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Li W, Zhu X, Bu L, He Y, Xu J, Yao G, Lu Z, Zhao F, Yan S. Alternating Expiration and Inspiration Breath-Hold Spares the Chest Wall During Stereotactic Body Radiation Therapy for Peripheral Lung Malignancies. Pract Radiat Oncol 2023:S1879-8500(23)00045-0. [PMID: 36822550 DOI: 10.1016/j.prro.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/27/2023] [Accepted: 01/31/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE The proximity of tumors to the chest wall brings additional risks of chest wall pain during stereotactic body radiation therapy. Herein, we dosimetrically compared alternated breath-hold (ABH) plans with single BH plans and determined the common characteristics of eligible patients who may obtain better chest wall sparing using this technique. METHODS AND MATERIALS Twenty patients with lung lesions adjacent to the chest wall were enrolled and received respiratory training. Their half-fraction end expiration BH and deep inspiration BH plans were summed to generate the ABH plans. Dosimetric parameters of the chest wall were compared between single and alternated BH plans, and the correlation between tumor location and the outcome of chest wall sparing was quantitatively evaluated. Pretreatment cone beam computed tomography variations in eligible patients were recorded as well. RESULTS Compared with the end expiration BH and deep inspiration BH plans, the ABH plans reduced chest wall dosimetric results with median reductions of 2.0% and 3.9% (Dmax: maximum point dose), 15.4% and 14.8% (D1cc: dose to a volume of 1 cm3), and 48.8% and 63% (V30: volume receiving 30 Gy or more), respectively. Relative tumor displacements (ratio of tumor displacement in the superior-inferior direction to planning target volume diameter) were greater in the lower lobe than in the upper and middle lobes (1.17 vs 0.18). Meanwhile, better median reductions of 44% (Dmax), 46% (D1cc), and 98% (V30) were obtained in the lower lobe cohort using the ABH technique. Pretreatment variations for all BHs met the 5-mm threshold. CONCLUSIONS The ABH technique can significantly spare the adjacent chest wall without compromising planning target volume coverage in comparison with the single BH, and patients with tumors in the lower lobes can obtain better chest wall sparing than in the upper and middle lobes. Further investigation is warranted to validate these findings.
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Affiliation(s)
- Wenxiang Li
- Department of Radiation Oncology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Zhejiang University Cancer Center, Hangzhou, Zhejiang, China
| | - Xinli Zhu
- Department of Radiation Oncology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Zhejiang University Cancer Center, Hangzhou, Zhejiang, China
| | - Luyi Bu
- Department of Radiation Oncology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Zhejiang University Cancer Center, Hangzhou, Zhejiang, China
| | - Yu He
- Department of Radiation Oncology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Zhejiang University Cancer Center, Hangzhou, Zhejiang, China
| | - Jiayi Xu
- Department of Radiation Oncology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Zhejiang University Cancer Center, Hangzhou, Zhejiang, China
| | - Guorong Yao
- Department of Radiation Oncology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Zhejiang University Cancer Center, Hangzhou, Zhejiang, China
| | - Zhongjie Lu
- Department of Radiation Oncology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Zhejiang University Cancer Center, Hangzhou, Zhejiang, China
| | - Feng Zhao
- Department of Radiation Oncology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Zhejiang University Cancer Center, Hangzhou, Zhejiang, China.
| | - Senxiang Yan
- Department of Radiation Oncology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Zhejiang University Cancer Center, Hangzhou, Zhejiang, China.
