Potential Morbidity Reduction for Lung Stereotactic Body Radiation Therapy Using Respiratory Gating.

Kim Melanie Kraus,Pavel Kundrát,Vanessa Waitz,Stephanie Elisabeth Combs,Kai Joachim Borm,Cristoforo Simonetto

doi:10.3390/cancers13205092

Abstract

Simple SummaryLung stereotactic body radiotherapy (SBRT) is the standard of care for early-stage lung cancer and oligometastases. For SBRT, motion has to be considered to avoid misdosage. Respiratory phase gating, meaning to irradiate the target volume only in a predefined gating motion phase window, can be applied to mitigate motion-induced effects. The aim of this study was to exploit the clinical benefit of gating for lung SBRT. For the majority of 14 lung tumor patients and various gating windows, we could prove a reduced dose to normal tissue by gating simulation. A normal tissue complication probability (NTCP) model analysis revealed a major reduction of normal tissue toxicity for moderate gating window sizes. The most beneficial effect of gating was found for those patients with the highest prior toxicity risk. The presented results are useful for personalized risk assessment prior to treatment and may help to select patients and optimal gating windows.We investigated the potential of respiratory gating to mitigate the motion-caused misdosage in lung stereotactic body radiotherapy (SBRT). For fourteen patients with lung tumors, we investigated treatment plans for a gating window (GW) including three breathing phases around the maximum exhalation phase, GW40–60. For a subset of six patients, we also assessed a preceding three-phase GW20–40 and six-phase GW20–70. We analyzed the target volume, lung, esophagus, and heart doses. Using normal tissue complication probability (NTCP) models, we estimated radiation pneumonitis and esophagitis risks. Compared to plans without gating, GW40–60 significantly reduced doses to organs at risk without impairing the tumor doses. On average, the mean lung dose decreased by 0.6 Gy (p < 0.001), treated lung V20Gy by 2.4% (p = 0.003), esophageal dose to 5cc by 2.0 Gy (p = 0.003), and maximum heart dose by 3.2 Gy (p = 0.009). The model-estimated mean risks of 11% for pneumonitis and 12% for esophagitis without gating decreased upon GW40–60 to 7% and 9%, respectively. For the highest-risk patient, gating reduced the pneumonitis risk from 43% to 32%. Gating is most beneficial for patients with high-toxicity risks. Pre-treatment toxicity risk assessment may help optimize patient selection for gating, as well as GW selection for individual patients.

Highlights

Stereotactic body radiation therapy (SBRT) is a well-established high-precision radiotherapy method
We present a normal tissue complication probability (NTCP) model-based toxicity prediction on an individual patient basis and discuss the expected toxicity risk reduction achievable with gating in lung SBRT
When symptomatic radiation pneumonitis risks were calculated by a logistic funcThe expected trend that a larger gating window (GW) increases doses to organs at risk (OARs) became obvious for tion of mean total in lung dose, resulted we found the mean estimated risk for radiation

Summary

Introduction

Stereotactic body radiation therapy (SBRT) is a well-established high-precision radiotherapy method. It represents a standard of care for treatment of early-stage lung tumors and pulmonary oligometastases [1,2,3,4,5,6,7,8]. Depending on the tumor size and location, as well as the dose fractionation scheme, symptomatic radiation pneumonitis has been reported to occur in 10–20% of patients after SBRT [11,12,13,14]. The risk of high-grade esophagus toxicity for central tumor SBRT has recently been found to be low for moderate SBRT fractionation schemes [19]. A common solution to reduce toxicity for more ambitious dose regimes often is an adaptation of the dose regimes to meet the constraints for the OARs, leading to a tradeoff between local tumor control and toxicity [20,21,22,23]

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