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					                                                            Adult reference dose/volume limits
                                  Volume      Total Dose    Max Dose
           Structure                                                               Endpoint                            Notes                   Reference
                                    (cc)         (Gy)         (Gy)
            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                 RTOG 0225
             Chiasm                  1%           60           54                                                    1% of PTV                 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                10 cm          60             -                                                  If necessary               RTOG 0623
          Esophagus                Mean           34             -                                                     Optimal                 RTOG 0623
              Eyes                    -            -           50                                                                              RTOG 0615
              Eyes                 Mean           35             -                                                                             RTOG 0225
        Femoral heads               10%           50             -                                                                             RTOG 0534
        Femoral heads               25%           45           50                                                                              RTOG 0822
        Femoral heads               40%           40           50                                                                              RTOG 0822
         Glottic larynx               -            -           45                                                                              RTOG 0619
         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
         Glottic larynx            Mean           45             -                                                                             RTOG 0225
              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                                                                              RTOG 0225
         Optic nerves                1%           60           54                                                    1% of PTV                 RTOG 0225
   Oral cavity (exclude PTV)       Mean           40             -                                                                             RTOG 0615
     Parotid gland (both)            20           20             -                Xerostomia                 Only if sparing both glands       RTOG 0619
     Parotid gland (one)            50%           30             -                Xerostomia                  Only if sparing one gland        RTOG 0619
     Parotid gland (one)           Mean           26             -                Xerostomia                  Only if sparing one gland        RTOG 0619
          Penile bulb              Mean          52.5            -                                                                             RTOG 0126
            Rectum                  15%           75             -                                                                             RTOG 0126
            Rectum                  25%           70             -                                                                             RTOG 0126
            Rectum                  25%           65             -                                                                             RTOG 0534
            Rectum                  35%           65             -                                                                             RTOG 0126
            Rectum                  50%           60             -                                                                             RTOG 0126
            Rectum                  45%           40             -                                                                             RTOG 0534
        Small intestine              2%           50           54                                                                               Spalding
        Small intestine             25%           45           54                                                                               Spalding
          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                 RTOG 0225
           T-M joint                  1           75           70                                                                              RTOG 0225
             Tongue                  1%           65           55                                                    1% of PTV                 RTOG 0225

  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)
           Values from Timmerman are "mostly unvalidated" and based on their SBS/SBRT experience. This table was mostly reproduced from his excellent article.
                                        Volume      Total Dose    Max Point
              Structure                                                                  Endpoint                                           Notes                                  Reference
                                           (cc)        (Gy)       Dose (Gy)
             Bladder wall                   15          8.7          22               Cystitis/fistula                                                                            Timmerman
     Brachial plexus (ipsilateral)          3          14.4          16                Neuropathy                                                                                 Timmerman
            Brain (normal)                  10          10            -                   Necrosis               Depends on TV, integral dose, 10 cc = 4/17 pats w/necrosis           Chin
              Brainstem                     1           10           15            Cranial neuropathy                                                                             Timmerman
        Bronchus (ipsilateral)              4           8.8          22              Stenosis/fistula                          Avoid circumferential radiation                    Timmerman
            Cauda equina                    5           14           16                   Neuritis                                                                                Timmerman
               Cochlea                       -           -           12                Hearing loss                                                                               Timmerman
                Colon                       20          11           22               Colitis/fistula                          Avoid circumferential radiation                    Timmerman
              Duodenum                      5           8.8          16                 Ulceration                             Avoid circumferential radiation                    Timmerman
              Esophagus                     5          14.5          19              Stenosis/fistula                          Avoid circumferential radiation                    Timmerman
    Femoral heads (right and left)          10          14            -                   Necrosis                                                                                Timmerman
            Great vessels                   10          31           37                  Aneurysm                                                                                 Timmerman
          Heart/pericardium                 15          16           22                 Pericarditis                                                                              Timmerman
           Jejunum/ileum                    5           9.8          19           Enteritis/obstruction                        Avoid circumferential radiation                    Timmerman
                 Liver                    >700          9.1           -            Basic liver function                 Parallel structure, spare at least this volume*           Timmerman
         Lung (right and left)           >1000          7.4           -                Pneumonitis                      Parallel structure, spare at least this volume*           Timmerman
         Lung (right and left)           >1500           7            -            Basic lung function                  Parallel structure, spare at least this volume*           Timmerman
           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                                                                                Timmerman
              Penile bulb                   3           14           34                 Impotence                                                                                 Timmerman
               Rectum                       20          11           22              Proctitis/fistula                         Avoid circumferential radiation                    Timmerman
     Renal corex (right and left)         >200          8.4           -           Basic renal function                  Parallel structure, spare at least this volume*           Timmerman
     Renal hilum/vascular trunk           67%          10.6           -          Malignant hypertension                                                                           Timmerman
             Sacral plexus                  3          14.4          16                Neuropathy                                                                                 Timmerman
                 Skin                       10         14.4          16                 Ulceration                                                                                Timmerman
              Spinal cord                 10%           10            -                   Myelitis                    Contour only cord 6 mm above and below target                   Ryu
              Spinal cord                 0.25          10           14                   Myelitis                                                                                Timmerman
              Spinal cord                  1.2           7           14                   Myelitis                                                                                Timmerman
               Stomach                      10          13           16             Ulceration/fistula                                                                            Timmerman
               Trachea                      4           8.8          22              Stenosis/fistula                          Avoid circumferential radiation                    Timmerman

