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Impact of Low-Dose Irradiation of the Lung and Heart on Toxicity and Pulmonary Function Parameters after Thoracic Radiotherapy. Cancers (Basel) 2020; 13:cancers13010022. [PMID: 33374564 PMCID: PMC7793060 DOI: 10.3390/cancers13010022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/14/2020] [Accepted: 12/19/2020] [Indexed: 02/07/2023] Open
Abstract
Simple Summary To assess the impact of thoracic (low) dose irradiation on pulmonary function changes after thoracic radiotherapy (RT) data of 62 patients were analyzed. There were several significant correlations between pulmonary function and dose parameters of the lung and heart, most of which remained significant in the multivariate analysis. Abstract Objective: To assess the impact of (low) dose irradiation to the lungs and heart on the incidence of pneumonitis and pulmonary function changes after thoracic radiotherapy (RT). Methods/Material: Data of 62 patients treated with curative thoracic radiotherapy were analyzed. Toxicity data and pulmonary function tests (PFTs) were obtained before RT and at 6 weeks, at 12 weeks, and at 6 months after RT. PFTs included ventilation (e.g., vital capacity) and diffusion parameters (e.g., diffusion capacity for carbon monoxide (DLCO)). Dosimetric data of the lung and heart were extracted to assess the impact of dose on PFT changes and radiation pneumonitis (RP). Results: No statistically significant correlations between dose parameters and changes in ventilation parameters were found. There were statistically significant correlations between DLCO and low-dose parameters of the lungs (V5Gy–V30Gy (%)) and irradiation of the heart during the follow-up up to 6 months after RT, as well as a temporary correlation of the V60Gy (%) on the blood gas parameters at 12 weeks after RT. On multivariate analysis, both heart and lung parameters had a significant impact on DLCO. There was no statistically significant influence of any patient or treatment-related (including dose parameters) factors on the incidence of ≥G2 pneumonitis. Conclusion: There seems to be a lasting impact of low dose irradiation to the lung as well as irradiation to the heart on the DLCO after thoracic radiotherapy. No influence on RP was found in this analysis.
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Zhu SC, Shen WB, Liu ZK, Li J, Su JW, Wang YX. Dosimetric and clinical predictors of radiation-induced lung toxicity in esophageal carcinoma. TUMORI JOURNAL 2018; 97:596-602. [DOI: 10.1177/030089161109700510] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Aims and background Radiation-induced lung toxicity occurs frequently in patients with esophageal carcinoma. This study aims to evaluate the clinical and three-dimensional dosimetric parameters associated with lung toxicity after radiotherapy for esophageal carcinoma. Methods and study design The records of 56 patients treated for esophageal carcinoma were reviewed. The Radiation Therapy Oncology Group criteria for grading of lung toxicity were followed. Spearman's correlation test, the chi-square test and logistic regression analyses were used for statistical analysis. Results Ten of the 56 patients developed acute toxicity. The toxicity grades were grade 2 in 7 patients and grade 3 in 3 patients; none of the patients developed grade 4 or worse toxicity. One case of toxicity occurred during radiotherapy and 9 occurred 2 weeks to 3 months after radiotherapy. The median time was 2.0 months after radiotherapy. Fourteen patients developed late irradiated lung injury, 3 after 3.5 months, 7 after 9 months, and 4 after 14 months. Radiographic imaging demonstrated patchy consolidation (n = 5), atelectasis with parenchymal distortion (n = 6), and solid consolidation (n = 3). For acute toxicity, the irradiated esophageal volume, number of fields, and most dosimetric parameters were predictive. For late toxicity, chemotherapy combined with radiotherapy and other dosimetric parameters were predictive. No obvious association between the occurrence of acute and late injury was observed. Conclusions The percent of lung tissue receiving at least 25 Gy (V25), the number of fields, and the irradiated length of the esophagus can be used as predictors of the risk of acute toxicity. Lungs V30, as well as chemotherapy combined with radiotherapy, are predictive of late lung injury.
