Skip to main content
Log in

The dosimetric effects of limited elective nodal irradiation in volumetric modulated arc therapy treatment planning for locally advanced non-small cell lung cancer

  • Original Research
  • Published:
Journal of Radiation Oncology



Contemporary radiotherapy guidelines for locally advanced non-small cell lung carcinoma (LA-NSCLC) recommend omitting elective nodal irradiation, despite the fact that evidence supporting this came primarily from older reports assessing comprehensive nodal coverage using 3D conformal techniques. Herein, we evaluated the dosimetric implications of the addition of limited elective nodal irradiation (LENI) to standard involved field irradiation (IFI) using volumetric modulated arc therapy (VMAT) planning.


Target volumes and organs-at-risk (OARs) were delineated on CT simulation images of 20 patients with LA-NSCLC. Two VMAT plans (IFI and LENI) were generated for each patient. Involved sites were treated to 60 Gy in 30 fractions for both IFI and LENI plans. Adjacent uninvolved nodal regions, considered high risk based on the primary tumor site and extent of nodal involvement, were treated to 51 Gy in 30 fractions in LENI plans using a simultaneous integrated boost approach.


All planning objectives for PTVs and OARs were achieved for both IFI and LENI plans. LENI resulted in significantly higher esophagus D mean (15.3 vs. 22.5 Gy, p < 0.01), spinal cord D max (34.9 vs. 42.4 Gy, p = 0.02) and lung D mean (13.5 vs. 15.9 Gy, p = 0.02), V 20 (23.0 vs. 27.9%, p = 0.03), and V 5 (52.6 vs. 59.4%, p = 0.02). No differences were observed in heart parameters. On average, only 32.2% of the high-risk nodal volume received an incidental dose of 51 Gy when untargeted in IFI plans.


The addition of LENI to VMAT plans for LA-NSCLC is feasible, with only modestly increased doses to OARs and marginal expected increase in associated toxicity.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others


  1. National Comprehensive Cancer Network® (NCCN) (2017) Practice guidelines in oncology: non-small cell lung cancer, Version 4.

  2. Belderbos JS, Kepka L, Spring Kong FM, Martel MK, Videtic GM, Jeremic B (2008) Report from the International Atomic Energy Agency (IAEA) consultants’ meeting on elective nodal irradiation in lung cancer: non-small-cell lung cancer (NSCLC). Int J Radiat Oncol Biol Phys 72(2):335–342

    Article  PubMed  Google Scholar 

  3. Emami B, Mirkovic N, Scott C et al (2003) The impact of regional nodal radiotherapy (dose/volume) on regional progression and survival in unresectable non-small cell lung cancer: an analysis of RTOG data. Lung Cancer 41(2):207–214

    Article  PubMed  Google Scholar 

  4. De Ruysscher D, Wanders S, van Haren E et al (2005) Selective mediastinal node irradiation based on FDG-PET scan data in patients with non-small-cell lung cancer: a prospective clinical study. Int J Radiat Oncol Biol Phys 62(4):988–994

    Article  PubMed  Google Scholar 

  5. Rosenzweig KE, Sura S, Jackson A, Yorke E (2007) Involved-field radiation therapy for inoperable non-small-cell lung cancer. J Clin Oncol 25(35):5557–5561

    Article  PubMed  Google Scholar 

  6. Sulman EP, Komaki R, Klopp AH, Cox JD, Chang JY (2009) Exclusion of elective nodal irradiation is associated with minimal elective nodal failure in non-small cell lung cancer. Radiat Oncol 4:5

    Article  PubMed  PubMed Central  Google Scholar 

  7. Sanuki-Fujimoto N, Sumi M et al (2009) Relation between elective nodal failure and irradiated volume in non-small-cell lung cancer (NSCLC) treated with radiotherapy using conventional fields and doses. Radiother Oncol 91(3):433–437

    Article  PubMed  Google Scholar 

  8. Yuan S, Sun X, Li M et al (2007) A randomized study of involved-field irradiation versus elective nodal irradiation in combination with concurrent chemotherapy for inoperable stage III nonsmall cell lung cancer. Am J Clin Oncol 30(3):239–244

    Article  CAS  PubMed  Google Scholar 

  9. Chen M, Bao Y, Ma HL et al (2013) Involved-field radiotherapy versus elective nodal irradiation in combination with concurrent chemotherapy for locally advanced non-small cell lung cancer: a prospective randomized study. Biomed Res Int 2013:371819

    PubMed  PubMed Central  Google Scholar 

  10. Ahmed I, DeMarco M, Stevens CW, Fulp WJ, Dilling TJ (2011) Analysis of incidental radiation dose to uninvolved mediastinal/supraclavicular lymph nodes in patients with limited-stage small cell lung cancer treated without elective nodal irradiation. Med Dosim 36(4):440–447

    Article  PubMed  Google Scholar 

  11. Kepka L, Bujko K, Zolciak-Siwinska A, Garmol D (2008) Incidental irradiation of mediastinal and hilar lymph node stations during 3D-conformal radiotherapy for non-small cell lung cancer. Acta Oncol 47(5):954–961

