Adult reference dose/volume limits

Structure Volume (cc) Total Dose (Gy) Max Dose (Gy) Endpoint Notes Reference
Bladder 15% 80 RTOG 0126
Bladder 25% 75 RTOG 0126
Bladder 35% 70 RTOG 0126
Bladder 50% 65 RTOG 0126
Brachial plexus 5% 60 66 RTOG 0619
Brainstem 1% 60 54 1% of PTV, use either limit RTOG 0225
Chiasm 1% 60 54 1% of PTV, use either limit RTOG 0225
Cochlea (each) 5% 55 RTOG 0615
Constrictor (inferior) Mean 54 Aspiration/stricture 96 patients, no complications Caglar
Constrictor (inferior) 60% 52 Aspiration/stricture 96 patients, no complications Caglar
Constrictor (inferior) 51% 50 Aspiration/stricture 96 patients, no complications Caglar
Duodenun 33% 45 60 Spalding
Ears (inner/middle) Mean 50 RTOG 0225
Esophagus 15% 54 60 Gy, if necessary RTOG 0920
Esophagus 33% 45 50 Gy, if necessary RTOG 0920
Esophagus Mean 35 45 Gy, if necessary RTOG 0920
Eyes 50 RTOG 0615
Eyes Mean 35 RTOG 0225
Femoral heads 25% 45 50 RTOG 0822
Femoral heads 40% 40 50 RTOG 0822
Glottic larynx 45 If possible RTOG 0920
Glottic larynx 21% 50 Aspiration/stricture 96 patients, no complications Caglar
Glottic larynx Mean 48 Aspiration/stricture 96 patients, no complications Caglar
Glottic larynx 60% 47 Aspiration/stricture 96 patients, no complications Caglar
Heart 33% 60 Clinical pericarditis RTOG 0623
Heart 67% 45 Clinical pericarditis RTOG 0623
Heart 100% 40 Clinical pericarditis RTOG 0623
Kidney 33% 50 Renal insufficiency RTOG 0436
Kidney 67% 30 Renal insufficiency RTOG 0436
Kidney 100% 23 Renal insufficiency RTOG 0436
Kidney 10% 18 20 Renal insufficiency Spalding
Lens 25 Cataracts RTOG 0615
Lens Cataracts Avoid direct beam exposure RTOG 0513
Liver 50% 35 Clinical hepatitis RTOG 0436
Liver 100% 30 Clinical hepatitis RTOG 0436
Lung minus GTV 37% 20 Clinical pneumonitis RTOG 0623
Lung minus GTV Mean 20 Clinical pneumonitis RTOG 0623
Mandible 1 75 70 Use either limit RTOG 0225
Optic nerves 1% 60 54 1% of PTV, use either limit RTOG 0225
Oral cavity (exclude PTV) Mean 40 RTOG 0615
Parotid gland (both) 20 20 Xerostomia Only if sparing both glands RTOG 0912
Parotid gland (one) 50% 30 Xerostomia Only if sparing one gland RTOG 0912
Parotid gland (one) Mean 26 Xerostomia Only if sparing one gland RTOG 0912
Penile bulb Mean 52.5 RTOG 0126
Rectum 15% 75 RTOG 0126
Rectum 25% 70 RTOG 0126
Rectum 35% 65 RTOG 0126
Rectum 50% 60 RTOG 0126
Small bowel 65 45 50 RTOG 0822
Small bowel 100 40 50 RTOG 0822
Small bowel 180 35 50 RTOG 0822
Spinal cord 45 Myelitis RTOG 0623
Spinal cord 0.03 48 Myelitis RTOG 0619
Stomach 2% 50 54 Spalding
Stomach 25% 45 54 Spalding
Temporal lobes 1% 65 60 1% of PTV, use either limit RTOG 0225
Tongue 1% 65 55 1% of PTV, use either limit RTOG 0225

Limits in this table are the default DVH objectives in Mobius3D (http://www.mobiusmed.com/)
 One fraction SRS / SBRT limits

