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Acute Radiation Pneumonitis After Conformal Radiation in Non-small Cell Lung Cancers: A Large French Prospective Study on Predictive Factors
S568
International Journal of Radiation Oncology Biology Physics
Materials/Methods: From January 2003 to March 2011, 33 patients (lesions n Z 42) with primary non-small cell lung cancer (n Z 28) or pulmonary metastases (n Z 14) were analyzed retrospectively. Patients were treated with IHRT (36 to 90 Gy in 5 to 27 fractions). Median biologically effective dose (BED) Gy10 was 85.6 Gy (range, 46.8 w 144). No elective nodal irradiation was delivered. Radiologic responses were categorized into complete response (CR), partial response (PR), stable disease (SD) and progression (PD) using modified RECIST criteria. The factor predicting patient’s clinical outcomes were analyzed using Kaplan-Meyer method and Cox-proportional hazard model. Results: The median age was 67 years (range, 44-87 years) and male to female ratio was 8:1. The primary lung cancer of parenchymal lung tumor was 67%. Most patients (73.8%) were not surgical candidates because of medical co-morbidities, old age or refusal of operation. The tumor control rate (CR+PR+SD) were 64% of the patients at 3-6 months, respectively. Twenty nine of 42 (69%) lung tumor lesions showed regression > 30% in tumor volume. With median follow-up of 20 months, the 2-year in-field local control rate after IHRT for lung parenchymal tumor was 75.4%, respectively. Univariate analysis revealed that tumor resource and BED 75 Gy10 is significant factors for in-field local control rate of parenchymal lung tumor. The 2-year in-field local control rate for primary lung tumor was 90.2%, respectively. Univariate analysis for primary lung tumor revealed that tumor location and tumor volume are significant factor for infield local control rate. Grade 1 to 2 pneumonitis occurred in 18 of 42 patients. Conclusions: IHRT for parenchymal lung tumor is safe and effective with good local tumor control rate. But, given the variable doses and fractionations used in this study, the prospective trials need to clarify the safety and utility of IHRT for parenchymal lung tumor. Author Disclosure: L. Jeongshim: None.
than 54 Gy were 49.1% and 12.9% (p Z 0.0145), for the number of fractions of 9, 8 and 7 (that is, fraction sizes are 6, 7 and 8 Gy) were 19.5%, 31.2% and 55.7% (p Z 0.0253), respectively. Other factors, such as age, sex, and planning target volume were not significant. Conclusions: The risk factors for radiation-induced rib fracture after SBRT were revealed to be maximum dose of the rib and fraction size of irradiation. Author Disclosure: M. Aoki: None. M. Sato: None. Y. Narita: None. K. Hirose: None. H. Kawaguchi: None. Y. Hatayama: None. Y. Takai: None.
2930 Radiation-induced Rib Fracture After Hypofractionated Stereotactic Body Radiation Therapy for Patients With Peripheral Lung Tumor: Impact of the Maximum Dose and the Fraction Size M. Aoki, M. Sato, Y. Narita, K. Hirose, H. Kawaguchi, Y. Hatayama, and Y. Takai; Hirosaki University Graduate School of Medicine, Hirosaki, Japan Purpose/Objective(s): To investigate risk factors of radiation-induced rib fracture after hypofractionated stereotactic body radiation therapy (SBRT) for the patients with peripheral lung tumor. Materials/Methods: During 2003-2008, 61 patients with medically inoperable lung tumor 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. The inclusion criteria for the study were at least 15 months of radiographic follow-up, and the tumor located within at least 2 cm from the chest wall. Among the 61 patients, there were 6 patients excluded due to short follow-up time and 14 patients excluded due to tumor location. Therefore the subjects of the study were 41 patients (28 Stage IA lung cancers, 5 Stage IB lung cancers and 9 lung metastases). Among 41 patients, one has two lung metastases, so 42 peripheral tumors were analyzed in the study. 