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What is Outer Annular Ring (OAR)?

Outer Annular Ring (OAR) is a type of radiation field exposure used in

radiotherapy to help spare healthy tissues surrounding a tumor during

treatment. Specifically, it refers to radiation exposure levels delivered to areas

outside of the treatment planning target volume (PTV) that still receive lower

radiation doses.

In external beam radiation treatment (EBRT), the radiation beam is shaped and

aimed to target the tumor site while avoiding critical structures nearby.

However, some exposure still occurs in normal tissues in the path of the beam

or bordering the target area. The OAR represents this region of lower dose

exposure that planners want to minimize to reduce treatment complications.

Defining OAR in Radiotherapy Planning

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When radiation oncologists create a treatment plan, they outline several key

areas:

 Gross Tumor Volume (GTV) - The visible tumor areas based on imaging scans and
physical exam.
 Clinical Target Volume (CTV) - The GTV plus a margin for suspected microscopic cancer
spread around the tumors.
 Planning Target Volume (PTV) - The CTV plus an additional margin to account for organ
and patient movement and beam delivery variability. This is the primary target area
prescribed the full tumor radiation dose.
 Organs at Risk (OARs) - Critical organs adjacent to the target that radiation exposure
should be limited in. Examples are the bladder, rectum, intestines, spinal cord, etc.
 Outer Annular Ring - The tissue outside the PTV that still receives some radiation
exposure, but at lower doses than target tissues or OARs.

The OAR typically starts at the edge of the PTV and extends outward several

centimeters with decreasing radiation intensity. It encompasses tissue likely to

receive 20-80% of the full prescription dose.

Purposes and Effects of the OAR

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The OAR allows radiation delivery to taper off gradually into surrounding

healthy areas rather than ending abruptly at the PTV margin. This creates a

more natural dose falloff that is less likely to negatively impact bordering

tissues.

Key effects and uses of defining an OAR include:

 Minimizes dose gradients: Steep drop-offs in radiation levels at the PTV edges can cause
unwanted concentrated effects. The OAR creates a more gradual intensity decline.
 Increases dose homogeneity: More consistent regional dosage leads to better tumor
control and fewer side effects.
 Allows flexibility in beam angles/arrangement: Beam paths can clip through OAR areas
if needed to improve target coverage.
 Reduces sensitivity to targeting errors: Minor everyday variability in beam or patient
positioning is less likely to significantly impact critical structures.
 Improves conformity around targets: Tapered exposure better conforms dose to the
abnormal tumor tissue rather than spreading uniformly beyond.

Though increased exposure outside the PTV, the lower OAR doses are set well

below tolerance levels for surrounding healthy structures. This allows

treatment plans to be more customizable and optimized depending on each

patient's unique anatomy.

Determining OAR Dose Limits

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Several factors guide radiation oncologists in deciding appropriate OAR dose

limits for each treatment plan:

 Fractionation scheme - The number of treatment sessions, dose per fraction, and
interval between fractions impact total dose tolerances.
 Individual radiation sensitivities - Some tissues or organs can receive more or less dose
depending on various sensitivity factors.
 Prior therapies - Previous surgeries, radiation, or medications may alter tolerance levels
for certain areas.
 Patient health conditions - Medical problems involving tumor-adjacent organs may
require even stricter dose limits.
 Potential toxicity risk - How much function needs preserved and what side effects are
acceptable guide limits.
 Tumor location - Critical OARs get stricter limits while areas with redundancy/recovery
capacity allow more dose.

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Guidelines from radiation therapy cooperative groups or past clinical studies

provide typical OAR constraints. But physicians further refine these for each

case using the criteria above and clinical judgement.

They choose OAR dose fall-off points and intensities estimated to maximize

tumor control while preserving surrounding structure/function at an

acceptable level of risk. These limits then guide physics staff in planning

appropriate beam arrangements and energies.

OAR Dose Reference Levels

While specific OAR dose limits vary, some general reference levels for a

standard fractionation scheme help classify outer annulus exposure:

Most planners try to limit OAR doses to 60% or less when adjacent to sensitive

structures like the spinal cord, optic chiasm, or brachial plexus. Areas

considered more tolerant allow higher exposures in the 60-80% range if

needed to improve target coverage.

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Normal early and late tissue effects from radiation only tend to emerge at

doses of 60% or more of the tumor prescription level based on clinical

observations. So keeping OAR exposure below this helps avoid toxicity.