Structure Volume (cc) Total Dose (Gy) Max Point Dose (Gy) Endpoint Notes Reference
Bladder wall 15 11.4 18.4 Cystitis/fistula TG-101
Brachial plexus (ipsilateral) 3 14 17.5 Neuropathy TG-101
Brain (normal) 10 10 Necrosis 4/17 patients w/necrosis Chin
Brainstem 0.5 10 15 Cranial neuropathy TG-101
Bronchus (ipsilateral) 0.5 12.4 13.3 Stenosis/fistula Avoid circumferential radiation TG-101
Cauda equina 5 14 16 Neuritis TG-101
Cochlea 9 Hearing loss TG-101
Colon 20 14.3 18.4 Colitis/fistula Avoid circumferential radiation TG-101
Duodenum 5 11.2 12.4 Ulceration Avoid circumferential radiation TG-101
Duodenum 10 9 12.4 Ulceration Avoid circumferential radiation TG-101
Esophagus 5 11.9 15.4 Stenosis/fistula Avoid circumferential radiation TG-101
Femoral heads (both) 10 14 Necrosis TG-101
Great vessels 10 31 37 Aneurysm TG-101
Heart/pericardium 15 16 22 Pericarditis TG-101
Jejunum/ileum 5 11.9 15.4 Enteritis/obstruction Avoid circumferential radiation TG-101
Liver >700 9.1 Basic liver function Spare at least this volume* TG-101
Lung (right and left) >1000 7.4 Pneumonitis Spare at least this volume* TG-101
Lung (right and left) >1500 7 Basic lung function Spare at least this volume* TG-101
Optic Pathway 8 Blindness Conservative Ove
Optic Pathway 10 Blindness Justifiable Ove
Optic Pathway "Short" 12 Blindness <1% risk Stafford
Optic Pathway "Long" 9 Blindness More significant risk Stafford
Optic Pathway 0.2 8 10 Blindness TG-101
Penile bulb 3 14 34 Impotence TG-101
Rectum 20 14.3 18.4 Proctitis/fistula Avoid circumferential radiation TG-101
Renal corex (right and left) >200 8.4 Basic renal function Spare at least this volume* TG-101
Renal hilum/vascular trunk 67% 10.6 Malignant hypertension TG-101
Rib 1 22 30 Pain or fracture TG-101
Sacral plexus 5 14.4 16 Neuropathy TG-101
Skin 10 23 26 Ulceration TG-101
Spinal cord 10% 10 14 Myelitis 5-6 mm above and below target Ryu
Spinal cord 0.35 10 14 Myelitis TG-101
Spinal cord 1.2 7 14 Myelitis TG-101
Stomach 10 11.2 12.4 Ulceration/fistula TG-101
Trachea 4 10.5 20.2 Stenosis/fistula Avoid circumferential radiation TG-101

*For parallel structures, subtract the volume that receives the listed dose from the total size of the organ and verify it is less than the volume listed. For example, a patient's liver is 2000 cc. An integral DVH graph shows 55%
receives 9.1 Gy. This means (100%-55%=) 45% of the liver has been spared from 9.1 Gy. 45% of this patient's liver is 900 cc, which is more than the listed 700 cc volume, so the plan would meet this liver objective. Note that the
DVH point you would use for IMRT optimization in this case would be (2000-700)/2000 = 65% volume and 9.1 Gy dose.

Limits in this table are the default DVH objectives in Mobius3D (http://www.mobiusmed.com/)
 Three fraction SBRT limits

