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Csiki E, Simon M, Papp J, Barabás M, Mikáczó J, Gál K, Sipos D, Kovács Á. Stereotactic body radiotherapy in lung cancer: a contemporary review. Pathol Oncol Res 2024; 30:1611709. [PMID: 38476352 PMCID: PMC10928908 DOI: 10.3389/pore.2024.1611709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 02/15/2024] [Indexed: 03/14/2024]
Abstract
The treatment of early stage non-small cell lung cancer (NSCLC) has improved enormously in the last two decades. Although surgery is not the only choice, lobectomy is still the gold standard treatment type for operable patients. For inoperable patients stereotactic body radiotherapy (SBRT) should be offered, reaching very high local control and overall survival rates. With SBRT we can precisely irradiate small, well-defined lesions with high doses. To select the appropriate fractionation schedule it is important to determine the size, localization and extent of the lung tumor. The introduction of novel and further developed planning (contouring guidelines, diagnostic image application, planning systems) and delivery techniques (motion management, image guided radiotherapy) led to lower rates of side effects and more conformal target volume coverage. The purpose of this study is to summarize the current developments, randomised studies, guidelines about lung SBRT, with emphasis on the possibility of increasing local control and overall rates in "fit," operable patients as well, so SBRT would be eligible in place of surgery.
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Affiliation(s)
- Emese Csiki
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary
| | - Mihály Simon
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Judit Papp
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Márton Barabás
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary
| | - Johanna Mikáczó
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary
| | - Kristóf Gál
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - David Sipos
- Faculty of Health Sciences, University of Pécs, Pecs, Hungary
| | - Árpád Kovács
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Kita N, Tomita N, Takaoka T, Matsuura A, Okazaki D, Niwa M, Torii A, Takano S, Mekata Y, Niimi A, Hiwatashi A. Symptomatic radiation-induced rib fractures after stereotactic body radiotherapy for early-stage non-small cell lung cancer. Clin Transl Radiat Oncol 2023; 43:100683. [PMID: 37790583 PMCID: PMC10543765 DOI: 10.1016/j.ctro.2023.100683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/21/2023] [Indexed: 10/05/2023] Open
Abstract
Background and purpose The present study investigated the relationships between the risk of radiation-induced rib fractures (RIRF) and clinical and dosimetric factors in stereotactic body radiotherapy (SBRT) for early-stage non-small cell lung cancer (NSCLC). We also examined dosimetric parameters associated with symptomatic or asymptomatic RIRF and the dosimetric threshold for symptomatic RIRF. Materials and methods We reviewed 244 cases of early-stage NSCLC treated with SBRT. Gray's test and the Fine-Gray model were performed to examine the relationships between clinical and dosimetric factors and grade ≥ 2 (i.e., symptomatic) RIRF. The effects of each dose parameter on grade ≥ 1 and ≥ 2 RIRF were assessed with the Fine-Gray model. The t-test was used to compare each dose parameter between the grade 1 and grade ≥ 2 groups. Optimal thresholds were tested using receiver operating characteristic (ROC) curves. Results With a median follow-up period of 48 months, the 4-year cumulative incidence of grade ≥ 1 and grade ≥ 2 RIRF were 26.4 % and 8.0 %, respectively. Regarding clinical factors, only age was associated with the development of grade ≥ 2 RIRF (p = 0.024). Among dosimetric parameters, only V40Gy significantly differed between the grade 1 and grade ≥ 2 groups (p = 0.015). The ROC curve analysis of grade ≥ 2 RIRF showed that the optimal diagnostic thresholds for D3cc, D4cc, D5cc, and V40Gy were 45.86 Gy (area under the curve [AUC], 0.706), 39.02 Gy (AUC, 0.705), 41.62 Gy (AUC, 0.702), and 3.83 cc (AUC, 0.730), respectively. These results showed that V40Gy ≤ 3.83 cc was the best indicator of grade ≥ 2 RIRF. The 4-year incidence of grade ≥ 2 RIRF in the V40Gy ≤ 3.83 cc vs. > 3.83 cc groups was 1.8 % vs. 14.2 % (p = 0.001). Conclusion The present results recommend V40Gy ≤ 3.83 cc as the threshold for grade ≥ 2 RIRF in SBRT.
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Affiliation(s)
- Nozomi Kita
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8601, Japan
| | - Natsuo Tomita
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8601, Japan
| | - Taiki Takaoka
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8601, Japan
| | - Akane Matsuura
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8601, Japan
| | - Dai Okazaki
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8601, Japan
| | - Masanari Niwa
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8601, Japan
| | - Akira Torii
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8601, Japan
| | - Seiya Takano
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8601, Japan
| | - Yuji Mekata
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8601, Japan
| | - Akio Niimi
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8601, Japan
| | - Akio Hiwatashi
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8601, Japan
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Greer MD, Koger B, Glenn M, Kang J, Rengan R, Zeng J, Ford E. Predicted Inferior Outcomes for Lung SBRT With Treatment Planning Systems That Fail Independent Phantom-Based Audits. Int J Radiat Oncol Biol Phys 2023; 115:1301-1308. [PMID: 36535431 DOI: 10.1016/j.ijrobp.2022.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 10/07/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE More than 15% of radiation therapy clinics fail external audits with anthropomorphic phantoms conducted by Imaging and Radiation Oncology Core-Houston (IROC-H) while passing other industry-standard quality assurance (QA) tests. We seek to evaluate the predicted effect of such failed plans on outcomes for patients treated with stereotactic body radiation therapy (SBRT) for lung tumors. METHODS AND MATERIALS We conducted a retrospective study of 55 patients treated with SBRT for lung tumors with a prescription biologically equivalent dose (BED)10 ≥100 Gy using a treatment planning system (TPS) that passed IROC-H phantom audits. Sample linear accelerator beam models with introduced errors were commissioned by varying the multileaf collimator leaf-tip offset parameter (ie, dosimetric leaf gap) over the range ±1.0 mm relative to the validated model. These models mimic TPS that pass internal QA measures but fail IROC-H tests. Patient plans were recalculated on sample beam models. The predicted tumor control probability (TCP) and normal tissue complication probability (NTCP) were calculated based on published dose-response models. RESULTS A leaf-tip offset value of -1.0 mm decreased the fraction of plans receiving a planning treatment volume of BED10 ≥100 Gy from 95% to 27%. This translated to a significant decrease in 2-year TCP of 4.8% (95% CI: 2.0%-5.5%) with a decrease in TCP up to 21%. Conversely, a leaf-tip offset of +1.0 mm resulted in 36% of patients exceeding previously met organs at risk (OAR) constraints, including 2 instances of spinal cord and brachial plexus overdoses and a small increase in chest wall NTCP of 0.7%, (95% CI: 0.5%-0.8%). CONCLUSIONS Simulated treatment plans with modest MLC leaf offsets result in lung SBRT plans that significantly underdose tumor or exceed OAR constraints. These dosimetric endpoints translate to significant detriments in TCP. These simulated plans mimic planning systems that pass internal QA measures but fail independent phantom-based tests, underscoring the need for enhanced quality assurance including external audits of TPS.
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Affiliation(s)
- Matthew D Greer
- University of Washington Department of Radiation Oncology, Seattle, Washington; The University of Arizona Cancer Center, Tucson, Arizona.
| | - Brandon Koger
- University of Pennsylvania Department of Radiation Oncology, Philadelphia, Pennsylvania
| | - Mallory Glenn
- University of Washington Department of Radiation Oncology, Seattle, Washington
| | - John Kang
- University of Washington Department of Radiation Oncology, Seattle, Washington
| | - Ramesh Rengan
- University of Washington Department of Radiation Oncology, Seattle, Washington
| | - Jing Zeng
- University of Washington Department of Radiation Oncology, Seattle, Washington
| | - Eric Ford
- University of Washington Department of Radiation Oncology, Seattle, Washington
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O'Keeffe S, Higgins MJ, Fleming C, Armstrong J, Thirion P, McClean B, Vintró LL. A strategy to reduce fraction number in peripheral lung stereotactic ablative body radiotherapy. Phys Imaging Radiat Oncol 2023; 26:100429. [PMID: 37007915 PMCID: PMC10060739 DOI: 10.1016/j.phro.2023.100429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023] Open
Abstract
Background and purpose Hypo-fractionated lung Stereotactic Ablative Body Radiotherapy (SABR) has often been avoided when tumours are close to the chest wall. Our strategic objective was the reduction of fraction number, while maintaining target biological effective dose coverage without increasing chest wall toxicity (CWT) predictors. Materials and methods Twenty previously treated lung SABR patients were stratified into four cohorts according to distance from PTV to the chest wall, <1 cm, <0.5 cm, overlapping up to 0.5 cm and 1.0 cm. For each patient, four plans were created; a chest wall optimised plan for 54 Gy in 3 fractions, the clinical plan re-prescribed for 55 Gy in 5, 48 Gy in 3 and 45 Gy in 3 fractions. Results For a PTV distance of 0.5-0.0 cm, a reduction of the median (range) Dmax from 55.7 (57.5-54.1) Gy to 40.0 (37.1-42.0 Gy) Gy was observed for the chest wall optimised plans. The median V30Gy decreased from 18.9 (9.7-25.6) cm3 to 3.1 (1.8-4.5) cm3. For a PTV overlap of up to 0.5 cm, the Dmax reduced from 66.5 (64.1-70) Gy to 53.2 (50.6-55.1) Gy. The V30Gy decreased from 21.5 (16.5-29.5) cm3 to 14.9 (11.3-20.2) cm3. For the cohort with up to 1.0 cm overlap, there was a reduction in Dmax values of 9.9 Gy. The V30Gy for clinical plans, at 66.8 (18.7-188.8) cm3, decreased to 55.3 (15.5-149) cm3. Conclusion When PTVs are within 0.5 cm of chest wall, lung SABR dose heterogeneity can be used to reduce fraction number without increasing CWT predictors.
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Pierrard J, Deheneffe S, Longton E, Henry S, Van Houtte P, Remouchamps V. Radiation therapy-induced left vocal cord paralysis following lung stereotactic body radiation therapy: A case report and review of the literature. Cancer Radiother 2023; 27:69-74. [PMID: 35872055 DOI: 10.1016/j.canrad.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/02/2022] [Accepted: 05/09/2022] [Indexed: 02/06/2023]
Abstract
We report the case of a 50-year old women with an oncological history of metastatic breast carcinoma who underwent lung stereotactic body radiation therapy (SBRT) of 60Gy in 8 fractions for a left upper lobe metastatic lesion. Seven months later, she complains about hoarseness and weakness of voice. Tumoral relapse and other frequent etiologies were excluded. The diagnosis of radiation induced left recurrent laryngeal nerve paralysis causing left vocal cord paralysis (VCP) was made. The symptomatology did not improve till the disease progression and death of the patient 29 months after SBRT. VCP after lung SBRT is a rare adverse event that has not yet been well described in the medical literature.