Role of OAR in Treatment Delivery

During the actual radiation treatments, several imaging techniques help ensure

accurate beam alignment and dosing relative to the designated OAR regions:

Image-Guided Radiation Therapy

Frequent images before radiation delivery allows adjustments for target

movement and confirmation beams are aligned properly relative to planning

contours:

 MV portal images - Beam’s eye view X-ray images.

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 Orthogonal kV images - Diagnostic quality X-ray images.

 CBCT - CT images from the treatment machine.
 MRI - Direct magnetic resonance imaging for tracking.

In-Vivo Dosimetry

Placing detectors directly on the patient to quantify delivered doses to confirm

they match planned distributions:

 TLDs - Small crystals that absorb and store radiation for readout.
 Diode detectors - Semiconductor devices that generate electrical current when
irradiated.
 MOSFETs - Metal–oxide–semiconductor field-effect transistor detectors.
 Film - Sheets that darken when exposed to radiation for analysis.

Clinical OAR Delineation and Evaluation

Accurately outlining OAR areas on planning scans is critical for appropriate

dose targeting and organ avoidance. Research continues evaluating the best

methods.

Atlas-based auto-segmentation

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Software is developed to automatically define OARs based on digital reference

atlases of human anatomy:

 Algorithms compare patient scans against an anatomical database.

 Probabilistic information guides region labeling around targets.
 Editing is still required to correct discrepancies but reduces workload.

Deformable image registration

Computational mapping techniques link OARs between different imaging sets

to extrapolate planning data:

 Mathematical models encode organ shapes/margins.

 Algorithms correlate and transform scans into one geometry.
 Provides data for biomarker research over patient courses.
 Improves contour consistency over multiple CTs.

radiomics texture analysis

Advanced imaging information like density patterns helps differentiate OARs

regions:

 Software extracts quantitative pixel data from CTs/MRIs.

 Signature textural maps aid tumor vs normal tissue classifications.
 Radiomic biomarkers predict dose tolerances and outcomes.
 Still investigational but shows significant OAR delineation potential.

Careful application of such emerging technologies continues improving OAR

assessment accuracy. This maximizes radiotherapy’s capacity to eradicate

tumors while protecting healthy surrounding anatomy.

Sample OAR Dose Constraint Table

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Here is an example dose constraint table for OARs around a head and neck

tumor receiving 70 Gy over 35 fractions:

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Tighter constraints are placed on critical structures like the brainstem and

spinal cord. Other areas allow more flexibility to ensure tumor coverage

uniformity.

The dose falls off gradually beyond the PTV edge (here 70 Gy). Goals aim to

keep maximum OAR doses around 60% of prescription (40-45 Gy). Hard limits

are set at stricter thresholds depending on toxicity risks (50-55 Gy).

Frequently Asked Questions about OARs

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Here are some common questions about the outer annular ring and organ

dose limits in radiotherapy:

What are the most important OARs to constrain exposure for?

The most critical OARs receiving the strictest dose limits are:

 Spinal cord
 Brainstem
 Optic nerves/chiasm
 Eyes
 Brachial plexus
 Major blood vessels
 Heart

Damage to these areas often causes severe, permanent deficits impacting

critical functions for quality of life.

How are dose limits set for OARs?

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Multiple factors guide appropriate dose constraints for each OAR:

 Published tolerance data from past studies

 Estimated toxicity and complication risks
 Preservation of organ function needed
 Opportunity for contralateral recovery
 Impact on quality of life if damaged

Limits balance cure potential against side effect risks.

Should OARs get priority over target coverage?

The tumor coverage takes priority, but OAR constraints help guide

optimization. Gaps in PTV coverage are more acceptable than exceeding

normal tissue limits and causing toxicity.

The planning goal is maximizing the therapeutic ratio - destroying tumors

while minimizing damage to adjacent healthy anatomy.

Does imaging show if OAR dose limits are exceeded?

Yes, frequent image guidance tracks dose delivery and related anatomy

changes. If limits might be exceeded, the plan can get adaptively modified to

protect OARs.

It helps staff evaluate constraint suitability and adjust constraints as needed

over the treatment course.

How are nearby OAR doses reduced?

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Common methods to reduce OAR exposure include:

 Using more radiation beams at lower intensities

 Altering beam angles or shapes for steeper dose fall-off
 Tuning treatment energies to affect penetration
 Using physical shielding blocks
 Adding dose-lowering materials like protons

Optimizing all beam parameters aims to limit scatter radiation to vulnerable

areas.

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