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Rib fracture after 177 patients with Hiroshi Onishi, Hiroshi Onishi, Rihito Tominaga, Marino, Takafumi Komiyama, Kengo University of Yamanashi,

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Presentation on theme: "Rib fracture after 177 patients with Hiroshi Onishi, Hiroshi Onishi, Rihito Tominaga, Marino, Takafumi Komiyama, Kengo University of Yamanashi,"— Presentation transcript:

1 Rib fracture after 177 patients with Hiroshi Onishi, Hiroshi Onishi, Rihito Tominaga, Marino, Takafumi Komiyama, Kengo University of Yamanashi,

2 stereotactic body stage I non-small Tsuyota Koshiishi, Shinichi Aoki. Kuriyama, Eiichi Sawada, Atsushi Yamanashi, Japan

3 radiotherapy in cell lung cancer Masayuki Araya, Ryo Saito, Kan Nambu, Naoki Sano, Tsutomu Araki

4 Background Despite the increasing popularity of SBRT, experience with extremely hypofractionated, high-dose radiotherapy regimens and their posttreatment radiologic findings and clinical toxicity remains limited. Multiple Phase I and II SBRT studies of the treatment of Stage I-II NSCLC have reported chest wall (CW) pain and/or rib fracture as a part of the toxicity profile. But an exact frequency of rib fracture after SBRT and risk factors for it was unknown.

5 Purpose The aim of the study was to assess the relationship between the background of factors in patients or the treatment and the development of rib fracture*. * Definition of the rib fracture in the study : A CT findings of linear line indicating fracture on rib on high dose-irradiated area

6 Total cases Age Stage Tumor diameter Distance to chest wall 177 (male 132, female 45) (median 78) years T1N0M0 118, T2N0M (median 25) mm 0-53 (median 6) mm Patients characteristics Irradiated from to Dose and prescription Total dose / fractionations/ days 40Gy / 10 fr / 4-7 days 48 Gy / 4 fr / 4-7 days 60 Gy / 10 fr / 5-8 days 70 Gy / 10 fr / 5-8 days BED(  =3Gy) 93.3 Gy 240 Gy 180 Gy Gy Prescription D95(PTV) Isocenter D95(PTV)

7 SBRT planning 1)Instruct patient to reproduce patients’ self-judged breath-holds according to a respiratory indicator (ABCHES). 2) Measurement of reproducibility of the patient’s self-inspired breath-hold by 3 times of CT scanning 3)Three dimensional (3D) treatment planning was performed. Planning target volume (PTV) was defined as gross tumor volume (GTV) + reproducibility of the patient’s self-breath-hold + 5mm safety margin. 4)Port margin around PTV 5mm in the protocol of 48Gy/4fr 0mm in the protocol of 60Gy/10fr and 70Gy/10fr 5)Beams: 6MV-X ray, non-coplanar multiple (>6) static ports or multiple (>400 degrees) dynamic arcs 6)Calculation algorithm: Clarkson or Convolution 7)Heterogeneity correction (+)

8 The treatment procedure In every fraction 1)Reassurance of reproducibility of patients’ self-breath-holds 2)Adjustment of the isocenter of the PTV to the planned position using CT- linac system under patients’ self-judged breath hold according to a respiratory indicator (ABCHES). 3)Irradiation performed under patients’ self-breath-holds 4)The tumor position in the irradiation port during irradiation was monitored with a real-time electronic portal imaging device (EPID) 5)The tumor position was verified using CT just after irradiation 【 CT 】 【 Symptom (pain) 】 SBRT Following up examination ( months after SBRT)

9 Analysis ①Time duration to detection of rib fracture ②Clinical symptom (pain) ③Comparison between cases with fracture (+) versus (-) a. Distance between tumor and chest wall b. Patient characteristics c. CT findings of chest wall d. Maximum dose of the rib

