title: The use of rectal balloon during the delivery of intensity modulated radiotherapy (IMRT) for prostate cancer: more than just a prostate gland immobilization device?
abstract: OBJECTIVE
  The purpose of this study was to investigate the role of a rectal balloon for prostate immobilization and rectal toxicity reduction in patients receiving dose-escalated intensity-modulated radiotherapy for prostate cancer.
  
  
  METHODS
  Patients with localized prostate cancer who were undergoing intensity-modulated radiotherapy were treated in a prone position, immobilized with a customized Vac-Lok bag (MED-TEC, Orange City, IA). A rectal balloon with 100 cc of air was used to immobilize the prostate. The prostate displacements were measured using computed tomography (CT)-CT fusion on 10 patients who received radioactive seed implant before intensity-modulated radiotherapy. They were scanned twice weekly during 5 weeks of intensity-modulated radiotherapy, and breathing studies were also performed. Rectal toxicity was evaluated by use of Radiation Therapy Oncology Group scoring in 100 patients. They were treated to a mean dose of 76 Gy over 35 fractions (2.17-Gy fraction size). Dose-volume histogram of the rectum was assessed. A film phantom was constructed to simulate the 4-cm diameter air cavity that was created by the rectal balloon. Kodak XV2 films (Rochester NY) were used to measure and compare dose distribution with and without the air cavity. A fraction of 1.25 Gy was delivered to the phantom at isocenter with 15-MV photons by use of the NOMOS Peacock system and the MIMiC treatment delivery system (Sewickley, PA).
  
  
  RESULTS
  The anterior-posterior and lateral prostate displacements were minimal, on the order of measurement uncertainty (approximately 1 mm). The standard deviation of superior-inferior displacement was 1.78 mm. Breathing studies showed no organ displacement during normal breathing when the rectal balloon was in place. The rectal toxicity profile was very favorable: 83% (83/100) patients had no rectal complaint, and 11% and 6% had grade 1 and 2 toxicity, respectively. Dose-volume histogram analysis revealed that in all of the patients, no more than 25% of the rectum received 70 Gy or greater. As visualized by film dosimetry, the dose at air-tissue interface was approximately 15% lower than that without an air cavity. The dose built up rapidly so that at 1 and 2 mm, the differential was approximately 8% and 5%, respectively. The dosimetric coverage at the depth of the posterior prostate wall was essentially equal, with or without the air cavity.
  
  
  CONCLUSIONS
  The use of a rectal balloon during intensity-modulated radiotherapy significantly reduces prostate motion. Prostate immobilization thus allows a safer and smaller planning target volume margin. It has also helped spare the anterior rectal wall (by its dosimetric effects) and reduced the rectal volume that received high-dose radiation (by rectal wall distension). All these factors may have further contributed to the decreased rectal toxicity achieved by intensity-modulated radiotherapy, despite dose escalation and higher-than-conventional fraction size.
authors.affiliation: Department of Radiology/Section of Radiation Oncology, Baylor College of Medicine, The Methodist Hospital, Houston, Texas, USA.
authors.forename: Bin S
authors.initials: BS
authors.lastname: Teh
authors.forename: John E
authors.initials: JE
authors.lastname: McGary
authors.forename: Lei
authors.initials: L
authors.lastname: Dong
authors.forename: Wei-Yuan
authors.initials: WY
authors.lastname: Mai
authors.forename: L Steve
authors.initials: LS
authors.lastname: Carpenter
authors.forename: Hsin H
authors.initials: HH
authors.lastname: Lu
authors.forename: J Kam
authors.initials: JK
authors.lastname: Chiu
authors.forename: Shiao Y
authors.initials: SY
authors.lastname: Woo
authors.forename: Walter H
authors.initials: WH
authors.lastname: Grant
authors.forename: E Brian
authors.initials: EB
authors.lastname: Butler
mesh_terms: D002404:Catheterization / Q000379:methods*; D019583:Dose Fractionation, Radiation; D004307:Dose-Response Relationship, Radiation; D006801:Humans; D007103:Immobilization; D008297:Male; D011471:Prostatic Neoplasms / Q000532:radiotherapy*; D011874:Radiometry; D020266:Radiotherapy, Conformal / Q000009:adverse effects / Q000379:methods*; D012007:Rectum / Q000528:radiation effects