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Affiliation(s)
- Shu-chai Zhu
- Department of Radiation Oncology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wen-bin Shen
- Department of Radiation Oncology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhi-kun Liu
- Department of Radiation Oncology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Juan Li
- Department of Radiation Oncology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jing-wei Su
- Department of Radiation Oncology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yu-xiang Wang
- Department of Radiation Oncology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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Niezink AGH, de Jong RA, Muijs CT, Langendijk JA, Widder J. Pulmonary Function Changes After Radiotherapy for Lung or Esophageal Cancer: A Systematic Review Focusing on Dose-Volume Parameters. Oncologist 2017; 22:1257-1264. [PMID: 28550029 DOI: 10.1634/theoncologist.2016-0324] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 03/28/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Despite technical developments in treatment delivery, radiation-induced lung toxicity (RILT) remains a crucial problem in thoracic radiotherapy. Clinically based RILT scores have their limitations, and more objective measures such as pulmonary functions tests (PFTs) might help to improve treatment strategies. PURPOSE To summarize the available evidence about the effect of dose to the lung in thoracic radiotherapy on forced expiratory volume in one second (FEV1) and diffusion capacity (DLCO) in patients with lung and esophageal cancer treated with curative intent. MATERIAL AND METHODS A systematic review following the PRISMA guidelines was performed, using MEDLINE and including clinical studies using (chemo)radiotherapy (CRT) or stereotactic ablative radiotherapy (SABR) for lung or CRT for esophageal cancer that reported both lung dose-volume histogram (DVH) parameters and changes in PFT results. Search terms included lung and esophageal neoplasms, respiratory function tests, and radiotherapy. RESULTS Fifteen studies met the inclusion criteria. Seven out of 13 studies on lung cancer reported significant declines (defined as a p value < .05) in PFT results. Both esophageal studies reported significant DLCO declines. One SABR study found a correlation between low lung-dose parameters and FEV1 decline. Relations between decline of FEV1 (three studies) or decline of DLCO (five studies), respectively, and DVH parameters were found in eight studies analyzing CRT. Furthermore, a heterogeneous range of clinical risk factors for pulmonary function changes were reported in the selected studies. CONCLUSIONS There is evidence that pulmonary function declines after RT in a dose-dependent manner, but solid data about lung DVH parameters predicting changes in PFT results are scarce. A major disadvantage was the wide variety of methods used, frequently lacking multivariable analyses. Studies using prospective high-quality data, analyzed with appropriate statistical methods, are needed. The Oncologist 2017;22:1257-1264 IMPLICATIONS FOR PRACTICE: Radiation-induced lung toxicity remains crucial in thoracic radiotherapy. To prevent this toxicity in the future and individualize patient treatment, objective measures of pulmonary toxicity are needed. Pulmonary function tests may provide such objective measures. This systematic review, included all available clinical studies using external beam radiotherapy for lung or esophageal cancer reporting pulmonary function combined with dose-volume histogram parameters. There is preliminary evidence that pulmonary function declines post radiotherapy in a dose-dependent manner. Data quality and analyses were generally limited. Analyses of high-quality data are therefore urgently needed to improve individualization of advanced radiation therapy.
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Affiliation(s)
- Anne G H Niezink
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Renske A de Jong
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Christina T Muijs
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Johannes A Langendijk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Joachim Widder
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
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Mihaylov IB. Integral Dose-Based Inverse Optimization May Reduce Side Effects in Radiotherapy of Prostate Carcinoma. Front Oncol 2017; 7:27. [PMID: 28299284 PMCID: PMC5331038 DOI: 10.3389/fonc.2017.00027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 02/15/2017] [Indexed: 12/01/2022] Open
Abstract
PURPOSE The purpose of this work is to apply a novel inverse optimization approach, based on utilization of quantitative imaging information in the optimization function, to prostate carcinoma. MATERIALS AND METHODS This new inverse optimization algorithm relies upon quantitative information derived from computed tomography (CT) imaging studies. The Hounsfield numbers of the CT voxels are converted to physical density, which in turn is used to calculate voxel mass and the corresponding integral dose, by summation over the product of dose and mass in each dose voxel. This integral dose is used for plan optimization through its global minimization. The optimization results are compared to the optimization results derived from most commonly used dose-volume-based inverse optimization, where objective functions are formed as summation over all dose voxels of the squared differences between voxel doses and user specified doses. The data from 25 prostate plans were optimized with dose-volume histogram (DVH) and integral dose (energy) minimization objective functions. The results obtained with the energy- and DVH-based optimization schemes were studied through commonly used dosimetric indices (DIs). Statistical equivalence tests were further performed to establish population-based significance results. RESULTS Both DVH- and energy-based plans for each case were normalized so that 95% of the planning target volume receives the prescription dose. The average differences for the rectum and bladder DIs ranged from 1.6 to 25%, where the energy-based quantities were lower. For both femoral heads, the energy-based optimization-derived doses were lower on average by 32%. The statistical tests demonstrated that the significant differences in the tallied dose indices range from 2.7% to more than 50% for rectum, bladder, and femoral heads. CONCLUSION For majority of the clinically relevant dosimetric quantities, energy-based inverse optimization performs better than the standard of care DVH-based optimization in prostate carcinoma. The population averaged statistically significant differences range from ~3 to ~50%. Therefore, this newly proposed optimization approach, incorporating explicitly quantitative imaging information in the inverse optimization function, holds potential for further reduction of complication rates in prostate cancer.