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Huang C, Shiue K, Bartlett G, Agrawal N, Arbab M, Maxim P, DesRosiers C, Mereniuk T, Ellsworth S, Rhome R, Holmes J, Langer M, Zellars R, Lautenschlaeger T. Exploiting tumor position differences between deep inspiration and expiration in lung stereotactic body radiation therapy planning. Med Dosim 2020; 45:293-297. [PMID: 32249105 DOI: 10.1016/j.meddos.2020.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 02/13/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE We demonstrate proof of principle that normal tissue doses can be greatly reduced in lung stereotactic body radiation therapy (SBRT) for mobile tumors, if the delivered dose is split between opposite respiratory states. METHODS Patients that underwent 5 fraction lung SBRT at our institution and had deep inspiration breath hold (DIBH) and free breathing 4D computed tomography scans were included. Volumetric modulated arc therapy plans were generated on both respiratory phases and a third composite plan was generated delivering half the dose using the DIBH plan and the other half using the expiratory phase plan for each fraction. Computed tomography scans for the composite plan were fused based on ribs adjacent to the tumor to evaluate the dose volume histogram of critical structures. RESULTS Four patients with 4 total tumors had requisite planning scans available. Tumor size was between 0.7 to 2.9 cm and tumor movement 1.4 to 2.9 cm. Median reduction in the chest wall (CW) V30Gy for the composite plan was 74.6% (range 33.7 to 100%), 76.9% (range 32.9 to 100%), and 89.3% (range 69.5 to 100%) compared to the DIBH, expiration phase, and free breathing plans, respectively. Median reduction in CW maximum dose for the composite plan was 23.3% (range 0.27% to 46.4%), 23.5% (range 3.2 to 48.2%), and 23.4% (range 0.27% to 48.4%) compared to the DIBH, expiration phase, and free breathing plans, respectively. Greater reduction in CW maximum dose was observed when patients had no overlap in planning target volumes between DIBH and expiration phases (median reduction 43.9% for no overlap vs 2.7% with overlap). Between all plans, lung V20Gy absolute differences were within 1.3%. For 2 of 4 patients, the composite plan met constraints for 3 fraction SBRT, while standard plans did not. CONCLUSIONS We conclude that composite DIBH-expiration SBRT planning has the potential to improve organ at risk sparing.
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Affiliation(s)
- Christina Huang
- Department of Radiation Oncology, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN
| | - Kevin Shiue
- Department of Radiation Oncology, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN
| | - Greg Bartlett
- Department of Radiation Oncology, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN
| | - Namita Agrawal
- Department of Radiation Oncology, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN
| | - Mona Arbab
- Department of Radiation Oncology, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN
| | - Peter Maxim
- Department of Radiation Oncology, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN
| | - Colleen DesRosiers
- Department of Radiation Oncology, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN
| | - Todd Mereniuk
- Department of Radiation Oncology, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN
| | - Susannah Ellsworth
- Department of Radiation Oncology, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN
| | - Ryan Rhome
- Department of Radiation Oncology, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN
| | - Jordan Holmes
- Department of Radiation Oncology, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN
| | - Mark Langer
- Department of Radiation Oncology, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN
| | - Richard Zellars
- Department of Radiation Oncology, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN
| | - Tim Lautenschlaeger
- Department of Radiation Oncology, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN.
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Kim ST, An HJ, Kim JI, Yoo JR, Kim HJ, Park JM. Non-coplanar VMAT plans for lung SABR to reduce dose to the heart: a planning study. Br J Radiol 2019; 93:20190596. [PMID: 31625759 DOI: 10.1259/bjr.20190596] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE This study aimed to compare the plan quality of non-coplanar partial arc (NPA) volumetric modulated arc therapy (VMAT) to that of coplanar partial arc (CPA) VMAT for stereotactic ablative radiotherapy (SABR) for lung cancer. METHODS A total of 20 patients treated for lung cancer with the SABR VMAT technique and whose lung tumors were close to the heart were retrospectively selected for this study. For the CPA VMAT, three coplanar half arcs were used while two coplanar half arcs and one noncoplanar arc rotating 315°-45° with couch rotations of 315° ± 5° were used for the NPA VMAT. For each patient, identical CT image sets and identical structures were used for both the CPA and NPA VMAT plans. Dose-volumetric parameters of each plan were analyzed. RESULTS For the planning target volume and both lungs, no statistically significant differences between the CPA and NPA VMAT plans were observed in general. For the heart, average values of D0.1cc of the CPA and NPA VMAT plans were 29.42 ± 13.37 and 21.71 ± 9.20 Gy, respectively (p < 0.001). For whole body, the mean dose and the gradient index of the CPA VMAT plans were 1.2 ± 0.5 Gy and 4.356 ± 0.608 while those of the NPA VMAT plans were 1.1 ± 0.5 Gy and 4.111 ± 0.480, respectively (both with p < 0.001). CONCLUSION The NPA VMAT proposed in this study showed more favorable plan quality than the CPA VMAT plans for lung SABR with tumors located close to the heart. ADVANCES IN KNOWLEDGE For lung SABR, NPA VMAT can reduce doses to the heart as well as whole-body irradiation.
