Chapter 25.
RETROPERITONEAL SARCOMA
CASE STUDY
JOHN B. FIVEASH, MD, RICHARD A. POPPLE, PHD, MARTIN J. HESLIN, MD
Patient History
A 60-year-old female presented with a 2-month history
of abdominal pain and a 25 lb weight loss. On physical
examination, an abdominal mass was palpated. A com-
puted tomography (CT) scan of the abdomen and pelvis
revealed an 8 cm retroperitoneal mass and right-sided
hydronephrosis. A core needle biopsy was consistent with
a high-grade leiomyosarcoma. The remainder of the
metastatic workup was negative.
At our institution, radiation therapy (RT) is used in
such cases prior to surgical resection. A large tumor mass
displaces the small bowel and other critical structures par-
tially out of the treatment volume. The margin at great-
est risk is typically away from the small bowel on the
posterior or posteriomedial aspect of the tumor, whereas
the anterior margin adjacent to the bowel is generally not
at risk of positive margins after resection. Intensity-
modulated radiation therapy (IMRT) planning and treat-
ment were used in this patient to simultaneously boost the
volume at greatest risk of positive margins while sparing
surrounding organs at risk.
Simulation
At the University of Alabama-Birmingham, patients with
retroperitoneal sarcoma undergoing IMRT are typically
simulated in the supine position and immobilized in a cus-
tom alpha cradle device. Although prone positioning may
help displace small bowel out of the treatment volume, it
is used only in selected cases.
After fabrication of the immobilization device, a plan-
ning CT scan (PQ 5000, Philips Medical Systems, Andover,
MA) was performed of the entire peritoneal cavity using
3 mm slices. If the tumor is very superior or inferior in the
abdomen, a larger volume is imaged, allowing for the poten-
tial use of noncoplanar beam arrangements. Intravenous
and oral contrast is used in all patients.
568
Target and Tissue Delineation
A gross tumor volume (GTV) was contoured on the plan-
ning CT scan consisting of all gross disease. Magnetic res-
onance imaging was also performed to aid in the delineation
of the GTV. In general, a separate clinical target volume
(CTV) is not defined in patients with retroperitoneal sar-
coma undergoing preoperative RT. Exceptions include
patients who have undergone subtotal resection or whose
tumors have hemorrhaged. In such cases, the GTV is
expanded by 3 cm, generating the CTV. However, this CTV
should respect and follow the possible patterns of dis-
semination and does not need to extend through solid
organs, such as bone. In patients diagnosed by core nee-
dle biospy (such as this case), the CTV is equivalent to the
GTV.
The organs at risk (OAR) delineated in this patient
included the small bowel, kidneys, liver, and spinal cord.
In most cases, the large bowel is generally not considered
dose limiting and is not included in the optimization
process as an avoidance structure. In selected cases, other
OAR are included. In one case, we contoured the con-
tralateral ovary in a premenopausal patient. If the resec-
tion of the ipsilateral kidney is planned, it is not included
as an OAR. The GTV and OAR for this patient are shown
in Figure 25.2-1.
Treatment Planning
As mentioned above, a simultaneous integrated boost
approach was used in this case. Two planning target vol-
umes (PTVs) were thus generated. PTV1 was created by
adding a 1 to 1.5 cm margin to the CTV, accounting for
organ motion and setup uncertainty. PTV2 included areas
judged to be at highest risk of microscopic tumor involve-
ment targeted for dose escalation and included a small
margin for setup uncertainty. PTV2 was delineated in con-
sultation with the operating surgeon.
 Retroperitoneal Sarcoma: Case Study / 569

FIGURE 25.2-1. Target volumes and organs at risk: gross tumor volume (blue), planning target volume (PTV)1 (magenta), PTV2 (brown), small bowel
(red), and spinal cord and cauda equina (green). (To view a color version of this image, please refer to the CD-ROM.)

The CTV-to-PTV margins may be reduced in some Total doses of 45 Gy (in 1.8 Gy daily fractions) and 57.5 Gy
aspects to avoid neighboring OAR. Note that although these (in 2.3 Gy daily fractions) were prescribed to the PTV1 and
margins may result in smaller treatment volumes (than PTV2, respectively. Treatment planning was performed using
conventional treatment fields), marginal recurrences have the Helios inverse planning system, version 6.27 (Varian Medical
not been seen in our patients who have not undergone prior Systems, Palo Alto, CA). Input parameters for the optimiza-
incisional biopsy or subtotal resection. For tumors very tion process in this patient are shown in Table 25.2-1.
near the spinal cord, a planning organ at risk volume should
be considered based on the specifications of Report 62 of TABLE 25.2-1. Input Parameters and Suggested Dose Limits
the International Commission on Radiation Units and Dose
Measurements (ICRU). Volume Limit, Gy Volume Priority, % Comment
Our experience is that five to seven coplanar beams result PTV1 > 45 100% 50 95% coverage is
in an acceptable IMRT plan in such patients. Treatment < 70 accepted
beams may be equally spaced, or their orientation may be PTV2 > 57.5 100% 90
intelligently selected by omitting gantry angles that pass < 70
Small bowel < 45 Maximum 50 54 Gy to 20 cc is
through large volumes of sensitive normal tissues. The addi-
absolute dose limit
tion of an anterior-inferior oblique beam often improves Kidney < 23 One-third 90 Depends on need for
sparing of the anterior bowel and may produce modest resection and
dosimetric benefits over coplanar beam arrangements in contralateral function
selected patients. In this patient, six coplanar 15 MV beams Liver < 33 Whole 50 NTCP model available
Spinal cord 45 Maximum 80
were used (gantry angles of 40, 80, 140, 200, 250, and 340
degrees). NTCP = normal tissue complication probability; PTV = planning target volume.
