title: Intentional avoidance of the esophagus using intensity modulated radiation therapy to reduce dysphagia after palliative thoracic radiation.
abstract: BACKGROUND
  Palliative thoracic radiotherapy is an effective technique to alleviate symptoms of disease burden in advanced-stage lung cancer patients. Previous randomized controlled studies demonstrated a survival benefit in patients with good performance status at radiation doses of 35Gy10or greater but with an increased incidence of esophagitis. The objective of this planning study was to assess the potential impact of esophageal-sparing IMRT (ES-IMRT) compared to the current standard of care using parallel-opposed pair beams (POP).
  
  
  METHODS
  In this study, 15 patients with lung cancer treated to a dose of 30Gy in 10 fractions between August 2015 and January 2016 were identified. Radiation treatment plans were optimized using ES-IMRT by limiting the max esophagus point dose to 24Gy. Using published Lyman-Kutcher-Burman normal tissue complication probabilities (LKB-NTCP) models, both plans were evaluated for the likelihood of esophagitis (≥ grade 2) and pneumonitis (≥ grade 2).
  
  
  RESULTS
  Using ES-IMRT, the median esophageal and lung mean doses reduced from 16 and 8Gy to 7 and 7Gy, respectively. Using the LKB models, the theoretical probability of symptomatic esophagitis and pneumonitis reduced from 13 to 2%, and from 5 to 3%, respectively. The median normalize total dose (NTD mean) accounting for fraction size for the GTV and PTV of the clinically approved POP plans compared to the ES-IMRT plans were similar.
  
  
  CONCLUSIONS
  Advanced radiotherapy techniques such as ES-IMRT may have clinical utility in reducing treatment-related toxicity in advanced lung cancer patients. Our data suggests that the rate of esophagitis can be reduced without compromising local control.
authors.affiliation: Department of Radiation Oncology, London Health Sciences Centre, Commissioners Road East, N6A 4 L6, London, ON, Canada.
authors.forename: Patrick V
authors.initials: PV
authors.lastname: Granton
authors.affiliation: Department of Radiation Oncology, London Health Sciences Centre, Commissioners Road East, N6A 4 L6, London, ON, Canada.
authors.forename: David A
authors.initials: DA
authors.lastname: Palma
authors.affiliation: Department of Radiation Oncology, London Health Sciences Centre, Commissioners Road East, N6A 4 L6, London, ON, Canada. alexander.louie@lhsc.on.ca.|Department of Epidemiology and Biostatics, Western University, London, ON, Canada. alexander.louie@lhsc.on.ca.
authors.forename: Alexander V
authors.initials: AV
authors.lastname: Louie
mesh_terms: D003680:Deglutition Disorders / Q000209:etiology / Q000517:prevention & control*; D004941:Esophagitis / Q000517:prevention & control; D004947:Esophagus / Q000528:radiation effects; D006801:Humans; D008175:Lung Neoplasms / Q000532:radiotherapy*; D058958:Organs at Risk; D010166:Palliative Care; D011832:Radiation Injuries / Q000517:prevention & control*; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D050397:Radiotherapy, Intensity-Modulated / Q000379:methods*
keywords: Dysphagia; Esophagitis; Lyman-Kutcher-Burman model; Normal tissue complication probability; Palliative care