  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).
                           Values from Timmerman are "mostly unvalidated" and based on their SBS/SBRT experience. This table was mostly reproduced from his excellent article.
                                   Volume    Total Dose      Dose per      Max Point    Max Point Dose per
            Structure                                                                                                 Endpoint                                   Notes                              Reference
                                     (cc)       (Gy)       Fraction (Gy)   Dose (Gy)      Fraction (Gy)
          Bladder wall                15         15             5.0           30               10.0                 Cystitis/fistula                                                               Timmerman
   Brachial plexus (ipsilateral)       3        22.5            7.5           24                8.0                   Neuropathy                                                               Timmerman, RTOG 0618
            Brainstem                  1         18             6.0           23                7.7               Cranial neuropathy                                                               Timmerman
      Bronchus (ipsilateral)           4         15             5.0           30               10.0                 Stenosis/fistula                Avoid circumferential radiation            Timmerman, RTOG 0618
          Cauda equina                 5        21.9            7.3           24                8.0                     Neuritis                                                                   Timmerman
             Cochlea                   -                        0.0           20                6.7                   Hearing loss                                                                 Timmerman
              Colon                   20         20.4           6.8           30               10.0                  Colitis/fistula                Avoid circumferential radiation                Timmerman
           Duodenum                    5          15            5.0           24                8.0                    Ulceration                   Avoid circumferential radiation                Timmerman
           Esophagus                   5          21            7.0           27                9.0                 Stenosis/fistula                Avoid circumferential radiation            Timmerman, RTOG 0618
  Femoral heads (right and left)      10         21.9           7.3           42               14.0                     Necrosis                                                                   Timmerman
          Great vessels               10          39           13.0           45               15.0                    Aneurysm                                                                    Timmerman
        Heart/pericardium             15          24            8.0           30               10.0                   Pericarditis                                                             Timmerman, RTOG 0618
         Jejunum/ileum                 5         16.2           5.4           27                9.0              Enteritis/obstruction              Avoid circumferential radiation                Timmerman
               Liver                 >700        17.1           5.7            -                 -                Basic liver function       Parallel structure, spare at least this volume*       Timmerman
       Lung (right and left)         15%          20            6.7            -                 -                                                           Minor deviation                        RTOG 0618
       Lung (right and left)         10%          20            6.7            -                 -                                                                 Ideal                            RTOG 0618
       Lung (right and left)        >1000        11.4           3.8            -                 -                   Pneumonitis             Parallel structure, spare at least this volume*       Timmerman
       Lung (right and left)        >1500        10.5           3.5            -                 -               Basic lung function         Parallel structure, spare at least this volume*       Timmerman
         Optic Pathway                0.2         15            5.0          19.5               6.5                    Blindness                                                                   Timmerman
           Penile bulb                 3         21.9           7.3           42               14.0                    Ipotence                                                                    Timmerman
             Rectum                   20         20.4           6.8           30               10.0                 Proctitis/fistula               Avoid circumferential radiation                Timmerman
   Renal corex (right and left)      >200        14.4           4.8                             0.0              Basic renal function        Parallel structure, spare at least this volume*       Timmerman
   Renal hilum/vascular trunk        67%         18.6           6.2                             0.0             Malignant hypertension                                                             Timmerman
          Sacral plexus                3         22.5           7.5            24               8.0                   Neuropathy                                                                   Timmerman
               Skin                   10         22.5           7.5            24               8.0                   Ulceration                                                               Timmerman, RTOG 0618
           Spinal cord               0.25         18            6.0            22               7.3                     Myelitis                                                               Timmerman, RTOG 0618
           Spinal cord                1.2        11.1           3.7            22               7.3                     Myelitis                                                               Timmerman, RTOG 0618
             Stomach                  10          21            7.0            24               8.0               Ulceration/fistula                                                               Timmerman
             Trachea                   4          15            5.0            30              10.0                 Stenosis/fistula                Avoid circumferential radiation            Timmerman, RTOG 0618

