title: Radiation pneumonitis following combined modality therapy for lung cancer: analysis of prognostic factors.
abstract: OBJECTIVE
  To identify factors associated with radiation pneumonitis (RP) resulting from combined modality therapy (CMT) for lung cancer.
  
  
  METHODS
  Series published before 1994 that used CMT for the treatment of lung cancer and explicitly reported the incidence of RP are the basis for this analysis. Factors evaluated included the radiation dose per fraction (Fx), total radiation dose, fractionation scheme (split v continuous), type of chemotherapy and intended dose-intensity, overall treatment time, histology (small-cell lung cancer [SCLC] v non-small-cell lung cancer [NSCLC]), and treatment schedule (concurrent v induction, sequential, or alternating CMT).
  
  
  RESULTS
  Twenty-four series, including 27 treatment groups and 1,911 assessable patients, met our criteria for inclusion in this analysis. The median total dose of radiation used in the trials analyzed was 50 Gy (range, 25 to 63 Gy). The median daily Fx used was 2.0 Gy (range, 1.5 to 4.0 Gy). Nineteen series included 22 treatment groups and 1,745 patients treated with single daily fractions. Among these patients, 136 received a daily Fx greater than 2.67 Gy. Five series used twice-daily radiotherapy and included 166 patients (Fx, 1.5 to 1.7 Gy). The incidence of RP was 7.8%. In a multivariate analysis, only daily Fx, number of daily fractions, and total dose were associated with the risk of RP (P < .0001, P < .018, and P < .003, respectively).
  
  
  CONCLUSIONS
  In this analysis, the use of Fx greater than 2.67 Gy was the most significant factor associated with an increased risk of RP. High total dose also appears to be associated with an increased risk, but twice-daily irradiation seems to reduce the risk expected if the same total daily dose is given as a single fraction. High-Fx radiotherapy should be avoided in patients who receive CMT with curative intent.
authors.affiliation: Department of Radiation Oncology, University of California, San Francisco 94143-0226, USA.
authors.forename: M
authors.initials: M
authors.lastname: Roach
authors.forename: D R
authors.initials: DR
authors.lastname: Gandara
authors.forename: H S
authors.initials: HS
authors.lastname: Yuo
authors.forename: P S
authors.initials: PS
authors.lastname: Swift
authors.forename: S
authors.initials: S
authors.lastname: Kroll
authors.forename: D C
authors.initials: DC
authors.lastname: Shrieve
authors.forename: W M
authors.initials: WM
authors.lastname: Wara
authors.forename: L
authors.initials: L
authors.lastname: Margolis
authors.forename: T L
authors.initials: TL
authors.lastname: Phillips
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D002289:Carcinoma, Non-Small-Cell Lung / Q000188:drug therapy / Q000532:radiotherapy*; D018288:Carcinoma, Small Cell / Q000188:drug therapy / Q000532:radiotherapy*; D016009:Chi-Square Distribution; D003131:Combined Modality Therapy / Q000009:adverse effects; D004307:Dose-Response Relationship, Radiation; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008175:Lung Neoplasms / Q000188:drug therapy / Q000532:radiotherapy*; D015999:Multivariate Analysis; D011379:Prognosis; D017564:Radiation Pneumonitis / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control; D012307:Risk Factors