title: Finding dose-volume constraints to reduce late rectal toxicity following 3D-conformal radiotherapy (3D-CRT) of prostate cancer.
abstract: OBJECTIVE
  The rectum is known to display a dose-volume effect following high-dose 3D-conformal radiotherapy (3D-CRT). The aim of the study is to search for significant dose-volume combinations with the specific treatment technique and patient set-up currently used in our institution.
  
  
  METHODS
  We retrospectively analyzed the dose-volume histograms (DVH) of 135 patients with stage T1b-T3b prostate cancer treated consecutively with 3D-CRT between 1996 and 2000 to a total dose of 76 Gy. The median follow-up was 28 months (range 12-62). All late rectal complications were scored using RTOG criteria. Time to late toxicity was assessed using the Kaplan-Meyer method. The association between variables at baseline and > or=2 rectal toxicity was tested using chi(2) test or Fisher's exact test. A multivariate analysis using logistic regression was performed.
  
  
  RESULTS
  Late rectal toxicity grade > or=2 was observed in 24 of the 135 patients (17.8%). A 'grey area' of increased risk has been identified. Average DVHs of the bleeding and non-bleeding patients were generated. The area under the percent volume DVH for the rectum of the bleeding patients was significantly higher than that of patients without late rectal toxicity. On multivariate analysis the correlation between the high risk DVHs and late rectal bleeding was confirmed.
  
  
  CONCLUSIONS
  The present analysis confirms the role of the rectal DVH as a tool to discriminate patients undergoing high-dose 3D-CRT into a low and a high risk of developing late rectal bleeding. Based on our own results and taking into account the data published in the literature, we have been able to establish new dose-volume constraints for treatment planning: if possible, the percentage of rectal volume exposed to 40, 50, 60, 72 and 76 Gy should be limited to 60, 50, 25, 15 and 5%, respectively.
authors.affiliation: Division of Radiation Oncology, European Institute of Oncology, Via Ripamonti 435, Milan 2014, Italy. carlo.greco@ieo.it
authors.forename: Carlo
authors.initials: C
authors.lastname: Greco
authors.forename: Chiara
authors.initials: C
authors.lastname: Mazzetta
authors.forename: Federica
authors.initials: F
authors.lastname: Cattani
authors.forename: Giampiero
authors.initials: G
authors.lastname: Tosi
authors.forename: Simona
authors.initials: S
authors.lastname: Castiglioni
authors.forename: Andrei
authors.initials: A
authors.lastname: Fodor
authors.forename: Roberto
authors.initials: R
authors.lastname: Orecchia
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D004307:Dose-Response Relationship, Radiation; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011471:Prostatic Neoplasms / Q000532:radiotherapy*; D011829:Radiation Dosage; D020266:Radiotherapy, Conformal / Q000009:adverse effects*; D012002:Rectal Diseases / Q000209:etiology*; D012007:Rectum / Q000528:radiation effects