Abstract
Purpose: Chest wall pain and discomfort has been recognized as a significant late effect of radiation therapy in historical and modern treatment models. Stereotactic Body Radiotherapy (SBRT) is becoming an important treatment tool in oncology care for patients with intrathoracic lesions. For lesions in close approximation to the chest wall with motion management, SBRT techniques can deliver high dose to the chest wall. As an unintended target of consequence, there is possibility of imposing significant chest wall pain and discomfort as a late effect of therapy. The purpose of this paper is to evaluate the potential role of Volume Modulated Arc Therapy (VMAT) technologies in decreasing chest wall dose in SBRT treatment of pulmonary lesions in close approximation to the chest wall.Materials and Methods: Ten patients with pulmonary lesions of various sizes and tomography in close approximation to the chest wall were selected for retrospective review. All volumes including tumor target, chest wall, ribs, and lung were contoured with maximal intensity projection maps and four-dimensional computer tomography planning. Radiation therapy planning consisted of static techniques including Intensity Modulated Radiation Therapy compared to VMAT therapy to a dose of 60 Gy in 12 Gy fraction dose. Dose volume histogram to rib, chest wall, and lung were compared between plans with statistical analysis.Results: In all patients, dose and volume were improved to ribs and chest wall using VMAT technologies compared to static field techniques. On average, volume receiving 30 Gy to the chest wall was improved by 74%; the ribs by 60%. In only one patient did the VMAT treatment technique increase pulmonary volume receiving 20 Gy (V20).Conclusions: VMAT technology has potential of limiting radiation dose to sensitive chest wall regions in patients with lesions in close approximation to this structure. This would also have potential value to lesions treated with SBRT in other body regions where targets abut critical structures.
Highlights
Radiation therapy is an important treatment modality in cancer care
The purpose of this paper is to evaluate the potential role of Volume Modulated Arc Therapy (VMAT) technologies in decreasing chest wall dose in Stereotactic Body Radiotherapy (SBRT) treatment of pulmonary lesions in close approximation to the chest wall
In all patients, dose and volume were improved to ribs and chest wall using VMAT technologies compared to static field techniques
Summary
Acute normal tissue effects during therapy generally affect tissues of rapid self renewal potential including skin and mucosal surfaces. Late effects from treatment can affect tissues of both rapid and limited self renewal potential. Injuries to tissues of limited self renewal potential including bone, muscle, and nerve often become chronic in nature and result in significant pain with limited successful treatment options. In early breast cancer management, patients were treated with enface photon techniques with varied fractionation strategies including strategies not commonly employed in modern care. On occasion, these patients would develop chest wall injury and rib fracture (Dalinka et al, 1974; Overgaard, 1988). Even with more modern preIMRT breast cancer therapy techniques, areas of radiation dose inhomogeneity were identified in medial and lateral rib/chest www.frontiersin.org
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