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Framework for radiation pneumonitis risk stratification based on anatomic and perfused lung dosimetry

Rahmenbedingungen zur Risikostratifizierung einer Strahlenpneumonie anhand anatomischer und perfundierter Lungendosimetrie

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Abstract

Purpose

To design and apply a framework for predicting symptomatic radiation pneumonitis in patients undergoing thoracic radiation, using both pretreatment anatomic and perfused lung dose–volume parameters.

Materials and methods

Radiation treatment planning CT scans were coregistered with pretreatment [99mTc]MAA perfusion SPECT/CT scans of 20 patients who underwent definitive thoracic radiation. Clinical radiation pneumonitis was defined as grade ≥ 2 (CTCAE v4 grading system). Anatomic lung dose–volume parameters were collected from the treatment planning scans. Perfusion dose–volume parameters were calculated from pretreatment SPECT/CT scans. Equivalent doses in 2 Gy per fraction were calculated in the lung to account for differences in treatment regimens and spatial variations in lung dose (EQD2lung).

Results

Anatomic lung dosimetric parameters (MLD) and functional lung dosimetric parameters (pMLD70%) were identified as candidate predictors of grade ≥ 2 radiation pneumonitis (AUC > 0.93, p < 0.01). Pairing of an anatomic and functional dosimetric parameter (e. g., MLD and pMLD70%) may further improve prediction accuracy. Not all individuals with high anatomic lung dose (MLD > 13.6 GyEQD2lung, 19.3 Gy for patients receiving 60 Gy in 30 fractions) developed radiation pneumonitis, but all individuals who also had high mean dose to perfused lung (pMLD70% > 13.3 GyEQD2) developed radiation pneumonitis.

Conclusions

The preliminary application of this framework revealed differences between anatomic and perfused lung dosimetry in this limited patient cohort. The addition of perfused lung parameters may help risk stratify patients for radiation pneumonitis, especially in treatment plans with high anatomic mean lung dose. Further investigations are warranted.

Zusammenfassung

Ziel

Erstellung und Anwendung eines Rahmenwerks zur Vorhersage symptomatischer Strahlenpneumonitis bei Patienten mit einer Thorax-Bestrahlung anhand anatomischer und perfundierter Lungendosis-Volumen-Parameter in der Vorbehandlung.

Material und Methoden

CT-Scans zur Bestrahlungsplanung wurden zusammen mit in der Vorbehandlung durchgeführten [99mTc]MAA-SPECT/CT-Perfusionsscans von 20 Patienten mit definitiver Thorax-Bestrahlung aufgezeichnet. Klinische Strahlenpneumonitis wurde als Grad ≥ 2 definiert (CTCAEv4-Gradierung). Anatomische Lungendosis-Volumen-Parameter wurden mittels Behandlungsplanungsscans erhoben und perfundierte Dosis-Volumen-Parameter mittels SPECT/CT-Scans während der Vorbehandlung berechnet. Gleichwertige Dosen von 2 Gy/Fraktion wurden in der Lunge berechnet, um abweichende Behandlungsregime und räumliche Schwankungen der lungengängigen Dosis (EQD2lung) auszugleichen.

Ergebnisse

Anatomische (MLD) und funktionale Parameter der Lungendosis (pMLD70%) wurden als Prädiktoren einer Strahlenpneumonitis vom Grad ≥ 2 (AUC > 0,93; p < 0,01) bestimmt. Gepaarte anatomische und funktionale dosimetrische Parameter (z. B. MLD und pMLD70%) könnten die Vorhersagegenauigkeit weiter erhöhen. Nicht alle Patienten mit hoher anatomischer Lungendosis (MLD > 13,6 GyEQD2lung; 19,3 Gy bei Patienten mit 60 Gy in 30 Fraktionen) entwickelten eine Strahlenpneumonitis, jedoch alle, die zur perfundierten Lunge zudem eine hohe mittlere Dosis aufwiesen (pMLD70% > 13,3 GyEQD2).

Schlussfolgerung

Die vorläufige Anwendung des Rahmenwerks ergab bei dem begrenzten Patientenkollektiv Unterschiede zwischen anatomischer und perfundierter Lungendosimetrie. Zusätzliche Parameter der perfundierten Lunge könnten bei der Risikostratifizierung von Patienten bezüglich einer Strahlenpneumonitis helfen, insbesondere bei Behandlungsplänen mit hoher anatomischer Lungendosis. Weitere Untersuchungen sind nötig.

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Funding

This work was financially supported by NIH/NCI R01CA204301, Radiological Society of North America RSCH1405, and the Fred Hutchinson Cancer Center Support Grant for Protocol-Specific Research Support, P30CA015704. We express our gratitude to the Nuclear Medicine and Radiation Oncology staff for assisting with patient setup during all imaging scans.

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Authors and Affiliations

  1. Department of Radiation Oncology, University of Washington School of Medicine, 98195, Seattle, WA, USA

    Gurleen Dhami MD, Jing Zeng MD, Shilpen A. Patel MD, Ramesh Rengan MD PhD & Stephen R. Bowen PhD

  2. Department of Radiology, University of Washington School of Medicine, 98195, Seattle, WA, USA

    Hubert J. Vesselle PhD MD, Paul E. Kinahan PhD, Robert S. Miyaoka PhD & Stephen R. Bowen PhD

Authors
  1. Gurleen Dhami MD
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  2. Jing Zeng MD
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  3. Hubert J. Vesselle PhD MD
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  4. Paul E. Kinahan PhD
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  5. Robert S. Miyaoka PhD
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  6. Shilpen A. Patel MD
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  7. Ramesh Rengan MD PhD
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  8. Stephen R. Bowen PhD
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Corresponding author

Correspondence to Stephen R. Bowen PhD.

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Conflict of interest

S.R. Bowen declares grants from NIH/NCI and the Radiological Society of North America during the conduct of the study. J. Zeng declares grants from NIH/NCI. G. Dhami, S.A. Patel, and R. Rengan declare that they have no competing interests. R.S. Miyaoka and H.J. Vesselle declare grants from Philips Healthcare outside of the submitted work. P.E. Kinahan declares a commercial interest as a cofounder of PET/X, LLC, and grants from GE Healthcare outside of the submitted work.

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Dhami, G., Zeng, J., Vesselle, H.J. et al. Framework for radiation pneumonitis risk stratification based on anatomic and perfused lung dosimetry. Strahlenther Onkol 193, 410–418 (2017). https://doi.org/10.1007/s00066-017-1114-0

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  • DOI: https://doi.org/10.1007/s00066-017-1114-0

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