Hemithoracic Radiotherapy After Extrapleural Pneumonectomy for Malignant Pleural Mesothelioma: A Dosimetric Comparison of Two Well-Described Techniques

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Saad El Din I, M.D *, Abd El AAl H, M.D *, Makaar W, M.D *, El Beih D, M.Sc †, Hashem W, M.Sc * *Department of Clinical Oncology and Radiotherapy, Kasr.

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Hemithoracic Radiotherapy After Extrapleural Pneumonectomy for Malignant Pleural Mesothelioma: A Dosimetric Comparison of Two Well-Described Techniques Christine E. Hill-Kayser, MD, Stephen Avery, PhD, Carmen F. Mesina, MS, Paul James, CMD, Joseph S. Friedberg, MD, Keith Cengel, MD, PhD, Lilie L. Lin, MD, Stephen M. Hahn, MD, Ramesh Rengan, MD, PhD Journal of Thoracic Oncology Volume 4, Issue 11, Pages 1431-1437 (November 2009) DOI: 10.1097/JTO.0b013e3181b9eb85 Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 1 Planning target volume (PTV) used for intensity-modulated radiotherapy (IMRT) planning for hemithoracic radiotherapy after extrapleural pneumonectomy. PTV included the entire chest cavity and chest wall and adjacent abdomen from the level of the thoracic inlet to the diaphragmatic insertion as delineated by surgical clips. Treatment volumes were extended to encompass skin in regions of scar and drain sites. Journal of Thoracic Oncology 2009 4, 1431-1437DOI: (10.1097/JTO.0b013e3181b9eb85) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 2 Sample beam arrangement and dose distribution for delivery of intensity-modulated radiation therapy (IMRT) to the (A) left and (B) right hemithorax after extrapleural pneumonectomy in treatment of malignant mesothelioma. Treatment consisted of delivery of 45 Gray (Gy) in daily fractions of 1.8 Gy to the planning target volume (PTV). Journal of Thoracic Oncology 2009 4, 1431-1437DOI: (10.1097/JTO.0b013e3181b9eb85) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 3 Field and block arrangements employed with use of combined electron-photon technique for hemithoracic radiotherapy after extrapleural pneumonectomy. The total prescribed dose from the anterior-posterior (AP-PA) photon fields and supplemental electron fields was 54 Gray (Gy) in 1.8 Gy fractions. At the initiation of treatment, blocks were placed in the region of the abdomen. During treatment of the left hemithorax, an anterior block was placed over the heart at 19.8 Gy. Blocked areas were subsequently delivered 1.53 Gy daily through an en face electron field. At 41.4 Gy, anterior and posterior blocks were placed over the spinal cord. Journal of Thoracic Oncology 2009 4, 1431-1437DOI: (10.1097/JTO.0b013e3181b9eb85) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 4 Average percent of prescribed dose to planning target volume with electron-photon technique (EPT) versus intensity-modulated radiotherapy (IMRT) during hemithoracic radiotherapy after extrapleural pneumonectomy. Journal of Thoracic Oncology 2009 4, 1431-1437DOI: (10.1097/JTO.0b013e3181b9eb85) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 5 Average contralateral lung volume receiving dose of 5 Gray (Gy) and 20 Gy with electron-photon technique (EPT), prescribed to 54 Gy, versus intensity-modulated radiotherapy (IMRT), prescribed to 45 Gy, during hemithoracic radiotherapy after extrapleural pneumonectomy. Journal of Thoracic Oncology 2009 4, 1431-1437DOI: (10.1097/JTO.0b013e3181b9eb85) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 6 Dose to organs at risk with electron-photon technique (EPT) versus intensity-modulated radiotherapy (IMRT) for hemithoracic radiotherapy after extrapleural pneumonectomy. *Median heart dose for only patients receiving left-sided treatment (n = 5). **Median liver dose for only patients receiving right-sided treatment (n = 5). CL, contralateral lung; IK, ipsilateral kidney; and CK, contralateral kidney. Journal of Thoracic Oncology 2009 4, 1431-1437DOI: (10.1097/JTO.0b013e3181b9eb85) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions