated sites. Strahlenther
Onkol. 2021;197(10):895-902. http://doi.org/10.1007/s00066-021-01816-y
9. Weissmann T, Rückert M, Zhou JG, et al. Low-dose radiotherapy leads to a systemic
anti-inflammatory shift in the pre-clinical K/BxN serum transfer model and reduces
osteoarthritic pain in patients. Front Immunol. 2022;12:777792.
http://doi.org/10.3389/fimmu.2021.777792

Figures
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Figure 1. Planning tumor volume (PTV) contour of shoulder and organs at risk (OAR). Figure
(A) demonstrates the left anterior oblique (LAO) view and Figure (B) displays the left posterior
oblique (LPO) view.

Figure 2. Image of isodose coverage of PTV

Tables
Table 1. Initial Patient Treatment Planning Dose Statistics for LDRT to the Shoulder
Mean Dose Maximum Dose Minimum Dose
PTV Coverage (V= 101.7% (305.1 cGy) 110% (330.1 cGy) 82.5% (247.4 cGy)
108.3 cm3)
Ipsilateral Lung 0.5% (1.4 cGy) 2.6% (7.9 cGy) 0.1% (0.3 cGy)
Dose (V= 1450.8 cm3)
Spinal Cord Dose 0.2% (0.5 cGy) 0.3% (0.9 cGy) 0.1% (0.2 cGy)
(V= 33.7 cm3)
Abbreviations: cGy, centigray; PTV, planning tumor volume; V, volume.
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Table 2. Additional Large Joints Treated for Osteoarthritis

Treatment Site for Prescribed OAR Constraints
OA Radiation Dose (Gy)
(cGy) (RTOG)

Hip Joint 300 cGy (50/6x) Bladder V80 < 15%

V75 < 25%
V70 < 35%
V65 < 50%

Femoral Heads Dmax < 50 Gy

Rectum V75 < 15%

V70 < 25%
V65 < 35%
V60 < 50%

Small Bowel Dmax < 50 Gy

Bilateral SI Joints 300 cGy (50/6fx) Bladder V80 < 15%

V75 < 25%
V70 < 35%
V65 < 50%

Femoral Heads Dmax< 50 Gy

Rectum V75 < 15%

V70 < 25%
V65 < 35%
V60 < 50%

Small Bowel Dmax < 50 Gy

Bilateral Knee
600 cGy (100/6fx) N/A N/A
Joints
Abbreviations: cGy, centigray; Dmax, dose maximum; FX, fractions; GY, gray; OA, osteoarthritis; RTOG, Radiation Therapy Oncology Group;
V, volume.