Abstract
Background and PurposeDyspnea is an important symptomatic endpoint for assessment of radiation-induced lung injury (RILI) following radical radiotherapy in locally advanced disease, which remains the mainstay of treatment at the time of significant advances in therapy including combination treatments with immunotherapy and chemotherapy and the use of local ablative radiotherapy techniques. We investigated the relationship between dose-volume parameters and subjective changes in dyspnea as a measure of RILI and the relationship to spirometry.Material and MethodsEighty patients receiving radical radiotherapy for non-small cell lung cancer were prospectively assessed for dyspnea using two patient-completed tools: EORTC QLQ-LC13 dyspnea quality of life assessment and dyspnea visual analogue scale (VAS). Global quality of life, spirometry and radiation pneumonitis grade were also assessed. Comparisons were made with lung dose-volume parameters.ResultsThe median survival of the cohort was 26 months. In the evaluable group of 59 patients there were positive correlations between lung dose-volume parameters and a change in dyspnea quality of life scale at 3 months (V30 p=0.017; V40 p=0.026; V50 p=0.049; mean lung dose p=0.05), and a change in dyspnea VAS at 6 months (V30 p=0.05; V40 p=0.026; V50 p=0.028) after radiotherapy. Lung dose-volume parameters predicted a 10% increase in dyspnea quality of life score at 3 months (V40; p=0.041, V50; p=0.037) and dyspnea VAS score at 6 months (V40; p=0.027) post-treatment.ConclusionsWorsening of dyspnea is an important symptom of RILI. We demonstrate a relationship between lung dose-volume parameters and a 10% worsening of subjective dyspnea scores. Our findings support the use of subjective dyspnea tools in future studies on radiation-induced lung toxicity, particularly at doses below conventional lung radiation tolerance limits.
Highlights
Radical radiotherapy (RT), with or without chemotherapy has an established role as an alternative to surgery in medically inoperable, localized and locally advanced non-small cell lung cancer (NSCLC) [1, 2]
All patients scheduled to receive radical RT to a dose of 64 Gray (Gy) in 32 daily fractions were eligible for study entry if they fulfilled the following criteria: histological or radiological diagnosis of localized medically inoperable or unresectable locally advanced NSCLC (AJCC 6th edition stages I-III, excluding T4 lesions associated with pleural effusion), baseline forced expiratory volume in 1 s (FEV1) greater than 40% of predicted normal value and World Health Organization (WHO) performance status 0-2
In patients treated in free breathing, a margin of 1.5 cm was added cranio-caudally with axially 1 cm for central disease and 1.5 cm for peripheral disease added to the clinical target volume (CTV) to create the planning target volume (PTV)
Summary
Radical radiotherapy (RT), with or without chemotherapy has an established role as an alternative to surgery in medically inoperable, localized and locally advanced non-small cell lung cancer (NSCLC) [1, 2]. The disappointing survival rates following radical conventionally fractionated RT have been the impetus behind application of advanced RT techniques with the aim of increasing radiation dose intensity without additional toxicity [6,7,8,9]. Radiation-induced lung injury (RILI) remains a significant limiting factor to dose escalation. The grading of RP is challenging as the most frequently used scoring systems, including the Common Terminology Criteria for Adverse Events (CTCAE) and the Radiation Therapy Oncology Group (RTOG) system, have a small number of broad categories combining symptomatic, functional, and radiological criteria in addition to indication of medical intervention. Dyspnea is an important symptomatic endpoint for assessment of radiation-induced lung injury (RILI) following radical radiotherapy in locally advanced disease, which remains the mainstay of treatment at the time of significant advances in therapy including combination treatments with immunotherapy and chemotherapy and the use of local ablative radiotherapy techniques. We investigated the relationship between dose-volume parameters and subjective changes in dyspnea as a measure of RILI and the relationship to spirometry
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