Quantitatively Excessive Normal Tissue Toxicity and Poor Target Coverage in Postoperative Lung Cancer Radiotherapy Meta-analysis

Yazan Abuodeh, Moffitt Cancer Center
Arash O. Naghavi, Moffitt Cancer Center
Michelle Echevarria, Moffitt Cancer Center
Mary Lou DeMarco, Moffitt Cancer Center
Brian Tonner, East Carolina University
Vladimir Feygelman, Moffitt Cancer Center
Craig W. Stevens, William Beaumont Medical Center
Bradford A. Perez, Moffitt Cancer Center
Thomas J. Dilling, Moffitt Cancer Center


© 2017 Elsevier Inc. In this dosimetric study, the outdated techniques used in postoperative radiation protocols included in the postoperative radiotherapy meta-analysis provided inadequate target coverage with excessive radiation doses to organs at risk. We provide quantitative evidence for one of the explanations behind the detrimental effect noticed in the meta-analysis, invalidating its finding in the modern era of radiation planning and delivery. Background: A previous meta-analysis (MA) found postoperative radiotherapy (PORT) in lung cancer patients to be detrimental in N0/N1 patients and equivocal in the N2 setting. We hypothesized that treatment plans generated using MA protocols had worse dosimetric outcomes compared to modern plans. Patients and Methods: We retrieved plans for 13 patients who received PORT with modern planning. A plan was recreated for each patient using the 8 protocols included in MA. Dosimetric values were then compared between the modern and simulated MA plans. Results: A total of 104 MA plans were generated. Median prescribed dose was 50.4 (range, 50-60) Gy in the modern plans and 53.2 (30-60) Gy in the MA protocols. Median planning volume coverage was 96% (93%-100%) in the modern plans, versus 58% (0%-100%) in the MA plans (P <.001). Internal target volume coverage was 100% (99%-100%) versus 65% (0%-100%), respectively (P <.001). Organs at risk received the following doses: spinal cord maximum dose, 36.8 (4.6-50.4) Gy versus 46.8 (2.9-74.0) Gy (P <.001); esophageal mean dose, 22.9 (5.5-35) Gy versus 30.5 (11.1-52.5) Gy (P =.003); heart V30 (percentage of volume of an organ receiving at least a dose of 30 Gy), 16% (0%-45%) versus 35% (0%-79%) (P =.047); mean lung dose, 12.4 (3.4-24.3) Gy versus 14.8 (4.1-27.4) Gy (P =.008); and lung V20, 18% (4%-34%) versus 25% (8%-67%) (P =.023). Conclusion: We quantitatively confirm the inferiority of the techniques used in the PORT MA. Our analysis showed a lower therapeutic ratio in the MA plans, which may explain the poor outcomes in the MA. The findings of the MA are not relevant in the era of modern treatment planning.