Brachial plexopathy from stereotactic body radiotherapy in early-stage NSCLC: Dose-limiting toxicity in apical tumor sites
Received 11 December 2008; received in revised form 13 April 2009; accepted 15 April 2009. published online 19 May 2009.
Abstract
Background and purpose
We report frequency of brachial plexopathy in early-stage non-small cell lung cancer treated with stereotactic body radiotherapy.
Materials and methods
276 T1–T2, N0 or peripheral T3, N0 lesions were treated in 253 patients with stereotactic radiotherapy at Indiana University and Richard L. Roudebush VAMC from 1998 to 2007. Thirty-seven lesions in 36 patients were identified as apical lesions, defined as epicenter of lesion superior to aortic arch. Brachial plexus toxicity was scored for these apical lesions according to CTCAE v. 3.0 for ipsilateral shoulder/arm neuropathic pain, motor weakness, or sensory alteration.
Results
The 37 apical lesions (19 Stage IA, 16 IB, and 2 IIB) were treated with stereotactic body radiotherapy to a median total dose of 57Gy (30–72). The associated brachial plexus of 7/37 apical lesions developed grade 2–4 plexopathy (4 pts – grade 2, 2 pts – grade 3, 1 pt – grade 4). Five patients had ipsilateral shoulder/arm neuropathic pain alone, one had pain and upper extremity weakness, and one had pain progressing to numbness of the upper extremity and paralysis of hand and wrist. The median of the maximum brachial plexus doses of patients developing brachial plexopathy was 30Gy (18–82). Two-year Kaplan–Meier risk of brachial plexopathy for maximum brachial plexus dose >26Gy was 46% vs 8% for doses ⩽26Gy (p=0.04 for likelihood ratio test).
Conclusions
Stereotactic body radiotherapy for apical lesions carries a risk of brachial plexopathy. Brachial plexus maximum dose should be kept <26Gy in 3 or 4 fractions.
aDepartment of Radiation Oncology, Indiana University School of Medicine, Indianapolis, USA
bDepartment of Radiation Oncology, UT Southwestern School of Medicine, Dallas, USA
cDepartment of Radiation Oncology, The Ohio State University, Columbus, USA
dDivision of Biostatistics, Indiana University School of Medicine, Indianapolis, USA
eDepartment of Radiation Medicine University of Kentucky, Lexington, USA
Corresponding author. Address: Department of Radiation Oncology, Indiana University School of Medicine, 535 Barnhill Dr (RT041), Indianapolis, IN 46202, United States.
ABSTRACT