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

John A Kalapurakal, Mahesh Gopalakrishnan, David O Walterhouse, Cynthia K Rigsby, Alfred W Rademaker, Irene Helenowski, Sandy Kessel, Karen Morano, Fran Laurie, Ken Ulin, Natia Esiashvili, Howard Katzenstein, Karen Marcus, David S. Followill, Suzanne L. Wolden, Anita Mahajan, Thomas J. Fitzgerald

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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.

LanguageEnglish (US)
Pages28-37
Number of pages10
JournalInternational Journal of Radiation Oncology Biology Physics
Volume103
Issue number1
DOIs
StatePublished - Jan 1 2019

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metastasis
lungs
Multicenter Studies
radiation therapy
Radiotherapy
tumors
Clinical Trials
Pediatrics
Neoplasm Metastasis
Lung
Neoplasms
irradiation
dosage
Cardiac Volume
chest
Thorax
tomography
Tomography
assurance
quality control

ASJC Scopus subject areas

  • Radiation
  • Oncology
  • Radiology Nuclear Medicine and imaging
  • Cancer Research

Cite this

Kalapurakal, John A ; Gopalakrishnan, Mahesh ; Walterhouse, David O ; Rigsby, Cynthia K ; Rademaker, Alfred W ; Helenowski, Irene ; Kessel, Sandy ; Morano, Karen ; Laurie, Fran ; Ulin, Ken ; Esiashvili, Natia ; Katzenstein, Howard ; Marcus, Karen ; Followill, David S. ; Wolden, Suzanne L. ; Mahajan, Anita ; Fitzgerald, Thomas J. / Cardiac-Sparing Whole Lung IMRT in Patients With Pediatric Tumors and Lung Metastasis : Final Report of a Prospective Multicenter Clinical Trial. In: International Journal of Radiation Oncology Biology Physics. 2019 ; Vol. 103, No. 1. pp. 28-37.
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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.",
author = "Kalapurakal, {John A} and Mahesh Gopalakrishnan and Walterhouse, {David O} and Rigsby, {Cynthia K} and Rademaker, {Alfred W} and Irene Helenowski and Sandy Kessel and Karen Morano and Fran Laurie and Ken Ulin and Natia Esiashvili and Howard Katzenstein and Karen Marcus and Followill, {David S.} and Wolden, {Suzanne L.} and Anita Mahajan and Fitzgerald, {Thomas J.}",
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Kalapurakal, JA, Gopalakrishnan, M, Walterhouse, DO, Rigsby, CK, Rademaker, AW, Helenowski, I, Kessel, S, Morano, K, Laurie, F, Ulin, K, Esiashvili, N, Katzenstein, H, Marcus, K, Followill, DS, Wolden, SL, Mahajan, A & Fitzgerald, TJ 2019, 'Cardiac-Sparing Whole Lung IMRT in Patients With Pediatric Tumors and Lung Metastasis: Final Report of a Prospective Multicenter Clinical Trial', International Journal of Radiation Oncology Biology Physics, vol. 103, no. 1, pp. 28-37. https://doi.org/10.1016/j.ijrobp.2018.08.034

Cardiac-Sparing Whole Lung IMRT in Patients With Pediatric Tumors and Lung Metastasis : Final Report of a Prospective Multicenter Clinical Trial. / Kalapurakal, John A; Gopalakrishnan, Mahesh; Walterhouse, David O; Rigsby, Cynthia K; Rademaker, Alfred W; Helenowski, Irene; Kessel, Sandy; Morano, Karen; Laurie, Fran; Ulin, Ken; Esiashvili, Natia; Katzenstein, Howard; Marcus, Karen; Followill, David S.; Wolden, Suzanne L.; Mahajan, Anita; Fitzgerald, Thomas J.

In: International Journal of Radiation Oncology Biology Physics, Vol. 103, No. 1, 01.01.2019, p. 28-37.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Cardiac-Sparing Whole Lung IMRT in Patients With Pediatric Tumors and Lung Metastasis

T2 - International Journal of Radiation Oncology Biology Physics

AU - Kalapurakal, John A

AU - Gopalakrishnan, Mahesh

AU - Walterhouse, David O

AU - Rigsby, Cynthia K

AU - Rademaker, Alfred W

AU - Helenowski, Irene

AU - Kessel, Sandy

AU - Morano, Karen

AU - Laurie, Fran

AU - Ulin, Ken

AU - Esiashvili, Natia

AU - Katzenstein, Howard

AU - Marcus, Karen

AU - Followill, David S.

AU - Wolden, Suzanne L.

AU - Mahajan, Anita

AU - Fitzgerald, Thomas J.

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N2 - 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.

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