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Affiliation(s)
- J Pierrard
- Department of Radiotherapy, CHU UCL Namur, Site Ste Elisabeth, Namur, Belgium.
| | - S Deheneffe
- Department of Radiotherapy, CHU UCL Namur, Site Ste Elisabeth, Namur, Belgium
| | - E Longton
- Department of Radiotherapy, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - S Henry
- Department of Medical Oncology, CHU UCL Namur, Site Ste Elisabeth, Namur, Belgium
| | - P Van Houtte
- Department of Radiotherapy, Institut Jules-Bordet, Université Libre Bruxelles, Brussels, Belgium
| | - V Remouchamps
- Department of Radiotherapy, CHU UCL Namur, Site Ste Elisabeth, Namur, Belgium
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Rydzewski NR, Yadav P, Musunuru HB, Condit KM, Francis D, Zhao SG, Baschnagel AM. Radiomic Modeling of Bone Density and Rib Fracture Risk After Stereotactic Body Radiation Therapy for Early-Stage Non-Small Cell Lung Cancer. Adv Radiat Oncol 2022; 7:100884. [PMID: 35647405 PMCID: PMC9133372 DOI: 10.1016/j.adro.2021.100884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/21/2021] [Indexed: 11/01/2022] Open
Abstract
Purpose Methods and Materials Results Conclusion
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Prado A, Zucca D, De la Casa MÁ, Martí J, Alonso L, de Acilu PG, García J, Hernando O, Fernández-Letón P, Rubio C. Intrafraction target shift comparison using two breath-hold systems in lung stereotactic body radiotherapy. Phys Imaging Radiat Oncol 2022; 22:57-62. [PMID: 35514526 PMCID: PMC9065403 DOI: 10.1016/j.phro.2022.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 04/13/2022] [Accepted: 04/20/2022] [Indexed: 12/25/2022] Open
Abstract
Background and purpose In lung Stereotactic Body Radiotherapy (SBRT) respiratory management is used to reduce target motion due to respiration. This study aimed (1) to estimate intrafraction shifts through a Cone Beam Computed Tomography (CBCT) acquired during the first treatment arc when deep inspiration breath-hold (DIBH) was performed using spirometry-based (SB) or surface-guidance (SG) systems and (2) to analyze the obtained results depending on lesion localization. Material and methods A sample of 157 patients with 243 lesions was analyzed. A total of 860 and 410 fractions were treated using SB and SG. Averaged intrafraction shifts were estimated by the offsets obtained when registering a CBCT acquired during the first treatment arc with the planning CT. Offsets were recorded in superior-inferior (SI), left-right (LR) and anterior-posterior (AP). Significance tests were applied to account for differences in average offsets and variances between DIBH systems. Systematic and random errors were computed. Results Average offset moduli were 2.4 ± 2.2 mm and 3.5 ± 2.6 mm for SB and SG treatments (p < 0.001). When comparing SB and SG offset distributions in each direction no differences were found in average values (p > 0.3). However, variances were statistically smaller for SB than for SG (p < 0.001). The number of vector moduli offsets greater than 5 mm was 2.1 times higher for SG. Compared to other locations, lower lobe lesions moduli were at least 2.3 times higher. Conclusions Both systems were accuracy-equivalent but not precision-equivalent systems. Furthermore, the SB system was more precise than the SG one. Despite DIBH, patients with lower lobe lesions had larger offsets than superior lobe ones, mainly in SI.
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Affiliation(s)
- Alejandro Prado
- Medical Physics and Radiation Protection Department, HU HM Sanchinarro, HM Hospitales, c\ Oña n°10, 28050 Madrid, Spain
| | - Daniel Zucca
- Medical Physics and Radiation Protection Department, HU HM Sanchinarro, HM Hospitales, c\ Oña n°10, 28050 Madrid, Spain
| | - Miguel Ángel De la Casa
- Medical Physics and Radiation Protection Department, HU HM Sanchinarro, HM Hospitales, c\ Oña n°10, 28050 Madrid, Spain
| | - Jaime Martí
- Medical Physics and Radiation Protection Department, HU HM Sanchinarro, HM Hospitales, c\ Oña n°10, 28050 Madrid, Spain
| | - Leyre Alonso
- Medical Physics and Radiation Protection Department, HU HM Sanchinarro, HM Hospitales, c\ Oña n°10, 28050 Madrid, Spain
| | - Paz García de Acilu
- Medical Physics and Radiation Protection Department, HU HM Puerta del Sur, HM Hospitales, Av. Carlos V n° 70, 28938 Móstoles, Madrid, Spain
| | - Juan García
- Medical Physics and Radiation Protection Department, HU HM Puerta del Sur, HM Hospitales, Av. Carlos V n° 70, 28938 Móstoles, Madrid, Spain
| | - Ovidio Hernando
- Radiation Oncology Department, HU HM Puerta del Sur, HM Hospitales, Av. Carlos V n° 70, 28938 Móstoles, Madrid, Spain
| | - Pedro Fernández-Letón
- Medical Physics and Radiation Protection Department, HU HM Sanchinarro, HM Hospitales, c\ Oña n°10, 28050 Madrid, Spain
- Medical Physics and Radiation Protection Department, HU HM Puerta del Sur, HM Hospitales, Av. Carlos V n° 70, 28938 Móstoles, Madrid, Spain
| | - Carmen Rubio
- Radiation Oncology Department, HU HM Sanchinarro, HM Hospitales, c\ Oña n°10, 28050 Madrid, Spain
- Radiation Oncology Department, HU HM Puerta del Sur, HM Hospitales, Av. Carlos V n° 70, 28938 Móstoles, Madrid, Spain
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Bartl AJ, Mahoney M, Hennon MW, Yendamuri S, Videtic GMM, Stephans KL, Siva S, Farrugia MK, Ma SJ, Singh AK. Systematic Review of Single-Fraction Stereotactic Body Radiation Therapy for Early Stage Non-Small-Cell Lung Cancer and Lung Oligometastases: How to Stop Worrying and Love One and Done. Cancers (Basel) 2022; 14:cancers14030790. [PMID: 35159057 PMCID: PMC8834253 DOI: 10.3390/cancers14030790] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/26/2022] [Accepted: 02/01/2022] [Indexed: 02/06/2023] Open
Abstract
Adoption of single-fraction lung stereotactic body radiation therapy (SBRT) for patients with medically inoperable early stage non-small-cell lung cancer (NSCLC) or oligometastatic lung disease, even during the coronavirus disease 2019 (COVID-19) pandemic, was limited despite encouraging phase II trial results. Barriers to using single-fraction SBRT may include lack of familiarity with the regimen and lack of clarity about the expected toxicity. To address these concerns, we performed a systematic review of prospective literature on single-fraction SBRT for definitive treatment of early stage and oligometastatic lung cancer. A PubMed search of prospective studies in English on single-fraction lung SBRT was conducted. A systematic review was performed of the studies that reported clinical outcomes of single-fraction SBRT in the treatment of early stage non-small-cell lung cancer and lung oligometastases. The current prospective literature including nine trials supports the use of single-fraction SBRT in the definitive treatment of early stage peripheral NSCLC and lung oligometastases. Most studies cite local control rates of >90%, mild toxicity profiles, and favorable survival outcomes. Most toxicities reported were grade 1–2, with grade ≥3 toxicity in 0–17% of patients. Prospective trial results suggest potential consideration of utilizing single-fraction SBRT beyond the COVID-19 pandemic.
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Affiliation(s)
- Austin J. Bartl
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY 14203, USA;
| | - Mary Mahoney
- College of Medicine, State University of New York Upstate Medical University, Syracuse, NY 13210, USA;
| | - Mark W. Hennon
- Department of Thoracic Surgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA; (M.W.H.); (S.Y.)
| | - Sai Yendamuri
- Department of Thoracic Surgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA; (M.W.H.); (S.Y.)
| | - Gregory M. M. Videtic
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH 44195, USA; (G.M.M.V.); (K.L.S.)
| | - Kevin L. Stephans
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH 44195, USA; (G.M.M.V.); (K.L.S.)
| | - Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia;
| | - Mark K. Farrugia
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA; (M.K.F.); (S.J.M.)
| | - Sung Jun Ma
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA; (M.K.F.); (S.J.M.)
| | - Anurag K. Singh
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA; (M.K.F.); (S.J.M.)
- Correspondence: ; Tel.: +1-716-845-5715
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Ouyang Z, Zhuang T, Marwaha G, Kolar MD, Qi P, Videtic GM, Stephans KL, Xia P. Evaluation of Automated Treatment Planning and Organ Dose Prediction for Lung Stereotactic Body Radiotherapy. Cureus 2021; 13:e18473. [PMID: 34754638 PMCID: PMC8569686 DOI: 10.7759/cureus.18473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2021] [Indexed: 12/14/2022] Open
Abstract
PURPOSES To evaluate whether the auto-planning (AP) module can achieve clinically acceptable treatment plans for lung stereotactic body radiotherapy (SBRT) and to evaluate the effectiveness of a dose prediction model. METHODS Twenty lung SBRT cases planned manually with 50 Gy in five fractions were replanned using the Pinnacle (Philips Radiation Oncology Systems, Fitchburg, WI) AP module according to the dose constraint tables from the Radiation Therapy Oncology Group (RTOG) 0813 protocol. Doses to the organs at risk (OAR) were compared between the manual and AP plans. Using a dose prediction model from a commercial product, PlanIQ (Sun Nuclear Corporation, Melbourne, FL), we also compared OAR doses from AP plans with predicted doses. RESULTS All manual and AP plans achieved clinically required dose coverage to the target volumes. The AP plans achieved equal or better OAR sparing when compared to the manual plans, most noticeable in the maximum doses of the spinal cord, ipsilateral brachial plexus, esophagus, and trachea. Predicted doses to the heart, esophagus, and trachea were highly correlated with the doses of these OARs from the AP plans with the highest correlation coefficient of 0.911, 0.823, and 0.803, respectively. CONCLUSION Auto-planning for lung SBRT improved OAR sparing while keeping the same dose coverage to the tumor. The dose prediction model can provide useful planning dose guidance.
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Affiliation(s)
- Zi Ouyang
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, USA
| | - Tingliang Zhuang
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, USA
| | - Gaurav Marwaha
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, USA
| | - Matthew D Kolar
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, USA
| | - Peng Qi
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, USA
| | | | - Kevin L Stephans
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, USA
| | - Ping Xia
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, USA
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Chmura S, Winter KA, Robinson C, Pisansky TM, Borges V, Al-Hallaq H, Matuszak M, Park SS, Yi S, Hasan Y, Bazan J, Wong P, Yoon HA, Horton J, Gan G, Milano MT, Sigurdson ER, Moughan J, Salama JK, White J. Evaluation of Safety of Stereotactic Body Radiotherapy for the Treatment of Patients With Multiple Metastases: Findings From the NRG-BR001 Phase 1 Trial. JAMA Oncol 2021; 7:845-852. [PMID: 33885704 PMCID: PMC8063134 DOI: 10.1001/jamaoncol.2021.0687] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Stereotactic body radiotherapy (SBRT) for oligometastases is hypothesized to improve survival and is increasingly used. Little evidence supports its safe use to treat patients with multiple metastases. OBJECTIVE To establish safety of SBRT dose schedules in patients with 3 to 4 metastases or 2 metastases in close proximity to each other. DESIGN, SETTING, AND PARTICIPANTS This phase 1 trial opened on August 4, 2014, and closed to accrual on March 20, 2018. Metastases to 7 anatomic locations were included: bone/osseous (BO), spinal/paraspinal (SP), peripheral lung (PL), central lung (CL), abdominal-pelvic (AP), mediastinal/cervical lymph node (MC), and liver (L). Six patients could be enrolled per anatomic site. The setting was a consortium of North American academic and community practice cancer centers participating in NRG Oncology trials. Patients with breast, prostate, or non-small cell lung cancer with 3 to 4 metastases or 2 metastases in close proximity (≤5 cm) amenable to SBRT were eligible for this phase 1 study. Statistical analyses were performed from December 31, 2017, to September 19, 2019. INTERVENTIONS The starting dose was 50 Gy in 5 fractions (CL, MC), 45 Gy in 3 fractions (PL, AP, L), and 30 Gy in 3 fractions (BO, SP). MAIN OUTCOMES AND MEASURES The primary end point was dose-limiting toxicity (DLT) defined by the Common Terminology Criteria for Adverse Events, version 4.0, as specific adverse events (AEs) of grades 3 to 5 (definite or probable per the protocol DLT definition) related to SBRT within 180 days of treatment. Dose levels were considered safe if DLTs were observed in no more than 1 of 6 patients per location; otherwise, the dose at that location would be de-escalated. RESULTS A total of 42 patients enrolled, 39 were eligible, and 35 (mean [SD] age, 63.1 [14.2] years; 20 men [57.1%]; 30 White patients [85.7%]) were evaluable for DLT. Twelve patients (34.3%) had breast cancer, 10 (28.6%) had non-small cell lung cancer, and 13 (37.1%) had prostate cancer; there was a median of 3 metastases treated per patient. Median survival was not reached. No protocol-defined DLTs were observed. When examining all AEs, 8 instances of grade 3 AEs, most likely related to protocol therapy, occurred approximately 125 to 556 days from SBRT initiation in 7 patients. CONCLUSIONS AND RELEVANCE This phase 1 trial demonstrated the safety of SBRT for patients with 3 to 4 metastases or 2 metastases in close proximity. There were no treatment-related deaths. Late grade 3 AEs demonstrate the need for extended follow-up in long-surviving patients with oligometastatic disease. Treatment with SBRT for multiple metastases has been expanded into multiple ongoing randomized phase 2/3 National Cancer Institute-sponsored trials (NRG-BR002, NRG-LU002). TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02206334.