Total Dose Max Point Max Dose / Fx

Structure Volume (cc) Dose / Fx (Gy) Endpoint Notes Reference
(Gy) Dose (Gy) (Gy)
Bladder wall 15 16.8 5.6 28.2 9.4 Cystitis/fistula TG-101
Brachial plexus (ipsilateral) 3 20.4 6.8 24 8.0 Neuropathy TG-101
Brainstem 0.5 18 6.0 23.1 7.7 Cranial neuropathy TG-101
Bronchus (ipsilateral) 0.5 18.9 6.3 23.1 7.7 Stenosis/fistula Avoid circumferential radiation TG-101
Cauda equina 5 21.9 7.3 24 8.0 Neuritis TG-101
Cochlea 17.1 5.7 Hearing loss TG-101
Colon 20 24 8.0 28.2 9.4 Colitis/fistula Avoid circumferential radiation TG-101
Duodenum 5 16.5 5.5 22.2 7.4 Ulceration Avoid circumferential radiation TG-101
Duodenum 10 11.4 3.8 22.2 7.4 Ulceration Avoid circumferential radiation TG-101
Esophagus 5 17.7 5.9 25.2 8.4 Stenosis/fistula Avoid circumferential radiation TG-101
Femoral heads (right and left) 10 21.9 7.3 Necrosis TG-101
Great vessels 10 39 13.0 45 15.0 Aneurysm TG-101
Heart/pericardium 15 24 8.0 30 10.0 Pericarditis TG-101
Jejunum/ileum 5 17.7 5.9 25.2 8.4 Enteritis/obstruction Avoid circumferential radiation TG-101
Liver >700 19.2 6.4 Basic liver function Parallel structure, spare at least this volume* TG-101
Lung (right and left) >1000 12.4 4.1 Pneumonitis Parallel structure, spare at least this volume* TG-101
Lung (right and left) >1500 11.6 3.9 Basic lung function Parallel structure, spare at least this volume* TG-101
Optic Pathway 0.2 15.3 5.1 17.4 5.8 Blindness TG-101
Penile bulb 3 21.9 7.3 42 14.0 Ipotence TG-101
Rectum 20 24 8.0 28.2 9.4 Proctitis/fistula Avoid circumferential radiation TG-101
Renal corex (right and left) >200 16 5.3 Basic renal function Parallel structure, spare at least this volume* TG-101
Renal hilum/vascular trunk 67% 18.6 6.2 Malignant hypertension TG-101
Rib 30 30 10.0 36.9 12.3 Pain or fracture TG-101
Rib 1 28.8 9.6 36.9 12.3 Pain or fracture TG-101
Sacral plexus 5 22.5 7.5 24 8.0 Neuropathy TG-101
Skin 10 30 10.0 33 11.0 Ulceration TG-101
Spinal cord 10% 18 6.0 21.9 7.3 Myelitis 5-6 mm above and below target Ryu
Spinal cord 0.35 18 6.0 21.9 7.3 Myelitis TG-101
Spinal cord 1.2 12.3 4.1 21.9 7.3 Myelitis TG-101
Stomach 10 16.5 5.5 22.2 7.4 Ulceration/fistula TG-101
Trachea 4 15 5.0 30 10.0 Stenosis/fistula Avoid circumferential radiation TG-101

*For parallel structures, subtract the volume that receives the listed dose from the total size of the organ and verify it is less than the volume listed. For example, a patient's liver is 2000 cc. An integral DVH graph shows 55% receives 17.1 Gy. This means (100%-
55%=) 45% of the liver has been spared from 17.1 Gy. 45% of this patient's liver is 900 cc, which is more than the listed 700 cc volume, so the plan would meet this liver objective. Note that the DVH point you would use for IMRT optimization in this case would
be (2000-700)/2000 = 65% volume and 17.1 Gy dose.

Limits in this table are the default DVH objectives in Mobius3D (http://www.mobiusmed.com/)
 Five fraction SBRT limits

Total Dose Max Point Max Dose / Fx

Structure Volume (cc) Dose / Fx (Gy) Endpoint Notes Reference
(Gy) Dose (Gy) (Gy)
Bladder wall 15 18.3 3.7 38 7.6 Cystitis/fistula TG-101
Brachial plexus (ipsilateral) 3 27 5.4 30.5 6.1 Neuropathy TG-101
Brainstem 0.5 23 4.6 31 6.2 Cranial neuropathy TG-101
Bronchus (ipsilateral) 0.5 21 4.2 33 6.6 Stenosis/fistula Avoid circumferential radiation TG-101
Cauda equina 5 30 6.0 32 6.4 Neuritis TG-101
Cochlea 25 5.0 Hearing loss TG-101
Colon 20 25 5.0 38 7.6 Colitis/fistula Avoid circumferential radiation TG-101
Duodenum 5 18 3.6 32 6.4 Ulceration Avoid circumferential radiation TG-101
Duodenum 10 12.5 2.5 32 6.4 TG-101
Esophagus 5 19.5 3.9 35 7.0 Stenosis/fistula Avoid circumferential radiation TG-101
Femoral heads (right and left) 10 30 6.0 Necrosis TG-101
Great vessels 10 47 9.4 53 10.6 Aneurysm TG-101
Heart/pericardium 15 32 6.4 38 7.6 Pericarditis TG-101
Jejunum/ileum 5 19.5 3.9 35 7.0 Enteritis/obstruction Avoid circumferential radiation TG-101
Liver >700 21 4.2 Basic liver function Parallel structure, spare at least this volume* TG-101
Lung (right and left) >1000 13.5 2.7 Pneumonitis Parallel structure, spare at least this volume* TG-101
Lung (right and left) >1500 12.5 2.5 Basic lung function Parallel structure, spare at least this volume* TG-101
Optic Pathway 0.2 23 4.6 25 5.0 Blindness TG-101
Penile bulb 3 30 6.0 50 10.0 Ipotence TG-101
Rectum 20 25 5.0 38 7.6 Proctitis/fistula Avoid circumferential radiation TG-101
Renal corex (right and left) >200 17.5 3.5 Basic renal function Parallel structure, spare at least this volume* TG-101
Renal hilum/vascular trunk 67% 23 4.6 Malignant hypertension TG-101
Rib 1 35 7.0 43 8.6 Pain or fracture TG-101
Sacral plexus 5 30 6.0 32 6.4 Neuropathy TG-101
Skin 10 36.5 7.3 39.5 7.9 Ulceration TG-101
Spinal cord 10% 23 4.6 30 6.0 Myelitis 5-6 mm above and below target Ryu
Spinal cord 0.35 23 4.6 30 6.0 Myelitis TG-101
Spinal cord 1.2 14.5 2.9 30 6.0 Myelitis TG-101
Stomach 10 18 3.6 32 6.4 Ulceration/fistula TG-101
Trachea 4 16.5 3.3 40 8.0 Stenosis/fistula Avoid circumferential radiation TG-101

