Radiation-induced rib fracture after stereotactic body radiotherapy with a total dose of 54-56 Gy given in 9-7 fractions for patients with peripheral lung tumor: impact of maximum dose and fraction size

Masahiko Aoki, Mariko Sato, Katsumi Hirose, Hiroyoshi Akimoto, Hideo Kawaguchi, Yoshiomi Hatayama, Shuichi Ono, Yoshihiro Takai, Masahiko Aoki, Mariko Sato, Katsumi Hirose, Hiroyoshi Akimoto, Hideo Kawaguchi, Yoshiomi Hatayama, Shuichi Ono, Yoshihiro Takai

Abstract

Background: Radiation-induced rib fracture after stereotactic body radiotherapy (SBRT) for lung cancer has been recently reported. However, incidence of radiation-induced rib fracture after SBRT using moderate fraction sizes with a long-term follow-up time are not clarified. We examined incidence and risk factors of radiation-induced rib fracture after SBRT using moderate fraction sizes for the patients with peripherally located lung tumor.

Methods: During 2003-2008, 41 patients with 42 lung tumors were treated with SBRT to 54-56 Gy in 9-7 fractions. The endpoint in the study was radiation-induced rib fracture detected by CT scan after the treatment. All ribs where the irradiated doses were more than 80% of prescribed dose were selected and contoured to build the dose-volume histograms (DVHs). Comparisons of the several factors obtained from the DVHs and the probabilities of rib fracture calculated by Kaplan-Meier method were performed in the study.

Results: Median follow-up time was 68 months. Among 75 contoured ribs, 23 rib fractures were observed in 34% of the patients during 16-48 months after SBRT, however, no patients complained of chest wall pain. The 4-year probabilities of rib fracture for maximum dose of ribs (Dmax) more than and less than 54 Gy were 47.7% and 12.9% (p = 0.0184), and for fraction size of 6, 7 and 8 Gy were 19.5%, 31.2% and 55.7% (p = 0.0458), respectively. Other factors, such as D2cc, mean dose of ribs, V10-55, age, sex, and planning target volume were not significantly different.

Conclusions: The doses and fractionations used in this study resulted in no clinically significant rib fractures for this population, but that higher Dmax and dose per fraction treatments resulted in an increase in asymptomatic grade 1 rib fractures.

Figures

Figure 1
Figure 1
An 83-year-old woman with adenocarcinoma after SBRT with a total dose of 56 Gy given in 7 fractions. (A): Dosimetry overlaying CT with bone window shows the 95% iso-dose line on the right 5th rib. (B): Rib fracture was noted at 36 months after SBRT (arrow).
Figure 2
Figure 2
All cumulative DVHs for ribs. DVHs with fracture (A), without fracture (B), and DVHs with standard deviation (C) with fracture (solid curve) and without fracture (dotted curve).
Figure 3
Figure 3
Cumulative incidence of radiation-induced rib fracture. Dmax more than and less than 54 Gy (A), fraction size of 6, 7, and 8 Gy (B).