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Affiliation(s)
- Sang-Tae Kim
- Nuclear Emergency Division, Radiation Protection and Emergency Preparedness Bureau, Nuclear Safety and Security Commission, Seoul, Korea
| | - Hyun Joon An
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea.,Department of Biomedical Sciences, Seoul National University, Seoul, Korea
| | - Jung-In Kim
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Jae-Ryong Yoo
- Radiation Emergency Medicine Regulation Team, National Radiation Emergency Medical Center, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Hak Jae Kim
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea.,Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Min Park
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea.,Robotics Research Laboratory for Extreme Environments, Advanced Institute of Convergence Technology, Suwon, Korea
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Chipko C, Ojwang J, Gharai LR, Deng X, Mukhopadhyay N, Weiss E. Characterization of Chest Wall Toxicity During Long-term Follow Up After Thoracic Stereotactic Body Radiation Therapy. Pract Radiat Oncol 2019; 9:e338-e346. [PMID: 30731275 DOI: 10.1016/j.prro.2019.01.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/28/2018] [Accepted: 01/27/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE Chest wall (CW) pain and rib fractures are frequently diagnosed after stereotactic body radiation therapy (SBRT) for malignant lung tumors. We hypothesize that multiple risk factors, including bone mineral density (BMD), are associated with CW toxicity, and that CW pain and rib fractures often evolve into chronic clinical problems. METHODS AND MATERIALS A total of 118 lung tumors treated with SBRT in 100 patients with a minimum follow-up period of 2 years were retrospectively analyzed. The incidence, clinical course, and related demographic, clinical, and dosimetric factors of CW pain and rib fractures were analyzed. In addition, BMD was assessed, and the radiographic appearance of radiation-induced rib fractures and their healing process were characterized. RESULTS The median follow-up was 49 months (range, 24-106 months). CW pain developed in 33 of 118 treatments (28%) after, on average, 12.5 months (range, 0-50 months), and was more common in women (P = .04). The mean duration of CW pain was 25 months (range, 2-63 months), and 36% of patients never had resolution of CW pain. A total of 34 of 118 treatments (29%) resulted in rib fractures at a mean time of 22 months (range, 3-46 months); rib fractures were more common in women, African Americans, upper/middle lobe tumors, and patients with lower BMD (P < .05). The mean duration of rib fractures was 25 months (range, 5-41 months), and only 16 rib fractures (47%) healed. Shorter CW planning target volume distance resulted in a higher risk for both rib fractures and CW pain (P = .01). Sixty-seven percent of fractures developed surrounding soft tissue fibrosis, and 62% (21 of 34 fractures) heterotopic ossification. Diabetes, body mass index, and steroid use were not associated with CW pain or rib fracture. CONCLUSIONS Several factors were associated with a higher risk of SBRT-related CW toxicity. Optimal CW sparing (eg, volumetric modulated arc therapy, lower dose per fraction) should be considered in this patient group without compromising tumor control. SBRT-induced rib fractures commonly heal abnormally and result in potential chronic CW pain.
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Affiliation(s)
- Christopher Chipko
- Department of Radiation Oncology, Virginia Commonwealth University Health Systems, Richmond, Virginia.
| | - Julius Ojwang
- Department of Radiation Oncology, Virginia Commonwealth University Health Systems, Richmond, Virginia
| | - Leila Rezai Gharai
- Department of Diagnostic Radiology, Virginia Commonwealth University Health Systems, Richmond, Virginia
| | - Xiaoyan Deng
- Department of Biostatistics, Virginia Commonwealth University Health Systems, Richmond, Virginia
| | - Nitai Mukhopadhyay
- Department of Biostatistics, Virginia Commonwealth University Health Systems, Richmond, Virginia
| | - Elisabeth Weiss
- Department of Radiation Oncology, Virginia Commonwealth University Health Systems, Richmond, Virginia
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