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 the rib fracture were performed in the study. Results: Among 75 contoured ribs, 23 rib fractures were observed in 34% of the patients (14/41) during 16-48 months after SBRT, however, no patients complained of chest wall pain. Maximum dose of ribs (Dmax) was a significant factor for rib fracture (p Z 0.045), whereas D2cc, mean dose of ribs (Dmean) and V10-50 were not significant. Regardless of the number of fractions, the thresholds of the Dmax related to rib fracture were approximately 53 Gy, however, average values of Dmax with rib fracture were somehow related to the number of fractions. They were 54.7, 55.5 and 56.3 Gy for 9, 8 and 7 fractions, respectively. The 4-year overall probability of the rib fracture calculated by Kaplan-Meier method was 39%. The 4-year rib fracture probabilities for the Dmax more than and less
2931 Acute Radiation Pneumonitis After Conformal Radiation in Non-small Cell Lung Cancers: A Large French Prospective Study on Predictive Factors M. Mahe,1 D. Arpin,2 S. Dussart,3 V. Servois,4 C. Carrie,3 I. Martel-Lafay,3 S. Helfre,4 B. Prevost,5 and L. Claude3; 1ICO Rene Gauducheau, SAINT HERBLAIN, France, 2Hoˆpital de Maˆcon, MACON, France, 3Centre Le´on Be´rard, LYON, France, 4Institut Curie, PARIS, France, 5Centre Oscar Lambret, LILLE, France Purpose/Objective(s): The “Gating 2006” trial was conducted to evaluate the real impact of respiratory-gated conformal radiation therapy on acute radiation pneumonitis (ARP) incidence. A prospective analysis of predictive factors of ARP is proposed. Materials/Methods: Between 07/2006 and 07/2011, 242 patients (pts) entered the trial. All pts had proven non-metastatic NSCLC, mainly stage III (87%), and treated with curative RT intent (66Gy, 2Gy/fr). ARP prospective evaluation included clinical, thoracic scans (all reviewed by an independent panel of experts) and management evaluations 6-8 and 10-12 weeks after RT. ARP was scored according to RTOG acute classification, identifying 4 groups (Gr) of patients. Results: Two hundred nine pts were evaluable for ARP and classified as: -
Gr Gr Gr Gr
1: 2: 3: 4:
no ARP (clinic or CT): nZ45 (21.5%) asymptomatic ARP: nZ54 (25.8%), moderate ARP: nZ96 (45.9%) severe ARP: nZ14 (6.7%).
Considering predictive factors for moderate/severe ARP (Gr 1-2 vs 3-4), the age and the percentage of the lungs irradiated over 25, 30 and 40 Gy (V25, V30, V40) were associated with ARP (p<.05). Surprisingly, the concomitant chemo-radiation was associated with less toxicity as well as a low baseline diffusion capacity (p<.05). In multivariate analysis, the age and V40 were significantly associated with ARP (pZ0.008 and pZ0.005). Regarding only the severe ARP (Gr 4), the age, the surgery before RT, V5, V20, V25, V30, V40, the mean lung dose and the clinical target volume (CTV) were associated with Gr4 ARP in univariate analysis. In multivariate analysis, only the age and V5 were significantly associated with Gr 4 ARP (pZ0.01 and PZ0.003). Nor the other clinical parameters, the baseline lung function nor the other dosimetric parameters were predictive of ARP. With a median follow-up of 25.2 months, the 1y-DFS was 38% (CI95%[31 - 45]). The 2y-DFS as well as the analysis of predictive factor of survival will be presented at the congress with mature data. Conclusions: ARP is quite frequent in this large prospective study. The older age is significantly associated with both moderate and severe ARP. V5 is also significantly and independently associated with severe ARP. Author Disclosure: M. Mahe: None. D. Arpin: None. S. Dussart: None. V. Servois: None. C. Carrie: None. I. Martel-Lafay: None. S. Helfre: None. B. Prevost: None. L. Claude: None.
