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An Introduction to Low Dose Radiation Therapy for Shoulder Osteoarthritis

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, Ashley
Cetnar, PhD, DABR
University of Wisconsin-La Crosse Medical Dosimetry Program
Abstract
Osteoarthritis (OA) 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 and anti-inflammatory medications, 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 was to provide an example of treatment planning techniques and considerations
for shoulder osteoarthritis. The Clinical Target Volume (CTV) and organs at risk (OAR) such as
the ipsilateral lung, breast, brachial plexus, and spinal cord, were contoured to develop a
treatment plan with the goal to keep OAR doses as low as reasonably achievable. Daily
kilovoltage (kV) images were acquired before treatment to verify patient setup and megavoltage
(MV) portal images were acquired to document treatment field delivery. Radiotherapy of the
shoulder relieved OA symptoms and improved daily activities for the patient. Low dose radiation
therapy for OA has the potential to become a widely used treatment option for those suffering
with the disease and has the potential to be incorporated into the routine treatment planning for
medical dosimetrists.
Keywords: Osteoarthritis, Low Dose Radiation Therapy, Benign Conditions
Introduction
Osteoarthritis (OA) is a common disease that causes inflammation and degeneration of
joint tissue. In 2020, the Centers for Disease Control (CDC) stated that over 32 million
Americans are affected by osteoarthritis.1 According to the World Health Organization (WHO),
OA is the fastest increasing health condition and the second leading cause of disability in the
United States.1 Due to the aging population and genetic predispositions, the incidence rate of OA
is expected to increase.2 Some researchers have shown that even after standard of care
treatments, such as corticosteroid injections and anti-inflammatory medications, 25% of patients
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either have no response or lose their response over time.3 Therefore, conventional medical
treatment options may not be beneficial to some patients due to unpredictable immune or
biological response.4 Unfortunately, it is estimated that 1 in 10 adults will endure the physical
limitations caused by arthritis-related conditions by the year 2040, but alternative treatment
methods may help ease this burden.4 One possible alternative treatment method,
radiosynoviorthesis, involves injecting radiocolloid-emitting beta particles into the joint space to
decrease the inflammatory response in osteoarthritic patients.5 However, this method can take up
to 6 months for patients to notice the effects of the treatment.5,6 Low dose radiation therapy
(LDRT), another alternative therapy, affects the inflammatory response to arthritic joint
conditions and has shown promising results in pain reduction.7,8
For inflammatory conditions such as OA, published clinical results show superior pain
relief and functional outcomes with LDRT as compared to conventional treatments.2 The use of
LDRT is a popular treatment option for OA in Germany; however, there are no published clinical
trials evaluating its use in the United States. In Germany, patients are treated for OA of the
shoulder with a total dose of 300 cGy in 6 fractions (fx). While there are currently no
multinational guidelines for treating shoulder OA with radiation, this prescription is based on the
2018 German Society for Radiation Oncology (DEGRO) recommendation and prior research.3,6
Lower single fraction doses of LDRT have been shown to have equivalent treatment outcomes
when compared to higher dosages. For example, a randomized clinical trial by Ott et al8
demonstrated that a single fraction of LDRT (50 cGy) provided equivalent therapeutic benefit
when compared to a single fraction dose of 100 cGy.2,3 Additionally, a total dose of LDRT (300
cGy) given 2-3 times per week for 6 weeks yielded equivalent therapeutic outcomes when
compared to a higher total dose of 600 cGy given 2-3 times per week for 6 weeks.8 However, the
prescribed radiation dose is determined by the radiation oncologist and is patient specific.
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
and anti-inflammatory medications, 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 was to provide an example of treatment planning techniques and considerations
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for shoulder osteoarthritis. Treatment techniques for shoulder LDRT, such as treatment field
borders, prescribed dose, beam arrangements, appropriate beam energy, and special
considerations are discussed.
Case Description
Patient Setup
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, CIVCO headrest level of 3, and an immobilization Vac-lok to keep the patient’s upper
body and shoulders flush with minimum positional 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 the target volume and reduce
unnecessary exposure to the OAR in the head and neck region.
Anatomical Contouring
The anatomical contours delineated included target structures and OAR. The clinical
