DVH CONSIDERATIONS FOR LUNG CANCER

DOSE-VOLUME CONSTRAINTS

ORGAN RT ALONE CHEMO-RT CHEMO-RT THEN SURGERY
CORD 50 Gy 45 Gy 45 Gy
LUNG MLD < 20 Gy
V20 < 40%
MLD < 20 Gy
V20 < 35%
V10 < 45%
V5 < 65%
MLD < 20 Gy
V20 < 20%
V10 < 40%
V5 < 55%
HEART V40 < 50% V40 < 50% V40 < 50%
ESOPHAGUS Dmax < 75 Gy
V60 < 50%
Dmax < 75 Gy
V55 < 50%
Dmax < 75 Gy
V55 < 50%
KIDNEY 20 Gy (<50% of combined kidneys or < 75% or one if other is not functional) Same as RT alone Same as RT alone
LIVER 30 Gy (< 40%) Same as RT alone Same as RT alone

MARY GRAHAM'S

V20 GRADE 2 PNEUMONITIS AT 2-YRS
< 22% 0%
22-31% 7%
32-40% 13%
> 40% 36%
  • Treated with 3-D planning system
  • 42% had chemotherapy (mostly concurrent ciplatinum type)
  • Typically 180-200 cGy per day

RTOG 0617 PHASE III NSCLC CONCURRENT (60 VS 74 GY) FOR STAGE IIIA/IIIB

LUNG

  • V20 and MLD are the best metrics for determining risk of radiation pneumonitis.
  • V20 < 37% (Gram reports 13% grade 2+ pneumonitis at 32-40%).
  • mean lung dose (MLD) ≤ 20 Gy.

MDA Recommendation for concurrent chemoradiation

  • V5 < 65%
  • V10 45%
  • V20 < 35%
LUNGDVH

Patient with pneumonectomy

  • MLD of < 8.8 Gy and
  • V20 < 10%

HEART

  • "Acceptable" radiation doses to the heart have not been well studied in the setting of the treatment of NSCLC. Typically one does want to limit the dose to all or most of the heart to 40 Gy. We (RTOG 0617) employ the dose limits of Emami et al. for the heart (60 Gy to 1/3, 45 Gy to 2/3 and 40 Gy to 100% of the heart).

BRACHIEAL PLEXUS

  • 66 Gy

SPINAL CORD

  • 45 GY when off cord contribution is not considered as in 2-D planning
  • 50 Gy with 3-D planning when off cord contribution is considered.

ESOPHAGEAL INJURY

  • The mean dose to the esophagus is optimally kept below 34 Gy. This is not an absolute requirement.
  • A55 and V60 are important parmeters in assessment of an individual patient's risk of acute esophagitis. With concurrent chemotherapy A55 and V60 were equally predictive of the development of Grade 2+ esophagitis.[1]
    • A55 is the esophageal surface area receiving ≥ 55 Gy.
    • V60 is esophageal volume receiving ≥ 60 Gy.
  • V60 ≤ 1/3 (of Emami et al.)
Bibliography
1. Jeffrey Bradley, M.D.*, Joseph O Deasy, Ph.D.*, Soeren Bentzen, D.Sc.†, Issam El Naqa, Ph.D. Dosimetric correlates for acute esophagitis in patients treated with radiotherapy for lung carcinoma. Volume 58, Issue 4, Pages 1106-1113 (15 March 2004)
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