Cardiac-Sparing Whole Lung IMRT in Patients With Pediatric Tumors and Lung Metastasis: Final Report of a Prospective Multicenter Clinical Trial

• Type of Material: Article
• Authors: John A. Kalapurakal, Northwestern University; Mahesh Gopalakrishnan, Northwestern University; David O. Walterhouse, Ann & Robert H Lurie Childrens Hospital Chicago; Cynthia K. Rigsby, Ann & Robert H Lurie Childrens Hospital Chicago; Alfred Rademaker, Northwestern University; Irene Helenowski, Northwestern University; Sandy Kessel, Imaging and Radiation Oncology Core Providence; Karen Morano, Imaging and Radiation Oncology Core Providence; Fran Laurie, Imaging and Radiation Oncology Core Providence; Ken Ulin, Imaging and Radiation Oncology Core Providence; Natia Esiashvili, Emory University; Howard Katzenstein, Nemours Childrens Clinic; Karen Marcus, Harvard University; David Followill, Imaging and Radiation Oncology Core Providence; Suzanne L. Wolden, Mem Sloan Kettering Cancer Center; Anita Mahajan, University of Texas MD Anderson Cancer Center; Thomas J Fitzgerald, Imaging and Radiation Oncology Core Providence; Irene B. Helenowski, Northwestern University
• Language: English
• Date: 2019-01-01
• Publisher: ELSEVIER SCIENCE INC
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2018
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1016/j.ijrobp.2018.08.034
• Title of Journal or Parent Work: INTERNATIONAL JOURNAL OF RADIATION ONCOLOGY BIOLOGY PHYSICS
• Volume: 103
• Issue: 1
• Start Page: 28
• End Page: 37
• Grant/Funding Information: This study was funded by NIH R21CA159547 grant (Kalapurakal)
• Keywords: LONG-TERM; RADIATION; Life Sciences & Biomedicine; CANCER-STUDY-GROUP; PULMONARY METASTASES; DIAGNOSIS; DOXORUBICIN; WILMS-TUMOR; Science & Technology; IRRADIATION; Oncology; THERAPY; RADIOTHERAPY; Radiology, Nuclear Medicine & Medical Imaging
• Research Categories: Biology, Radiation; Health Sciences, Oncology

Abstract

Purpose: A prospective clinical trial was conducted for patients undergoing cardiac sparing (CS) whole lung irradiation (WLI) using intensity modulated radiation therapy (IMRT). The 3 trial aims were (1) to demonstrate the feasibility of CS IMRT with real-time central quality control; (2) to determine the dosimetric advantages of WLI using IMRT compared with standard anteroposterior (AP) techniques; and (3) to determine acute tolerance and short-term efficacy after a protocol-mandated minimum 2-year follow-up for all patients. Methods and Materials: All patients underwent a 3-dimensional chest computed tomography scan and a contrast-enhanced 4-dimensional (4D) gated chest computed tomography scan using a standard gating device. The clinical target volume was the entire bilateral 3-dimensional lung volume, and the internal target volume was the 4D minimum intensity projection of both lungs. The internal target volume was expanded by 1 cm to get the planning target volume. All target volumes, cardiac contours, and treatment plans were centrally reviewed before treatment. The different cardiac volumes receiving percentages of prescribed radiation therapy (RT) doses on AP and IMRT WLI plans were estimated and compared. Results: The target 20 patients were accrued in 2 years. Median RT dose was 15 Gy. Real-time central quality assurance review and plan preapproval were obtained for all patients. WLI using IMRT was feasible in all patients. Compared with standard AP WLI, CS IMRT resulted in a statistically significant reduction in radiation doses to the whole heart, atria, ventricles, and coronaries. One child developed cardiac dysfunction and pulmonary restrictive disease 5.5 years after CS IMRT (15 Gy) and doxorubicin (375 mg/m2). The 2- and 3-year lung metastasis progression-free survival was 65% and 52%, respectively. Conclusions: We have demonstrated the feasibility of WLI using CS IMRT and confirmed the previously reported advantages of IMRT, including superior cardiac protection and superior dose coverage of 4D lung volumes. Further studies are required to establish the efficacy and safety of this irradiation technique.