Brachial plexopathy from stereotactic body radiotherapy in early-stage NSCLC: Dose-limiting toxicity in apical tumor sites

Jeffrey A. Forquer, Achilles J. Fakiris, Robert D. Timmerman, Simon S. Lo, Susan M. Perkins, Ronald C. McGarry, Peter A.S. Johnstone

Research output: Contribution to journalArticle

114 Citations (Scopus)

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 57 Gy (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 30 Gy (18-82). Two-year Kaplan-Meier risk of brachial plexopathy for maximum brachial plexus dose >26 Gy was 46% vs 8% for doses ≤26 Gy (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 <26 Gy in 3 or 4 fractions.

Original languageEnglish (US)
Pages (from-to)408-413
Number of pages6
JournalRadiotherapy and Oncology
Volume93
Issue number3
DOIs
StatePublished - Dec 1 2009

Fingerprint

Brachial Plexus Neuropathies
Brachial Plexus
Radiosurgery
Neuralgia
Neoplasms
Upper Extremity
Arm
Pain
Hypesthesia
Wrist
Thoracic Aorta
Non-Small Cell Lung Carcinoma
Paralysis
Radiotherapy
Hand

Keywords

  • Apical
  • Brachial plexopathy
  • Hypofractionation
  • Non-small cell lung cancer
  • Stereotactic body radiotherapy

ASJC Scopus subject areas

  • Oncology
  • Radiology Nuclear Medicine and imaging
  • Hematology

Cite this

Brachial plexopathy from stereotactic body radiotherapy in early-stage NSCLC : Dose-limiting toxicity in apical tumor sites. / Forquer, Jeffrey A.; Fakiris, Achilles J.; Timmerman, Robert D.; Lo, Simon S.; Perkins, Susan M.; McGarry, Ronald C.; Johnstone, Peter A.S.

In: Radiotherapy and Oncology, Vol. 93, No. 3, 01.12.2009, p. 408-413.

Research output: Contribution to journalArticle

Forquer, Jeffrey A. ; Fakiris, Achilles J. ; Timmerman, Robert D. ; Lo, Simon S. ; Perkins, Susan M. ; McGarry, Ronald C. ; Johnstone, Peter A.S. / Brachial plexopathy from stereotactic body radiotherapy in early-stage NSCLC : Dose-limiting toxicity in apical tumor sites. In: Radiotherapy and Oncology. 2009 ; Vol. 93, No. 3. pp. 408-413.
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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 57 Gy (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 30 Gy (18-82). Two-year Kaplan-Meier risk of brachial plexopathy for maximum brachial plexus dose >26 Gy was 46{\%} vs 8{\%} for doses ≤26 Gy (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 <26 Gy in 3 or 4 fractions.",
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AU - Fakiris, Achilles J.

AU - Timmerman, Robert D.

AU - Lo, Simon S.

AU - Perkins, Susan M.

AU - McGarry, Ronald C.

AU - Johnstone, Peter A.S.

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AB - 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 57 Gy (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 30 Gy (18-82). Two-year Kaplan-Meier risk of brachial plexopathy for maximum brachial plexus dose >26 Gy was 46% vs 8% for doses ≤26 Gy (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 <26 Gy in 3 or 4 fractions.

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