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Schröder C, Engenhart-Cabillic R, Vorwerk H, Schmidt M, Huhnt W, Blank E, Sidow D, Buchali A. Changes in pulmonary function and influencing factors after high-dose intrathoracic radio(chemo)therapy. Strahlenther Onkol 2016; 193:125-131. [PMID: 27783103 DOI: 10.1007/s00066-016-1067-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 10/06/2016] [Indexed: 12/11/2022]
Abstract
PURPOSE Using prospectively collected patient-related, dose-related, and pulmonary function test (PFT) data before radiotherapy (RT) and at several follow-up visits after RT, the time course of PFT changes after high-dose radio(chemo)therapy and influencing factors were analyzed. MATERIALS AND METHODS From April 2012 to October 2015, 81 patients with non-small-cell lung carcinoma (NSCLC), small cell lung carcinoma (SCLC), or esophageal carcinoma where treated with high-dose radio(chemo)therapy. PFT data were collected before treatment and 6 weeks, 12 weeks, and 6 months after RT. The influence of patient- and treatment-related factors on PFT was analyzed. RESULTS Mean forced expiratory volume in 1 s (FEV1) constantly declined during follow-up (p = 0.001). In total, 68% of patients had a reduced FEV1 at 6 months. Mean vital capacity (VC) didn't change during follow-up (p > 0.05). Mean total lung capacity (TLC) showed a constant decline after RT (p = 0.026). At 6 months, 60% of patients showed a decline in VC and 73% in TLC. The mean diffusion capacity for carbon monoxide (DLCO) declined at 6 and 12 weeks, but recovered slightly at 6 months (p < 0.0005). At 6 months, 86% of patients had a reduced DLCO. After treatment, the partial pressure of CO2 in the blood (pCO2) was increased and pO2 was decreased (p > 0.05). Only the pretreatment PFT classification had a significant influence on the post-RT FEV1. CONCLUSION DLCO seems to be the most reliable indicator for lung tissue damage after thoracic RT. Ventilation parameters appear to be less reliable. Concerning patient- or treatment-related factors, no reliable conclusion can be drawn regarding which factors may be relevant.
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Affiliation(s)
- Christina Schröder
- Clinic for Radiotherapy and Radiation Oncology, University Clinic Giessen and Marburg, Marburg, Germany. .,Clinic for Radiotherapy and Radiation Oncology, Ruppiner Kliniken GmbH, Neuruppin, Germany.
