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Comparison of dosimetric parameters and toxicity in esophageal cancer patients undergoing 3D conformal radiotherapy or VMAT

Vergleich von dosimetrischen Parametern und Toxizität zwischen 3D-konformaler Strahlentherapie und VMAT bei Patienten mit Ösophaguskarzinom

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Abstract

Purpose

Volumetric-modulated arc therapy (VMAT) achieves high conformity to the planned target volume (PTV) and good sparing of organs at risk (OAR). This study compares dosimetric parameters and toxicity in esophageal cancer (EC) patients treated with VMAT and 3D conformal radiotherapy (3D-CRT).

Materials and methods

Between 2007 and 2014, 17 SC patients received neoadjuvant chemoradiation (CRT) with VMAT. Dose–volume histograms and toxicity were compared between these patients and 20 treated with 3D-CRT. All patients were irradiated with a total dose of 45 Gy. All VMAT patients received simultaneous chemotherapy with cisplatin and 5‑fluorouracil (5-FU) in treatment weeks 1 and 5. Of 20 patients treated with 3D-CRT, 13 (65 %) also received CRT with cisplatin and 5‑FU, whereas 6 patients (30 %) received CRT with weekly oxaliplatin and cetuximab, and a continuous infusion of 5‑FU (OE-7).

Results

There were no differences in baseline characteristics between the treatment groups. For the lungs, VMAT was associated with a higher V5 (median 90.1 % vs. 79.7 %; p = 0.013) and V10 (68.2 % vs. 56.6 %; p = 0.014), but with a lower V30 (median 6.6 % vs. 11.0 %; p = 0.030). Regarding heart parameters, VMAT was associated with a higher V5 (median 100.0 % vs. 91.0 %; p = 0.043), V10 (92.0 % vs. 79.2 %; p = 0.047), and Dmax (47.5 Gy vs. 46.3 Gy; p = 0.003), but with a lower median dose (18.7 Gy vs. 30.0 Gy; p = 0.026) and V30 (17.7 % vs. 50.4 %; p = 0.015). Complete resection was achieved in 16 VMAT and 19 3D-CRT patients. Due to systemic progression, 2 patients did not undergo surgery. The most frequent postoperative complication was anastomosis insufficiency, occurring in 1 VMAT (6.7 %) and 5 3D-CRT patients (27.8 %; p = 0.180). Postoperative pneumonia was seen in 2 patients of each group (p = 1.000). There was no significant difference in 3‑year overall (65 % VMAT vs. 45 % 3D-CRT; p = 0.493) or 3‑year progression-free survival (53 % VMAT vs. 35 % 3D-CRT; p = 0.453).

Conclusion

Although dosimetric differences in lung and heart exposure were observed, no clinically relevant impact was detected in either patient group. In a real-life patient cohort, VMAT enables reduction of lung and heart V30 compared to 3D-CRT, which may contribute to reduced toxicity.

Zusammenfassung

Ziel

Die volumetrisch modulierte Rotationstherapie (VMAT) erreicht eine hohe Abdeckung des Planungszielvolumens mit guter Schonung der Risikoorgane. Verglichen wurden dosimetrische Parameter und Toxizität zwischen VMAT und 3D-konformaler Strahlentherapie (3D-CRT) bei Patienten mit Ösophaguskarzinom.

Material und Methoden

Zwischen 2007 und 2014 erhielten 17 Patienten während der neoadjuvanten Radiochemotherapie eine VMAT. Dosis-Volumen-Histogramme und Toxizität wurden mit 20 mit 3D-CRT behandelten Patienten verglichen. Die Gesamtdosis aller Patienten betrug 45 Gy (Tagesdosis 1,8 Gy). Die VMAT-Gruppe erhielt eine simultane Chemotherapie mit Cisplatin und 5‑Fluoruracil (5-FU) in der 1. und 5. Woche. In der 3D-CRT-Gruppe bekamen 13 Patienten (65%) ebenfalls eine Chemotherapie mit Cisplatin und 5‑FU, 6 Patienten (30%) eine wöchentliche Chemotherapie mit Oxaliplatin und Cetuximab, sowie eine kontinuierliche Chemotherapie mit 5‑FU (OE-7).

Ergebnisse

Hinsichtlich der Basischarakteristika zeigte sich kein Unterschied zwischen den Gruppen. Für die Lungen war VMAT mit einer höheren V5 (Median 90,1% vs. 79,7%; p = 0,013) und V10 (68,2% vs. 56,6%; p = 0,014), aber einer niedrigeren V30 assoziiert (Median 6,6% vs. 11,0%; p = 0,030). Für das Herz waren für VMAT V5 (Median 100 % vs. 91 %; p = 0,043), V10 (92 % vs. 79,2 %, p = 0,047) und Dmax (47,5 Gy vs. 46,3 Gy; p = 0,003) höher, die mittlere Dosis (18,7 Gy vs. 30 Gy, p = 0,026) und V30 (17,7 % vs. 50,4 %; p = 0,015) niedriger. Bei 16 VMAT- bzw. 19 3D-CRT-Patienten wurde der Tumor komplett reseziert. Aufgrund eines systemischen Progresses wurden 2 Patienten nicht operiert. Häufigste postoperative Komplikation war die Anastomoseninsuffizienz bei einem VMAT- (6,7 %) und 5 3D-CRT-Patienten (27,8 %; p = 0,180). In jeder Gruppe entwickelten 2 Patienten eine postoperative Pneumonie (p = 1,000). Beim 3‑Jahres-Gesamt- (65 % vs. 45 %; p = 0,493) und progressionsfreien Überleben (53 % vs. 35 %; p = 0,453) zeigte sich kein Unterschied. Ein Lokalrezidiv wurde bei 6 3D-CRT- (30 %) und bei einem VMAT-Patienten (6 %) beobachtet (p = 0,097).

Schlussfolgerung

Dosimetrische Unterschiede der Dosisverteilung in Herz und Lungen waren klinisch nicht relevant. Verglichen mit 3D-CRT reduziert VMAT V30 für Lunge und Herz und somit möglicherweise die Toxizität.

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Authors and Affiliations

  1. Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Germany

    Stefan Münch MD, Sylvia Aichmeier, Marciana-Nona Duma MD, Markus Oechsner PhD, Stephanie E. Combs MD & Daniel Habermehl MD

  2. Institute of Medical Statistics and Epidemiology (IMSE), Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Germany

    Alexander Hapfelmeier PhD

  3. Department of Visceral Surgery, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Germany

    Marcus Feith MD

  4. Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Oberschleißheim, Germany

    Stephanie E. Combs MD

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  1. Stefan Münch MD
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  2. Sylvia Aichmeier
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Correspondence to Daniel Habermehl MD.

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Conflict of interest

S. Münch, S. Aichmeier, A. Hapfelmeier, M.-N. Duma, M. Oechsner, M. Feith, S.E. Combs, and D. Habermehl declare that they have no competing interests.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The local ethics committee supported and approved the retrospective analysis of the included patients (project number: 288/15).

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Münch, S., Aichmeier, S., Hapfelmeier, A. et al. Comparison of dosimetric parameters and toxicity in esophageal cancer patients undergoing 3D conformal radiotherapy or VMAT. Strahlenther Onkol 192, 722–729 (2016). https://doi.org/10.1007/s00066-016-1020-x

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  • DOI: https://doi.org/10.1007/s00066-016-1020-x

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