target volume (CTV) for the shoulder included the joint space and all articular surfaces in the
treatment field. The radiation oncologist contoured the CTV. A planning target volume (PTV)
margin of 0.8 cm was added to ensure coverage of the CTV (Figure 1). The OAR that were of
interest included the ipsilateral lung, breast, brachial plexus, and spinal cord. Protection of these
OAR was essential to reduce the likelihood of a secondary malignancy.
Treatment Planning
The treatment planning process consisted of the development of a 3-dimensional
treatment plan for the left shoulder by the medical dosimetrist. Dove et al1 recommended parallel
opposed anterior-posterior beams for shoulder osteoarthritis LDRT. The treatment fields
employed for this case study were parallel opposed obliques with multi-leaf collimation (MLC)
for adequate blocking of normal tissue, and oblique beams with collimator rotation were used
because of the patient’s anatomy and positioning (Figure 2). Tilting the gantry angle slightly and
rotating the collimator allowed the medical dosimetrist to minimize the amount of lung and
breast tissue within the treatment field. 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. To maintain acceptable dose
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homogeneity within the target volume, a 15º enhanced dynamic wedge (EDW) was utilized on
the RAO beam. This allowed for proper coverage of the PTV and lower dose to OAR. The
radiation dose prescribed for the shoulder joint was 300 cGy in 6 fractions. The patient’s PTV
coverage was acceptable to the radiation oncologist with low doses to the OAR (Table 1). Due to
the dearth of research regarding the late effects of LDRT for OA, there are no specific dose
constraints for these procedures and OAR dose constraints for this treatment since the total
prescription dose is only 300 cGy. The medical dosimetrist followed the ALARA principle to
maintain low doses to the ipsilateral lung, brachial plexus, breast, and spinal cord.
Treatment Delivery
To ensure proper daily setup and exclusion of OAR from the treatment area, daily
orthogonal kilovoltage (kV) setup films were performed prior to treatment. In addition,
megavoltage (MV) port films were performed on the first day of treatment and approved by the
radiation oncologist prior to the second fraction. The port films provided verification for proper
MLC blocking on each field. After the initial imaging, treatment was successfully delivered to
the patient.
Treatment Summary
Throughout the duration of LDRT treatment for OA, the patient experienced no adverse
side effects and mentioned feeling relief of OA symptoms while still under treatment. The
patient in this case study successfully completed treatment and followed up with the radiation
oncologist after four weeks. The patient’s follow up documents detailed successful relief of OA
symptoms and increased functionality in daily activities.
Conclusion
Because the incidence of OA is expected to become more prevalent and current medical
treatment options are sometimes unable to provide symptom-free alleviation of OA symptoms,
LDRT could be a solution to this challenge.2 The problem is that there is a paucity of literature
about treatment considerations for this new treatment option. The purpose of this case study was
to inform medical dosimetrists of the treatment planning details of LDRT for OA treatment.
Although this practice has yet to be widely adopted within the United States, it is possible that
LDRT for OA has the potential to be incorporated into the routine treatment planning for medical
dosimetrists. Limited research has been completed on the possibility of other treatment sites and
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re-treatment for those experiencing OA symptoms. Future investigation on the potential of this
approach and any associated risks is recommended.
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References
1. 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
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. 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/10.3390/ijms21165854
5. 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.org/10.1097/rul.0000000000004322
6. 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
7. 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
8. 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
9. 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
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Figures

Figure 1. Planning target volume (PTV) contour of shoulder and OAR. Figure (A) demonstrates
the right anterior oblique (RAO) view and Figure (B) displays the left posterior oblique (LPO)
view.

Figure 2. Image of prescription isodose coverage of PTV in red.

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Tables
Table 1. Patient Treatment Planning Dose Statistics for LDRT to the Shoulder.
Mean Dose Maximum Dose Minimum Dose
PTV Coverage
101.7% (305.1 cGy) 110% (330.1 cGy) 82.5% (247.4 cGy)
(V=108.3 cm3)
Ipsilateral Lung Dose
0.5% (1.4 cGy) 2.6% (7.9 cGy) 0.1% (0.3 cGy)
(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, centi-gray; cm3, cubic centimeters; PTV, planning target volume; V, volume.