    Article  PubMed  Google Scholar 

  12. Kong FM, Cuneo KC, Wang L et al Patterns of practice in radiation therapy for non-small cell lung cancer among members of the American Society for Radiation Oncology. Pract Radiat Oncol 4(2):e133–e141

  13. Bradley JD, Paulus R, Komaki R et al (2015) Standard-dose versus high-dose conformal radiotherapy with concurrent and consolidation carboplatin plus paclitaxel with or without cetuximab for patients with stage IIIA or IIIB non-small-cell lung cancer (RTOG 0617): a randomised, two-by-two factorial phase 3 study. Lancet Oncol 16(2):187–199

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Kanzaki R, Higashiyama M, Fujiwara A et al (2011) Occult mediastinal lymph node metastasis in NSCLC patients diagnosed as clinical N0-1 by preoperative integrated FDG-PET/CT and CT: risk factors, pattern, and histopathological study. Lung Cancer 71(3):333–337

    Article  PubMed  Google Scholar 

  15. Cerfolio RJ, Bryant AS (2008) Survival of patients with unsuspected N2 (stage IIIA) nonsmall-cell lung cancer. Ann Thorac Surg 86(2):362–366 discussion 366-367

    Article  PubMed  Google Scholar 

  16. Naruke T, Tsuchiya R, Kondo H, Nakayama H, Asamura H (1999) Lymph node sampling in lung cancer: how should it be done? Eur J Cardiothorac Surg 16(Suppl 1):S17–S24

    Article  PubMed  Google Scholar 

  17. Kotoulas CS, Foroulis CN, Kostikas K et al (2004) Involvement of lymphatic metastatic spread in non-small cell lung cancer accordingly to the primary cancer location. Lung Cancer 44(2):183–191

    Article  PubMed  Google Scholar 

  18. Navani N, Spiro SG, Janes SM (2009) Mediastinal staging of NSCLC with endoscopic and endobronchial ultrasound. Nat Rev Clin Oncol 6(5):278–286

    Article  PubMed  PubMed Central  Google Scholar 

  19. Dunant A, Pignon JP, De Ruysscher D, et al (2006) Phase III study comparing post-operative conformal radiotherapy to no post-operative radiotherapy in patients with completely resected non-small cell lung cancer and mediastinal N2 involvement (Lung Art)

  20. Kim JH, van Beek EJ, Murchison JT, Marin A, Mirsadraee S (2015) The International Association for the Study of Lung Cancer lymph node map: a radiologic atlas and review. Tuberc Respir Dis (Seoul) 78(3):180–189

    Article  Google Scholar 

  21. Kong FM, Galvin J, Haken RT, Machtay M, Bradley J (2017) RTOG Foundation Inc. Contouring atlas

  22. Marks LB, Yorke ED, Jackson A et al (2010) Use of normal tissue complication probability models in the clinic. Int J Radiat Oncol Biol Phys 76(3 Suppl):S10–S19

    Article  PubMed  PubMed Central  Google Scholar 

  23. Graham MV, Purdy JA, Emami B et al (1999) Clinical dose-volume histogram analysis for pneumonitis after 3D treatment for non-small cell lung cancer (NSCLC). Int J Radiat Oncol Biol Phys 45(2):323–329

    Article  CAS  PubMed  Google Scholar 

  24. Bernard ME, Glaser SM, Gill BS et al (2017) Results of a single institution experience with dose-escalated chemoradiation for locally advanced unresectable non-small cell lung cancer. Front Oncol 7:1

    Article  PubMed  PubMed Central  Google Scholar 

  25. Kharofa J, Gore E (2013) Symptomatic radiation pneumonitis in elderly patients receiving thoracic irradiation. Clin Lung Cancer 14(3):283–287

    Article  PubMed  Google Scholar 

  26. Qiao W-B, Zhao Y-H, Zhao Y-B, Wang R-Z (2005) Clinical and dosimetric factors of radiation-induced esophageal injury: radiation-induced esophageal toxicity. World J Gastroenterol 11(17):2626–2629

    Article  PubMed  PubMed Central  Google Scholar 

  27. Bradley J, Deasy JO, Bentzen S, El-Naqa I (2004) Dosimetric correlates for acute esophagitis in patients treated with radiotherapy for lung carcinoma. Int J Radiat Oncol Biol Phys 58(4):1106–1113

    Article  PubMed  Google Scholar 

  28. Vielva LR, Jaen MW, Alcacer JA, Cardona MC (2014) State of the art in surgery for early stage NSCLC—does the number of resected lymph nodes matter? Transl Lung Cancer Res 3(2):95–99

    PubMed  PubMed Central  Google Scholar 

Download references


We thank Brenda Darnell, Brenda Maxwell, and Robert Bice for teaching and assisting in dosimetric planning and calculations, as well as the West Virginia University Initiation to Research Opportunities (INTRO) Summer Research Program for their support.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Malcolm D. Mattes.

Ethics declarations


No funding was received for this study.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Statement of informed consent was not applicable since the manuscript does not contain any patient data.

Electronic supplementary material

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kenamond, M.C., Alfredo Siochi, R. & Mattes, M.D. The dosimetric effects of limited elective nodal irradiation in volumetric modulated arc therapy treatment planning for locally advanced non-small cell lung cancer. J Radiat Oncol 7, 45–51 (2018).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: