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As improvements in surgical and radiation techniques and chemotherapy regimens lead to longer survival for patients with lung cancer, the need to monitor toxicity and adapt our practice accordingly becomes ever more imperative.
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This work was made possible through the generosity of the family of M. Our findings here, focusing specifically on patients treated for lung cancer, indicate that the median dose to the brachial plexus should be kept below 69 Gy, 561 the maximum dose to 2 cm 3 below 75 Gy,for patients with NSCLC. Abstract Purpose As the recommended radiation dose for non-small cell lung cancer NSCLC increases, meeting dose constraints for critical structures like the brachial plexus becomes increasingly challenging, particularly for tumors in the superior sulcus.
J Natl Cancer Inst. However, with current trials evaluating 74 Gy, the dose constraints for the brachial plexus need to be revisited, particularly because most of the literature on brachial plexus toxicity comes from studies of head and neck or breast cancer.
A Axial CT scan delineating the brachial plexus based on physician consensus green and computer-generated contours red. The manuscript will undergo copyediting, typesetting, and review of xvh resulting proof before it is published in its final citable form. The median radiation dose to the brachial plexus was 70 Gy range OR, odds ratio; CI, confidence interval.
This may prove to be problematic for complying with dose constraints to structures like the brachial plexus.
As a service to our customers we are providing this early version of the manuscript. CA Cancer J Clin. Next we plan to validate dvn dose constraints in an ongoing randomized phase III trial looking at dose escalation for lung cancer.
These auto-delineated contours for the entire cohort were then reviewed and modified individually by hand after auto-segmentation had been completed to maintain consistency in contours for all 90 patients. Minor clinical symptoms with no medical intervention required were dhv grade 1; moderate symptoms requiring pain medication with good response, grade 2; and severe symptoms, treated with multiple pain medications, including neuropathic drugs or steroid injections, with some or no improvement in symptoms, grade 3.
The multi-atlas segmentation technique we used has the potential to reduce inter-subject, inter-observer, or even intra-observer variability in contouring the brachial plexus. The resultant displacement vector fields characterizing the individual registrations were then used to deform the atlas brachial plexus contours to obtain 10 individual segmentations for each patient. B Digitally-reconstructed radiographs DRR showing manual contours green and computer-generated contours red.
Also, the borders of the brachial plexus, unlike those of other organs can be difficult to define. Evaluation of Brachial Plexus Dose The Pinnacle planning system was used to calculate the dose to the brachial plexus using the original treatment plan.
The superior border of the plexus was initiated between the neural foramina at C4-C5 where the nerve was traced as it exited the foramina. Our results could be used as a guideline in future prospective trialswithhigh dose radiation therapy for unresectable lung cancer.
This patient later developed grade 2 toxicity. When patients were treated with proton therapy using Varian Eclipse treatment planning, DICOM-RT dose plans were first exported from Eclipse planning system and then converted and imported into Pinnacle planning system for dose calculation. Brachial plexus contouring using deformable image registration. P values of 0.
Finally, the Simultaneous Truth and Performance Level Estimation STAPLE algorithm [ 14 ] was used to combine these 10 individual segmentations to produce a single fused contour, which was considered the best statistical estimation of the cvh segmentation from multiple measurements. The Mann-Whitney two-sample statistic or Wilcoxon rank-sum test was used to test the distribution of continuous variables according to plexopathy status.
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This study was approved by the appropriate institutional review board of MD Anderson. Gender, concurrent chemoradiation, and the presence of diabetes were not associated with risk of brachial plexopathy Table 2.
It is well known that peripheral nerves are sensitive to recurrent episodes of trauma, whether from tumor invasion or from surgical intervention [ 915 ]; multiple traumas might be expected to reduce the threshold for development of symptoms. In this study we found that plexopathy before treatment was also associated with greater risk of toxicity after treatment. This is a PDF file of an unedited manuscript that has been accepted for publication. Initial results of the phase II trial RTOG to evaluate the feasibility of dose escalation to 74 Gy with concurrent chemotherapy for unresectable NSCLC were encouraging; the median overall survival time, 24 months, compares favorably 5611 that produced dvn the lower Gy dose used in RTOG [ 6 ].
Other significant risk factors were having plexopathy before treatment OR 4. Implementation and validation of a three-dimensional deformable registration algorithm for targeted prostate dbh radiotherapy.
Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. The inferior and lateral borders of the plexus terminated with the subclavian vascular bundle Fig. Contouring the brachial plexus on CT scans continues to be challenging.
Schierle C, Winograd JM. The contours created by the image registration provided a good approximate location of the brachial plexus. Our study had several limitations. The V 10 values volume of brachial plexus volume receiving 10 Gy were The authors declare no conflicts of interest regarding the work presented here.