Association of lung and heart dose with survival in patients with non-small cell lung cancer underwent volumetric modulated arc therapy

Background: Controversial conclusions had been reported in studies trying to confirm the impact of heart dose on overall survival (OS) reported in RTOG 0167 for non-small cell lung cancer (NSCLC) patients who underwent radiotherapy (RT). The purpose of this study is to investigate the association of lung and heart dosimetric parameters with OS in NSCLC patients treated by volumetric modulated arc therapy (VMAT). Methods: Inoperable NSCLC patients treated by VMAT from March 2012 to December 2015 were retrospectively reviewed. OS and progression-free survival (PFS) were estimated with the Kaplan-Meier method. Univariate and multivariate analyses were conducted with Cox proportional hazards model. Multivariate model building was conducted using stepwise regression for variables with p-value smaller than 0.2 in the univariate analysis. Results: There were 130 NSCLC patients enrolled in this study with a median age of 63 years (range from 34 to 82 y). The median prescription dose for these patients was 56 Gy (range 40-70 Gy) with a mean heart and lung dose of 14.8 +/- 8.5 Gy and 13.6 +/- 4.4 Gy, respectively. The rates of patients with above grade III radiation pneumonitis (RP) and fibrosis were 8.5% and 8.5%, respectively. The 2-year PFS and OS of these patients were 15.2% and 39.8%, with a median PFS and OS of 7.2 and 18.8 months, respectively. RP was correlated with OS (p=0.048) and lung V20 was associated with PFS (p=0.04) according to the univariate analysis. Multivariate analysis demonstrated that RP (HR 1.39, 95% CI 1.010-1.909, p=0.043) and heart V15 (HR 1.02, 95% CI 1.006-1.025 p=0.002) were progression factors of OS, and no factor was associated with PFS. Conclusions: RP and heart V15 were associated with OS for patients with stage III NSCLC who underwent VMAT. Heart and lung dosimetric parameters were highly correlated with each other, sparing of heart and lung should be considered equally during the treatment planning.