| | - Rita Engenhart-Cabillic
- Clinic for Radiotherapy and Radiation Oncology, University Clinic Giessen and Marburg, Marburg, Germany
| | - Hilke Vorwerk
- Clinic for Radiotherapy and Radiation Oncology, University Clinic Giessen and Marburg, Marburg, Germany
| | - Michael Schmidt
- Clinic for Radiotherapy and Radiation Oncology, Ruppiner Kliniken GmbH, Neuruppin, Germany
| | - Winfried Huhnt
- Clinic for Radiotherapy and Radiation Oncology, Ruppiner Kliniken GmbH, Neuruppin, Germany
| | - Eyck Blank
- Clinic for Radiotherapy and Radiation Oncology, Ruppiner Kliniken GmbH, Neuruppin, Germany
| | - Dietrich Sidow
- Clinic for Radiotherapy and Radiation Oncology, Ruppiner Kliniken GmbH, Neuruppin, Germany
| | - André Buchali
- Clinic for Radiotherapy and Radiation Oncology, Ruppiner Kliniken GmbH, Neuruppin, Germany
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Caudrelier JM, Truong P. Role of hypofractionated radiotherapy in breast locoregional radiation. Cancer Radiother 2015; 19:241-7. [DOI: 10.1016/j.canrad.2015.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 02/26/2015] [Indexed: 12/25/2022]
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Mihaylov IB, Moros EG. Mathematical Formulation of DMH-Based Inverse Optimization. Front Oncol 2014; 4:331. [PMID: 25478325 PMCID: PMC4235072 DOI: 10.3389/fonc.2014.00331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 10/31/2014] [Indexed: 11/17/2022] Open
Abstract
Purpose: To introduce the concept of dose–mass-based inverse optimization for radiotherapy applications. Materials and Methods: Mathematical derivation of the dose–mass-based formalism is presented. This mathematical representation is compared to the most commonly used dose–volume-based formulation used in inverse optimization. A simple example on digitally created phantom is presented. The phantom consists of three regions: a target surrounded by high- and low-density regions. The target is irradiated with two beams through those regions and inverse optimization with dose–volume and dose–mass-based objective functions is performed. The basic properties of the two optimization types are demonstrated on the phantom. Results: It is demonstrated that dose–volume optimization is a special case of dose–mass optimization. In a homogenous media, dose–mass optimization turns into dose–volume optimization. The dose calculations performed on the digital phantom show that in this very simple case dose–mass optimization tends to penalize more the dose delivery through the high-density region and therefore it results in delivering more dose through the low-density region. Conclusion: It was demonstrated that dose–mass-based optimization is mathematically more general than dose–volume-based optimization. In the case of constant density media, dose–mass optimization transforms into dose–volume optimization.
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Affiliation(s)
- Ivaylo B Mihaylov
- Department of Radiation Oncology, University of Miami , Miami, FL , USA
| | - Eduardo G Moros
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center , Tampa, FL , USA
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Filaire E, Dupuis C, Galvaing G, Aubreton S, Laurent H, Richard R, Filaire M. Lung cancer: what are the links with oxidative stress, physical activity and nutrition. Lung Cancer 2013; 82:383-9. [PMID: 24161719 DOI: 10.1016/j.lungcan.2013.09.009] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 09/14/2013] [Accepted: 09/16/2013] [Indexed: 01/15/2023]
Abstract
Oxidative stress appears to play an essential role as a secondary messenger in the normal regulation of a variety of physiological processes, such as apoptosis, survival, and proliferative signaling pathways. Oxidative stress also plays important roles in the pathogenesis of many diseases, including aging, degenerative disease, and cancer. Among cancers, lung cancer is the leading cause of cancer in the Western world. Lung cancer is the commonest fatal cancer whose risk is dependent on the number of cigarettes smoked per day as well as the number of years smoking, some components of cigarette smoke inducing oxidative stress by transmitting or generating oxidative stress. It can be subdivided into two broad categories, small cell lung cancer and non-small-cell lung cancer, the latter is the most common type. Distinct measures of primary and secondary prevention have been investigated to reduce the risk of morbidity and mortality caused by lung cancer. Among them, it seems that physical activity and nutrition have some beneficial effects. However, physical activity can have different influences on carcinogenesis, depending on energy supply, strength and frequency of exercise loads as well as the degree of exercise-mediated oxidative stress. Micronutrient supplementation seems to have a positive impact in lung surgery, particularly as an antioxidant, even if the role of micronutrients in lung cancer remains controversial. The purpose of this review is to examine lung cancer in relation to oxidative stress, physical activity, and nutrition.
