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Table 3 Whole bowel and small bowel studies – significant findings and quality assessment

From: A systematic review of dose-volume predictors and constraints for late bowel toxicity following pelvic radiotherapy

       Quality Assessment
Author OAR studied OAR defined Toxicity definition Pts with toxicity Significant findings Statistical criteria met (1–7) Endpoint criteria met (1–3)
Deville [7] Intestinal cavity Intestinal cavity below L4–5 RTOG Gr ≥ 1 5/36 (14%) Toxicity associated with total volume & V20. No constraints specified. 1,7
(n/a: 2–6)
None
Mouttet-Audouard [6] “Small bowel” [outlined as abdominal cavity hence included in this section] Entire abdominal cavity including all possible organ locations to iliac crests or D12/L1 CTCAE v4.0 Gr1–3 –diarrhoea or “whole digestive toxicity” (diarrhoea, gastritis, bleeding, pain, incontinence) 8/37 (21.6%)
17/37 (46%)
Larger volumes of bowel receiving 10–30Gy associated with diarrhoea & whole digestive toxicity. (No constraints specified)
“Whole digestive toxicity” associated with many parameters including D20%-D95%.
1, 7
(n/a 2–6)
2
Green [36] Intestinal cavity Not stated CTCAE v4.0 9 (12%) No dose-volume relationship found. 1 (n/a 2–6) 2
Deville [31] Intestinal cavity Large & small bowel below L4–5 RTOG Gr ≥ 2 2/30 (6%) No dose-volume relationship found 1,7
(n/a 2–6)
None
Isohashi [10] Peritoneal cavity Volume surrounding small bowel loops to edge of peritoneum excluding bladder & rectum RTOG/EORTC Gr ≥ 2 16/97 (16.5%) No dose-volume relationship found 1,7
(n/a 2–6)
2
Poorvu [16] 1. Peritoneum
2. Peritoneum + Colon
1. Possible location of small bowel excluding solid organs & retroperitoneal structures.
2. Peritoneum (as above) plus asc & desc colon
CTCAE v4.0 Gr > 3 3/46 (6.5%) No dose-volume relationship found 1, 7
(n/a 2–6)
2
Guerrero-Urbano [8] Bowel loops Loops from recto-sigmoid junction to 2 cm above PTV RTOG Gr ≥ 2 diarrhoea; LENT-SOMA consistency & frequency- worst grade 21/79 (26%) RTOG diarrhoea; ≥gr2 6/79 (7.6%) V40, V45, V60 and bowel volume of > 450 cc had both higher RTOG & LENTSOMA diarrhoea.
Constraints suggested: V40 < 124 cc, V45 < 71 cc, V60 < 0.5 cc for RTOG<gr 2
1,7
(n/a 2–3)
1
McDonald [9] Bowel loops Loops from recto-sigmoid junction to 2 cm above PTV RTOG Gr ≥ 1 7/47 (14.9%) gr1; 3/47 (6.4%) gr2 Constraints for < 25% ≥ gr2 toxicity: V30 < 178 cc;V35 < 163 cc;V40 < 151 cc;V45 < 139c; V50 < 127 cc; V55 < 115 cc; V60 < 98 cc V65 < 40 cc 1,4,7
(n/a 2–3)
2
Chopra [11] Small bowel 2 cm above target, individual small bowel loops (unclear how differentiated from large bowel) CTCAE v3.0 Gr3+ 9/71 (12.6%) V15 associated with ≥gr3 toxicity. Recommend V15 < 275 cc, V30 < 190 cc, V40 < 150 cc reduces Gr3 toxicity from 23.6 to 5.6%. 1, 4, 6
(n/a 2,3)
2
Isohashi [10] Small bowel Bowel loops remaining after exclusion of large bowel loops RTOG/EORTC Gr ≥ 2 16/97 (16.5%) V40 best predictor of late toxicity; Recommend V40 < 340 ml to reduce toxicity from 46.2 to 8.7% 1,4,6,7
(n/a 2,3)
2
Lind [12] Small bowel All visible small bowel in small pelvic cavity to caudal part of sacroiliac joints Defecation into clothing without warning > 1 in last 6 months 63/519 (12.1%) Mean dose>50Gy to small bowel or sigmoid or anal sphincter region associated with symptom (findings for individual organs not clarified) 1, 7 (n/a 2,3) 1,2,3
Adkison [34] Small bowel Not clearly defined CTCAE v3.0 Gr1 and Gr2 Gr1 16/53 (30%); Gr2 4/53 (8%) No dose-volume relationship with V30-V60 small bowel 1
(n/a 2–6)
None
Fokdal [14] Small bowel Opacified & unopacified small intestine loops (outer contour & contents) from 1st slice to minor pelvis LENT-SOMA G1–4 Symptom specific No dose-volume relationship found 1,7
(n/a 2–6)
1,2,3
Fonteyne [17] Small bowel Not clearly defined RTOG and “RILIT” Gr1 & Gr2 Gr1 112/241 (46%), Gr2 32/241(13%) No dose-volume relationship found 1,
(n/a 2–6)
1,2
Poorvu [16] Small bowel Opacified & non-opacified small bowel loops CTCAE v4.0 Gr3+ 3/46 (6.5%) No dose-volume relationship found 1,7
(n/a 2–6)
2
Huang [15] Duodenum Duodenal bulb to ligament of Treitz CTCAE v4.0 Gr ≥ 3 8/46 (17.4%) With a V25 > 45% toxicity rates increase from 8 to 48% 1,4,6,7
(n/a 2,3)
2
Kelly [13] Duodenum Gastric pylorus until end of duodenum 3 cm past midline CTCAE v4.0 Gr ≥ 2 20/106 (18.9%) With a V55 > 1 cc toxicity rates increase from 9 to 47% 1,4,6,7
(n/a 2,3)
2
Verma [30] Duodenum From gastric outlet through transverse portion of duodenum (ascending portion excluded) RTOG, all grades 9 /105 (8.6%) With a V55 > 15 cc toxicity rates increase from 7.4 to 48.6% 1,4,6,7
(n/a 2,3)
2
Poorvu [16] Duodenal segments D1 segment: bulblike shape & origin beyond gastric pylorus. Transitions between 2nd & 3rd segments was lateral border of IVC; Between 3rd & 4th was medial border of aorta CTCAE v4.0 Gr ≥ 3 3/46 (6.5%) No dose-volume relationship found with duodenum 1,7
(n/a 2–6)
2
  1. Abbreviations: Pts Patients, OAR Organs at risk, RT Radiotherapy, Gr Grade, CTCAE Common terminology criteria for adverse events, RTOG Radiation therapy oncology group, LENT-SOMA Late Effects of Normal Tissue – Subjective Objective Management Analytical, RILIT Radiation induced late intestinal toxicity, EORTC European Organisation for Research and Treatment of Cancer, Vx Volume receiving x Gy, AUC Area under curve