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Small bowel toxicity after high dose spot scanning-based proton beam therapy for paraspinal/retroperitoneal neoplasms

Hochdosis-Spot Scanning basierte Protonen-Strahlentherapie von paraspinalen/retroperitonealen Tumoren und Dünndarm-Toxizität

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Abstract

Purpose

Mesenchymal tumours require high-dose radiation therapy (RT). Small bowel (SB) dose constraints have historically limited dose delivery to paraspinal and retroperitoneal targets. This retrospective study correlated SB dose–volume histograms with side-effects after proton radiation therapy (PT).

Patients and methods

Between 1997 and 2008, 31 patients (mean age 52.1 years) underwent spot scanning-based PT for paraspinal/retroperitoneal chordomas (81 %), sarcomas (16 %) and meningiom (3 %). Mean total prescribed dose was 72.3 Gy (relative biologic effectiveness, RBE) delivered in 1.8–2 Gy (RBE) fractions. Mean follow-up was 3.8 years. Based on the pretreatment planning CT, SB dose distributions were reanalysed.

Results

Planning target volume (PTV) was defined as gross tumour volume (GTV) plus 5–7 mm margins. Mean PTV was 560.22 cm3. A mean of 93.2 % of the PTV was covered by at least 90 % of the prescribed dose. SB volumes (cm3) receiving doses of 5, 20, 30, 40, 50, 60, 70, 75 and 80 Gy (RBE) were calculated to give V5, V20, V30, V40, V50, V60, V70, V75 and V80 respectively. In 7/31 patients, PT was accomplished without any significant SB irradiation (V5 = 0). In 24/31 patients, mean maximum dose (Dmax) to SB was 64.1 Gy (RBE). Despite target doses of > 70 Gy (RBE), SB received > 50 and > 60 Gy (RBE) in only 61 and 54 % of patients, respectively. Mean SB volumes (cm3) covered by different dose levels (Gy, RBE) were: V20 (n = 24): 45.1, V50 (n = 19): 17.7, V60 (n = 17): 7.6 and V70 (n = 12): 2.4. No acute toxicity ≥ grade 2 or late SB sequelae were observed.

Conclusion

Small noncircumferential volumes of SB tolerated doses in excess of 60 Gy (RBE) without any clinically-significant late adverse effects. This small retrospective study has limited statistical power but encourages further efforts with higher patient numbers to define and establish high-dose threshold models for SB toxicity in modern radiation oncology.

Zusammenfassung

Hintergrund

Paraspinale und retroperitoneale mesenchymale Tumoren benötigen hohe strahlentherapeutische Dosen. Der Dünndarm ist ein dosislimitierendes Risikoorgan. In dieser retrospektiven Studie verglichen wir Dosis-Volumen-Histogramme des Dünndarms mit Nebenwirkungen nach Protonenstrahlentherapie (PT).

Material und Methode

Zwischen 1997 und 2008 erhielten 31 Patienten (Durchschnittsalter: 52,1 Jahre) mit paraspinalen/retroperitonealen Chordomen (81 %), Sarkomen (16 %) und einem Meningeom (3 %) eine Spot-Scanning-basierte PT. Die verschriebene Gesamtdosis betrug im Mittel 72,3 Gy (RBE) mit Fraktionierungsdosen zwischen 1,8 und 2 Gy (RBE). Die durchschnittliche Nachbeobachtungszeit betrug 3,8 Jahre. Basierend auf dem initialen Planungs-CT wurde die Dosisverteilung am Dünndarm reanalysiert.

Ergebnisse

Gemittelte 93,2 % des PTVs (GTV + 5–7 mm) mit durchschnittlich 560,22 cm3 wurden von mindestens 90 % der verschriebenen Dosis erfasst. Bei 7 von 31 Patienten wurden keine wesentlichen Dünndarmdosen (V5 = 0) appliziert. Die Maximaldosis am Dünndarm der übrigen 24 Patienten betrug durchschnittlich 64,1 Gy (RBE). Trotz üblicher Zieldosen von > 70 Gy (RBE) erhielt der Dünndarm nur bei 61/54 % der Patienten > 50/60 Gy (RBE). Das durchschnittlich belastete Dünndarmvolumen (cm3) innerhalb unterschiedlicher Dosisstufen [Gy (RBE)] betrug V5 (24 Patienten): 86,5, V20 (24 Patienten): 45,1, V50 (19 Patienten): 17,7, V60 (17 Patienten): 7,6, V70 (12 Patienten): 2,4. Es traten keine Akut- oder Spättoxizitäten ≥ Grad 2 am Dünndarm auf.

Schlussfolgerung

In dieser retrospektiven Untersuchung an 31 Patienten wurden Dosen von mehr als 60 Gy (RBE) an nichtzirkumferenziellen kleinen Dünndarmvolumina ohne signifikante Spätnebenwirkungen toleriert. Bei entsprechend limitierter statistischer Aussagekraft sollten weitergehende Untersuchungen mit höheren Patientenzahlen durchgeführt werden, um Hochdosisschwellen-Modelle für akute und späte Dünndarmtoxizitäten in moderner Strahlentherapie zu definieren und zu etablieren.

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Compliance with ethical guidelines

Conflict of interest. R.A. Schneider, V. Vitolo, F. Albertini, T. Koch, C. Ares, A. Lomax, G. Goitein and E.B. Hug state that there are no conflicts of interest.

The accompanying manuscript does not include studies on humans or animals.

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Authors and Affiliations

  1. Center for Proton Therapy, Paul Scherrer Institute, 5232, Villigen PSI, Germany

    R.A. Schneider, F. Albertini, T. Koch, C. Ares, A. Lomax, G. Goitein & E.B. Hug

  2. Fondazione CNAO, Pavia, Italy

    V. Vitolo

  3. ProCure Proton Therapy Centers, New York, USA

    E.B. Hug

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  1. R.A. Schneider
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  2. V. Vitolo
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  3. F. Albertini
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Correspondence to R.A. Schneider.

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Schneider, R., Vitolo, V., Albertini, F. et al. Small bowel toxicity after high dose spot scanning-based proton beam therapy for paraspinal/retroperitoneal neoplasms. Strahlenther Onkol 189, 1020–1025 (2013). https://doi.org/10.1007/s00066-013-0432-0

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  • DOI: https://doi.org/10.1007/s00066-013-0432-0

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