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Affiliation(s)
- Edith Filaire
- Laboratoire CIAMS, EA4532, Université Paris-Sud, Université Orléans, UFRSTAPS, 2 allée du Château, 45067 Orleans, France
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Zhang W, Wang J, Tang M, Pan J, Bai P, Lin D, Qian F, Lin F, Yang X, Zhang S. Quantitative study of lung perfusion SPECT scanning and pulmonary function testing for early radiation-induced lung injury in patients with locally advanced non-small cell lung cancer. Exp Ther Med 2012; 3:631-635. [PMID: 22969942 DOI: 10.3892/etm.2012.468] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Accepted: 01/12/2012] [Indexed: 11/06/2022] Open
Abstract
Radiation lung injury is a common side-effect of pulmonary radiotherapy. The aim of this study was to quantitatively assess early changes in lung perfusion single photon emission computed tomography (SPECT) scanning and pulmonary function testing (PFT) prior to and after intensity modulated radiotherapy (IMRT) for patients suffering from locally advanced non-small cell lung cancer (LANSCLC). Twenty patients with LANSCLC received lung perfusion SPECT scanning and PFT prior to IMRT and immediately after IMRT. Lung perfusion index (LPI) was calculated after the quantification of perfusion SPECT images. The LPI of the two groups was analyzed by matched t-test. The radioactive count of each layer of single lung was added to obtain the sum of the irradiated area. The percentage of the irradiated area of single lung was calculated. Linear correlation analysis was carried out between the percentage of the irradiated area and LPI in order to verify the validity of LPI. In this study, LPI and the percentage of the irradiated area of single lung exhibited an excellent correlation either prior to or after IMRT (r=0.820 and r=0.823, respectively; p<0.001). There was no statistically significant difference between pre-IMRT LPI and post-IMRT LPI (p=0.135). LPI in the group receiving a radical dose had no statistically significant difference (p=0.993), however, it showed a statistically significant difference in the group receiving a non-radical dose (p=0.025). In the non-radical dose group, the post-IMRT LPI was larger compared to pre-IMRT. None of the parameters of PFT exhibited a statistically significant difference prior to and after IMRT (p>0.05). The quantitative method of lung perfusion SPECT scanning can be used to evaluate changes in perfusion early in patients receiving a non-radical dose (BED ≤126,500 cGy) IMRT. Evaluating early changes in global lung function using the current method of PFT is difficult, since time can be a contributing factor for radiation-induced lung injury.
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Affiliation(s)
- Wei Zhang
- Departments of Radiation Oncology, and
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Ng A, Li S, Neuberg D, Chi R, Fisher D, Silver B, Mauch P. A prospective study of pulmonary function in Hodgkin’s lymphoma patients. Ann Oncol 2008; 19:1754-8. [DOI: 10.1093/annonc/mdn284] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
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Milano MT, Constine LS, Okunieff P. Normal Tissue Tolerance Dose Metrics for Radiation Therapy of Major Organs. Semin Radiat Oncol 2007; 17:131-40. [PMID: 17395043 DOI: 10.1016/j.semradonc.2006.11.009] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Late organ toxicity from therapeutic radiation is a function of many confounding variables. The total dose delivered to the organ and the volumes of organ exposed to a given dose of radiation are 2 important variables that can be used to predict the risk of late toxicity. Three-dimensional radiation planning enables accurate calculation of the volume of tissue exposed to a given dose of radiation, graphically depicted as a dose-volume histogram. Dose metrics obtained from this 3-dimensional dataset can be used as a quantitative measure to predict late toxicity. This review summarizes the published clinical data on the risk of late toxicity as a function of quantitative dose metrics and attempts to offer suggested dose constraints for radiation treatment planning.
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Affiliation(s)
- Michael T Milano
- Department of Radiation Oncology and James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
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12
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Koh ES, Sun A, Tran TH, Tsang R, Pintilie M, Hodgson DC, Wells W, Heaton R, Gospodarowicz MK. Clinical dose-volume histogram analysis in predicting radiation pneumonitis in Hodgkin's lymphoma. Int J Radiat Oncol Biol Phys 2006; 66:223-8. [PMID: 16904523 DOI: 10.1016/j.ijrobp.2006.03.063] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Revised: 03/22/2006] [Accepted: 03/23/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE To quantify the incidence of radiation pneumonitis (RP) in a modern Hodgkin's lymphoma (HL) cohort, and to identify any clinically relevant parameters that may influence the risk of RP. METHODS AND MATERIALS Between January 2003 and February 2005, 64 consecutive HL patients aged 18 years or older receiving radical mediastinal radiation therapy (RT) were retrospectively reviewed. Symptomatic cases of radiation pneumonitis were identified. Dose-volume histogram parameters, including V(13), V(20), V(30), and mean lung dose (MLD), were quantified. RESULTS At a median follow-up of 2.1 years, the actuarial survival for all patients was 91% at 3 years. There were 2 (2/64) cases of Radiation Therapy Oncology Group (RTOG) Grade 2 RP (incidence 3.1%). Both index cases with corresponding V(20) values of 47.0% and 40.7% were located in the upper quartile (2/16 cases), defined by a V(20) value of > or =36%, an incidence of 12.5% (p = 0.03). Similarly for total MLD, both index cases with values of 17.6 Gy and 16.4 Gy, respectively, were located in the upper quartile defined by MLD > or =14.2 Gy, an incidence of 11.8% (2/17 cases, p = 0.02). CONCLUSIONS Despite relatively high V(20) values in this study of HL patients, the incidence of RP was only 3%, lower compared with the lung cancer literature. We suggest the following clinically relevant parameters be considered in treatment plan assessment: a V(20) greater than 36% and an MLD greater than 14 Gy, over and above which the risk of RTOG Grade 2 or greater RP would be considered clinically significant.