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Affiliation(s)
- Steve Chmura
- University of Chicago Comprehensive Cancer Center, Chicago, Illinois
| | - Kathryn A Winter
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Clifford Robinson
- Department of Radiation Oncology, Washington University in St Louis, St Louis, Missouri
| | - Thomas M Pisansky
- Department of Medicine-Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Hania Al-Hallaq
- University of Chicago Comprehensive Cancer Center, Chicago, Illinois
| | - Martha Matuszak
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Sean S Park
- Department of Medicine-Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sun Yi
- Department of Radiation Oncology, University of Arizona Medical Center - University Campus, Tucson
| | - Yasmin Hasan
- University of Chicago Comprehensive Cancer Center, Chicago, Illinois
| | - Jose Bazan
- Ohio State University Comprehensive Cancer Center, Columbus
| | - Philip Wong
- Centre Hospitalier de L'Universite de Montréal, Hotel Dieu de Montréal, Montréal, Quebec, Canada
| | - Harold A Yoon
- Heartland Cancer Research National Cancer Institute Community Oncology Research Program, Decatur, Illinois
| | - Janet Horton
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Gregory Gan
- New Mexico Minority Underserved National Cancer Institute Community Oncology Research Program, Albuquerque
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | | | - Jennifer Moughan
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Joseph K Salama
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Julia White
- Ohio State University Comprehensive Cancer Center, Columbus
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Analysis of the efficacy and safety of iodine-125 seeds implantation in the treatment of patients with inoperable early-stage non-small cell lung cancer. J Contemp Brachytherapy 2021; 13:347-357. [PMID: 34122576 PMCID: PMC8170524 DOI: 10.5114/jcb.2021.106241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 02/24/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose To evaluate the efficacy and safety of iodine-125 (125I) seeds implantation for inoperable early-stage non-small cell lung cancer (NSCLC). Material and methods PubMed, Cochrane Library, Embase, China Biology Medicine disc (CBM), China National Knowledge Infrastructure (CNKI), and Wanfang Data were searched from inception until April 2020. Data were collected concerning overall survival, short-term efficacy, and complications. Meta-analysis was performed using R software (version 3.6.3). Results Nine studies involving 308 patients were included. Meta-analysis showed that the 1-, 2-, and 3-year survival rates were 0.98% (95% CI: 0.95-0.99%), 0.83% (95% CI: 0.77-0.89%), and 0.65% (95% CI: 0.55-0.75%), respectively; short-term local control rate (LCR) and effective rates were 0.99% (95% CI: 0.98-1.00%) and 0.92% (95% CI: 0.83-0.98%), respectively; 1-, 2-, and 3-year LCRs were 0.96% (95% CI: 0.83-1.00%), 0.94% (95% CI: 0.85-0.99%), and 0.95% (95% CI: 0.76-1.00%), respectively. Sub-group analysis of the prescribed dose found that when the prescribed dose was > 120 Gy, short-term efficacy and 1-year LCR were increased significantly (p < 0.01). The incidence of bleeding, pneumothorax, and radiation lung injury was 0.14% (95% CI: 0.07-0.21%), 0.19% (95% CI: 0.11-0.28%), and 0.00% (95% CI: 0.00-0.03%), respectively. Two studies involving 106 patients compared 125I seeds combined with chemotherapy versus chemotherapy alone for NSCLC. Results showed that compared with chemotherapy alone, 125I seeds combined with chemotherapy could improve short-term LCR (RR = 1.34, 95% CI: 1.09-1.65%, p = 0.005) and short-term effective rate (RR = 1.49, 95% CI: 1.14-1.96%, p = 0.004). Conclusions 125I seeds implantation is safe and effective approach for the treatment of inoperable early-stage NSCLC, but high-quality clinical research is still needed to further confirm the findings.
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12
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Liu G, Zhao L, Qin A, Grills I, Deraniyagala R, Stevens C, Zhang S, Yan D, Li X, Ding X. Lung Stereotactic Body Radiotherapy (SBRT) Using Spot-Scanning Proton Arc (SPArc) Therapy: A Feasibility Study. Front Oncol 2021; 11:664455. [PMID: 33968770 PMCID: PMC8100671 DOI: 10.3389/fonc.2021.664455] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/26/2021] [Indexed: 12/26/2022] Open
Abstract
Purpose We developed a 4D interplay effect model to quantitatively evaluate breathing-induced interplay effects and assess the feasibility of utilizing spot-scanning proton arc (SPArc) therapy for hypo-fractionated lung stereotactic body radiotherapy (SBRT). The model was then validated by retrospective application to clinical cases. Materials and Methods A digital lung 4DCT phantoms was used to mimic targets in diameter of 3cm with breathing motion amplitudes: 5, 10, 15, and 20 mm, respectively. Two planning groups based on robust optimization were generated: (1) Two-field Intensity Modulated Proton Therapy (IMPT) plans and (2) SPArc plans via a partial arc. 5,000 cGy relative biological effectiveness (RBE) was prescribed to the internal target volume (ITV) in five fractions. To quantitatively assess the breathing induced interplay effect, the 4D dynamic dose was calculated by synchronizing the breathing pattern with the simulated proton machine delivery sequence, including IMPT, Volumetric repainting (IMPTvolumetric), iso-layered repainting (IMPTlayer) and SPArc. Ten lung patients’ 4DCT previously treated with VMAT SBRT, were used to validate the digital lung tumor model. Normal tissue complicated probability (NTCP) of chestwall toxicity was calculated. Result Target dose were degraded as the tumor motion amplitude increased. The 4D interplay effect phantom model indicated that motion mitigation effectiveness using SPArc was about five times of IMPTvolumetric or IMPTlayer using maximum MU/spot as 0.5 MU at 20 mm motion amplitude. The retrospective study showed that SPArc has an advantage in normal tissue sparing. The probability of chestwall’s toxicity were significantly improved from 40.2 ± 29.0% (VMAT) (p = 0.01) and 16.3 ± 12.0% (IMPT) (p = 0.01) to 10.1 ± 5.4% (SPArc). SPArc could play a significant role in the interplay effect mitigation with breathing-induced motion more than 20 mm, where the target D99 of 4D dynamic dose for patient #10 was improved from 4,514 ± 138 cGy [RBE] (IMPT) vs. 4,755 ± 129 cGy [RBE] (SPArc) (p = 0.01). Conclusion SPArc effectively mitigated the interplay effect for proton lung SBRT compared to IMPT with repainting and was associated with normal tissue sparing. This technology may make delivery of proton SBRT more technically feasible and less complex with fewer concerns over underdosing the target compared to other proton therapy techniques.
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Affiliation(s)
- Gang Liu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Lewei Zhao
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - An Qin
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Inga Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Rohan Deraniyagala
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Craig Stevens
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Sheng Zhang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Di Yan
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Xiaoqiang Li
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
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Nance M, Khazi Z, Kaifi J, Avella D, Alnijoumi M, Davis R, Bhat A. Computerized tomography-Guided Microwave Ablation of Patients with Stage I Non-small Cell Lung Cancers: A Single-Institution Retrospective Study. J Clin Imaging Sci 2021; 11:7. [PMID: 33654576 PMCID: PMC7911126 DOI: 10.25259/jcis_224_2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 01/23/2021] [Indexed: 11/16/2022] Open
Abstract
Objectives: The objective of the study was to retrospectively investigate the safety and efficacy of computerized tomography-guided microwave ablation (MWA) in the treatment of Stage I non-small cell lung cancers (NSCLCs). Material and Methods: This retrospective, single-center study evaluated 21 patients (10 males and 11 females; mean age 73.8 ± 8.2 years) with Stage I peripheral NSCLCs treated with MWA between 2010 and 2020. All patients were surveyed for metastatic disease. Clinical success was defined as absence of FDG avidity on follow-up imaging. Tumor growth within 5 mm of the original ablated territory was defined as local recurrence. Welch t-test and Fisher’s exact test were used for univariate analysis. Hazard ratio (HR) and odds ratio (OR) were determined using Cox regression and Firth logistic regression. Significance was P < 0.05. Data are expressed as mean ± standard deviation. Results: Ablated tumors had longest dimension 17.4 ± 5.4 mm and depth 19.7 ± 15.1 mm from the pleural surface. Median follow-up was 20 months (range, 0.6–56 months). Mean overall survival (OS) following lung cancer diagnosis or MWA was 26.2 ± 15.4 months (range, 5–56 months) and 23.7 ± 15.1 months (range, 3–55 months). OS at 1, 2, and 5 years was 67.6%, 61.8%, and 45.7%, respectively. Progression-free survival (PFS) was 19.1 ± 16.2 months (range, 1–55 months). PFS at 1, 2, and 5 years was 44.5%, 32.9%, and 32.9%, respectively. Technical success was 100%, while clinical success was observed in 95.2% (20/21) of patients. One patient had local residual disease following MWA and was treated with chemotherapy. Local control was 90% with recurrence in two patients following ablation. Six patients (28.6%) experienced post-ablation complications, with pneumothorax being the most common event (23.8% of patients). Female gender was associated with 90% reduction in risk of death (HR 0.1, P = 0.014). Tumor longest dimension was associated with a 10% increase in risk of death (P = 0.197). Several comorbidities were associated with increased hazard. Univariate analysis revealed pre-ablation forced vital capacity trended higher among survivors (84.7 ± 15.2% vs. 73 ± 21.6%, P = 0.093). Adjusted for age and sex, adenocarcinoma, and neuroendocrine histology trended toward improved OS (OR: 0.13, 0.13) and PFS (OR: 0.88, 0.37) compared to squamous cell carcinoma. Conclusion: MWA provides a safe and effective alternative to stereotactic brachytherapy resulting in promising OS and PFS in patients with Stage I peripheral NSCLC. Larger sample sizes are needed to further define the effects of underlying comorbidities and tumor biology.
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Affiliation(s)
- Michael Nance
- Department of Vascular and Interventional Radiology, School of Medicine, Columbia, Missouri, United States
| | - Zain Khazi
- Department of Radiology, Division of Cardiothoracic Surgery, Columbia, Missouri, United States
| | - Jussuf Kaifi
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia, Missouri, United States
| | - Diego Avella
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia, Missouri, United States
| | - Mohammed Alnijoumi
- Department of Pulmonary, Critical Care, and Environmental Medicine, Columbia, Missouri, United States
| | - Ryan Davis
- Department of Vascular and Interventional Radiology, University of Missouri Columbia, One Hospital Drive, Columbia, Missouri, United States
| | - Ambarish Bhat
- Department of Vascular and Interventional Radiology, University of Missouri Columbia, One Hospital Drive, Columbia, Missouri, United States
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14
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Arbab M, Bartlett G, DesRosiers C, Maxim PG, Lautenschlaeger T. Early‐stage lung adenocarcinoma treated with stereotactic body radiation therapy using a combined deep inspiration breath hold and free breathing technique: case report and literature review. PRECISION RADIATION ONCOLOGY 2020. [DOI: 10.1002/pro6.1101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Mona Arbab
- Department of Radiation Oncology Radiation Oncology Indiana University Health Indianapolis Indiana USA
| | - Gregory Bartlett
- Department of Radiation Oncology Radiation Oncology Indiana University Health Indianapolis Indiana USA
| | - Colleen DesRosiers
- Department of Radiation Oncology Radiation Oncology Indiana University Health Indianapolis Indiana USA
| | - Peter G Maxim
- Department of Radiation Oncology Radiation Oncology Indiana University Health Indianapolis Indiana USA
| | - Tim Lautenschlaeger
- Department of Radiation Oncology Radiation Oncology Indiana University Health Indianapolis Indiana USA
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15
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Keane FK, Driscoll E, Bowes C, Durgin B, Khandekar MJ, Willers H. Low Rates of Chest Wall Toxicity When Individualizing the Planning Target Volume Margin in Patients With Early Stage Lung Cancer Treated With Stereotactic Body Radiation Therapy. Pract Radiat Oncol 2020; 11:e282-e291. [PMID: 33239160 DOI: 10.1016/j.prro.2020.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/25/2020] [Accepted: 10/05/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Chest wall (CW) toxicity is a potentially debilitating complication of stereotactic body radiation therapy for non-small cell lung cancer, occurring in 10% to 40% of patients. Smaller tumor-to-CW distance has been identified as a risk factor for CW toxicity. We report our experience with individualizing the planning target volume (PTV) along the CW in an effort to reduce the volume of this organ at risk receiving 30 Gy to 50 Gy. METHODS AND MATERIALS We performed an institutional review board-approved retrospective analysis of patients with stage I (T1-2aN0M0) non-small cell lung cancer who received stereotactic body radiation therapy between June 2009 and July 2016. Four-dimensional computed tomography was used for treatment planning. A uniform 5-mm expansion of the internal target volume was generated for the PTV. Areas of overlap with the CW were removed from the PTV. Treatment was delivered with cone beam computed tomography guidance. CW toxicity was assessed per the Common Terminology Criteria for Adverse Events, version 5. Descriptive statistics were used to analyze outcomes. RESULTS The median follow-up time was 36.8 months. A total of 260 tumors were treated in 225 patients. 225 tumors in 203 patients were peripheral. The internal target volumes for 143 tumors (63.6%) were located within 5 mm of the CW. The median total dose was 48 Gy (range, 42-60 Gy) in 4 fractions (range, 3-5 fractions). The overall rate of grade 1 to 2 CW toxicity was 2.2%, and 2.8% for tumors located within 5 mm of the CW. There were no grade 3/4 cases and no increase in local recurrences with the use of a truncated PTV with a 3-year local control of 92.1% (95% confidence interval, 87.4%-96.8%). CONCLUSIONS Truncation of the PTV margin along the CW resulted in a marked reduction of CW toxicity for tumors in close proximity to the CW, with only a 2.8% rate of grade 1 to 2 CW toxicity. Despite PTV reduction, there was no appreciable increase in local failures. A multi-institutional validation of this technique is needed before general incorporation into clinical practice.
