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Abstract
The purpose of this study is to evaluate efficacy and feasibility of adaptive radiotherapy according to tumor volume change (TVC) in early stage non-small cell lung cancer (NSCLC) using stereotactic body radiotherapy (SBRT). Twenty-two lesions previously treated with SBRT were selected. SBRT was usually performed with a total dose of 48 Gy or 60 Gy in four fractions with an interval of three to four days between treatments. For evaluation of TVC, gross tumor volume (GTV) was contoured on each cone-beam computed tomography (CBCT) image used for image guidance. Intensity modulated radiotherapy (IMRT) planning was performed in the first CBCT (CBCT1) using a baseline plan. For ART planning (ART), re-optimization was performed at 2nd, 3rd, and 4th CBCTs (CBCT2, CBCT3, and CBCT4) using the same angle and constraint used for the baseline plan. The ART plan was compared with the non-ART plan, which generated copying of the baseline plan to other CBCTs. Average GTV volume was 10.7 cc. Average TVC was −1.5%, 7.3%, and −25.1% in CBCT2, CBCT3, and CBCT4 and the TVC after CBCT3 was significant (p＜0.05). However, the nine lesions were increased GTV in CBCT2. In the ART plan, V20 Gy, D1500 cc, and D1000 cc of lung were significantly decreased (p＜0.05), and V30 Gy and V32 Gy of the chest wall were also decreased (p＜0.05). While D min of planning target volume (PTV) decreased by 8.3% in the non-ART plan of CBCT2 compared with the baseline plan in lesions with increased tumor size (p=0.021), PTV coverage was not compromised in the ART plan. Based on this result, use of the ART plan may improve target coverage and OAR saving. Thus ART using CBCT should be considered in early stage NSCLC with SBRT.
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Fig. 1.
Schematics of the planning procedure. (a) The intensity modulated radiotherapy (IMRT) plan was performed in 1st CBCT (baseline plan). (b) The beam angle and MLC motion of baseline plan was copied to other CBCTs. (c) The treatment isocenter was adjusted based on 3-dimensional registration data of each CBCT using the Varian offline review program (Varian Medical Systems Inc., Palo Alto, CA). (d) Non-adaptive plans were generated by direct calculation. Adaptive plans were generated by re-optimization process.
Fig. 2.
The absolute and relative volume of GTV in all studied patients. (a) absolute GTV. (b) relative GTV.
Fig. 4.
Differences of GTV change according to dose schedule. GTV in lesions treated with 15 Gy per fraction was significantly larger than the volume of tumors treated with less than 15 Gy per fraction (p=0.005).
Fig. 5.
The dose-volume histogram of PTV coverage on the baseline plan in CBCT1, non-adaptive plan and adaptive plan of CBCT2. While Dmin was decreased by approximately 8.3% in non-ART (p＜0.021), PTV coverage was not compromised compared with the initial plan in the ART plan.
Table 1.
Absolute and relative volume of GTV in the course of stereotactic body radiotherapy.
Table 2.
Dosimetric parameters comparing non-adaptive versus adaptive plan.
Table 3.
Comparisons of PTV coverage of non-adaptive and adaptive plans in CBCT2 compared with CBCT1.
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