The radiation dose constraints below are meant to serve as a guide only and may not be applicable to all clinical scenarios. Most doses are derived from randomized studies or consensus guidelines and we have attempted to provide the sources for these recommendations. Please refer to the individual pediatric chapters for dose constraints in the pediatric population as these can vary greatly from protocol to protocol and tend to be particularly site- and age-dependent.
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What are the recommended dose constraints for the following organs and clinical scenarios? |
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ORGAN |
CONSTRAINTS |
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CNS (1.8–2.0 Gy/fx) |
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Spinal cord |
max 50 Gy (full cord cross-section); tolerance increases by 25% 6 mos after 1st course (for re-irradiation) (QUANTEC) |
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Brain |
max 72 Gy (partial brain); avoid >2 Gy/fx or hyperfractionation (QUANTEC) |
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Chiasm/optic nerves |
max 55 Gy (QUANTEC) |
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Brainstem |
Entire brainstem <54 Gy, V59 Gy <1–10 cc (QUANTEC) |
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Eyes (globe) |
Mean <35 Gy (RTOG 0225), max 54 Gy (RTOG 0615) |
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Lens |
max 7 Gy (RTOG 0539) |
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Retina |
max 50 Gy (RTOG 0539) |
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Lacrimal Gland |
max 40 Gy (Parsons) |
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Inner ear/cochlea |
mean ≤45 Gy (consider constraining to ≤35 Gy with concurrent cisplatin) (QUANTEC) |
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Pituitary gland |
max 45 Gy (for panhypopituitarism, lower for GH deficiency) (Emami) |
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Cauda equina |
Max 60 Gy (Emami) |
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CNS (single fraction) |
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Spinal cord |
max 13 Gy (if 3 fxs, max 20 Gy) (QUANTEC) |
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CNS (single fraction) |
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Brain |
V12 Gy <5–10 cc (QUANTEC) |
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Chiasm/optic nerves |
max 10 Gy (QUANTEC) |
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Brainstem |
max 12.5 Gy (QUANTEC) |
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Sacral plexus |
V18 <0.035 cc, V14.4 <5 cc (RTOG 0631) |
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Cauda equina |
V16 <0.035 cc, V14 <5 cc (RTOG 0631) |
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H&N (1.8–2.0 Gy/fx) |
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Parotid gland(s) |
mean <25 Gy (both glands) or mean <20 Gy (1 gland) (QUANTEC) |
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Submandibular gland(s) |
mean <35 Gy (QUANTEC) |
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Larynx |
mean ≤44 Gy, V50 ≤27%, max 63–66 Gy (when risk of tumor involvement is limited) (QUANTEC) |
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TMJ/mandible |
max 70 Gy (if not possible, then V75 <1 cc) (RTOG 0615) |
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Oral cavity |
Nonoral cavity cancer: mean <30 Gy, avoid hot spots >60 Gy (RTOG 0920) |
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Oral cavity cancer: mean < 50 Gy, V55 <1 cc, max 65 Gy (RTOG 0920) |
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Esophagus (cervical) |
V45 <33% (RTOG 0920) |
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Pharyngeal constrictors |
Mean <50 Gy (QUANTEC) |
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Thyroid |
V26 <20% (JHH) |
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Thoracic (1.8–2.0 Gy/fx) |
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Brachial plexus |
max 66 Gy, V60 <5% (RTOG 0619) |
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Lung (combined lung for lung cancer treatment) |
mean <20–23 Gy, V20 <30%–35% (QUANTEC) |
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Lung (ipsilateral lung for breast cancer treatment) |
V25 <10% (JHH) |
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Single lung (after pneumonectomy) |
V5 <60%, V20 <4–10%, MLD <8 Gy (QUANTEC) |
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Bronchial tree |
max 80 Gy (QUANTEC) |
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Heart (lung cancer treatment) |
Heart V45 <67%; V60 <33% (NCCN 2010) |
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Heart (breast cancer treatment) |
V25 <10% (QUANTEC) |
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Esophagus |
V50 <32% (Maguire), V60 <33% (Emami) |
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Thoracic (hypofractionation) |
Total recommended cumulative dose by the number of fractions per NCCN 2010. Note: the max dose limits refer to volumes >0.035 cc (~3 mm3). |
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Spinal cord |
1. 1 fraction: 14 Gy 2. 3 fractions: 18 Gy (6 Gy/fx) 3. 4 fractions: 26 Gy (6.5 Gy/fx) 4. 5 fractions: 30 Gy (6 Gy/fx) |
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Esophagus |