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Affiliation(s)
- Florence K Keane
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
| | - Erin Driscoll
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Cynthia Bowes
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Brittany Durgin
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Melin J Khandekar
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Henning Willers
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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16
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Billiet C, Chiairi I, Berzenji L, Van Schil PE. [Early-stage lung cancer: Is there still a role for surgery?]. Rev Mal Respir 2020; 37:735-742. [PMID: 33059960 DOI: 10.1016/j.rmr.2020.06.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 06/04/2020] [Indexed: 12/25/2022]
Abstract
For a patient with stage I or II non-small cell lung cancer (NSCLC) surgical resection remains the treatment of choice on condition that the patient is functionally operable. A complete resection should be obtained. Often lobectomy is feasible by a minimally invasive approach. For patients with compromised cardiopulmonary function stereotactic radiotherapy is an alternative treatment. For patients who are functionally operable, no definite recommendation can be made as no large, randomised studies have been performed with a sufficient number of patients and long-term follow-up. For this reason, it is important to discuss every patient within a multidisciplinary team with participation of thoracic surgeons and radiation oncologists. To provide personalised advice, the primary tumour, its extension, the patient's comorbidities and his respiratory and cardiac function have to be considered.
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Affiliation(s)
- C Billiet
- Department of Radiation Oncology, Iridium Kankernetwerk, Wilrijk, Antwerp, Belgique; University of Antwerp, Faculty of Medicine and Health Sciences, Campus Drie Eiken, Building S, Universiteitsplein 1, 2610 Wilrijk, Antwerp, Belgique
| | - I Chiairi
- Department of Radiation Oncology, Iridium Kankernetwerk, Wilrijk, Antwerp, Belgique; University of Antwerp, Faculty of Medicine and Health Sciences, Campus Drie Eiken, Building S, Universiteitsplein 1, 2610 Wilrijk, Antwerp, Belgique
| | - L Berzenji
- University of Antwerp, Faculty of Medicine and Health Sciences, Campus Drie Eiken, Building S, Universiteitsplein 1, 2610 Wilrijk, Antwerp, Belgique; Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgique
| | - P E Van Schil
- University of Antwerp, Faculty of Medicine and Health Sciences, Campus Drie Eiken, Building S, Universiteitsplein 1, 2610 Wilrijk, Antwerp, Belgique; Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgique.
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Sood SS, Pokhrel D, Badkul R, TenNapel M, McClinton C, Kimler B, Wang F. Correlation of clinical outcome, radiobiological modeling of tumor control, normal tissue complication probability in lung cancer patients treated with SBRT using Monte Carlo calculation algorithm. J Appl Clin Med Phys 2020; 21:56-62. [PMID: 32794632 PMCID: PMC7592969 DOI: 10.1002/acm2.13004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/05/2020] [Accepted: 07/02/2020] [Indexed: 11/20/2022] Open
Abstract
Purpose/Background We analyzed the predictive value of non‐x‐ray voxel Monte Carlo (XVMC)‐based modeling of tumor control probability (TCP) and normal tissue complication probability (NTCP) in patients treated with stereotactic body radiotherapy (SBRT) using the XVMC dose calculation algorithm. Materials/Methods We conducted an IRB‐approved retrospective analysis in patients with lung tumors treated with XVMC‐based lung SBRT. For TCP, we utilized tumor size‐adjusted biological effective dose (s‐BED) TCP modeling validated in non‐MC dose calculated SBRT to: (1) verify modeling as a function of s‐BED in patients treated with XVMC‐based SBRT; and (2) evaluate the predictive potential of different PTV dosimetric parameters (mean dose, minimum dose, max dose, prescription dose, D95, D98, and D99) for incorporation into the TCP model. Correlation between observed local control and TCPs was assessed by Pearson's correlation coefficient. For NTCP, Lyman NTCP Model was utilized to predict grade 2 pneumonitis and rib fracture. Results Eighty‐four patients with 109 lung tumors were treated with XVMC‐based SBRT to total doses of 40 to 60 Gy in 3 to 5 fractions. Median follow‐up was 17 months. The 2‐year local and local‐regional control rates were 91% and and 78%, respectievly. All estimated TCPs correlated significantly with 2‐year actuarial local control rates (P < 0.05). Significant corelations between TCPs and tumor control rate according to PTV dosimetric parameters were observed. D99 parameterization demonstrated the most robust correlation between observed and predicted tumor control. The incidences of grade 2 pneumonitis and rib fracture vs. predicted were 1% vs. 3% and 10% vs. 13%, respectively. Conclusion Our TCP results using a XVMC‐based dose calculation algorithm are encouraging and yield validation to previously described TCP models using non‐XVMC dose methods. Furthermore, D99 as potential predictive parameter in the TCP model demonstrated better correlation with clinical outcome.
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Affiliation(s)
- Sumit S Sood
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Damodar Pokhrel
- Department of Radiation Medicine, University of Kentucky, Lexington, KY, USA
| | - Rajeev Badkul
- Department of Radiation Oncology, The University of Kansas Cancer Center, Kansas City, KS, USA
| | - Mindi TenNapel
- Department of Radiation Oncology, The University of Kansas Cancer Center, Kansas City, KS, USA
| | | | - Bruce Kimler
- Department of Radiation Oncology, The University of Kansas Cancer Center, Kansas City, KS, USA
| | - Fen Wang
- Department of Radiation Oncology, The University of Kansas Cancer Center, Kansas City, KS, USA
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Pokhrel D, Sanford L, Larkin S, Dhanireddy B, Bernard ME, Randall M, McGarry RC. On the use of single‐isocenter VMAT plans for SBRT treatment of synchronous multiple lung lesions: Plan quality, treatment efficiency, and early clinical outcomes. J Appl Clin Med Phys 2020. [PMCID: PMC7484875 DOI: 10.1002/acm2.12938] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Cone‐beam computed tomography (CT)‐guided volumetric‐modulated arc therapy (VMAT) plans for stereotactic body radiotherapy (SBRT) treatment of synchronous multiple lung lesions with a flattening filter‐free (FFF) beam is a safe and highly effective treatment option for oligometastases lung cancer patients. Fourteen patients with metastatic non–small‐cell lung cancer (NSCLC) lesions (two to five) received a single‐isocenter VMAT SBRT treatment in our clinic. Four‐dimensional (4D) CT‐based treatment plans were generated using advanced AcurosXB‐based dose calculation algorithm using heterogeneity corrections with a single isocenter placed between/among the lesions. Compared to 10X‐FFF and traditional flattened 6X (6X‐FF) beams, 6X‐FFF beam produced highly conformal radiosurgical dose distribution to each target volume, reduced dose to adjacent organs at risk (OAR), and significantly reduced the lung SBRT fraction duration to < 3.5 min/fraction for 54/50 Gy treatments in 3/5 fractions — significantly improving patient convenience and clinic workflow. Early follow‐up CT imaging (mean, 9 months) results show high local control rates (100%) with no acute lung or rib toxicity. Longer clinical follow up in a larger patient cohort is ongoing to further validate the outcomes of this treatment approach.
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Affiliation(s)
- Damodar Pokhrel
- Department of Radiation Medicine Medical Physics Graduate Program University of Kentucky Lexington KY USA
| | - Lana Sanford
- Department of Radiation Medicine Medical Physics Graduate Program University of Kentucky Lexington KY USA
| | - Shilpa Larkin
- Department of Radiation Medicine Medical Physics Graduate Program University of Kentucky Lexington KY USA
| | - Bhaswanth Dhanireddy
- Department of Radiation Medicine Medical Physics Graduate Program University of Kentucky Lexington KY USA
| | - Mark E. Bernard
- Department of Radiation Medicine Medical Physics Graduate Program University of Kentucky Lexington KY USA
| | - Marcus Randall
- Department of Radiation Medicine Medical Physics Graduate Program University of Kentucky Lexington KY USA
| | - Ronald C. McGarry
- Department of Radiation Medicine Medical Physics Graduate Program University of Kentucky Lexington KY USA
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Pokhrel D, Visak J, Sanford L. A novel and clinically useful dynamic conformal arc (DCA)-based VMAT planning technique for lung SBRT. J Appl Clin Med Phys 2020; 21:29-38. [PMID: 32306530 PMCID: PMC7386176 DOI: 10.1002/acm2.12878] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/12/2020] [Accepted: 03/15/2020] [Indexed: 12/26/2022] Open
Abstract
Purpose Volumetric modulated arc therapy (VMAT) is gaining popularity for stereotactic treatment of lung lesions for medically inoperable patients. Due to multiple beamlets in delivery of highly modulated VMAT plans, there are dose delivery uncertainties associated with small‐field dosimetry error and interplay effects with small lesions. We describe and compare a clinically useful dynamic conformal arc (DCA)‐based VMAT (d‐VMAT) technique for lung SBRT using flattening filter free (FFF) beams to minimize these effects. Materials and Methods Ten solitary early‐stage I‐II non‐small‐cell lung cancer (NSCLC) patients were treated with a single dose of 30 Gy using 3–6 non‐coplanar VMAT arcs (clinical VMAT) with 6X‐FFF beams in our clinic. These clinically treated plans were re‐optimized using a novel d‐VMAT planning technique. For comparison, d‐VMAT plans were recalculated using DCA with user‐controlled field aperture shape before VMAT optimization. Identical beam geometry, dose calculation algorithm, grid size, and planning objectives were used. The clinical VMAT and d‐VMAT plans were compared via RTOG‐0915 protocol compliances for conformity, gradient indices, and dose to organs at risk (OAR). Additionally, treatment delivery efficiency and accuracy were recorded. Results All plans met RTOG‐0915 requirements. Comparing with clinical VMAT, d‐VMAT plans gave similar target coverage with better target conformity, tighter radiosurgical dose distribution with lower gradient indices, and dose to OAR. Lower total number of monitor units and small beam modulation factor reduced beam‐on time by 1.75 min (P < 0.001), on average (maximum up to 2.52 min). Beam delivery accuracy was improved by 2%, on average (P < 0.05) and maximum up to 6% in some cases for d‐VMAT plans. Conclusion This simple d‐VMAT technique provided excellent plan quality, reduced intermediate dose‐spillage, and dose to OAR while providing faster treatment delivery by significantly reducing beam‐on time. This novel treatment planning approach will improve patient compliance along with potentially reducing intrafraction motion error. Moreover, with less MLC modulation through the target, d‐VMAT could potentially minimize small‐field dosimetry errors and MLC interplay effects. If available, d‐VMAT planning approach is recommended for future clinical lung SBRT plan optimization.
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Affiliation(s)
- Damodar Pokhrel
- Department of Radiation Medicine, Medical Physics Graduate Program, University of Kentucky, Lexington, KY, USA.,Department of Radiation Medicine, University of Kentucky, Markey Cancer Center, Lexington, KY, USA
| | - Justin Visak
- Department of Radiation Medicine, Medical Physics Graduate Program, University of Kentucky, Lexington, KY, USA
| | - Lana Sanford
- Department of Radiation Medicine, Medical Physics Graduate Program, University of Kentucky, Lexington, KY, USA
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Beaty BT, Weiner AA. Alternatives to Surgery for Early-Stage Non-Small Cell Lung Cancer: Stereotactic Radiotherapy. Clin Chest Med 2020; 41:185-195. [PMID: 32402355 DOI: 10.1016/j.ccm.2020.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Lung cancer is the leading cause of cancer death worldwide. Diagnosis of early-stage disease is becoming more common. In an aging population, more and more patients have substantial comorbidities that might limit feasibility of surgical management of early-stage disease. Stereotactic body radiotherapy (SBRT) enables delivery of high-dose, precisely delivered radiation to early-stage lung cancers without surgical risk. This technique has rates of local control similar to surgery and can be considered in medically operable patients who refuse surgery. This article details the technique of SBRT, the data for its efficacy, as well as the potential toxicities of treatment.