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Affiliation(s)
- Eng-Siew Koh
- Department of Radiation Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada
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Kong FM, Hayman JA, Griffith KA, Kalemkerian GP, Arenberg D, Lyons S, Turrisi A, Lichter A, Fraass B, Eisbruch A, Lawrence TS, Ten Haken RK. Final toxicity results of a radiation-dose escalation study in patients with non-small-cell lung cancer (NSCLC): predictors for radiation pneumonitis and fibrosis. Int J Radiat Oncol Biol Phys 2006; 65:1075-86. [PMID: 16647222 DOI: 10.1016/j.ijrobp.2006.01.051] [Citation(s) in RCA: 247] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2006] [Revised: 01/28/2006] [Accepted: 01/30/2006] [Indexed: 11/17/2022]
Abstract
PURPOSE We aimed to report the final toxicity results on a radiation-dose escalation trial designed to test a hypothesis that very high doses of radiation could be safely administered to patients with non-small-cell lung cancer (NSCLC) by quantifying the dose-volume toxicity relationship of the lung. METHODS AND MATERIALS A total of 109 patients with unresectable or medically inoperable NSCLC were enrolled and treated with radiation-dose escalation (on the basis of predicted normal-lung toxicity) either alone or with neoadjuvant chemotherapy by use of 3D conformal techniques. Eighty-four patients (77%) received more than 69 Gy, the trial was stopped after the dose reached 103 Gy. Estimated median follow-up was 110 months. RESULTS There were 17 (14.6%) Grade 2 to 3 pneumonitis and 15 (13.8%) Grade 2 to 3 fibrosis and no Grade 4 to 5 lung toxicity. Multivariate analyses showed them to be (1) not associated with the dose prescribed to the tumor, and (2) significantly (p<0.001) associated with lung-dosimetric parameters such as the mean lung dose (MLD), volume of lung that received at least 20 Gy (V20), and the normal-tissue complication probability (NTCP) of the lung. If cutoffs are 30% for V20, 20 Gy for MLD, and 10% for NTCP, these factors have positive predictive values of 50% to 71% and negative predictive value of 85% to 89%. CONCLUSIONS With long-term follow-up for toxicity, we have demonstrated that much higher doses of radiation than are traditionally administered can be safely delivered to a majority of patients with NSCLC. Quantitative lung dose-volume toxicity-based dose escalation can form the basis for individualized high-dose radiation treatment to maximize the therapeutic ratio in these patients.
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Affiliation(s)
- Feng-Ming Kong
- Department of Radiation Oncology, University of Michigan, and Radiation Oncology, Veterans Administration Medical Center, Ann Arbor, MI 48109, USA.
