Predictors of Chest Wall Toxicity after Lung Stereotactic Ablative Radiotherapy.

AIMS: To determine the incidence and predictive factors of rib fracture and chest wall pain after lung stereotactic ablative radiotherapy (SABR). MATERIALS AND METHODS: Patients were treated with lung SABR of 48-60 Gy in four to five fractions. The treatment plan and follow-up computed tomography scans of 289 tumours in 239 patients were reviewed. Dose-volume histogram (DVH) metrics and clinical factors were evaluated as potential predictors of chest wall toxicity. RESULTS: The median follow-up was 21.0 months (range 6.2-52.1). Seventeen per cent (50/289) developed a rib fracture, 44% (22/50) were symptomatic; the median time to fracture was 16.4 months. On univariate analysis, female gender, osteoporosis, tumours adjacent (within 5 mm) to the chest wall and all of the chest wall DVH metrics predicted for rib fracture, but only tumour location adjacent to the chest wall remained significant on the multivariate model (P < 0.01). The 2 year fracture-free probability for those adjacent to the chest wall was 65.6%. Among those tumours adjacent to the chest wall, only osteoporosis (P = 0.02) predicted for fracture, whereas none of the chest wall DVH metrics were predictive. Eight per cent (24/289) experienced chest wall pain without fracture. CONCLUSIONS: None of the chest wall DVH metrics independently predicted for SABR-induced rib fracture when tumour location is taken into account. Patients with tumours adjacent (within 5 mm) to the chest wall are at greater risk of rib fracture after lung SABR, and among these, an additional risk was observed in osteoporotic patients.

Predictive factors for local control in primary and metastatic lung tumours after four to five fraction stereotactic ablative body radiotherapy: a single institution's comprehensive experience.

AIMS: We report the outcomes of a large lung stereotactic ablative body radiotherapy (SABR) programme for primary non-small cell lung cancer (NSCLC) and pulmonary metastases. The primary study aim was to identify factors predictive for local control. MATERIALS AND METHODS: In total, 311 pulmonary tumours in 254 patients were treated between 2008 and 2011 with SABR using 48-60 Gy in four to five fractions. Local, regional and distant failure data were collected prospectively, whereas other end points were collected retrospectively. Potential clinical and dosimetric predictors of local control were evaluated using univariate and multivariate analyses. RESULTS: Of the 311 tumours, 240 were NSCLC and 71 were other histologies. The 2 year local control rate was 96% in stage I NSCLC, 76% in colorectal cancer (CRC) metastases and 91% in non-lung/non-CRC metastases. Predictors of better local control on multivariate analysis were non-CRC tumours and a larger proportion of the planning target volume (PTV) receiving ≥100% of the prescribed dose (higher PTV V100). Among the 45 CRC metastases, a higher PTV V100 and previous chemotherapy predicted for better local control. CONCLUSIONS: Lung SABR of 48-60 Gy/four to five fractions resulted in high local control rates for all tumours except CRC metastases. Covering more of the PTV with the prescription dose (a higher PTV V100) also resulted in superior local control.

Sci-Fri PM: Delivery - 03: Spine SBRT: Treating multiple vertebrae using cone-beam CT image-guidance and the hexapod robotic couch.

PURPOSE: The intent of spinal SBRT is to maximize the biological effective dose and improve local control, while sparing the adjacent spinal cord. We report on the spinal SBRT positional accuracy for multiple, consecutive vertebrae in a single course, using the Elekta Synergy-S and BodyFIX immobilization systems. METHODS: After initial patient adjustment, verification cone-beam CT (CBCT) images were acquired before, during and after treatment. These images were used to assess immobilization and correct any misalignment exceeding 1 mm or 1°, in all six degrees-of-freedom using the HexaPOD robotic couch. This analysis is based on 415 verification images from 67 consecutive courses of treatment. These treatment courses comprised 25 single thoracic vertebrae, 16 multiple thoracic vertebrae, 20 single lumbar vertebrae and 6 multiple lumbar vertebrae. RESULTS: The absolute intra-fraction motion averaged over all directions (±std dev.) for the T-single, T-multiple, L-Single and L-Multiple was 0.54 (±0.73) mm, 0.54 (±0.88) mm, 0.36 (±0.57) mm, and 0.47 (±0.63) mm respectively. The percentage that exceeded the 1.5 mm planning margin was 3.8%, 4.0%, 1.0% and 0.85% respectively. T-spine treatments were out-of-tolerance more frequently than the L-spine. There was a statistically significant difference between single and multiple lumbar treatments (unpaired t-test, p<0.01), but this was not clinically significant as 99% were within our 1.5 mm margin. CONCLUSIONS: Near-rigid immobilization with the acquisition of intra-fraction CBCT images and the correction of misalignments in all six degrees-of-freedom provides the necessary precision to safely perform SBRT of consecutive spinal metastases within one course of treatment.