Research Proposal

Working Title
Treatment planning considerations in low dose radiotherapy for shoulder arthritis
Problem Statement
Osteoarthritis is a painful, degenerative disease that affects the tissues of joints, such as the
shoulder. Sometimes conventional medical treatment options, such as corticosteroid injections,
are not 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.
Purpose Statement
The purpose of this case study is to provide an overview of treatment planning techniques and
considerations for shoulder osteoarthritis.

Hypotheses Statements or Research Questions

Q1: What are some of the treatment planning considerations for shoulder osteoarthritis low dose
radiotherapy?
A. Consider collimator rotation to keep breast tissue out of treatment field
B. Consider thyroid shield
Q2: What treatment techniques are used for this new treatment option?
A. 3D conformal planning technique is used most often – POP
B. Treatment field borders
a. Superior: 2 cm above coracoid process (AP)/acromion (PA)
b. Lateral: 2-cm lateral to humeral greater tuberosity
c. Inferior: 2 cm below surgical neck of humerus
d. Medial: 2-cm medial to glenoid cavity
C. Energy: 6MV
D. Dose: 0.5 Gy in 6 fractions QOD or BIW prescribed to midpoint
Summary
Osteoarthritis (OA) is a common disease that causes inflammation and degeneration of
joint tissue. In 2017, the CDC stated that 23 percent, or 54 million people (about twice the
population of Texas) 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
continue to increase.2 Conventional medical treatment options may not be beneficial to some
patients. Some studies, such as one conducted by Donaubauer A-J et al, show that even after
typical intervention, 25 percent 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
utilized in some countries, such as Germany. Clinical results demonstrate that LDRT can
alleviate the painful symptoms caused by degenerative diseases like OA.2 These studies also
demonstrate that this response is more durable when compared to conventional treatment
methods, which could reduce the clinical burden of treating this disease. 3,4 Lower dosages of
LDRT, such as 50cGy per fraction, have been shown to have equivalent treatment outcomes
when compared to higher dosages. A randomized clinical trial carried out by Ott et al.
demonstrated that a single fraction of lower dose LDRT (50cGy) provided equivalent
therapeutic benefit when compared to a single fraction at a dose of 100cGy. 2,3

Currently at Blue Ridge Radiation Oncology in Anderson, SC, patients are being treated
for osteoarthritis of the shoulder with a dose of 300cGy in 6 fractions (50cGy per fraction).
While there are currently no guidelines for treating shoulder osteoarthritis with radiation, this
dose is based on the 2018 DEGRO level of recommendation and prior research. 3,5 The eligibility
criteria at Blue Ridge Radiation Oncology center are that patients have had previous curative
radiation therapy treatment, in the past five years, and suffer from chronic osteoarthritis that
has not been alleviated with traditional methods. This is a new treatment method in the
American clinical setting, but we feel that it has potential to grow much larger due to the
increasing number of affected individuals and the positive outcomes from the treatment.

There are already some alternative treatment methods in use that incorporate
radiation, such as radiosynoviorthesis. This is the process of injecting, into the joint space, a
radiocolloid emitting beta particles.6 These injected radiopharmaceuticals are phagocytized by
the macrophages in the synovial membrane. These macrophages are the cause of the
inflammatory response that results in pain felt by people who suffer from arthritis. However,
this method can take up to six months for patients to notice the effects of the treatment. 6,7
Similarly, low dose radiation therapy affects the bodies inflammatory response to arthritic joint
conditions and reduces the inflammation and pain.8,9 This treatment method shows many
benefits over conventional methods of arthritis treatments and if LDRT becomes more
prevalent, it could change the field of radiation oncology greatly.

Osteoarthritis is a painful, degenerative disease that affects the tissues of joints, such as
the shoulder. Sometimes conventional medical treatment options, such as corticosteroid
injections, are not 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 low dose radiotherapy; such as
treatment field borders, current dosages, beam arrangements, and appropriate beam energy,
will be discussed. Additionally, any special considerations for shoulder radiotherapy will be
highlighted in detail.
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.
doi: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. doi:10.1007/s00066-022-02038-6
3. Donaubauer A-J, Zhou J-G, Ott OJ, Putz F, Fietkau R, Keilholz L, Gaipl US, Frey B,
Weissmann T. Low Dose Radiation Therapy, Particularly with 0.5 Gy, Improves Pain
in Degenerative Joint Disease of the Fingers: Results of a Retrospective Analysis.
International Journal of Molecular Sciences. 2020; 21(16):5854.
https://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.
doi:10.1097/RLU.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. https://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.
doi: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.
doi: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. doi: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. Published
2022 Jan 3. doi:10.3389/fimmu.2021.777792