*For parallel structures, subtract the volume that receives the listed dose from the total size of the organ and verify it is less than the volume listed. For example, a patient's liver is 2000 cc. An integral DVH graph shows 55% receives 21 Gy. This means (100%-
55%=) 45% of the liver has been spared from 21 Gy. 45% of this patient's liver is 900 cc, which is more than the listed 700 cc volume, so the plan would meet this liver objective. Note that the DVH point you would use for IMRT optimization in this case would be
(2000-700)/2000 = 65% volume and 21 Gy dose.

Limits in this table are the default DVH objectives in Mobius3D (http://www.mobiusmed.com/)
 Number of fractions: 28 To give the same BED with: 5 fractions,
Dose per fraction: 2.0 Gy you should deliver: 7.6 Gy per fraction.
Alpha / beta ratio: 10.0

Total dose: 56.0 Gy

BED: 67.2 Gy

Typical alpha/beta ratios

Cancer: 10
Normal tissue: 3
Protate cancer: 1.5
Distribution
Compiled and distributed by Nathan Childress, Ph.D., through http://www.medphysfiles.com/
This file is distributed without fitness guarantee, and is free for all to use and modify.

References
Caglar: Hale B. Caglar et al., "Dose to larynx predicts for swallowing complications after IMRT," IJROBP 72, 1110-
1118 (2008)
Spalding: Aaron C. Spalding et al., "Potential for dose-escalation and reduction of risk in pancreatic cancer using
IMRT," Medical Physics 34, 521-529 (2007)
Chin: Lawrence S. Chin, L. Ma, and S. DiBiase, "Radiation necrosis following gamma knife surgery: a case-
controlled comparison of treatment parameters and long-term clinical follow up," J Neurosurgery 94, 899-904
(2001).
Ove: R. Ove, S. Kelman, P.P. Amin, and L.S. Chin, "Preservation of visual fields after peri-sellar gamma knife
radiosurgery," Int J Cancer 90, 343-350 (2000).
Ryu: S. Ryu et al., "Partial volume tolerance of the spinal cord and complications of single-dose radiosurgery,"
Cancer 109, 628-636 (2007).
Timmerman: Robert D. Timmerman, "An Overview of Hypofractionation and Introduction to This Issue of
Seminars in Radiation Oncology," Sem Rad Onc 18, 215-222 (2008).
Benedict: Stanley H. Benedict et al., "Stereotactic body radiation therapy: The report of AAPM Task Group 101,"
Medical Physics 37, 4078-4101 (2010)

Additional references
http://en.wikibooks.org/wiki/Radiation_Oncology/Toxicity
Wiki book on Radiation Oncology, with a fantastic collection of normal tissue information

http://www.ncbi.nlm.nih.gov/pubmed/2032882?dopt=Abstract
Emami's 1991 article on normal tissue doses

http://www.amazon.com/Handbook-Evidence-based-Radiation-Oncology-Hansen/dp/0387306471
Hansen's 2006 book Handbook of Evidence-Based Radiation Oncology

http://www.ncbi.nlm.nih.gov/pubmed/17395043?dopt=Abstract
Milano's 2007 article summarizing dose limits and endpoints

Acknowledgements
Bradley A. Beck, M.Sc., St. Vincent's Medical Center
Walter Nikesch, Ph.D., CyberKnife Center of Palm Beach
Kathleen Shadle, M.D., The Methodist Hospital