Recommendations for implementing stereotactic radiotherapy in peripheral stage IA non-small cell lung cancer: report from the Quality Assurance Working Party of the randomised phase III ROSEL study

Coen W Hurkmans, Johan P Cuijpers, Frank J Lagerwaard, Joachim Widder, Uulke A van der Heide, Danny Schuring, Suresh Senan, Coen W Hurkmans, Johan P Cuijpers, Frank J Lagerwaard, Joachim Widder, Uulke A van der Heide, Danny Schuring, Suresh Senan

Abstract

Background: A phase III multi-centre randomised trial (ROSEL) has been initiated to establish the role of stereotactic radiotherapy in patients with operable stage IA lung cancer. Due to rapid changes in radiotherapy technology and evolving techniques for image-guided delivery, guidelines had to be developed in order to ensure uniformity in implementation of stereotactic radiotherapy in this multi-centre study.

Methods/design: A Quality Assurance Working Party was formed by radiation oncologists and clinical physicists from both academic as well as non-academic hospitals that had already implemented stereotactic radiotherapy for lung cancer. A literature survey was conducted and consensus meetings were held in which both the knowledge from the literature and clinical experience were pooled. In addition, a planning study was performed in 26 stage I patients, of which 22 were stage 1A, in order to develop and evaluate the planning guidelines. Plans were optimised according to parameters adopted from RTOG trials using both an algorithm with a simple homogeneity correction (Type A) and a more advanced algorithm (Type B). Dose conformity requirements were then formulated based on these results.

Conclusion: Based on current literature and expert experience, guidelines were formulated for this phase III study of stereotactic radiotherapy versus surgery. These guidelines can serve to facilitate the design of future multi-centre clinical trials of stereotactic radiotherapy in other patient groups and aid a more uniform implementation of this technique outside clinical trials.

Figures

Figure 1
Figure 1
ROSEL study design.
Figure 2
Figure 2
Ratio of Prescription Isodose Volume to the PTV (R100%) from a total of 22 patients with stage IA tumours and 4 patients with stage 1B tumours (with PTVs of 59 cc, 85 cc, 107 cc and 108 cc).
Figure 3
Figure 3
Ratio of 50% Prescription Isodose Volume to the PTV (R50%) from a total of 22 patients with stage IA tumours and 4 patients with stage 1B tumours (with PTVs of 59 cc, 85 cc, 107 cc and 108 cc).
Figure 4
Figure 4
Maximum dose 2 cm from PTV in any direction (D2 cm) as % of prescribed dose from a total of 22 patients with stage I tumours and 4 patients with stage 1B tumours (with PTVs of 59 cc, 85 cc, 107 cc and 108 cc).
Figure 5
Figure 5
Percent of lung (both lungs minus GTV) receiving 20 Gy or more (V20 Gy) from a total of 22 patients with stage I tumours and 4 patients with stage 1B tumours (with PTVs of 59 cc, 85 cc, 107 cc and 108 cc).
Figure 6
Figure 6
Dose to 95% of the PTV as a function of the PTV after recalculation using a type B algorithm (Collapsed Cone (CC) algorithm, Pinnacle 8.0 h) from a total of 22 patients with stage IA tumours and 4 patients with stage 1B tumours (with PTVs of 59 cc, 85 cc, 107 cc and 108 cc) (reprinted with permission from ref 20). Plans were optimized using a type A algorithm (EPL), a unit density calculation (UD) or a type B algorithm (CC).

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