References

    1. Uematsu M, Shioda A, Suda A, Fukui T, Ozeki Y, Hama Y, et al. Computed tomography-guided frameless stereotactic radiotherapy for stage I non-small-cell lung cancer: a 5-year experience. Int J Radiat Oncol Biol Phys. 2001;51:666–70. doi: 10.1016/S0360-3016(01)01703-5.
    1. Onishi H, Araki T, Shiato H, Nagata Y, Hiraoka M, Gomi K, et al. Stereotactic hypofractionated high-dose irradiation for stage I nonsmall cell lung carcinoma: clinical outcomes in 245 subjects in a Japanese multiinstitutional study. Cancer. 2004;101:1623–31. doi: 10.1002/cncr.20539.
    1. Nagata Y, Negoro Y, Aoki T, Mizowaki T, Takayama K, Kokubo M, et al. Clinical outcomes of 3D conformal hypofractionated single high dose radiotherapy for one or two lung tumors using a stereotactic body frame. Int J Radiat Oncol Biol Phys. 2002;52:1041–6. doi: 10.1016/S0360-3016(01)02731-6.
    1. Fukumoto S, Shirato H, Shimzu S, Ogura S, Onimaru R, Kitamura K, et al. Small-volume image-guided radiotherapy using hypofractionated, coplanar, and noncoplanar multiple fields for patients with inoperable stage I nonsmall cell lung carcinomas. Cancer. 2002;95:1546–53. doi: 10.1002/cncr.10853.
    1. Timmerman R, Papiez L, McGarry R, Likes L, DesRosiers C, Frost S, et al. Extra Extracranial stereotactic radioablation: results of a phase I study in medically inoperable stage I non-small cell lung cancer. Chest. 2003;124:1946–55. doi: 10.1378/chest.124.5.1946.
    1. Koto M, Takai Y, Ogawa Y, Matsushita H, Takeda K, Takahashi C, et al. A phase II study on stereotactic body radiotherapy for stage I non-small cell lung cancer. Radiother Oncol. 2007;85:429–34. doi: 10.1016/j.radonc.2007.10.017.
    1. Zimmermann FB, Geinitz H, Schill S, Grosu A, Schratzenstaller U, Molls M, et al. Stereotactic hypofractionated radiation therapy for stage I non-small cell lung cancer. Lung Cancer. 2005;48:107–14. doi: 10.1016/j.lungcan.2004.10.015.
    1. Nyman J, Johansson KA, Hultén U. Stereotactic hypofractionated radiotherapy for stage I non-small cell lung cancer-mature results for medically inoperable patients. Lung Cancer. 2006;51:97–103. doi: 10.1016/j.lungcan.2005.08.011.
    1. Fritz P, Kraus HJ, Blaschke T, Muhlnickel W, Strauch K, Engel-Riedel W, et al. Stereotactic, high single-dose irradiation of stage I non-small cell lung cancer (NSCLC) using four-dimensional CT scan for treatment planning. Lung Cancer. 2008;60:193–9. doi: 10.1016/j.lungcan.2007.10.005.
    1. Voroney JP, Hope A, Dahele MR, Purdy T, Franks KN, Pearson S, et al. Chest wall pain and rib fracture after stereotactic radiotherapy for peripheral non-small cell lung cancer. J Thorac Oncol. 2009;4:1035–7. doi: 10.1097/JTO.0b013e3181ae2962.
    1. Pettersson N, Nyman L, Johansson KA. Radiation-induced rib fractures after hypofractionated stereotactic body radiation therapy of non-small cell lung cancer: a dose- and volume-response analysis. Radiother Oncol. 2009;91:360–8. doi: 10.1016/j.radonc.2009.03.022.
    1. Andolino DL, Forqur JA, Henderson MA, Barriger RB, Shapiro RH, Brabham JG, et al. Chest wall toxicity after stereotactic body radiotherapy for malignant lesions of the lung and liver. Int J Radiat Oncol Biol Phys. 2011;80:692–7. doi: 10.1016/j.ijrobp.2010.03.020.
    1. Pierce SM, Recht A, Lingos TI, Abner A, Vicini F, Silver B, et al. Long-term radiation complications following conservative surgery (CS) and radiation therapy (RT) in patients with early stage breast cancer. Int J Radiat Oncol Biol Phys. 1992;23:915–23. doi: 10.1016/0360-3016(92)90895-O.
    1. Overgaard M. Spontaneous radiation-induced rib fractures in breast cancer patients treated with postmastectomy irradiation. A clinical radiobiological analysis of the influence of fraction size and dose–response relationships on late bone damage. Acta Oncol. 1988;27:117–22. doi: 10.3109/02841868809090331.
    1. Aoki M, Abe Y, Kondo H, Hatayama Y, Kawaguchi H, Fujimori A, et al. Clinical outcome of stereotactic body radiotherapy of 54 Gy in nine fractions for patients with localized lung tumor using a custom-made immobilization system. Radiat Med. 2006;25:289–94. doi: 10.1007/s11604-007-0141-7.
    1. Nambu A, Onishi H, Aoki S, Tominaga L, Kuriyama K, Araya M, et al. Rib fracture after stereotactic radiotherapy for primary lung cancer: prevalence, degree of clinical symptoms and risk factors. BMC Cancer. 2013;13:68. doi: 10.1186/1471-2407-13-68.
    1. Quddus AM, Kerr GR, Price A, Gregor A. Long-term survival in patients with non-small cell lung cancer treated with palliative radiotherapy. Clin Oncol (R Coll Radiol) 2001;13:95–8.
    1. Asai K, Shioyama Y, Nakamura K, Sasaki T, Ohga S, Nonoshita T, et al. Radiation-induced rib fractures after hypofractionated stereotactic body radiation therapy: risk factors and dose-volume relationship. Int J Radiat Oncol Biol Phys. 2012;84:768–73. doi: 10.1016/j.ijrobp.2012.01.027.
    1. Kim SS, Song SY, Kwak J, Ahn SD, Kim JH, Lee JS, et al. Clinical prognostic factors and grading system for rib fracture following stereotactic body radiation therapy (SBRT) in patients with peripheral lung tumors. Lung Cancer. 2013;79:161–6. doi: 10.1016/j.lungcan.2012.10.011.
    1. Nambu A, Onishi H, Aoki S, Koshiishi T, Kuriyama K, Komiyama T, et al. Rib fracture after stereotactic radiotherapy on follow-up thin-section computed tomography in 177 primary lung cancer patients. Radiat Oncol. 2011;6:137. doi: 10.1186/1748-717X-6-137.
    1. Welsh J, Thomas J, Shah D, Allen PK, Wei X, Mitchell K. Obesity increases the risk of chest wall pain from thoracic stereotactic body radiation therapy. Int J Radiat Oncol Biol Phys. 2011;81:91–6. doi: 10.1016/j.ijrobp.2010.04.022.
    1. Woody NM, Videtic GM, Stephans KL, Djemil T, Kim Y, Xia P. Predicting chest wall pain from lung stereotactic body radiotherapy for different fractionation schemes. Int J Radiat Oncol Biol Phys. 2012;83:427–34. doi: 10.1016/j.ijrobp.2011.06.1971.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir