Dosimetric effects of oral contrast in the planning of conventional radiotherapy and IMRT, for rectal cancer treatment

Abstract Introduction: Contrast media are frequently used during radiation therapy simulation. However, there are concerns about dosimetric variations when dose calculation is done on contrast-enhanced computed tomography (CT). This study evaluates the dosimetric effect of oral contrast during three-dimensional conformal radiotherapy (3D-CRT) and volumetric modulated arc radiotherapy (VMAT) planning. Methods: Rectal cancer patients were consecutively enrolled. For each patient, one unenhanced CT and one contrast-enhanced CT were taken using oral and intravenous contrast. Then, a 3D-CRT plan and an Intensity-modulated radiation therapy (IMRT)/VMAT plan were generated in the enhanced CT, and the dose distribution was recalculated in the respective unenhanced CT. The beam intensities were kept the same as for the enhanced CT plans. Finally, the unenhanced and enhanced plans were compared by calculating the gamma index. Results: For 3D-CRT plans, there were statistically significant differences in second phase planning target volume (PTV) D2% (Mean difference (MD) between unenhanced and enhanced CT 0·01 Gy, 95% CI [0·003 to 0·02 Gy]) and in maximum doses to the bladder (MD 0·26 Gy, 95% CI [0·05 to 0·47 Gy]). For IMRT/VMAT plans, there were statistically significant differences in small intestine V45 Gy (MD 3·1 cc, 95% CI [0·81 to 5·4 cc]), bladder V45 Gy (MD 2·9%, 95% CI [1·4 to 4·3%]) and maximum dose to the bladder (MD 0·65 Gy, 95% CI [0·46 Gy to 0·85 Gy]). In addition, for PTV D98% the MD between unenhanced and enhanced CT was 0·22 Gy 95% CI [0·05 to 0·39]. Conclusions: For most of the dose metrics, the differences were not clinically meaningful. The greatest differences were found in VMAT plans, especially in V45 Gy of the small intestine. This difference could lead to an underestimation of dose–volume metrics when the plan is based on an enhanced CT. The use of small bowel oral contrast does not significantly influence dose calculations and may not affect the acceptability of plans when adhering to constraints.