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Journal of Radiation Oncology
Published in: Journal of Radiation Oncology 4/2018

01-12-2018 | Original Research

Clinical evidence for dose tolerance of the central nervous system in hypofractionated radiotherapy

Authors: Jinyu Xue, Bahman Emami, Jimm Grimm, Gregory J. Kubicek, Sucha O. Asbell, Rachelle Lanciano, James S. Welsh, Luke Peng, Harry Quon, Wolfram Laub, Chengcheng Gui, Nicholas Spoleti, Indra J. Das, Howard Warren Goldman, Kristin J. Redmond, Lawrence R. Kleinberg, Luther W. Brady

Published in: Journal of Radiation Oncology | Issue 4/2018

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Abstract

Background

Stereotactic radiosurgery (SRS), stereotactic body radiotherapy (SBRT), and stereotactic ablative body radiotherapy (SABR) are commonly used in the treatment of central nervous system (CNS) disease. This study has refined the radiation toxicity estimates for some normal tissues of the CNS based on review and analysis of the clinical evidence for single fraction radiosurgery, hypofractionated SBRT, and conventionally fractionated radiation therapy.

Methods

Published guidelines and protocols are reviewed. In the past, many normal tissue tolerances were compiled based on the experience of the investigators and publications in the literature. Some tolerances were determined by modeling or calculation using the existing biological formulas, in particular the linear quadratic (LQ) model. In the present study, the estimate of risk for each dose tolerance limit in some CNS tissues is provided exclusively with normal tissue complication probability (NTCP). The clinical outcomes are compared to understand the difference in biological effect between radiosurgery and radiotherapy.

Results

Normal tissue dose tolerances and the corresponding complication rates are provided for brainstem, optic nerves, cochlea, and spinal cord, including single fraction SRS, five-fraction SBRT, and conventional radiation therapy. Calculation of biologically effective dose (BED) or single fraction equivalent dose (SFED) alone using the LQ model conveys no consensus on the biological effect across different fractionations. Comparison of conventional radiation therapy to brain and spinal cord with single fraction equivalent dose leads to even conflicting clinical outcomes.

Conclusions

Effective differences between single fraction SRS and conventional radiotherapy need to be better understood. The existing biological model might not be valid to predict the radiosurgical outcomes based on conventionally fractionated radiotherapy. However, application of the statistical dose response models of clinical SRS and SBRT outcomes data to selected current dose tolerance guidelines into simple tables can be a clinically useful resource.
Footnotes
1
The Hindo et al. study [90] of parallel opposed whole brain fields during the era of Cobalt differs in many ways from the modern era of radiosurgery, especially in terms of patient selection, prognosis, dose distribution, and other factors. Perhaps the most relevant comparison is for brainstem, since the entire cross-section of brainstem was probably within ± 10% of a comparable physical dose of 10 Gy/1 fraction in the whole brain study, whereas for modern radiosurgery only a small volume of the critical structure is usually allowed to reach levels like 10 Gy in 1 fraction. We are not advocating 10 Gy in 1 fraction to a large volume, but we feel it is an interesting historical point of comparison.
 
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Metadata
Title
Clinical evidence for dose tolerance of the central nervous system in hypofractionated radiotherapy
Authors
Jinyu Xue
Bahman Emami
Jimm Grimm
Gregory J. Kubicek
Sucha O. Asbell
Rachelle Lanciano
James S. Welsh
Luke Peng
Harry Quon
Wolfram Laub
Chengcheng Gui
Nicholas Spoleti
Indra J. Das
Howard Warren Goldman
Kristin J. Redmond
Lawrence R. Kleinberg
Luther W. Brady
Publication date
01-12-2018
Publisher
Springer Berlin Heidelberg
Published in
Journal of Radiation Oncology / Issue 4/2018
Print ISSN: 1948-7894
Electronic ISSN: 1948-7908
DOI
https://doi.org/10.1007/s13566-018-0367-2

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