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Affiliation(s)
- Brian T Beaty
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, 101 Manning Drive, CB 7512, Chapel Hill, NC 27599-7512, USA
| | - Ashley A Weiner
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, 101 Manning Drive, CB 7512, Chapel Hill, NC 27599-7512, USA.
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Pokhrel D, Halfman M, Sanford L. A simple, yet novel hybrid-dynamic conformal arc therapy planning via flattening filter-free beam for lung stereotactic body radiotherapy. J Appl Clin Med Phys 2020; 21:83-92. [PMID: 32243704 PMCID: PMC7324700 DOI: 10.1002/acm2.12868] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 02/23/2020] [Accepted: 03/09/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose Due to multiple beamlets in the delivery of highly modulated volumetric arc therapy (VMAT) plans, dose delivery uncertainties associated with small‐field dosimetry and interplay effects can be concerns in the treatment of mobile lung lesions using a single‐dose of stereotactic body radiotherapy (SBRT). Herein, we describe and compare a simple, yet clinically useful, hybrid 3D‐dynamic conformal arc (h‐DCA) planning technique using flattening filter‐free (FFF) beams to minimize these effects. Materials and Methods Fifteen consecutive solitary early‐stage I‐II non‐small‐cell lung cancer (NSCLC) patients who underwent a single‐dose of 30 Gy using 3–6 non‐coplanar VMAT arcs with 6X‐FFF beams in our clinic. These patients’ plans were re‐planned using a non‐coplanar hybrid technique with 2–3 differentially‐weighted partial dynamic conformal arcs (DCA) plus 4–6 static beams. About 60–70% of the total beam weight was given to the DCA and the rest was distributed among the static beams to maximize the tumor coverage and spare the organs‐at‐risk (OAR). The clinical VMAT and h‐DCA plans were compared via RTOG‐0915 protocol for conformity and dose to OAR. Additionally, delivery efficiency, accuracy, and overall h‐DCA planning time were recorded. Results All plans met RTOG‐0915 requirements. Comparison with clinical VMAT plans h‐DAC gave better target coverage with a higher dose to the tumor and exhibited statistically insignificance differences in gradient index, D2cm, gradient distance and OAR doses with the exception of maximal dose to skin (P = 0.015). For h‐DCA plans, higher values of tumor heterogeneity and tumor maximum, minimum and mean doses were observed and were 10%, 2.8, 1.0, and 2.0 Gy, on average, respectively, compared to the clinical VMAT plans. Average beam on time was reduced by a factor of 1.51. Overall treatment planning time for h‐DCA was about an hour. Conclusion Due to no beam modulation through the target, h‐DCA plans avoid small‐field dosimetry and MLC interplay effects and resulting in enhanced target coverage by improving tumor dose (characteristic of FFF‐beam). The h‐DCA simplifies treatment planning and beam on time significantly compared to clinical VMAT plans. Additionally, h‐DCA allows for the real time target verification and eliminates patient‐specific VMAT quality assurance; potentially offering cost‐effective, same or next day SBRT treatments. Moreover, this technique can be easily adopted to other disease sites and small clinics with less extensive physics or machine support.
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Affiliation(s)
- Damodar Pokhrel
- Department of Radiation Medicine, Medical Physics Graduate Program, University of Kentucky, Lexington, KY, USA
| | - Matthew Halfman
- Department of Radiation Medicine, Medical Physics Graduate Program, University of Kentucky, Lexington, KY, USA
| | - Lana Sanford
- Department of Radiation Medicine, Medical Physics Graduate Program, University of Kentucky, Lexington, KY, USA
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Shintani T, Nakamura M, Matsuo Y, Miyabe Y, Mukumoto N, Mitsuyoshi T, Iizuka Y, Mizowaki T. Investigation of 4D dose in volumetric modulated arc therapy-based stereotactic body radiation therapy: does fractional dose or number of arcs matter? JOURNAL OF RADIATION RESEARCH 2020; 61:325-334. [PMID: 32030408 PMCID: PMC7246072 DOI: 10.1093/jrr/rrz103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 12/05/2019] [Accepted: 01/09/2020] [Indexed: 06/10/2023]
Abstract
The aim of this study was to assess the impact of fractional dose and the number of arcs on interplay effects when volumetric modulated arc therapy (VMAT) is used to treat lung tumors with large respiratory motions. A three (fractional dose of 4, 7.5 or 12.5 Gy) by two (number of arcs, one or two) VMAT plan was created for 10 lung cancer cases. The median 3D tumor motion was 17.9 mm (range: 8.2-27.2 mm). Ten phase-specific subplans were generated by calculating the dose on each respiratory phase computed tomography (CT) scan using temporally assigned VMAT arcs. We performed temporal assignment of VMAT arcs using respiratory information obtained from infrared markers placed on the abdomens of the patients during CT simulations. Each phase-specific dose distribution was deformed onto exhale phase CT scans using contour-based deformable image registration, and a 4D plan was created by dose accumulation. The gross tumor volume dose of each 4D plan (4D GTV dose) was compared with the internal target volume dose of the original plan (3D ITV dose). The near-minimum 4D GTV dose (D99%) was higher than the near-minimum 3D internal target volume (ITV) dose, whereas the near-maximum 4D GTV dose (D1%) was lower than the near-maximum 3D ITV dose. However, the difference was negligible, and thus the 4D GTV dose corresponded well with the 3D ITV dose, regardless of the fractional dose and number of arcs. Therefore, interplay effects were negligible in VMAT-based stereotactic body radiation therapy for lung tumors with large respiratory motions.
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Affiliation(s)
- Takashi Shintani
- Department of Radiation Oncology and Image-applied Therapy, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Mitsuhiro Nakamura
- Department of Radiation Oncology and Image-applied Therapy, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
- Division of Medical Physics, Department of Information Technology and Medical Engineering, Human Health Sciences, Graduate School of Medicine, Kyoto University, 53 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - Yukinori Matsuo
- Department of Radiation Oncology and Image-applied Therapy, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Yuki Miyabe
- Department of Radiation Oncology and Image-applied Therapy, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Nobutaka Mukumoto
- Department of Radiation Oncology and Image-applied Therapy, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Takamasa Mitsuyoshi
- Department of Radiation Oncology and Image-applied Therapy, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Yusuke Iizuka
- Department of Radiation Oncology and Image-applied Therapy, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-applied Therapy, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
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Pokhrel D, Halfman M, Sanford L. FFF-VMAT for SBRT of lung lesions: Improves dose coverage at tumor-lung interface compared to flattened beams. J Appl Clin Med Phys 2019; 21:26-35. [PMID: 31859456 PMCID: PMC6964748 DOI: 10.1002/acm2.12764] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 08/09/2019] [Accepted: 10/07/2019] [Indexed: 12/14/2022] Open
Abstract
Purpose To quantify the differences in dosimetry as a function of ipsilateral lung density and treatment delivery parameters for stereotactic, single dose of volumetric modulated arc therapy (VMAT) lung stereotactic body radiation therapy (SBRT) delivered with 6X flattening filter free (6X‐FFF) beams compared to traditional flattened 6X (6X‐FF) beams. Materials/methods Thirteen consecutive early stage I–II non‐small‐cell‐lung cancer (NSCLC) patients were treated with highly conformal noncoplanar VMAT SBRT plans (3–6 partial arcs) using 6X‐FFF beam and advanced Acuros‐based dose calculations to a prescription dose of 30 Gy in one fraction to the tumor margin. These clinical cases included relatively smaller tumor (island tumors) sizes (2.0–4.2 cm diameters) and varying average ipsilateral lung densities between 0.14 g/cc and 0.34 g/cc. Treatment plans were reoptimized with 6X‐FF beams for identical beam/arc geometries and planning objectives. For same target coverage, the organs‐at‐risk (OAR) dose metrics as a function of ipsilateral lung density were compared between 6X‐FFF and 6X‐FF plans. Moreover, monitor units (MU), beam modulation factor (MF) and beam‐on time (BOT) were evaluated. Results Both plans met the RTOG‐0915 protocol compliance. The ipsilateral lung density and the tumor location heavily influenced the treatment plans with 6X‐FFF and 6X‐FF beams, showing differences up to 12% for the gradient indices. For similar target coverage, 6X‐FFF beams showed better target conformity, lower intermediate dose‐spillage, and lower dose to the OAR. Additionally, BOT was reduced by a factor of 2.3 with 6X‐FFF beams compared to 6X‐FF beams. Conclusion While prescribing dose to the tumor periphery, 6X‐FFF VMAT plans for stereotactic single‐dose lung SBRT provided similar target coverage with better dose conformity, superior intermediate dose‐spillage (improved dose coverage at tumor interface), and improved OAR sparing compared to traditional 6X‐FF beams and significantly reduced treatment time. The ipsilateral lung density and tumor location considerably affected dose distributions requiring special attention for clinical SBRT plan optimization on a per‐patient basis. Clinical follow up of these patients for tumor local‐control rate and treatment‐related toxicities is in progress.
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Affiliation(s)
- Damodar Pokhrel
- Department of Radiation Medicine, Medical Physics Graduate Program, University of Kentucky, Lexington, KY, USA
| | - Matthew Halfman
- Department of Radiation Medicine, Medical Physics Graduate Program, University of Kentucky, Lexington, KY, USA
| | - Lana Sanford
- Department of Radiation Medicine, Medical Physics Graduate Program, University of Kentucky, Lexington, KY, USA
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Chest wall pain following lung stereotactic body radiation therapy using 48Gy in three fractions: A search for predictors. Cancer Radiother 2019; 23:98-103. [PMID: 30952561 DOI: 10.1016/j.canrad.2018.07.140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 07/17/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE Chest wall pain is an uncommon but bothersome late complication following lung stereotactic body radiation therapy. Despite numerous studies investigating predictors of chest wall pain, no clear consensus has been established for a chest wall constraint. The aim of our study was to investigate factors related to chest wall pain in a homogeneous group of patients treated at our institution. PATIENTS AND METHODS All 122 patients were treated with the same stereotactic body radiation therapy regimen of 48Gy in three fractions, seen for at least 6 months of follow-up, and planned with heterogeneity correction. Chest wall pain was scored according to the Common Terminology Criteria for Adverse Events classification v3.0. Patient (age, sex, diabetes, osteoporosis), tumour (planning target volume, volume of the overlapping region between planning target volume and chest wall) and chest wall dosimetric parameters (volumes receiving at least 30, 40, and 50Gy, the minimal doses received by the highest irradiated 1, 2, and 5cm3, and maximum dose) were collected. The correlation between chest wall pain (grade 2 or higher) and the different parameters was evaluated using univariate and multivariate logistic regression. RESULTS Median follow-up was 18 months (range: 6-56 months). Twelve patients out of 122 developed chest wall pain of any grade (seven with grade 1, three with grade 2 and two with grade 3 pain). In univariate analysis, only the volume receiving 30Gy or more (P=0.034) and the volume of the overlapping region between the planning target volume and chest wall (P=0.038) significantly predicted chest wall pain, but these variables were later proved non-significant in multivariate regression. CONCLUSION Our analysis could not find any correlation between the studied parameters and chest wall pain. Considering our present study and the wide range of differing results from the literature, a reasonable conclusion is that a constraint for chest wall pain is yet to be defined.
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Kennedy WR, Gabani P, Nikitas J, Samson PP, Robinson CG, Bradley JD, Roach MC. Treatment of T3N0 non-small cell lung cancer with chest wall invasion using stereotactic body radiotherapy. Clin Transl Radiat Oncol 2019; 16:1-6. [PMID: 30859139 PMCID: PMC6396077 DOI: 10.1016/j.ctro.2019.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 02/19/2019] [Indexed: 11/08/2022] Open
Abstract
The role of SBRT for T3N0 lung cancer invading the chest wall is unknown. We treated 12 patients with T3N0 chest wall-invading lung cancer with SBRT. Local control was excellent and no grade 3+ toxicity was observed. Pre-treatment chest wall pain was relieved after SBRT in most patients.
