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Non-small cell lung cancer (NSCLC) is the most common malignancy which requires radiotherapy (RT) as an important part of its multimodality treatment. With the advent of the novel irradiation technique, the clinical outcome of NSCLC patients who receive RT has been dramatically improved. The emergence of proton therapy, which allows for a sharper dose of build-up and drop-off compared to photon therapy, has potentially improved clinical outcomes of NSCLC. Dosimetry studies have indicated that proton therapy can significantly reduce the doses for normal organs, especially the lung, heart, and esophagus while maintaining similar robust target volume coverage in both early and advanced NSCLC compared with photon therapy.
(A) | |||||||||
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Authors | Design | Year | Cases | NSCLC Stage | Treatment | Dose(Gy) | Fractions | CTV Dosimetric Outcomes (Gy) | OAR Dosimetric Outcomes (Gy) |
Wang et al. [13] | - | 2009 | 24 | I | PSPT/3D-CRT | 66 | 10 | 95% isodose line covered 86.4% CTV for proton, and 43.2% for 3D-CRT | Proton delivers lower mean doses to the ipsilateral lung, total lung, heart, esophagus, and spinal cord |
Wink et al. [15] | Retrospective | 2018 | 24 | I | IMRT/VMAT/CyberKnife/PSPT | 60 | 8 | Scattered proton has a lower Dmean of CTV (65.1/65.7/68.1/63.6) and D2% (70.6/70.3/72.9/67.4) | Doses to the spinal cord were lowest with PSPT |
Roelofs et al. [17] | Prospective | 2012 | 25 | IA-IIIB | 3D-CRT/IMRT/PSPT | 70 | 35 | - | Higher integral dose for 3D-CRT (59%) and IMRT (43%); Reduced mean lung dose for PSPT (18.9/16.4/13.5, respectively) |
Ohno et al. [19] | - | 2015 | 35 | 3IIB/15IIIA/17 IIIB | Proton/CRT | 74 | 37 | 45.7% of the X-ray/17.1% of the proton plans were inadequate | Mean lung dose and V5 to V50 were significantly lower in proton |
Giaddui et al. [23] | Phase III trial | 2016 | 26 | II- IIIB |
PSPT/IMRT | 70 | 35 | Dose parameters for the target volume were very close for the IMRT and PSPT plans | Lower dose for PSPT plans: lung V5 (34.4 vs. 47.2); maximum spinal cord dose (31.7 vs. 43.5 Gy); heart V5 (19 vs. 47); heart V30 (11 vs. 9); heart V45 (7.8 vs. 12.1); heart V50% (7.1 vs. 9.8) and mean heart dose (7.7 vs. 14.9) |
Wu et al. [22] | Retrospective | 2016 | 33 | III | PSPT/3D-CRT | 60–66 | 33 | - | All the dose parameters of proton therapy, except for the esophageal the dose was lower than 3D-CRT |
Shusharina et al. [24] | Retrospective | 2018 | 83 | II–IV | IMRT/PSPT | 74 | 37 | - | Higher Lung V5 for IMRT, whereas higher V60 for protons; The mean lung dose was similar |
(B) | |||||||||
Authors | Design | Year | Cases | NSCLC Stage | Treatment | Dose(Gy) | Fractions | CTV Dosimetric Outcomes (Gy) | OAR Dosimetric Outcomes (Gy) |
Register et al. [14] | - | 2011 | 15 | I | PSPT/IMPT/SBRT | - | - | Only 6 photons, 12 PSPT, and 14 IMPT were satisfied | PSPT and IMPT reduced mean total lung dose from 5.4 to 3.5 and 2.8, and total lung volume receiving 5 Gy, 10 Gy, and 20 Gy |
Zhang et al. [16] | - | 2010 | 20 | IIIB | IMRT/PSPT/IMPT | 74 | IMPT prevented lower-dose target coverage in complicated cases | IMPT spared more lung, heart, spinal cord, and esophagus | |
Berman et al. [18] | Retrospective | 2013 | 10 | IIIA | PSPT/IMPT/IMRT | 50.4 | 28 | - | IMPT decreases the dose to all OARs. PSPT reduces the low-dose lung bath, increases the volume of lung receiving high dose |
Kesarwala et al. [20] | - | 2015 | 20 | 14IIIA/6IIIB | Proton IFRT/ENI vs. photon IFRT/ENI | 66.6–72 | 36–40 | Proton IFRT/ENI both improved D95-PTV coverage by 4% compared to photon IFRT | Decreased lung V20/mean lung dose by 18%/36%, mean esophagus dose by 16% with proton IFRT and by 11%/26%, 12% with proton ENI. Heart V25 decreased 63% with both |
Inoue et al. [21] | - | 2016 | 10 | III | IMPT/VMAT | 60 | 25 | IMPT showed better target homogeneity than VMAT | IMPT reduced 40% mean lung and 60% heart dose |
Li et al. [25] | - | 2018 | 14 | III | SPArc/IMPT | 66 | 33 | Similar robust target volume coverage | SPArc reduced the doses to critical structures as well as the interplay effect |
Liu et al. [26] | Retrospective | 2018 | 24 | III | VMAT/IMPT | 60 | - | Comparable CTV dose homogeneity | IMPT with lower cord Dmax, heart Dmean and lung V5 Gy and better robustness in heart Dmean, but worse in CTV dose coverage, cord Dmax, lung Dmean, and V5 Gy |
Ferris et al. [27] | Retrospective | 2019 | 26 | III | IMPT/VMAT | 60 | 30 | - | IMPT improves cardiac dosimetry metrics, maintaining/improving other thoracic OAR constraints |