Chest Wall Pain and Rib Fracture after Stereotactic Radiotherapy for Peripheral Non- small Cell Lung Cancer Jon-Paul J. Voroney, PhD, MD, Andrew Hope,

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Chest Wall Pain and Rib Fracture after Stereotactic Radiotherapy for Peripheral Non- small Cell Lung Cancer Jon-Paul J. Voroney, PhD, MD, Andrew Hope, MD, CM, MSc, Max R. Dahele, MBChB, Thomas Purdy, PhD, Kevin N. Franks, MB, Shannon Pearson, MRRT, John B.C. Cho, MD, PhD, Alex Sun, MD, David G. Payne, MSc, MD, Jean-Pierre Bissonnette, PhD, Andrea Bezjak, MD, CM, MSc, Anthony M. Brade, MD, CM, PhD Journal of Thoracic Oncology Volume 4, Issue 8, Pages 1035-1037 (August 2009) DOI: 10.1097/JTO.0b013e3181ae2962 Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 1 Isodose distribution showing the 20 Gray (Gy), 40 Gy, and 60 Gy isodose lines on a coronal computed tomography (CT) slice. Heterogeneity correction was not used for dose calculation. Portions of the rib, chest wall, neurovascular bundle, pleura, and pulmonary parenchyma receive doses in excess of 40 Gy in three fractions. Journal of Thoracic Oncology 2009 4, 1035-1037DOI: (10.1097/JTO.0b013e3181ae2962) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 2 Follow-up computed tomography (CT) (bone windowing) demonstrating changes at 16 months postradiotherapy including cortical thinning (arrow), suggestive of osteonecrosis, and fibrosis of pulmonary parenchyma, pleura, and chest wall. Journal of Thoracic Oncology 2009 4, 1035-1037DOI: (10.1097/JTO.0b013e3181ae2962) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 3 Progression to fracture (arrow) and further progression of parenchymal pulmonary fibrosis 29 months postradiation therapy (RT). Journal of Thoracic Oncology 2009 4, 1035-1037DOI: (10.1097/JTO.0b013e3181ae2962) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 4 Actuarial proportion of patients free of fracture as a function of time since treatment. The exes mark patient deaths, tick marks show censored patients (last follow-up), and dashed lines show 95% confidence interval. Journal of Thoracic Oncology 2009 4, 1035-1037DOI: (10.1097/JTO.0b013e3181ae2962) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions