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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

I. Abstract
II. Introduction
A. PI: History of osteoarthritis, statistical data on the population affected, and the
current standard of care for the degenerative joint disease (Reference: Abdus-
Salam et al,1 Weissmann et al,2 Donaubauer et al3)
B. PII: Recent descriptions of prescription doses used globally to treat osteoarthritis
with radiotherapy (Reference: Abdus-Salam et al,1 Weissmann et al,2 Donaubauer
et al,3 Ehlich et al4)
C. PIII: Details of current radiation prescription doses used for shoulder arthritis and
history of treatments for osteoarthritis utilizing radiation (Reference: Donaubauer
et al,3 Ott et al,5 Dove et al,6 Kampen et al7)
D. PIV: Summarize introduction and introduce treatment planning considerations for
shoulder low dose radiotherapy treatments (Reference: Rühle et al,8 Weissmann et
al9)
1. Problem: Sometimes conventional medical treatment options are insufficient
to alleviate the symptoms from osteoarthritis.
2. Purpose: This case study provides an overview of treatment planning
techniques and considerations for shoulder osteoarthritis and information on
other possible subsequent treatment areas.
III. Case Description
A. Patient Selection
1. PI: Inclusion Criteria
a. Osteoarthritis diagnosis
b. Previous radiotherapy treatment
2. PII: Simulation procedures
a. Simulation setup details
B. Target Delineation (Figure 1)
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1. PI: Targets (joint space, articular surfaces) & OR (ipsilateral lung and spinal
cord)
2. PII: KV-KV daily setup films; MV port film 1st day of treatment
C. Treatment Planning
1. PI: Planning Details (Figure 2)
a. Field arrangement for shoulder joint
b. Prescription dose, fractions, and isodose coverage
2. PII: OR Constraints
a. Ipsilateral Lung V20 and Dmean < 20 Gy
b. Spinal Cord Dmax < 45 Gy
3. Patient 1 Results (Table 1)
a. Total target coverage
b. Ipsilateral lung dosage
c. Spinal cord dosage
4. Summary of results
a. Follow-up results of initial patient
IV. Conclusion
A. PI: Summary of treatment details and results
B. PII: Details of other areas that received RT for OA (Table 3)
C. PIII: Limitations/future research
1. Limitations: information on re-treatment of OA treatment areas
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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 [published online
ahead of print, 2023 Jan 5]. Strahlenther Onkol. 2023;10.1007/s00066-022-02038-6.
http://doi.org/10.1007/s00066-022-02038-6
3. Donaubauer AJ, Zhou JG, Ott OJ, Putz F, Fietkau R, Keilholz L, 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 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/RLU.0000000000004322
5. Ott OJ, 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.org10.1016/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
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Figures

Figure 1. CTV contour of shoulder and OAR. Figure (A) demonstrates the LPO view and Figure
(B) displays the RAO view.

Figure 2. Images of isodose coverage of PTV

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Tables
Table 1. OAR for LDRT to Shoulder Joint
Abbreviations: LDRT, low dose radiotherapy; RTOG, Radiation Therapy Oncology Group.

OAR Constraints (Gy)

Ipsilateral Lung V20 and Dmean ≤ 20 Gy (RTOG)
Spinal Cord Dmax ≤ 45 Gy (RTOG)

Table 2. Initial Patient Dose Volumes

Mean Dose: 101.7% (305.1 cGy); Max dose:

PTV Coverage (volume 108.3 cm ) 3
110% (330.1 cGy); Min Dose: 82.5% (247.4
cGy) (95% received 97.3% of Rx)

Mean Dose: 0.5% (1.4 cGy); Max dose:

Ipsilateral Lung Dose (volume 1450.8 cm3)
2.6% (7.9 cGy); Min Dose: 0.1% (0.3 cGy)

Mean Dose: 0.2% (0.5 cGy); Max dose:

Spinal Cord Dose (volume 33.7 cm3)
0.3% (0.9 cGy); Min Dose: 0.1% (0.2 cGy)

Table 3. Additional Large Joints Treated for Osteoarthritis

Abbreviations: FX, fractions; RTOG, Radiation Therapy Oncology Group; V, volume.

Treatment Site Prescribed OAR Constraints

for OA Radiation Dose (Gy)
(cGy) (RTOG)
Hip Joint 300 cGy (50/6fx) Bladder V80 < 15%,
V75 < 25%,
V70 < 35%,
V65 < 50%

Dmax< 50Gy
Femoral Heads
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V75 < 15%,

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

Dmax<50 Gy

Small Bowel
Bilateral SI 300 cGy (50/6fx) Bladder V80 < 15%,
Joints V75 < 25%,
V70 < 35%,
V65 < 50%

Dmax< 50Gy
Femoral Heads

V75 < 15%,

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

Dmax<50 Gy
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Small Bowel
Bilateral Knee 600 cGy N/A N/A
Joints (100/6fx)