Clinical Implementation of Hypofractionated Radiation therapy for Lung Malignancies

Abstract

For patients with oligometastases, metastases limited in number and site, the use of radiation therapy treatment with a hypofractionated dose scheme has been proposed as a potential ablative approach. There are a limited number of prospective studies looking at hypofractionated radiation therapy (HRT) for lung oligometastasis. Normal lung tissue complication and radiation planning technique are significant limiting factors for the implementation of hypofractionated lung metastasis. The problem statement of this study is how to improve the clinical implementation of HRT for lung metastasis exploring lung toxicity predictors, and developing an efficient radiation planning method.

In the first study, we analyzed the dose distribution for 28 patients with lung oligometastasis and treated with HRT to multiple metastases in the lungs. We identified several significant predictors for lung radiation pneumonitis (RP) including the mean lung dose (MLD), V13 and V20. In addition a dose-effect relation between the lung normalized total dose (NTD) and RP may exist up to 48 Gy in three fractions. The dose-response parameters derived in our study appear to agree with other hypofractionated results published in the literature.

In the second study, we used an inverse planning algorithm to develop a new radiation planning method by limiting the number of segments per beam angle down to 1 segment. Single segment plans were able to significantly improve tumor coverage and conformality, reduce the risk of lung RP, while simplifying the planning process and delivery. Target conformality and normal lung tissue sparing did not gain much improvement from an increase of plan complexity to five segments over the simplified one segment technique. The automation of our method is a good alternative to more traditional methods and offers significant dosimetric benefits.

In the third study, we verified the single segment planning technique via patient specific quality assurance (QA) in a motion phantom. We found good agreement between calculated and measured doses via thermoluminescent detectors (TLD) inside the target. A dose to distance agreement of 3%/3 mm and 2%/2 mm between calculation and film measurements for representative plans in a motion phantom was verified at 98.99% and 97.15%, respectively.