2932 Complications From CT-guided Needle Biopsy for Patients Receiving Stereotactic Body Radiation Therapy V. Chowdhry,1 A.K. Chowdhry,2 N. Goldman,3 E.M. Scalzetti,1 R.A. Grage,1 and J.A. Bogart1; 1SUNY Upstate Medical University,
International Journal of Radiation Oncology Biology Physics
Materials/Methods: From January 2003 to March 2011, 33 patients (lesions n Z 42) with primary non-small cell lung cancer (n Z 28) or pulmonary metastases (n Z 14) were analyzed retrospectively. Patients were treated with IHRT (36 to 90 Gy in 5 to 27 fractions). Median biologically effective dose (BED) Gy10 was 85.6 Gy (range, 46.8 w 144). No elective nodal irradiation was delivered. Radiologic responses were categorized into complete response (CR), partial response (PR), stable disease (SD) and progression (PD) using modified RECIST criteria. The factor predicting patient’s clinical outcomes were analyzed using Kaplan-Meyer method and Cox-proportional hazard model. Results: The median age was 67 years (range, 44-87 years) and male to female ratio was 8:1. The primary lung cancer of parenchymal lung tumor was 67%. Most patients (73.8%) were not surgical candidates because of medical co-morbidities, old age or refusal of operation. The tumor control rate (CR+PR+SD) were 64% of the patients at 3-6 months, respectively. Twenty nine of 42 (69%) lung tumor lesions showed regression > 30% in tumor volume. With median follow-up of 20 months, the 2-year in-field local control rate after IHRT for lung parenchymal tumor was 75.4%, respectively. Univariate analysis revealed that tumor resource and BED 75 Gy10 is significant factors for in-field local control rate of parenchymal lung tumor. The 2-year in-field local control rate for primary lung tumor was 90.2%, respectively. Univariate analysis for primary lung tumor revealed that tumor location and tumor volume are significant factor for infield local control rate. Grade 1 to 2 pneumonitis occurred in 18 of 42 patients. Conclusions: IHRT for parenchymal lung tumor is safe and effective with good local tumor control rate. But, given the variable doses and fractionations used in this study, the prospective trials need to clarify the safety and utility of IHRT for parenchymal lung tumor. Author Disclosure: L. Jeongshim: None.
than 54 Gy were 49.1% and 12.9% (p Z 0.0145), for the number of fractions of 9, 8 and 7 (that is, fraction sizes are 6, 7 and 8 Gy) were 19.5%, 31.2% and 55.7% (p Z 0.0253), respectively. Other factors, such as age, sex, and planning target volume were not significant. Conclusions: The risk factors for radiation-induced rib fracture after SBRT were revealed to be maximum dose of the rib and fraction size of irradiation. Author Disclosure: M. Aoki: None. M. Sato: None. Y. Narita: None. K. Hirose: None. H. Kawaguchi: None. Y. Hatayama: None. Y. Takai: None.
2930 Radiation-induced Rib Fracture After Hypofractionated Stereotactic Body Radiation Therapy for Patients With Peripheral Lung Tumor: Impact of the Maximum Dose and the Fraction Size M. Aoki, M. Sato, Y. Narita, K. Hirose, H. Kawaguchi, Y. Hatayama, and Y. Takai; Hirosaki University Graduate School of Medicine, Hirosaki, Japan Purpose/Objective(s): To investigate risk factors of radiation-induced rib fracture after hypofractionated stereotactic body radiation therapy (SBRT) for the patients with peripheral lung tumor. Materials/Methods: During 2003-2008, 61 patients with medically inoperable lung tumor 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. The inclusion criteria for the study were at least 15 months of radiographic follow-up, and the tumor located within at least 2 cm from the chest wall. Among the 61 patients, there were 6 patients excluded due to short follow-up time and 14 patients excluded due to tumor location. Therefore the subjects of the study were 41 patients (28 Stage IA lung cancers, 5 Stage IB lung cancers and 9 lung metastases). Among 41 patients, one has two lung metastases, so 42 peripheral tumors were analyzed in the study. 