title: Limiting the risk of cardiac toxicity with esophageal-sparing intensity modulated radiotherapy for locally advanced lung cancers.
abstract: BACKGROUND
  Intensity modulated radiotherapy (IMRT) is routinely utilized in the treatment of locally advanced non-small cell lung cancer (NSCLC). RTOG 0617 found that overall survival was impacted by increased low (5 Gy) and intermediate (30 Gy) cardiac doses. We evaluated the impact of esophageal-sparing IMRT on cardiac doses with and without the heart considered in the planning process and predicted toxicity compared to 3D-conventional radiotherapy (3DCRT).
  
  
  METHODS
  Ten consecutive patients with N2 Stage III NSCLC treated to 60 Gy in 30 fractions, between February 2012 and September 2014, were evaluated. For each patient, 3DCRT and esophageal-sparing IMRT plans were generated. IMRT plans were then created with and without the heart considered in the optimization process. To compare plans, the dose delivered to 95% and 99% of the target (D95% and D99%), and doses to the esophagus, lung and heart were compared by determining the volume receiving X dose (VXGy) and the normal tissue complication probability (NTCP) calculated.
  
  
  RESULTS
  IMRT reduced maximum esophagus dose to below 60 Gy in all patients and produced significant reductions to V50Gy, V40Gy and esophageal NTCP. The cost of this reduction was a non-statistically, non-clinically significant increase in low dose (5 Gy) lung exposure that did not worsen lung NTCP. IMRT plans produced significant cardiac sparing, with the amount of improvement correlating to the amount of heart overlapping with the target. When included in plan optimization, for selected patients further sparing of the heart and improvement in heart NTCP was possible.
  
  
  CONCLUSIONS
  Esophageal-sparing IMRT can significantly spare the heart even if it is not considered in the optimization process. Further sparing can be achieved if plan optimization constrains low and intermediate heart doses, without compromising lung doses.
authors.affiliation: 1 Alfred Health Radiation Oncology, The Alfred Hospital, Melbourne, Victoria, Australia ; 2 Central Clinical School, Monash University, Clayton, Victoria, Australia.
authors.forename: Katrina
authors.initials: K
authors.lastname: Woodford
authors.affiliation: 1 Alfred Health Radiation Oncology, The Alfred Hospital, Melbourne, Victoria, Australia ; 2 Central Clinical School, Monash University, Clayton, Victoria, Australia.
authors.forename: Vanessa
authors.initials: V
authors.lastname: Panettieri
authors.affiliation: 1 Alfred Health Radiation Oncology, The Alfred Hospital, Melbourne, Victoria, Australia ; 2 Central Clinical School, Monash University, Clayton, Victoria, Australia.
authors.forename: Jeremy D
authors.initials: JD
authors.lastname: Ruben
authors.affiliation: 1 Alfred Health Radiation Oncology, The Alfred Hospital, Melbourne, Victoria, Australia ; 2 Central Clinical School, Monash University, Clayton, Victoria, Australia.
authors.forename: Sashendra
authors.initials: S
authors.lastname: Senthi
keywords: Lung cancer; cardiac toxicity; esophagitis; intensity modulated radiotherapy (IMRT); mortality