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Mehta V. Radiation pneumonitis and pulmonary fibrosis in non-small-cell lung cancer: pulmonary function, prediction, and prevention. Int J Radiat Oncol Biol Phys 2005; 63:5-24. [PMID: 15963660 DOI: 10.1016/j.ijrobp.2005.03.047] [Citation(s) in RCA: 298] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2004] [Revised: 03/14/2005] [Accepted: 03/16/2005] [Indexed: 12/15/2022]
Abstract
Although radiotherapy improves locoregional control and survival in patients with non-small-cell lung cancer, radiation pneumonitis is a common treatment-related toxicity. Many pulmonary function tests are not significantly altered by pulmonary toxicity of irradiation, but reductions in D(L(CO)), the diffusing capacity of carbon monoxide, are more commonly associated with pneumonitis. Several patient-specific factors (e.g. age, smoking history, tumor location, performance score, gender) and treatment-specific factors (e.g. chemotherapy regimen and dose) have been proposed as potential predictors of the risk of radiation pneumonitis, but these have not been consistently demonstrated across different studies. The risk of radiation pneumonitis also seems to increase as the cumulative dose of radiation to normal lung tissue increases, as measured by dose-volume histograms. However, controversy persists about which dosimetric parameter optimally predicts the risk of radiation pneumonitis, and whether the volume of lung or the dose of radiation is more important. Radiation oncologists ought to consider these dosimetric factors when designing radiation treatment plans for all patients who receive thoracic radiotherapy. Newer radiotherapy techniques and technologies may reduce the exposure of normal lung to irradiation. Several medications have also been evaluated for their ability to reduce radiation pneumonitis in animals and humans, including corticosteroids, amifostine, ACE inhibitors or angiotensin II type 1 receptor blockers, pentoxifylline, melatonin, carvedilol, and manganese superoxide dismutase-plasmid/liposome. Additional research is warranted to determine the efficacy of these medications and identify nonpharmacologic strategies to predict and prevent radiation pneumonitis.
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Affiliation(s)
- Vivek Mehta
- Department of Radiation Oncology, Swedish Cancer Institute, Seattle, WA 98104, USA.
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Kim TH, Cho KH, Pyo HR, Lee JS, Zo JI, Lee DH, Lee JM, Kim HY, Hwangbo B, Park SY, Kim JY, Shin KH, Kim DY. Dose-volumetric parameters for predicting severe radiation pneumonitis after three-dimensional conformal radiation therapy for lung cancer. Radiology 2005; 235:208-15. [PMID: 15703313 DOI: 10.1148/radiol.2351040248] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To retrospectively evaluate dose-volumetric parameters for association with risk of severe (grade >/=3) radiation pneumonitis (RP) in patients after three-dimensional (3D) conformal radiation therapy for lung cancer. MATERIALS AND METHODS The study was approved by the institutional review board, which did not require informed consent. Data from 76 patients (66 men, 10 women; median age, 60 years; range, 35-79 years) with histologically proved lung cancer treated curatively with 3D conformal radiation therapy between August 2001 and October 2002 were retrospectively analyzed. Twenty patients underwent surgery before radiation therapy; 57 patients received chemotherapy. Median total radiation dose of 60 Gy (range, 54-66 Gy) was delivered in 30 (range, 27-33) fractions over 6 weeks. RP was scored by using Radiation Therapy Oncology Group criteria. Clinical parameters were analyzed. Dose-volumetric parameters analyzed were percentage of lung volume that received a dose of 20 Gy or more (V20), 30 Gy or more (V30), 40 Gy or more (V40), or 50 Gy or more (V50); mean lung dose (MLD); normal tissue complication probability (NTCP); and total dose. Fisher exact test was performed to compare clinical parameters between patients who developed severe RP and those who did not. Univariate and multivariate logistic regression analyses were performed to evaluate data for association between dose-volumetric parameters and severe RP. Pearson chi(2) test was used to assess data for correlations among dose-volumetric parameters. P < or = .05 was considered to indicate statistically significant difference. RESULTS Of 76 patients, 30 (39%) did not develop RP; 23 (30%) developed RP of grade 1; 11 (14%), grade 2; 11 (14%), grade 3; and 1 (1%), grade 4. None had grade 5 RP. Age (< 60 vs > or =60), sex, Karnofsky performance status (< 70 vs > or =70), forced expiratory volume in 1 second, presence of weight loss, preexisting lung disease, history of thoracic surgery, and history of chemotherapy did not significantly differ between patients who developed severe RP and those who did not. In univariate analyses, MLD, V20, V30, V40, V50, and NTCP were associated with severe RP (P < .05). In multivariate analysis, MLD was the only variable associated with severe RP. CONCLUSION MLD is a useful indicator of risk for development of severe RP after 3D conformal radiation therapy in patients with lung cancer.
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Affiliation(s)
- Tae Hyun Kim
- Research Institute and Hospital, National Cancer Center, 809 Madu 1-dong, Ilsan-gu, Goyang, Gyeonggi 411-764, Korea
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