570 / Intensity-Modulated Radiation Therapy
The dose-volume histograms for the targets and normal
tissues are shown in Figure 25.2-2. In this case, a significant
portion of the GTV within PTV2 could be dose escalated.
Such hot spots are acceptable within the GTV. When using
the simultaneous integrated boost technique, one should
not attempt to force dose homogeneity within PTV1.
Isodose curves superimposed on representative axial CT
slices are shown in Figure 25.2-3. All plans should be care-
fully reviewed for high-dose gradients near critical struc-
tures. The partial volume tolerance of the small bowel at
low volumes is unknown. We have limited 20 cc of small
bowel to 54 Gy and have not had any significant untoward
late toxicity. In patients who have had previous abdominal
surgery and whose bowel is thought to be fixed or non-
mobile, a dose limit of 50 Gy is used.
Treatment Delivery and Quality
Assurance
IMRT treatment was delivered on a Varian 2100 EX linear
accelerator (Varian Medical Systems) equipped with a 120
multileaf collimator. Treatment was delivered using the dynam-
ic (sliding window) technique. All fields were filmed on the
first treatment day. On subsequent weeks, orthogonal pairs
of port films were obtained to confirm isocenter placement.
The treatment plan was verified by applying the beams
to a near water equivalent polystyrene phantom. These beams
were applied in the same geometry as the patient to a CT
scan of the phantom in the treatment planning system. Dose
was calculated and the expected mean dose to the ionization
chamber was noted. Four transverse planes were selected
for placement of film. The ionization chamber measurement
agreed with the calculated value to within 3%. In the high-
dose region, film dosimetry agreed to within 3% or 2 mm
and to within 5% or 5 mm in the low-dose region.
On average, the total treatment time was 15 to 20 min-
utes (including patient setup). In many patients with
retroperitoneal sarcoma, however, two carriage groups may
be needed owing to the large treatment volume. In such
cases, intelligent selection of beams may help minimize the
number of fields, reducing overall treatment time.
FIGURE 25.2-2. Cumulative dose-volume his-
tograms (DVHs) for (A) organs at risk and (B)
targets. The color of the DVH line corresponds
to the organ or target color in Figure 25.2-1.
(To view a color version of this image, please
refer to the CD-ROM.)
Patient Outcome
The patient tolerated IMRT treatment well, with only grade
2 nausea, which responded to oral antiemetics. Approximately
6 weeks following the completion of IMRT, she underwent
resection of the residual tumor mass. No viable tumor was
present in the surgical specimen. At 12 months post-IMRT,
the patient developed distant progression in the lungs. She
underwent bilateral thoracotomies and is responding to sys-
temic chemotherapy. The patient was alive 30 months after
completion of IMRT. She is without evidence of local or
regional progression and has not experienced any signifi-
cant late toxicity.
Our experience to date using this technique was recent-
ly presented.1 Between June 1999 and January 2002, 14
consecutive patients were treated. The first seven patients
were treated with forward planned multiple static segmented
fields. Inverse planning with dynamic multileaf collimator
delivery was used in the remainder. All patients completed
preoperative IMRT as planned, and 12 patients underwent
laparotomy with planned resection. Only one patient expe-
rienced grade 3 or higher toxicity. This patient had the largest
tumor in the series (> 35 cm in greatest diameter) and devel-
oped nausea and vomiting, leading to dehydration, and
required admission for intravenous fluids.
Of the 12 patients who underwent laparotomy and
attempted resection, 11 had a complete resection with neg-
ative margins. In the remaining case, surgery was aborted
when peritoneal spread was found. At a median follow-up
of 71 weeks, 4 of the 12 patients who underwent a curative
resection developed disease recurrence (1 locally, 3 dis-
tantly). No patients developed chronic RT-related toxici-
ty, although one patient had severe edema after resection
of the inferior cava. Others have similarly reported favor-
able experiences using preoperative IMRT in patients with
retroperitoneal sarcomas.2
FIGURE 25.2-3. Opposite Axial isodose curves demonstrating dose
escalation to planning target volume 2 to 57.5 Gy in 25 fractions. The
100% isodose line corresponds to 45 Gy. (To view a color version of this
image, please refer to the CD-ROM.)
Retroperitoneal Sarcoma: Case Study / 571
572 / Intensity-Modulated Radiation Therapy
As part of our initial report, three patients were replanned
to evaluate the potential of further dose escalation beyond
57.5 Gy in 25 fractions while maintaining acceptable nor-
mal tissue dosimetry.1 Our results suggest that the PTV2
dose could be escalated to a total dose of 75.2 to 82.8 in
25 fractions without exceeding tolerance of nearby sensi-
tive structures. Clearly, prospective clinical trials are need-
ed to evaluate the benefits and risks of further dose
escalation in these patients.
References
1. Fiveash JB, Hyatt MD, Caranto J, et al. Preoperative IMRT with
dose escalation to tumor subvolumes for retroperitoneal
sarcomas: initial clinical results and potential for future dose
escalation [abstract]. Int J Radiat Oncol Biol Phys 2002;54:140.
2. Koshy M, Landry JC, Lawson JD, et al. Potential for toxicity
reduction using intensity modulated radiation therapy
(IMRT) for retroperitoneal sarcoma [abstract]. Int J
Radiat Oncol Biol Phys 2003;57:S448–9.