Retrospective Study
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World J Gastroenterol. Oct 14, 2014; 20(38): 13973-13980
Published online Oct 14, 2014. doi: 10.3748/wjg.v20.i38.13973
Simultaneous modulated accelerated radiation therapy for esophageal cancer: A feasibility study
Wu-Zhe Zhang, Jian-Zhou Chen, De-Rui Li, Zhi-Jian Chen, Hong Guo, Ting-Ting Zhuang, Dong-Sheng Li, Ming-Zhen Zhou, Chuang-Zhen Chen
Wu-Zhe Zhang, Jian-Zhou Chen, De-Rui Li, Zhi-Jian Chen, Hong Guo, Ting-Ting Zhuang, Dong-Sheng Li, Ming-Zhen Zhou, Chuang-Zhen Chen, Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou 515031, Guangdong Province, China
Author contributions: Zhang WZ and Chen JZ contributed equally to this work; Li DR, Chen ZJ and Chen CZ designed the research; Zhang WZ, Chen JZ, Guo H, and Zhuang TT performed the research; Li DS and Zhou MZ analyzed the data; Chen JZ and Chen CZ wrote the paper.
Supported by Shantou University Medical College Clinical Research Enhancement Initiative, and Research and Travel Grants from the Science and Technology Key Project of Shantou City, China, 2012, No. 2012-165-131
Correspondence to: Chuang-Zhen Chen, MD, Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, No. 7 Raoping Road, Shantou 515031, Guangdong Province, China. stccz@139.com
Telephone: +86-754-88555844-1086 Fax: +86-754-88560352
Received: February 27, 2014
Revised: June 4, 2014
Accepted: June 25, 2014
Published online: October 14, 2014
Processing time: 230 Days and 16.1 Hours
Abstract

AIM: To establish the feasibility of simultaneous modulated accelerated radiation therapy (SMART) in esophageal cancer (EC).

METHODS: Computed tomography (CT) datasets of 10 patients with upper or middle thoracic squamous cell EC undergoing chemoradiotherapy were used to generate SMART, conventionally-fractionated three-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiation therapy (cf-IMRT) plans, respectively. The gross target volume (GTV) of the esophagus, positive regional lymph nodes (LN), and suspected lymph nodes (LN±) were contoured for each patient. The clinical target volume (CTV) was delineated with 2-cm longitudinal and 0.5- to 1.0-cm radial margins with respect to the GTV and with 0.5-cm uniform margins for LN and LN(±). For the SMART plans, there were two planning target volumes (PTVs): PTV66 = (GTV + LN) + 0.5 cm and PTV54 = CTV + 0.5 cm. For the 3DCRT and cf-IMRT plans, there was only a single PTV: PTV60 = CTV + 0.5 cm. The prescribed dose for the SMART plans was 66 Gy/30 F to PTV66 and 54 Gy/30 F to PTV54. The dose prescription to the PTV60 for both the 3DCRT and cf-IMRT plans was set to 60 Gy/30 F. All the plans were generated on the Eclipse 10.0 treatment planning system. Fulfillment of the dose criteria for the PTVs received the highest priority, followed by the spinal cord, heart, and lungs. The dose-volume histograms were compared.

RESULTS: Clinically acceptable plans were achieved for all the SMART, cf-IMRT, and 3DCRT plans. Compared with the 3DCRT plans, the SMART plans increased the dose delivered to the primary tumor (66 Gy vs 60 Gy), with improved sparing of normal tissues in all patients. The Dmax of the spinal cord, V20 of the lungs, and Dmean and V50 of the heart for the SMART and 3DCRT plans were as follows: 38.5 ± 2.0 vs 44.7 ± 0.8 (P = 0.002), 17.1 ± 4.0 vs 25.8 ± 5.0 (P = 0.000), 14.4 ± 7.5 vs 21.4 ± 11.1 (P = 0.000), and 4.9 ± 3.4 vs 12.9 ± 7.6 (P = 0.000), respectively. In contrast to the cf-IMRT plans, the SMART plans permitted a simultaneous dose escalation (6 Gy) to the primary tumor while demonstrating a significant trend of a lower irradiation dose to all organs at risk except the spinal cord, for which no significant difference was found.

CONCLUSION: SMART offers the potential for a 6 Gy simultaneous escalation in the irradiation dose delivered to the primary tumor of EC and improves the sparing of normal tissues.

Keywords: Simultaneous modulated accelerated radiation therapy, Three-dimensional conformal radiotherapy, Intensity-modulated radiation therapy, Esophageal cancer, Feasibility

Core tip: The feasibility of simultaneous modulated accelerated radiotherapy (SMART) in the treatment of upper or middle thoracic esophageal cancer is evaluated in this study. Computed tomography datasets of 10 patients were used to generate SMART, conventionally-fractionated three-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (cf-IMRT) plans, respectively. The prescribed dose for the SMART plans was 66 Gy/30 F to the gross tumor and 54 Gy/30 F to subclinical diseases. The dose for both the 3DCRT and cf-IMRT was 60 Gy/30 F to a single target volume. The results demonstrate that SMART can offer the potential for a 6 Gy simultaneous escalation in the dose delivered to the primary tumor of esophageal cancer and improve normal tissue sparing compared with 3DCRT and cf-IMRT.