title: 4π noncoplanar stereotactic body radiation therapy for head-and-neck cancer: potential to improve tumor control and late toxicity.
abstract: OBJECTIVE
  To evaluate the potential benefit of 4π radiation therapy in recurrent, locally advanced, or metastatic head-and-neck cancer treated with stereotactic body radiation therapy (SBRT).
  
  
  METHODS
  Twenty-seven patients with 29 tumors who were treated using SBRT were included. In recurrent disease (n=26), SBRT was delivered with a median 44 Gy (range, 35-44 Gy) in 5 fractions. Three patients with sinonasal mucosal melanoma, metastatic breast cancer, and primary undifferentiated carcinoma received 35 Gy, 22.5 Gy, and 40 Gy in 5 fractions, respectively. Novel 4π treatment plans were created for each patient to meet the objective that 95% of the planning target volume was covered by 100% of the prescription dose. Doses to organs at risk (OARs) and 50% dose spillage volumes were compared against the delivered clinical SBRT plans. Local control (LC), late toxicity, tumor control probability (TCP), and normal tissue complication probability were determined.
  
  
  RESULTS
  Using 4π plans, mean/maximum doses to all OARs were reduced by 22% to 89%/10% to 86%. With 4π plans, the 50% dose spillage volume was decreased by 33%. Planning target volume prescription dose escalation by 10 Gy and 20 Gy were achieved while keeping doses to OARs significantly improved or unchanged from clinical plans, except for the carotid artery maximum dose at 20-Gy escalation. At a median follow-up of 10 months (range, 1-41 months), crude LC was 52%. The 2-year LC of 39.2% approximated the predicted mean TCP of 42.2%, which increased to 45.9% with 4π plans. For 10-Gy and 20-Gy dose escalation, 4π plans increased TCP from 80.1% and 88.1% to 85.5% and 91.4%, respectively. The 7.4% rate of grade ≥3 late toxicity was comparable to the predicted 5.6% mean normal tissue complication probability for OARs, which was significantly reduced by 4π planning at the prescribed and escalated doses.
  
  
  CONCLUSIONS
  4π plans may allow dose escalation with significant and consistent improvements in critical organ sparing, tumor control, and coverage.
authors.affiliation: Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California.
authors.forename: Jean-Claude M
authors.initials: JC
authors.lastname: Rwigema
authors.affiliation: Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California.
authors.forename: Dan
authors.initials: D
authors.lastname: Nguyen
authors.affiliation: Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
authors.forename: Dwight E
authors.initials: DE
authors.lastname: Heron
authors.affiliation: Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California.
authors.forename: Allen M
authors.initials: AM
authors.lastname: Chen
authors.affiliation: Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California.
authors.forename: Percy
authors.initials: P
authors.lastname: Lee
authors.affiliation: Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California.
authors.forename: Pin-Chieh
authors.initials: PC
authors.lastname: Wang
authors.affiliation: Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
authors.forename: John A
authors.initials: JA
authors.lastname: Vargo
authors.affiliation: Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California.
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Low
authors.affiliation: Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
authors.forename: M Saiful
authors.initials: MS
authors.lastname: Huq
authors.affiliation: Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California.
authors.forename: Stephen
authors.initials: S
authors.lastname: Tenn
authors.affiliation: Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Steinberg
authors.affiliation: Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California.
authors.forename: Patrick
authors.initials: P
authors.lastname: Kupelian
authors.affiliation: Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California. Electronic address: ksheng@mednet.ucla.edu.
authors.forename: Ke
authors.initials: K
authors.lastname: Sheng
mesh_terms: D000368:Aged; D005260:Female; D006258:Head and Neck Neoplasms / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000175:diagnosis / Q000517:prevention & control*; D011832:Radiation Injuries / Q000175:diagnosis / Q000209:etiology* / Q000517:prevention & control*; D016634:Radiosurgery / Q000009:adverse effects* / Q000379:methods*; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*