title: Chest wall toxicity after stereotactic body radiotherapy for malignant lesions of the lung and liver.
abstract: OBJECTIVE
  To quantify the frequency of rib fracture and chest wall (CW) pain and identify the dose-volume parameters that predict CW toxicity after stereotactic body radiotherapy (SBRT).
  
  
  METHODS
  The records of patients treated with SBRT between 2000 and 2008 were reviewed, and toxicity was scored according to Common Terminology Criteria for Adverse Events v3.0 for pain and rib fracture. Dosimetric data for CW and rib were analyzed and related to the frequency of toxicity. The risks of CW toxicity were then further characterized according to the median effective concentration (EC(50)) dose-response model.
  
  
  RESULTS
  A total of 347 lesions were treated with a median follow-up of 19 months. Frequency of Grade I and higher CW pain and/or fracture for CW vs. non-CW lesions was 21% vs. 4%, respectively (p < 0.0001). A dose of 50 Gy was the cutoff for maximum dose (Dmax) to CW and rib above which there was a significant increase in the frequency of any grade pain and fracture (p = 0.03 and p = 0.025, respectively). Volume of CW receiving 15 Gy - 40 Gy was highly predictive of toxicity (R(2) > 0.9). According to the EC(50) model, 5 cc and 15 cc of CW receiving 40 Gy predict a 10% and 30% risk of CW toxicity, respectively.
  
  
  CONCLUSIONS
  Adequate tumor coverage remains the primary objective when treating lung or liver lesions with SBRT. To minimize toxicity when treating lesions in close proximity to the CW, Dmax of the CW and/or ribs should remain <50 Gy, and <5 cc of CW should receive ≥ 40 Gy.
authors.affiliation: Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA. dandolin@iupui.edu
authors.forename: David L
authors.initials: DL
authors.lastname: Andolino
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Forquer
authors.forename: Mark A
authors.initials: MA
authors.lastname: Henderson
authors.forename: Robert B
authors.initials: RB
authors.lastname: Barriger
authors.forename: Ronald H
authors.initials: RH
authors.lastname: Shapiro
authors.forename: Jeffrey G
authors.initials: JG
authors.lastname: Brabham
authors.forename: Peter A S
authors.initials: PA
authors.lastname: Johnstone
authors.forename: Higinia R
authors.initials: HR
authors.lastname: Cardenes
authors.forename: Achilles J
authors.initials: AJ
authors.lastname: Fakiris
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002637:Chest Pain / Q000209:etiology*; D004307:Dose-Response Relationship, Radiation; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000601:surgery*; D008175:Lung Neoplasms / Q000601:surgery*; D008297:Male; D020714:Maximum Tolerated Dose; D008875:Middle Aged; D011832:Radiation Injuries / Q000209:etiology; D016634:Radiosurgery / Q000009:adverse effects*; D012189:Retrospective Studies; D012253:Rib Fractures / Q000209:etiology*; D035441:Thoracic Wall / Q000528:radiation effects*; D055815:Young Adult