Objectives Chest wall invasion (CWI) is observed in 5% of localized non-small cell lung cancer (NSCLC). The role of stereotactic body radiotherapy (SBRT) in these patients is unknown. We investigate the safety and efficacy of SBRT in patients with T3N0 NSCLC due to CWI. Methods Patients with T3N0 NSCLC due to CWI were identified using a prospective registry. CWI was defined as radiographic evidence of soft tissue invasion or bony destruction. We excluded patients with recurrent or metastatic disease. All patients were treated with definitive SBRT. Prescribed dose was 50 Gy in 5 fractions for most patients. Kaplan-Meier analysis was used to estimate survival outcomes. Results We identified 12 patients treated between 2006 and 2017. Median age was 70 (range, 58–85). Median tumor diameter was 3.0 cm (range, 0.9–7.2). Median survival was 12.0 months (range, 2.4–63). At a median follow-up of 8.9 months (range, 2.1–63), 1-year primary tumor control was 89%, involved lobar control was 89%, local–regional control was 82%, distant control was 91%, and survival was 63%. Of the 4 patients with pre-treatment chest wall pain, 3 reported improvement after SBRT. Two patients reported new grade 1–2 chest wall pain. No grade 3+ toxicity was reported, with 1 patient experiencing grade 1 skin toxicity and 3 patients experiencing grade 1–2 radiation pneumonitis. Conclusions SBRT for CWI NSCLC is safe, with high early tumor control and low treatment-related toxicity. Most patients with pre-treatment chest wall pain experienced relief after SBRT, with no grade 3+ toxicity observed.
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Affiliation(s)
- William R Kennedy
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO 63110, United States
| | - Prashant Gabani
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO 63110, United States
| | - John Nikitas
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO 63110, United States
| | - Pamela P Samson
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO 63110, United States
| | - Clifford G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO 63110, United States
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO 63110, United States
| | - Michael C Roach
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO 63110, United States
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Abel S, Hasan S, Horne ZD, Colonias A, Wegner RE. Stereotactic body radiation therapy in early-stage NSCLC: historical review, contemporary evidence and future implications. Lung Cancer Manag 2019; 8:LMT09. [PMID: 31044018 PMCID: PMC6488937 DOI: 10.2217/lmt-2018-0013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 01/22/2018] [Indexed: 12/17/2022] Open
Abstract
Clinical use of stereotactic body radiation therapy (SBRT) has increased dramatically over the last 2 decades and is the current standard-of-care in cases of inoperable early stage non-small-cell lung cancer. While surgical resection remains the standard-of-care for operable patients, several ongoing clinical trials are investigating the role of SBRT in these operative candidates as well. Taking into consideration the expanding role and utility of SBRT, this paper will: review the historical basis of SBRT; examine landmark trials establishing the framework for the current body of evidence; discuss areas of active and future research; and identify epidemiological trends that are likely to further increase the use of SBRT.
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Affiliation(s)
- Stephen Abel
- Allegheny Health Network Cancer Institute, Division of Radiation Oncology, Pittsburgh, PA, 15212, USA
| | - Shaakir Hasan
- Allegheny Health Network Cancer Institute, Division of Radiation Oncology, Pittsburgh, PA, 15212, USA
| | - Zachary D Horne
- Allegheny Health Network Cancer Institute, Division of Radiation Oncology, Pittsburgh, PA, 15212, USA
| | - Athanasios Colonias
- Allegheny Health Network Cancer Institute, Division of Radiation Oncology, Pittsburgh, PA, 15212, USA
| | - Rodney E Wegner
- Allegheny Health Network Cancer Institute, Division of Radiation Oncology, Pittsburgh, PA, 15212, USA
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Thompson M, Rosenzweig KE. The evolving toxicity profile of SBRT for lung cancer. Transl Lung Cancer Res 2019; 8:48-57. [PMID: 30788234 PMCID: PMC6351399 DOI: 10.21037/tlcr.2018.10.06] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 10/16/2018] [Indexed: 12/25/2022]
Abstract
Stereotactic body radiation therapy (SBRT) is an effective and well tolerated treatment for early stage non-small cell lung cancer (NSCLC). The high doses used in thoracic SBRT can sometimes cause adverse effects ranging from mild fatigue and transient esophagitis to fatal events such as pneumonitis or hemorrhage. Efforts continue to expand in both the utility of this technique as well as our understanding of the mechanisms of the adverse effects it can cause. In this review, we discuss the current literature regarding the potential mechanisms, dosimetric constraints and toxicities associated with SBRT alone and in conjunction with definitive chemoradiotherapy and immunotherapy. As the use of SBRT expands to these spheres, we examine the available recommendations for mitigating potential associated treatment related toxicities.
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Affiliation(s)
- Marcher Thompson
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kenneth E Rosenzweig
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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28
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Tsakok M, Little M, Hynes G, Millington R, Boardman P, Gleeson F, Anderson E. Local control, safety, and survival following image-guided percutaneous microwave thermal ablation in primary lung malignancy. Clin Radiol 2019; 74:80.e19-80.e26. [DOI: 10.1016/j.crad.2018.09.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 09/14/2018] [Indexed: 12/17/2022]
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Rijken J, Kairn T, Crowe S, Trapp J. Effect of arc length on skin dose from hypofractionated volumetric modulated arc radiotherapy treatments of the lung and spine. Med Dosim 2019; 44:309-314. [DOI: 10.1016/j.meddos.2018.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/01/2018] [Accepted: 11/06/2018] [Indexed: 02/07/2023]
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30
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Manyam BV, Videtic GMM, Verdecchia K, Reddy CA, Woody NM, Stephans KL. Effect of Tumor Location and Dosimetric Predictors for Chest Wall Toxicity in Single-Fraction Stereotactic Body Radiation Therapy for Stage I Non-Small Cell Lung Cancer. Pract Radiat Oncol 2018; 9:e187-e195. [PMID: 30529796 DOI: 10.1016/j.prro.2018.11.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/17/2018] [Accepted: 11/29/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE Dosimetric parameters to limit chest wall toxicity (CWT) are not well defined in single-fraction (SF) stereotactic body radiation therapy (SBRT) phase 2 trials. We sought to determine the relationship of tumor location and dosimetric parameters with CWT for SF-SBRT. METHODS AND MATERIALS From a prospective registry of 1462 patients, we identified patients treated with 30 Gy or 34 Gy. Gross tumor volume was measured as abutting, ≤1 cm, 1 to 2 cm, or >2 cm from the chest wall. CWT was prospectively graded according to Common Terminology Criteria for Adverse Events version 3.0, with grade 2 requiring medical therapy, grade 3 requiring procedural intervention, and grade 4 being disabling pain. Grade 1 CWT or radiographic rib fracture was not included. Logistic regression analysis was used to identify the parameters associated with CWT and calculate the probability of CWT with dose. RESULTS This study included 146 lesions. The median follow-up time was 23.8 months. The 5-year local control, distant metastasis, and overall survival rates were 91.8%, 19.2%, and 28.7%, respectively. Grade 2 to 4 CWT was 30.6% for lesions abutting the chest wall, 8.2% for ≤1 cm from the chest wall, 3.8% for 1 to 2 cm from the chest wall, and 5.7% for >2 cm from the chest wall. Grade ≥3 CWT was 1.4%. Tumor abutment (odds ratio [OR]: 6.5; P = .0005), body mass index (OR: 1.1; P = .02), rib D1cc (OR: 1.01/Gy; P = .03), chest wall D1cc (OR: 1.08/Gy; P = .03), and chest wall D5cc (OR: 1.10/Gy; P = .01) were significant predictors for CWT on univariate analysis. Tumor abutment was significant for CWT (OR: 7.5; P = .007) on multivariate analysis. The probability of CWT was 15% with chest wall D5cc at 27.2 Gy and rib D1cc at 30.2 Gy. CONCLUSIONS The rate of CWT with SF-SBRT is similar to the rates published for fractionated SBRT, with most CWT being low grade. Tumor location relative to the chest wall is not a contraindication to SF-SBRT, but the rates increase significantly with abutment. Rib D1cc and chest wall D1cc and D5cc may be used as predictors of CWT.
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Affiliation(s)
- Bindu V Manyam
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio.
| | | | - Kyle Verdecchia
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Chandana A Reddy
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Neil M Woody
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Kevin L Stephans
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
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Ma JT, Liu Y, Sun L, Milano MT, Zhang SL, Huang LT, Jing W, Zhao JZ, Han CB, Kong FMS. Chest Wall Toxicity After Stereotactic Body Radiation Therapy: A Pooled Analysis of 57 Studies. Int J Radiat Oncol Biol Phys 2018; 103:843-850. [PMID: 30496884 DOI: 10.1016/j.ijrobp.2018.11.036] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 11/03/2018] [Accepted: 11/16/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE The significance of clinical and dosimetric risk factors in relation to chest wall (CW) injury after stereotactic body radiation therapy (SBRT) for lung tumors were analyzed through a meta-analysis of 57 published studies. METHODS AND MATERIALS Studies related to CW injury after lung SBRT were obtained through searching PubMed, Embase, and Cochrane electronic databases. An estimate of the incidence of CW pain (CWP) or rib fracture (RF) was derived using a Bayesian hierarchical model. Linear regression analysis was performed to assess the relationship between CWP or RF and clinical or dosimetric factors. RESULTS A total of 57 studies incorporating 5985 cases reporting clinical data on CW injury after SBRT were analyzed. The overall CWP and RF rates by Bayesian hierarchical modeling were 11.0% (95% confidence interval [CI], 8.0-14.4) and 6.3% (95% CI, 3.7-9.7), respectively. The rates of grade ≥2 and grade ≥3 CWP were 6.2% (95% CI, 3.88-8.93) and 1.2% (95% CI, 0.48-2.12), respectively. Sex was significantly correlated with RF (P < .001), with female patients having a greater risk of RF than male patients (hazard ratio = 0.59; 95% CI, 0.46-0.76). No correlation was found between RF, grade ≥2 CWP, or grade ≥3 CWP, with the clinical and dosimetric factors of age, tumor size, origin of lung tumor, gross tumor volume, planning target volume, fractional dose, number of fractions, or biologically effective dose. However, tumor to CW distance (<16-25 mm), body mass index, maximum dose (Dmax) of 0.5 to 5 cm3, and the volume of CW or ribs receiving >30 Gy were significantly associated with CWP and RF. CONCLUSIONS The overall rates of RF and grade ≥2 CWP after thoracic SBRT are relatively low. Sex, tumor to CW distance, maximum dose, and the radiation exposure of the CW or ribs are factors associated with the risk of CW toxicity after SBRT.
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Affiliation(s)
- Jie-Tao Ma
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yang Liu
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Li Sun
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester School of Medicine, Rochester, New York
| | - Shu-Ling Zhang
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Le-Tian Huang
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Wei Jing
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jian-Zhu Zhao
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Cheng-Bo Han
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, China.
| | - Feng-Ming Spring Kong
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Duijm M, Schipaanboord B, Granton PV, Nuyttens J. Local Reirradiation of Recurrent Non-small Cell Lung Carcinoma Resulting in Long Disease-free Survival, Although in the Presence of Osteonecrosis. Cureus 2018; 10:e3471. [PMID: 30648023 PMCID: PMC6318081 DOI: 10.7759/cureus.3471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
High-dose reirradiation of the thorax can be offered to patients with only local disease progression of non-small-cell lung cancer (NSCLC) resulting in promising disease-free-survival. However, much is still unknown about related side-effects and occasionally an uncommon presentation can be caused by reirradiation. In this case report, we present a patient with a 3.5-year progression-free survival, although in the presence of a late, unexpected toxicity. A dosimetric analysis was performed to investigate the possibility of radiation-induced toxicity.
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Affiliation(s)
- Marloes Duijm
- Radiation Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, NLD
| | - Bas Schipaanboord
- Radiation Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, NLD
| | - Patrick V Granton
- Radiation Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, NLD
| | - Joost Nuyttens
- Radiation Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, NLD
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Treatment-Related Adverse Effects in Lung Cancer Patients after Stereotactic Ablative Radiation Therapy. JOURNAL OF ONCOLOGY 2018; 2018:6483626. [PMID: 30402100 PMCID: PMC6193322 DOI: 10.1155/2018/6483626] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 09/04/2018] [Indexed: 12/25/2022]
Abstract
Introduction Lung cancer is a disease which, despite the advancements in treatment, still has a very poor 5-year survival rate. Stereotactic ablative radiation therapy (SABR) is a highly advanced, sophisticated, and safe treatment which allows patients with early stage lung cancer to be treated effectively without invasive procedures and with excellent clinical outcomes. Avoiding surgery minimises morbidity and recovery time, bettering patients' quality of life. Furthermore, SABR allows patients unsuitable for surgery to still undergo curative treatment. Methods We aimed to review SABR-related normal tissue toxicities reported in the literature. While many studies assess safety, clinical efficacy, and disease control of SABR for lung cancer, the number of comprehensive reviews that analyse SABR-related side-effects is scarce. This integrative review summarises the toxicities reported in literature based on published clinical trials and tumour location (central or peripheral tumours) for available SABR techniques. Given that the majority of the clinical studies did not report on the statistical significance (e.g., p-values and confidence intervals) of the toxicities experienced by patients, statistical analyses cannot be performed. As a result, adverse events are compiled from clinical reports; however, due to various techniques and nonstandard toxicity reports, no meta-analysis is possible at the current stage of reported data. Results When comparing lobectomy and SABR in phase III trials, surgery resulted in increased procedure-related morbidity. In phase II trials, very few studies showed high grade toxicities/fatalities as a result of SABR for lung cancer. Gross target volume size was a significant predictor of toxicity. An ipsilateral mean lung dose larger than 9 Gy was significantly associated with radiation pneumonitis. Conclusions Based on the studies reviewed SABR is a safe treatment technique for lung cancer; however, further well-designed phase III randomised clinical trials are required to produce timely conclusive results and to enable their comparison and statistical analysis.
