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IMRT and 3D conformal radiotherapy with or without elective nodal irradiation in locally advanced NSCLC

A direct comparison of PET-based treatment planning

IMRT und 3-D-konformale Radiotherapie mit oder ohne elektive Nodalbestrahlung bei lokal fortgeschrittenem nichtkleinzelligem Bronchialkarzinom

Direkter Vergleich der PET-basierten Therapieplanung

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Abstract

Aim

The potential of intensity-modulated radiation therapy (IMRT) as opposed to three-dimensional conformal radiotherapy (3D-CRT) is analyzed for two different concepts of fluorodeoxyglucose positron emission tomography (FDG PET)-based target volume delineation in locally advanced non-small cell lung cancer (LA-NSCLC): involved-field radiotherapy (IF-RT) vs. elective nodal irradiation (ENI).

Methods

Treatment planning was performed for 41 patients with LA-NSCLC, using four different planning approaches (3D-CRT-IF, 3D-CRT-ENI, IMRT-IF, IMRT-ENI). ENI included a boost irradiation after 50 Gy. For each plan, maximum dose escalation was calculated based on prespecified normal tissue constraints. The maximum prescription dose (PD), tumor control probability (TCP), conformal indices (CI), and normal tissue complication probabilities (NTCP) were analyzed.

Results

IMRT resulted in statistically significant higher prescription doses for both target volume concepts as compared with 3D-CRT (ENI: 68.4 vs. 60.9 Gy, p < 0.001; IF: 74.3 vs. 70.1 Gy, p < 0.03). With IMRT-IF, a PD of at least 66 Gy was achieved for 95 % of all plans. For IF as compared with ENI, there was a considerable theoretical increase in TCP (IMRT: 27.3 vs. 17.7 %, p < 0.00001; 3D-CRT: 20.2 vs. 9.9 %, p < 0.00001). The esophageal NTCP showed a particularly good sparing with IMRT vs. 3D-CRT (ENI: 12.3 vs. 30.9 % p < 0.0001; IF: 15.9 vs. 24.1 %; p < 0.001).

Conclusion

The IMRT technique and IF target volume delineation allow a significant dose escalation and an increase in TCP. IMRT results in an improved sparing of OARs as compared with 3D-CRT at equivalent dose levels.

Zusammenfassung

Zielsetzung

Das Potenzial der intensitätsmodulierten Strahlentherapie (IMRT) soll im Rahmen der FDG-PET basierten Bestrahlungsplanung des lokal fortgeschrittenen nichtkleinzelligen Bronchialkarzinoms (LA-NSCLC) für 2 Zielvolumenansätze (Involved-Field-Bestrahlung, IF) sowie elektive Nodalbestrahlung (ENI) geprüft und mit der 3-D-konformalen Strahlentherapie (3-D-CRT) als Referenz verglichen werden.

Material und Methoden

Die Bestrahlungsplanung erfolgte an CT-Datensätzen von 41 Patienten mit LA-NSCLC in 4 Ansätzen (3-D-CRT-IF, 3-D-CRT-ENI, IMRT-IF, IMRT-ENI) jeweils mit 2 Gy Einzeldosis. ENI beinhaltete einen zusätzlichen Boost nach 50 Gy. Für jeden Plan wurde die maximal mögliche Dosiseskalation nach vordefinierten Grenzwerten für Normalgewebe vorgenommen.

Es wurden die maximal erreichbare Dosis, die Tumorkontrollwahrscheinlichkeit (TCP), der Konformitätsindex (CI) und Normalgewebsrisiken nach dem NTCP-Modell („normal tissue complication probabilities“) analysiert.

Ergebnisse

Die IMRT-Pläne resultierten in statistisch signifikant höheren Gesamtdosen für beide Zielvolumenkonzepte im Vergleich zur 3-D-CRT (ENI: 68,4 Gy vs. 60,9 Gy; p < 0,001; IF: 74,3 vs. 70,1 Gy; p < 0,03). Mittels IMRT-IF wurde eine Gesamtdosis von 66 Gy für 95 % der Pläne erreicht. Der rechnerische TCP-Anstieg mittels IF im Vergleich zu ENI war erheblich (IMRT: 27,3 vs. 17,7 %; p < 0,00001; 3-D-CRT: 20,2 vs. 9,9 %; p < 0,00001). NTCP-Werte für den Ösophagus waren mit der IMRT im Vergleich zur 3-D-CRT signifikant niedriger (ENI: 12,3 vs. 30,9 %; p < 0,0001; IF: 15,9 vs. 24,1 %; p < 0,001).

Schlussfolgerung

Mittels IMRT und IF lässt sich beim LA-NSCLC eine signifikante Dosiseskalation und ein Anstieg der TCP erreichen. Die IMRT ermöglicht außerdem eine signifikant geringere Normalgewebsbelastung im Vergleich zur 3-D-CRT bei äquivalenten Gesamtdosen.

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Authors and Affiliations

  1. Department of Radiotherapy and Radiation Oncology, Saarland University Medical School, 66421, Homburg/Saar, Germany

    Jochen Fleckenstein MD, Katharina Kremp MD, Stephanie Kremp MSc, Jan Palm MD & Christian Rübe MD, PhD

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  1. Jochen Fleckenstein MD
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  2. Katharina Kremp MD
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  3. Stephanie Kremp MSc
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  4. Jan Palm MD
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  5. Christian Rübe MD, PhD
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Correspondence to Jochen Fleckenstein MD.

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Conflict of interest

J. Fleckenstein, K. Kremp, S. Kremp, J. Palm, and C. Rübe state that there are no conflicts of interest.

All studies on humans described in the present manuscript were carried out with the approval of the responsible ethics committee and in accordance with national law and the Helsinki Declaration of 1975 (in its current, revised form). Informed consent was obtained from all patients included in studies.

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Fleckenstein, J., Kremp, K., Kremp, S. et al. IMRT and 3D conformal radiotherapy with or without elective nodal irradiation in locally advanced NSCLC. Strahlenther Onkol 192, 75–82 (2016). https://doi.org/10.1007/s00066-015-0900-9

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