1. 1 fraction: 15.4 Gy 2. 3 fractions: 30 Gy (10 Gy/fx) 3. 4 fractions: 30 Gy (7.5 Gy/fx) 4. 5 fractions: 32.5 Gy (6.5 Gy/fx) |
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Brachial plexus |
1. 1 fraction: 17.5 Gy 2. 3 fractions: 21 Gy (7 Gy/fx) 3. 4 fractions: 27.2 Gy (6.8 Gy/fx) 4. 5 fractions: 30 Gy (6 Gy/fx) |
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Heart/Pericardium |
1. 1 fraction: 22 Gy 2. 3 fractions: 30 Gy (10 Gy/fx) 3. 4 fractions: 34 Gy (8.5 Gy/fx) 4. 5 fractions: 35 Gy (7 Gy/fx) |
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Great vessels |
1. 1 fraction: 37 Gy 2. 3 fractions: 39 Gy (13 Gy/fx) 3. 4 fractions: 49 Gy (12.25 Gy/fx) 4. 5 fractions: 55 Gy (11 Gy/fx) |
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Trachea/Large Bronchus |
1. 1 fraction: 20.2 Gy 2. 3 fractions: 30 Gy (10 Gy/fx) 3. 4 fractions: 34.8 Gy (8.7 Gy/fx) 4. 5 fractions: 40 Gy (8 Gy/fx) |
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Rib |
1. 1 fraction: 30 Gy 2. 3 fractions: 30 Gy (10 Gy/fx) 3. 4 fractions: 32 Gy (7.8 Gy/fx) 4. 5 fractions: 32.5 Gy (6.5 Gy/fx) |
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Skin |
1. 1 fraction: 26 Gy 2. 3 fractions: 30 Gy (10 Gy/fx) 3. 4 fractions: 36 Gy (9 Gy/fx) 4. 5 fractions: 40 Gy (8 Gy/fx) |
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Stomach |
1. 1 fraction: 12.4 Gy 2. 3 fractions: 27 Gy (9 Gy/fx) 3. 4 fractions: 30 Gy (7.5 Gy/fx) 4. 5 fractions: 35 Gy (7 Gy/fx) |
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GI (1.8–2.0 Gy/fx) |
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Stomach |
TD 5/5 whole stomach: 45 Gy (QUANTEC) |
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Small bowel |
V45 <195 cc (QUANTEC) |
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Liver (metastatic disease) |
mean liver <32 Gy (liver = normal liver minus gross disease)(QUANTEC) |
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Liver (primary liver cancer) |
mean liver <28 Gy (liver = normal liver minus gross disease) (QUANTEC) |
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Colon |
45 Gy, max dose 55 Gy (Emami) |
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Kidney (bilateral) |
mean <18 Gy, V28 <20%, V23 Gy <30%, V20 <32%, V12 <55%. If mean kidney dose to 1 kidney > 18 Gy, then constrain remaining kidney to V6 <30%. (QUANTEC) |
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GI (single fraction) |
Dose constraints per RTOG 0631 |
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Duodenum |
V16 <0.035 cc, V11.2 <5 cc |
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Kidney (Cortex) |
V8.4 <200 cc |
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Kidney (Hilum) |
V10.6 <66% |
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Colon |
V14.3 <20 cc, V18.4 <0.035 cc |
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Jejunum/Ileum |
V15.4 <0.035 cc, V11.9 <5 cc |
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Stomach |
V16 <0.035 cc, V11.2 <10 cc |
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Rectum |
V18.4 <0.035 cc, V14.3 <20 cc |
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GU (1.8-2.0 Gy/fx) |
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Femoral heads |
V50 <5% (RTOG GU Consensus) |
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Rectum |
V75 <15%, V70 <20%, V65 <25%, V60 <35%, V50 <50% (QUANTEC) |
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Bladder |
V80 <15%, V75 <25%, V70 <35%, V65 <50% (QUANTEC) |
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Testis |
V3 <50% (RTOG 0630) |
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Penile bulb |
Mean dose to 95% of the volume <50 Gy. D70 ≤70 Gy, D50 ≤50 Gy (QUANTEC 2010) |
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GU (LDR prostate brachytherapy) |
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Urethra |
Volume of urethra receiving 150% of prescribed dose (Ur150) <30% (JHH) |
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Rectum |
Volume of rectum receiving 100% of prescribed dose (RV100) <0.5 cc (JHH) |
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GYN |
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Bladder point (cervical brachytherapy) |
Max 80 Gy (LDR equivalent dose) (ABS 2000) |
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Rectal point (cervical brachytherapy) |
Max 75 Gy (LDR equivalent dose) (ABS 2000) |
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Proximal vagina (mucosa) (cervical brachytherapy) |
Max 120 Gy (LDR equivalent dose) (Hintz) |
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Distal vagina (mucosa) (cervical brachytherapy) |
Max 98 Gy (LDR equivalent dose) (Hintz) |
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Sources: ABS 2000: American Brachytherapy Society consensus statement for HDR brachytherapy for cervical cancer (Nag S, et al., IJROBP, 2000); Emami: Emami et al., IJROBP 31:5, 1995; Hintz: Hintz BL, et al., IJROBP, 1980; JHH: clinical practice at Johns Hopkins Hospital; Maguire: Maguire PD, Sibley GS, Zhou SM, et al: Clinical and dosimetric predictors of radiation-induced esophageal toxicity. IJROBP 45:97–103, 1999; NCCN 2010: www.nccn.org; Parsons: Parsons JT, et al., Oncology, 2006; QUANTEC (Quantitative Analyses of Normal Tissue Effects in the Clinic): IJROBP, 76 (2), Suppl, Mar 1, 2010; RTOG protocols: www.rtog.org; RTOG |
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