title: Fractionated, three-dimensional, planning-assisted proton-radiation therapy for orbital rhabdomyosarcoma: a novel technique.
abstract: OBJECTIVE
  Most children with orbital rhabdomyosarcoma will survive their disease. However, conventional photon-radiation treatment, as part of multimodality therapy, results in varying degrees of long-term functional and cosmetic side effects. This report introduces external beam proton radiation therapy (PRT) as a conformal, three-dimensional planned radiation technique for this disease, analyzes normal tissue dosimetry, and describes the technique's application in the first 2 patients.
  
  
  METHODS
  Between January 1995 and February 1996, 2 patients underwent PRT following biopsy and chemotherapy for orbital rhabdomyosarcoma. Fifty and 55 Cobalt Gray Equivalent (CGE) were delivered to the gross tumor volume and 40 CGE to clinical target volumes in both patients. A relative biologic effectiveness (RBE) of 1.1 was utilized to correlate proton dose calculations with CGE. To achieve dose conformity, a "patch technique" was utilized, where target regions were divided into segments, each treated by a separate proton field. Dose-volume histograms were obtained for target and nontarget regions, including lens, bony orbit, pituitary gland, optic chiasm, optic nerves, lacrimal gland, and ipsilateral frontal and temporal lobes.
  
  
  RESULTS
  At 3.4 and 2.5 years after PRT, both patients are clinically and radiographically free of disease. Visual acuity remains excellent, without signs of cataract formation; pituitary function is normal; cosmetically, only mild enophthalmos is noticeable. Doses to 90%, 50%, and 5% of lens volume were kept at less than 1%, less than 2%, and less than 8%, respectively. Fifty percent of lacrimal gland volume received less than 36% of the prescribed dose and 50% of the volume of the optic chiasm, pituitary gland, and hypothalamus were restricted to less than 2%. Proton conformity to orbital contents resulted in between 9% and 36% of the prescribed dose reaching the ipsilateral temporal and frontal lobes immediately adjacent to bony orbit (5% volume).
  
  
  CONCLUSIONS
  PRT can offer excellent sparing of lens and selected intraorbital and ocular normal structures, while maintaining conformal target-dose coverage. The steep dose gradient beyond the orbit minimizes irradiation of normal brain parenchyma, with almost complete sparing of the pituitary gland. Reduction of integral irradiation exposure of the periorbital region will, hopefully, reduce the risk of second malignancy later in life. Reduced radiation dose to specific organs in close proximity to, but not part of the target region promises improved functional outcome and better cosmesis for childhood cancer survivors.
authors.affiliation: Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA. ehug@dominion.llumc.edu
authors.forename: E B
authors.initials: EB
authors.lastname: Hug
authors.forename: J
authors.initials: J
authors.lastname: Adams
authors.forename: M
authors.initials: M
authors.lastname: Fitzek
authors.forename: A
authors.initials: A
authors.lastname: De Vries
authors.forename: J E
authors.initials: JE
authors.lastname: Munzenrider
mesh_terms: D002648:Child; D019583:Dose Fractionation, Radiation; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D009915:Orbit / Q000000981:diagnostic imaging; D009918:Orbital Neoplasms / Q000000981:diagnostic imaging / Q000532:radiotherapy*; D061766:Proton Therapy; D020266:Radiotherapy, Conformal / Q000379:methods*; D012208:Rhabdomyosarcoma / Q000000981:diagnostic imaging / Q000532:radiotherapy*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D011522:Protons
chemical_list: D011522:Protons