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Ahmed N, Hasan S, Schumacher L, Colonias A, Wegner RE. Stereotactic body radiotherapy for central lung tumors: Finding the balance between safety and efficacy in the "no fly" zone. Thorac Cancer 2018; 9:1211-1214. [PMID: 30095228 PMCID: PMC6166089 DOI: 10.1111/1759-7714.12764] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 04/09/2018] [Accepted: 04/15/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) has emerged as a highly effective technique to treat medically inoperable non-small cell lung cancer (NSCLC). Doses must be chosen carefully when treating central lesions because of the potential for significant toxicity. This study reviews the outcomes of a cohort of patients with central lung tumors treated with SBRT. METHODS We identified 18 patients (12 women, 6 men) with central lesions that were treated with SBRT at our institution. Overall survival and local, regional, and distant control rates were assessed by Kaplan-Meier methodology. Correlations with outcomes were determined by multivariate analysis via Cox regression models. RESULTS Eighty-nine percent of patients had a pathological diagnosis of NSCLC. The median dose to the planning target volume was 40 Gy (range: 30-50) in five fractions, yielding a median biologic equivalent dose (BED10 ) of 72 (range: 48-100). The median planning target volume was 34 cc (range: 13.3-89). Local control was 87% at one year. Median overall survival was 45 months, with a two-year rate of 61%. The two-year regional control rate was 87%. BED10 > 72 predicted improved progression-free survival, with one-year rates of 100% versus 40% with increased BED (P = 0.012). No grade 3 or higher acute or late toxicity was observed. CONCLUSIONS Lung SBRT to central lesions is safe and effective when using five fraction regimens. BED10 < 72 predicted disease progression, highlighting the importance of choosing an effective dose fractionation scheme, which must in turn be balanced with potential toxicity.
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Affiliation(s)
- Nissar Ahmed
- Allegheny Health Network, Radiation Oncology, Pittsburgh, Pennsylvania, USA
| | - Shaakir Hasan
- Allegheny Health Network, Radiation Oncology, Pittsburgh, Pennsylvania, USA
| | - Lana Schumacher
- Allegheny Health Network, Radiation Oncology, Pittsburgh, Pennsylvania, USA
| | | | - Rodney E Wegner
- Allegheny Health Network, Radiation Oncology, Pittsburgh, Pennsylvania, USA
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Chao HH, Valdes G, Luna JM, Heskel M, Berman AT, Solberg TD, Simone CB. Exploratory analysis using machine learning to predict for chest wall pain in patients with stage I non-small-cell lung cancer treated with stereotactic body radiation therapy. J Appl Clin Med Phys 2018; 19:539-546. [PMID: 29992732 PMCID: PMC6123157 DOI: 10.1002/acm2.12415] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 05/24/2018] [Accepted: 06/13/2018] [Indexed: 12/25/2022] Open
Abstract
Background and purpose Chest wall toxicity is observed after stereotactic body radiation therapy (SBRT) for peripherally located lung tumors. We utilize machine learning algorithms to identify toxicity predictors to develop dose–volume constraints. Materials and methods Twenty‐five patient, tumor, and dosimetric features were recorded for 197 consecutive patients with Stage I NSCLC treated with SBRT, 11 of whom (5.6%) developed CTCAEv4 grade ≥2 chest wall pain. Decision tree modeling was used to determine chest wall syndrome (CWS) thresholds for individual features. Significant features were determined using independent multivariate methods. These methods incorporate out‐of‐bag estimation using Random forests (RF) and bootstrapping (100 iterations) using decision trees. Results Univariate analysis identified rib dose to 1 cc < 4000 cGy (P = 0.01), chest wall dose to 30 cc < 1900 cGy (P = 0.035), rib Dmax < 5100 cGy (P = 0.05) and lung dose to 1000 cc < 70 cGy (P = 0.039) to be statistically significant thresholds for avoiding CWS. Subsequent multivariate analysis confirmed the importance of rib dose to 1 cc, chest wall dose to 30 cc, and rib Dmax. Using learning‐curve experiments, the dataset proved to be self‐consistent and provides a realistic model for CWS analysis. Conclusions Using machine learning algorithms in this first of its kind study, we identify robust features and cutoffs predictive for the rare clinical event of CWS. Additional data in planned subsequent multicenter studies will help increase the accuracy of multivariate analysis.
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Affiliation(s)
- Hann-Hsiang Chao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Gilmer Valdes
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA.,Department of Radiation Oncology, University of California - San Francisco, San Francisco, CA, USA
| | - Jose M Luna
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Marina Heskel
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Abigail T Berman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy D Solberg
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA.,Department of Radiation Oncology, University of California - San Francisco, San Francisco, CA, USA
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, MD, USA
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Dunne EM, Fraser IM, Liu M. Stereotactic body radiation therapy for lung, spine and oligometastatic disease: current evidence and future directions. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:283. [PMID: 30105233 PMCID: PMC6068327 DOI: 10.21037/atm.2018.06.40] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 06/11/2018] [Indexed: 12/16/2022]
Abstract
Stereotactic body radiation therapy (SBRT) also referred to as stereotactic ablative radiotherapy (SABR), is a technique which has emerged over the past two decades due to improvements in radiation technology. Unlike conventional external beam radiotherapy (cEBRT) which traditionally delivers radiation in small doses [approximately 2 Gray (Gy) per fraction] over several weeks, SBRT, typically delivered in one to eight fractions, is a technique whereby potentially ablative doses of radiotherapy (usually 7.5-20 Gy per fraction) can be delivered with steeper dose gradients and sub millimetre precision, minimising risk to surrounding normal tissues. The potential benefits of excellent tumor control with low toxicity has led to the increasing use of SBRT in a number of clinical situations. Due to compelling evidence, SBRT is now the treatment of choice for medically inoperable patients with peripherally located stage I non-small cell lung cancer (NSCLC). Controversy remains however as to its efficacy and safety for central or ultra-central lung tumors. The evidence base supporting the use of SBRT as a novel treatment for spinal metastases and oligometastases is rapidly expanding but challenges remain in these difficult patient populations. In an era where targeted therapy and improved systemic treatments for stage IV cancer have resulted in increased disease-free survival, and our knowledge of the oligometastatic state is ever expanding, using SBRT to treat metastatic disease and gain durable local control is increasingly desirable. Several randomized trials are currently underway and are sure to provide valuable information on the benefit and utility of SBRT across many tumor sites including early-stage NSCLC, spinal metastases and oligometastatic disease. Recognizing the evolving role of SBRT in clinical practice, this paper provides a critical review of recent developments in each of these areas particularly highlighting the challenges facing clinicians and discusses potential areas for future research.
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Affiliation(s)
- Emma Maria Dunne
- Department of Radiation Oncology, British Columbia Cancer Agency (BCCA), Vancouver, Canada
| | - Ian Mark Fraser
- Department of Radiation Oncology, British Columbia Cancer Agency (BCCA), Vancouver, Canada
| | - Mitchell Liu
- Department of Radiation Oncology, British Columbia Cancer Agency (BCCA), Vancouver, Canada
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Choi JI. Medically inoperable stage I non-small cell lung cancer: best practices and long-term outcomes. Transl Lung Cancer Res 2018; 8:32-47. [PMID: 30788233 DOI: 10.21037/tlcr.2018.06.11] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Early-stage non-small cell lung cancer (ES-NSCLC) currently represents a minority of all NSCLC diagnoses but, with ongoing refinement and improvement of treatment approaches, is a group with increasing likelihood of long-term disease control and survival. A significant proportion of this population will not be optimal candidates for definitive surgical resection due to tumor characteristics, patient frailty, or comorbid status. The clinical evidence to support the use of stereotactic body radiation therapy (SBRT) in patients with medically inoperable stage I NSCLC is growing as long-term data are obtained. In this review, initial workup, SBRT delivery considerations, recent trial data, and post-treatment surveillance of this population are discussed.
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Affiliation(s)
- J Isabelle Choi
- Department of Radiation Oncology, University of Maryland, Baltimore, MD, USA
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Weder W, Moghanaki D, Stiles B, Siva S, Rocco G. The great debate flashes: surgery versus stereotactic body radiotherapy as the primary treatment of early-stage lung cancer. Eur J Cardiothorac Surg 2017; 53:295-305. [DOI: 10.1093/ejcts/ezx410] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/23/2017] [Accepted: 10/28/2017] [Indexed: 12/25/2022] Open
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Yu AS, Maxim PG, Loo BW, Gensheimer MF. Chest wall dose reduction using noncoplanar volumetric modulated arc radiation therapy for lung stereotactic ablative radiation therapy. Pract Radiat Oncol 2017; 8:e199-e207. [PMID: 29452868 DOI: 10.1016/j.prro.2017.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/08/2017] [Accepted: 12/11/2017] [Indexed: 11/17/2022]
Abstract
PURPOSE Stereotactic ablative radiation therapy (SABR) to lung tumors close to the chest wall can cause rib fractures or chest wall pain. We evaluated and propose a clinically practical solution of using noncoplanar volumetric modulated arc radiation therapy (VMAT) to reduce chest wall dose from lung SABR. METHODS AND MATERIALS Twenty lung SABR VMAT plans in which the chest wall volume receiving 30 Gy or higher (V30) exceeded 30 mL were replanned by noncoplanar VMAT with opposite 15° couch kicks. Dosimetric parameters including chest wall V30 and V40; lung V5, V10, V20, and mean dose; Paddick high-dose conformity index; intermediate-dose conformity index; and monitor units (MU) for each plan were used to evaluate the plan quality. The treatment time was also estimated by delivering the entire treatment. Two-sided paired t test was used to evaluate the difference of the dosimetric parameters between coplanar 1 arc (cVMAT1), coplanar 2 arcs (cVMAT2), and noncoplanar two arcs (nVMAT2) plans; differences with P < .05 were considered statistically significant. RESULTS V30 and V40 for chest wall were reduced on average by 20% ± 9% and 15% ± 11% (mean ± standard deviation) from cVMAT2 plans to nVMAT2 plans (P < .01 for both comparisons) and by 8% ± 7% and 16% ± 13% from cVMAT1 plans to cVMAT2 plans (P < .003 for both comparisons). The differences in lung mean dose were <0.2 Gy among cVMAT1, cVMAT2, and nVMAT2. There were no significant differences in lung V5, V10, and V20. On average, the number of MU increased 14% for nVMAT2 compared with cVMAT2. The Paddick high-dose conformity indexes were 0.88 ± 0.03, 0.89 ± 0.04, and 0.91 ± 0.03, and intermediate-dose conformity indexes were 3.88 ± 0.49, 3.80 ± 0.44 and 3.51 ± 0.38 for cVMAT1, cVMAT2, and nVMAT2, respectively. CONCLUSIONS We found that noncoplanar VMAT plans are feasible, clinically practical to deliver, and significantly reduce V30 and V40 of chest wall without increasing lung dose.
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Affiliation(s)
- Amy S Yu
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California.
| | - Peter G Maxim
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Billy W Loo
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Michael F Gensheimer
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California.