RTOG 0618 only lists Max Point Doses, so all Volume/Dose points are from Timmerman
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).
                                 Values from Timmerman are "mostly unvalidated" and based on their SBS/SBRT experience. This table was mostly reproduced from his excellent article.
                                               Volume     Total Dose      Dose per      Max Point     Max Point Dose
                  Structure                                                                                                       Endpoint                                   Notes                              Reference
                                                 (cc)        (Gy)       Fraction (Gy)   Dose (Gy)     per Fraction (Gy)
                 Bladder wall                     15         18.3            3.7            38               7.6                Cystitis/fistula                                                               Timmerman
         Brachial plexus (ipsilateral)             3          30             6.0            32               6.4                 Neuropathy                                                                Timmerman, RTOG 0813
                  Brainstem                        1          26             5.2            31               6.2             Cranial neuropathy                                                                Timmerman
            Bronchus (ipsilateral)                 4          18             3.6            38               7.6               Stenosis/fistula                 Avoid circumferential radiation                Timmerman
   Bronchus (ipsilateral), non-adjacent wall       4          18             3.6        105% of Rx       105% of Rx           Stenosis / fistula                 PTV Rx ranges from 8-12 Gy                     RTOG 0813
                Cauda equina                       5          30             6.0            34               6.8                    Neuritis                                                                   Timmerman
                    Cochlea                        -           -              -            27.5              5.5                 Hearing loss                                                                  Timmerman
                     Colon                        20          25             5.0            38               7.6                Colitis/fistula                 Avoid circumferential radiation                Timmerman
                  Duodenum                         5          18             3.6            32               6.4                  Ulceration                    Avoid circumferential radiation                Timmerman
                  Esophagus                        5         27.5            5.5            35               7.0               Stenosis/fistula                 Avoid circumferential radiation                Timmerman
        Esophagus, non-adjacent wall               5         27.5            5.5        105% of Rx       105% of Rx           Stenosis / fistula                 PTV Rx ranges from 8-12 Gy                     RTOG 0813
       Femoral heads (right and left)             10          30             6.0             -                -                    Necrosis                                                                    Timmerman
                Great vessels                     10          47             9.4            53              10.6                  Aneurysm                                                                     Timmerman
      Great vessels, non-adjacent wall            15          47             9.4        105% of Rx       105% of Rx               Aneurysm                        PTV Rx ranges from 8-12 Gy                    RTOG 0813
              Heart/pericardium                   15          32             6.4            38               7.6                  Pericarditis                                                                 Timmerman
              Heart/pericardium                   10          32             6.4        105% of Rx       105% of Rx               Pericarditis                     PTV Rx ranges from 8-12 Gy                   RTOG 0813
               Jejunum/ileum                       5         19.5            3.9            35               7.0            Enteritis/obstruction               Avoid circumferential radiation                Timmerman
                     Liver                       >700         21             4.2             -                -              Basic liver function        Parallel structure, spare at least this volume*       Timmerman
             Lung (right and left)              >1000        13.5            2.7             -                -                  Pneumonitis             Parallel structure, spare at least this volume*   Timmerman, RTOG 0813
             Lung (right and left)              >1500        12.5            2.5             -                -              Basic lung function         Parallel structure, spare at least this volume*   Timmerman, RTOG 0813
               Optic Pathway                      0.2         20             4.0            25               5.0                   Blindness                                                                   Timmerman
                  Penile bulb                      3          30             6.0            50              10.0                   Ipotence                                                                    Timmerman
                    Rectum                        20          25             5.0            38               7.6               Proctitis/fistula                Avoid circumferential radiation                Timmerman
         Renal corex (right and left)            >200        17.5            3.5             -                -             Basic renal function         Parallel structure, spare at least this volume*       Timmerman
         Renal hilum/vascular trunk              67%          23             4.6             -                -            Malignant hypertension                                                              Timmerman
                Sacral plexus                      3          30             6.0            32               6.4                 Neuropathy                                                                    Timmerman
                      Skin                        10          30             6.0            32               6.4                  Ulceration                                                               Timmerman, RTOG 0813
                  Spinal cord                    0.25        22.5            4.5            30               6.0                    Myelitis                                                               Timmerman, RTOG 0813
                  Spinal cord                     1.2        13.5            2.7            30               6.0                    Myelitis                                                                   Timmerman
                  Spinal cord                     0.5        13.5            2.7             -                -                     Myelitis                                                                    RTOG 0813
                   Stomach                        10          28             5.6            32               6.4              Ulceration/fistula                                                               Timmerman
                   Trachea                         4          18             3.6            38               7.6               Stenosis/fistula                 Avoid circumferential radiation                Timmerman
         Trachea, non-adjacent wall                4          18             3.6        105% of Rx       105% of Rx           Stenosis / fistula                 PTV Rx ranges from 8-12 Gy                     RTOG 0813

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).
      Number of fractions:     28            To give the same BED with:
        Dose per fraction:    2.0       Gy            you should deliver:
        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
 5    fractions,
7.6   Gy per fraction.
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.



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

				
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