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 the rib fracture were performed in the study. Results: Among 75 contoured ribs, 23 rib fractures were observed in 34% of the patients (14/41) during 16-48 months after SBRT, however, no patients complained of chest wall pain. Maximum dose of ribs (Dmax) was a significant factor for rib fracture (p Z 0.045), whereas D2cc, mean dose of ribs (Dmean) and V10-50 were not significant. Regardless of the number of fractions, the thresholds of the Dmax related to rib fracture were approximately 53 Gy, however, average values of Dmax with rib fracture were somehow related to the number of fractions. They were 54.7, 55.5 and 56.3 Gy for 9, 8 and 7 fractions, respectively. The 4-year overall probability of the rib fracture calculated by Kaplan-Meier method was 39%. The 4-year rib fracture probabilities for the Dmax more than and less
2931 Acute Radiation Pneumonitis After Conformal Radiation in Non-small Cell Lung Cancers: A Large French Prospective Study on Predictive Factors M. Mahe,1 D. Arpin,2 S. Dussart,3 V. Servois,4 C. Carrie,3 I. Martel-Lafay,3 S. Helfre,4 B. Prevost,5 and L. Claude3; 1ICO Rene Gauducheau, SAINT HERBLAIN, France, 2Hoˆpital de Maˆcon, MACON, France, 3Centre Le´on Be´rard, LYON, France, 4Institut Curie, PARIS, France, 5Centre Oscar Lambret, LILLE, France Purpose/Objective(s): The “Gating 2006” trial was conducted to evaluate the real impact of respiratory-gated conformal radiation therapy on acute radiation pneumonitis (ARP) incidence. A prospective analysis of predictive factors of ARP is proposed. Materials/Methods: Between 07/2006 and 07/2011, 242 patients (pts) entered the trial. All pts had proven non-metastatic NSCLC, mainly stage III (87%), and treated with curative RT intent (66Gy, 2Gy/fr). ARP prospective evaluation included clinical, thoracic scans (all reviewed by an independent panel of experts) and management evaluations 6-8 and 10-12 weeks after RT. ARP was scored according to RTOG acute classification, identifying 4 groups (Gr) of patients. Results: Two hundred nine pts were evaluable for ARP and classified as: -
Gr Gr Gr Gr
1: 2: 3: 4:
no ARP (clinic or CT): nZ45 (21.5%) asymptomatic ARP: nZ54 (25.8%), moderate ARP: nZ96 (45.9%) severe ARP: nZ14 (6.7%).
Considering predictive factors for moderate/severe ARP (Gr 1-2 vs 3-4), the age and the percentage of the lungs irradiated over 25, 30 and 40 Gy (V25, V30, V40) were associated with ARP (p<.05). Surprisingly, the concomitant chemo-radiation was associated with less toxicity as well as a low baseline diffusion capacity (p<.05). In multivariate analysis, the age and V40 were significantly associated with ARP (pZ0.008 and pZ0.005). Regarding only the severe ARP (Gr 4), the age, the surgery before RT, V5, V20, V25, V30, V40, the mean lung dose and the clinical target volume (CTV) were associated with Gr4 ARP in univariate analysis. In multivariate analysis, only the age and V5 were significantly associated with Gr 4 ARP (pZ0.01 and PZ0.003). Nor the other clinical parameters, the baseline lung function nor the other dosimetric parameters were predictive of ARP. With a median follow-up of 25.2 months, the 1y-DFS was 38% (CI95%[31 - 45]). The 2y-DFS as well as the analysis of predictive factor of survival will be presented at the congress with mature data. Conclusions: ARP is quite frequent in this large prospective study. The older age is significantly associated with both moderate and severe ARP. V5 is also significantly and independently associated with severe ARP. Author Disclosure: M. Mahe: None. D. Arpin: None. S. Dussart: None. V. Servois: None. C. Carrie: None. I. Martel-Lafay: None. S. Helfre: None. B. Prevost: None. L. Claude: None.
2932 Complications From CT-guided Needle Biopsy for Patients Receiving Stereotactic Body Radiation Therapy V. Chowdhry,1 A.K. Chowdhry,2 N. Goldman,3 E.M. Scalzetti,1 R.A. Grage,1 and J.A. Bogart1; 1SUNY Upstate Medical University,