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Ohri N, Tomé W, Kalnicki S, Garg M. Stereotactic body radiation therapy for stage I non-small cell lung cancer: The importance of treatment planning algorithm and evaluation of a tumor control probability model. Pract Radiat Oncol 2017; 8:e33-e39. [PMID: 29233523 DOI: 10.1016/j.prro.2017.10.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/02/2017] [Accepted: 10/03/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Stereotactic body radiation therapy (SBRT) is increasingly used to treat early-stage non-small cell lung cancer (NSCLC). A previous report introduced the term size-adjusted biologically effective dose (sBED), which accounts for tumor diameter and biologically effective dose (BED) and may be used to predict the likelihood of local control following SBRT. Here we seek to replicate those findings using a separate dataset. METHODS AND MATERIALS We queried the RSSearch Patient Registry for patients treated with SBRT for stage I NSCLC. Kaplan-Meier survival curves, log-rank testing, and Cox proportional hazards modeling were used to evaluate tumor diameter, BED, and treatment planning algorithm as predictors of local control. sBED was defined as BED minus 10 times the tumor diameter (in centimeters). Tumor control probability (TCP) modeling was performed to characterize the relationship between sBED and the likelihood of local control 2 years after SBRT. RESULTS A total of 928 patients met inclusion criteria. Median BED was 115.5 Gy, and 59% of patients had T1 tumors. Local control rates following treatments planned using a pencil beam algorithm were inferior to those observed following treatments planned using a Monte Carlo algorithm (89% vs 96% at 2 years, log-rank P = .022). In a multivariable Cox model adjusted for tumor diameter and BED, the use of a pencil beam planning algorithm was associated with increased risk of local failure (hazard ratio, 2.39; 95% confidence interval, 1.08-5.29; P = .032). TCP modeling, restricted to patients treated using a Monte Carlo algorithm, demonstrated that sBED values of 60, 80, and 100 Gy yield predicted TCP rates of 91%, 95%, and 97%, respectively. CONCLUSIONS Using a large, multi-institutional database, we found a strong association between treatment planning algorithm and local control rates following SBRT for early-stage NSCLC. sBED is a useful tool for predicting the likelihood of local control following SBRT in this setting.
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Affiliation(s)
- Nitin Ohri
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
| | - Wolfgang Tomé
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Shalom Kalnicki
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Madhur Garg
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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De Rose F, Franceschini D, Reggiori G, Stravato A, Navarria P, Ascolese AM, Tomatis S, Mancosu P, Scorsetti M. Organs at risk in lung SBRT. Phys Med 2017; 44:131-138. [PMID: 28433508 DOI: 10.1016/j.ejmp.2017.04.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 03/24/2017] [Accepted: 04/09/2017] [Indexed: 12/23/2022] Open
Abstract
Lung stereotactic body radiotherapy (SBRT) is an accurate and precise technique to treat lung tumors with high 'ablative' doses. Given the encouraging data in terms of local control and toxicity profile, SBRT has currently become a treatment option for both early stage lung cancer and lung oligometastatic disease in patients who are medically inoperable or refuse surgical resection. Dose-adapted fractionation schedules and ongoing prospective trials should provide further evidence of SBRT safety trying to reduce toxicities and complications. In this heterogeneous scenario, a non-systematic review of dose constraints for lung SBRT was performed, including the main organs at risk in the thorax.
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Affiliation(s)
- F De Rose
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Milan, Italy
| | - D Franceschini
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Milan, Italy
| | - G Reggiori
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Milan, Italy
| | - A Stravato
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Milan, Italy.
| | - P Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Milan, Italy
| | - A M Ascolese
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Milan, Italy
| | - S Tomatis
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Milan, Italy
| | - P Mancosu
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Milan, Italy
| | - M Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center and Research Hospital, Milan, Italy; Depart ment of Biomedical Sciences, Humanitas University, Milan, Italy
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Schrenk O, Spindeldreier CK, Burigo LN, Hoerner-Rieber J, Pfaffenberger A. Effects of magnetic field orientation and strength on the treatment planning of nonsmall cell lung cancer. Med Phys 2017; 44:6621-6631. [PMID: 29064573 DOI: 10.1002/mp.12631] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 09/14/2017] [Accepted: 10/11/2017] [Indexed: 11/08/2022] Open
Abstract
PURPOSE Magnetic resonance image-guided radiotherapy (MRgRT) has the potential to increase the accuracy of radiation treatment delivery. Several research groups have developed hybrid MRgRT devices differing by radiation source used and magnetic field orientation and strength. In this work, we investigate the impact of different magnetic field orientations and strengths on the treatment planning of nonsmall cell lung cancer patients (NSCLC). METHODS A framework using the in-house developed treatment planning system matRad and the EGSnrc Monte Carlo code system was introduced to perform Monte Carlo-based treatment planning in the presence of a magnetic field. A specialized spectrum-based source model for the beam qualities of 6 MV and cobalt-60 was applied. Optimized plans for stereotactic body radiation therapy (SBRT) and intensity-modulated radiation therapy (IMRT) were generated for four NSCLC patients in the presence of different magnetic field orientations and strengths which are applied in hybrid MRgRT devices currently under development or in clinical use. RESULTS SBRT and IMRT treatment planning could be performed with consistent plan quality for all magnetic field setups. Only minor effects on the treatment planning outcome were found in the case of magnetic fields orientated perpendicular to the beam direction. Compared to the perpendicular magnetic field orientation, the inline orientation showed the capability to reduce the dose to lung while maintaining equal target coverage. Particularly for tumors with a central position in lung, a distinct dose reduction was obtained which led to a maximum reduction of mean lung dose by 18.5% (0.5 Gy), when applying a 1 T inline magnetic field. CONCLUSION All plans generated in this work obtained dose metrics within clinical constraints according to RTOG guidelines. When considering conventional dose metrics, no detrimental effects due to the magnetic fields were observed on the dose to the tumor or to organs at risk. An evaluation of the effects on skin dose was not ascertainable due to the simplified specification of the source model used. By accounting for the magnetic field during treatment planning, a dose reduction in lung could be achieved for inline-oriented magnetic fields. An inline orientation of the magnetic field therefore showed a potential benefit when treating NSCLC with MRgRT.
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Affiliation(s)
- Oliver Schrenk
- Division of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), 69120, Heidelberg, Germany
| | - Claudia Katharina Spindeldreier
- Division of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), 69120, Heidelberg, Germany
| | - Lucas Norberto Burigo
- Division of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), 69120, Heidelberg, Germany
| | - Juliane Hoerner-Rieber
- Department of Radiation Oncology, University Hospital Heidelberg, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), 69120, Heidelberg, Germany
| | - Asja Pfaffenberger
- Division of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), 69120, Heidelberg, Germany
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44
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Gallbladder toxicity and high-dose ablative-intent radiation for liver tumors: Should we constrain the dose? Pract Radiat Oncol 2017; 7:e323-e329. [DOI: 10.1016/j.prro.2017.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 01/26/2017] [Accepted: 02/02/2017] [Indexed: 12/21/2022]
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Abstract
Patient motion can cause misalignment of the tumour and toxicities to the healthy lung tissue during lung stereotactic body radiation therapy (SBRT). Any deviations from the reference setup can miss the target and have acute toxic effects on the patient with consequences onto its quality of life and survival outcomes. Correction for motion, either immediately prior to treatment or intra-treatment, can be realized with image-guided radiation therapy (IGRT) and motion management devices. The use of these techniques has demonstrated the feasibility of integrating complex technology with clinical linear accelerator to provide a higher standard of care for the patients and increase their quality of life.
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Affiliation(s)
- Vincent Caillet
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia; School of Physics, University of Sydney, Sydney, Australia.
| | - Jeremy T Booth
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia; School of Physics, University of Sydney, Sydney, Australia
| | - Paul Keall
- School of Medicine, University of Sydney, Sydney, Australia
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47
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Jumeau R, Filion É, Bahig H, Vu T, Lambert L, Roberge D, Doucet R, Campeau MP. A dosimetric parameter to limit chest wall toxicity in SABR of NSCLC. Br J Radiol 2017; 90:20170196. [PMID: 28590814 DOI: 10.1259/bjr.20170196] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Chest wall (CW) toxicity (rib fracture and/or pain) is a recognized complication of stereotactic ablative radiotherapy (SABR) for non-small-cell lung cancer. The aim of this study was to evaluate the frequency of CW toxicity following SABR and to propose a new dosimetric parameter. METHODS We reviewed the charts and SABR plans from patients treated for T1-T2N0 peripheral non-small-cell lung cancer between 2009 and 2015. The CW structure was created through a 3-cm expansion of the lung. The median dose delivered to the planning target volume was 60 Gy. SABR was delivered in three fractions for patients with CW V30 < 30 cm3. If the CW V30 exceeded 30 cm3, five fractions were used, and the plan was optimized based on CW V37 (biologically equivalent to the V30 of three-fraction plans). RESULTS In 6 years, 361 lesions from 356 patients were treated (3 fractions: 297; 5 fractions: 64). The median follow-up was 16 months. 23 patients (6.5%) developed CW toxicity after a median time of 10 months following treatment. The mean CW V30/V37 was 21 cm3 for patients with CW toxicity and 17 cm3 for patients without toxicity (p < 0.05). The 2-year local control and the CW toxicity rates were similar, whether patients received three or five fractions (97% vs 96% and 7% vs 5%). CONCLUSION When the CW V30 is >30 cm3, altered fractionation combined with V37 optimization can limit CW toxicity. Advances in knowledge: The CW V37 is a suggested dosimetric parameter adapted to fractionation that may potentially limit CW toxicity after lung SABR.
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Affiliation(s)
- Raphaël Jumeau
- 1 Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Édith Filion
- 1 Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Houda Bahig
- 1 Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Toni Vu
- 1 Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Louise Lambert
- 1 Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - David Roberge
- 1 Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Robert Doucet
- 2 Department of Radiation Physics, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Marie-Pierre Campeau
- 1 Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
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Dan T, Williams NL. Management of Stage I Lung Cancer with Stereotactic Ablative Radiation Therapy. Surg Oncol Clin N Am 2017; 26:393-403. [PMID: 28576179 DOI: 10.1016/j.soc.2017.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Early stage non-small cell lung cancer is a growing clinical entity with evolving standards of care. With the adoption of lung screening guidelines, the incidence of early stage disease is expected to increase. Surgical resection for early stage disease has been considered standard of care; however, there is evidence that stereotactic ablative radiation therapy (SABR) may be a viable alternate to surgery. In the last decade, advances in image guidance, treatment planning systems, and improved spatial accuracy of treatment delivery have converged to result in the effective use of SABR in the treatment of early stage lung cancer.
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Affiliation(s)
- Tu Dan
- Department of Radiation Oncology, UT Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
| | - Noelle L Williams
- Department of Radiation Oncology, Thomas Jefferson University, 111 South 11th Street, Philadelphia, PA 19107, USA
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Ishikawa Y, Nakamura T, Kato T, Kadoya N, Suzuki M, Azami Y, Hareyama M, Kikuchi Y, Jingu K. Dosemetric Parameters Predictive of Rib Fractures after Proton Beam Therapy for Early-Stage Lung Cancer. TOHOKU J EXP MED 2017; 238:339-45. [PMID: 27087118 DOI: 10.1620/tjem.238.339] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Proton beam therapy (PBT) is the preferred modality for early-stage lung cancer. Compared with X-ray therapy, PBT offers good dose concentration as revealed by the characteristics of the Bragg peak. Rib fractures (RFs) after PBT lead to decreased quality of life for patients. However, the incidence of and the risk factors for RFs after PBT have not yet been clarified. We therefore explored the relationship between irradiated rib volume and RFs after PBT for early-stage lung cancer. The purpose of this study was to investigate the incidence and the risk factors for RFs following PBT for early-stage lung cancer. We investigated 52 early-stage lung cancer patients and analyzed a total of 215 irradiated ribs after PBT. Grade 2 RFs occurred in 12 patients (20 ribs); these RFs were symptomatic without displacement. No patient experienced more severe RFs. The median time to grade 2 RFs development was 17 months (range: 9-29 months). The three-year incidence of grade 2 RFs was 30.2%. According to the analysis comparing radiation dose and rib volume using receiver operating characteristic curves, we demonstrated that the volume of ribs receiving more than 120 Gy3 (relative biological effectiveness (RBE)) was more than 3.7 cm(3) at an area under the curve of 0.81, which increased the incidence of RFs after PBT (P < 0.001). In this study, RFs were frequently observed following PBT for early-stage lung cancer. We demonstrated that the volume of ribs receiving more than 120 Gy3 (RBE) was the most significant parameter for predicting RFs.
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Affiliation(s)
- Yojiro Ishikawa
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine
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Wijsman R, Braam PM, Bussink J. Radiation-induced rib fractures after stereotactic body radiation therapy: Predict to prevent? Radiother Oncol 2017; 123:173-175. [DOI: 10.1016/j.radonc.2017.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 03/09/2017] [Accepted: 03/10/2017] [Indexed: 12/23/2022]
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