10 Results  Positive rib fracture (+) : 41 cases  No rib fracture (-) for more than 24 months until the last follow-up : 46 cases 40Gy / 4 fr / 4-7 days 48 Gy / 4 fr / 4-7 days 60 Gy / 10 fr / 5-8 days 70 Gy / 10 fr / 5-8 days T1 T2 Fracture (+)Fracture (-) 0 / 1 (0.0%) 16 / 37 (43.2%) 14 / 34 (41.2%) 11 / 15 (73.3%) 25 / 61 (41.0%) 16 / 26 (61.5%) 1 / 1 (100.0%) 21 / 37 (56.8%) 20 / 34 (58.8%) 4 / 15 (26.7%) 36 / 61 (59.0%) 10 / %)

11 Time duration from SRT to detection of rib fracture Median : 15 months Mean : 16.8 months Cases number Time duration (months)

12 Pain*Fractute (+)(n=41)Fracture (-)(n=46) Grade 027/41(65.9%)39/46(84.8%) Grade 17/41(17.1%)4/46(8.7%) Grade 27/41(17.1%)3/46(7.7%) Grade 30/41(0%)0/46(0%) *CTCAE(Common Terminology Criteria for Adverse Events) v3.0 Clinical symptom (pain )

13 Distance between tumor and chest wall (mm) 16mm Fracture (-)Fracture (+) Comparison between cases with fracture (+) versus (-) Distance between tumor and chest wall

14 Fracture (+)(n=41)Fracture(-)(n=46) Age Mean 76.9 (64-89) Mean78.5 (61-91) Gender * male: female 24 : 1736 : 10 * p < 0.05 (chi-square test) Comparison between cases with fracture (+) versus (-) Patient characteristics

15 Fracture (+) (n=41)Fracture (-) (n=46) Chest wall edema 35(85.4%)10(21.7%) Thinning or erosion of the rib 30(73.2%)6(13.0%) Comparison between cases with fracture (+) versus (-) CT findings

16 Case 24 カ月後 86 y.o. female adenoca,T2N0M0 70Gy/10fr 24 months after 6 months after Chest wall edema and thinning of rib cortex Rib fracture

17 Risk factor* for rib fracture Odds ratio 95% confidential interval Age Gender(Female) Distance between tumor and chest wall * Stepwise Logistic regression anlysis

18 Fracture (+)(n=9)Fracture (-)(n=8) Maximum chest wall dose (BED Gy) ± ± 76.1 Comparison between cases with fracture (+) versus (-) Maximum dose in chest wall ( in 17 cases in which detailed dose was calculated) * *  = 3 Gy p<0.01 t-test

19 Fracture (+) (BED Gy) Comparison between cases with fracture (+) versus (-) Maximum chest wall dose (BED)  = 3 Gy Fracture (-)

20 ROC analysis Chest wall maximum BED = 225.5Gy Sensiivity = Specificity= 0.11 Sensitivity (1-specificity) Comparison between cases with fracture (+) versus (-) Maximum chest wall dose (BED)

21 Fracture (-) Fracture (+) (Gy) 225.5Gy Likelihood ration=sensitivity/ (1-specificity )= 0.71/0.11=6.45 Comparison between cases with fracture (+) versus (-) Maximum chest wall dose (BED)

22 1.J. Thorac Oncol 2009:4: Int J Radiat Oncol Biol Phys 2010; 76: Radiotherapy and Oncology 2009;91: Lung Cancer 2005;48: Lung Cancer 2008;60: Lung Cancer 2006;51: Author Total Dose (Gy) High risk factors Voloney(1) Dunlap(2) Pettersson(3) Zimmermann4) Fritz(5) Nyman(6) – Distance to chest wall < 2cm, Median dose = 46.4Gy /3fr Chest wall volume receiving > 30Gy 2mL of rib received > 40Gy not demonstrated 9 (21.4%) 5 (8.3%) 7 (10.3%) 1 (3 %) 2 (5 %) 4 (8.9%) Fractions number No. of patients Chest wall complications including rib fracture in previous literatures Rib fracture

23 Conclusion  Rib fracture after SBRT for lung cancer was produced in 41 of 177 cases (23.2%).  Female and short distance between the tumor and the chest wall were risk factors for production of rib fracture.  The distance between the tumor and the chest wall was under 16mm in all rib fracture cases.  Maximum BED(  =3Gy) of the chest wall in all rib fracture cases was over 200Gy


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