Correlation between coronary artery doses and survival in locally advanced lung cancer patients.

Abstract

Purpose or Objective It has been demonstrated that irradiating the base of the heart is linked to poorer overall survival (OS) in both early stage and locally advanced non-small cell lung cancer (NSCLC) patients 1,2. In this study, we hypothesised that the origin of both coronary arteries are the dose sensitive structure driving this increased mortality. We therefore investigated the correlation between OS and the dose to the origin of the left and right coronary arteries (LCA and RCA) in a large, single institution cohort. Material and Methods Two observers identified the origin of the LCA and RCA on contrast enhanced CT scans from a total of 804 patients treated between 2010 and 2013 with curative-intent radiotherapy (55Gy in 20 fractions). For 167 of 804 patients, LCA and RCA were identified by both observers, allowing intra-observer variation to be calculated. The mean lung dose (MLD) and dose to the origin of RCA and LCA (DRCA, DLCA) were extracted from the radiotherapy plan. These were use in a multivariate survival analysis including patient and tumour characteristics (age, sex, tumour size, TNM stage, induction chemotherapy and performance status). Smoking status was available for less than one third of the cohort and was not included in the analysis. Data on co-morbidities and cause of deaths were not available, so only overall survival was analysed. Results Median follow up was 18 months and 623 deaths were recorded. Observers deviated in their identification of the LCA and RCA (average vector length 8 mm). Tumour size, sex, MLD, TNM stage, performance status as well as DRCA and DLCA were significant (p <0.05) on univariate Coxregression. However, DRCA and DLCA did not remain significant when included in a multivariate analysis (Table 1). Conclusion Even though the dose to the base of the heart has been linked with survival, in this cohort, the dose to the origin of the coronary arteries was not an independent predictor of OS. However, the inter-observer variation in localising the origin of the LCA and RCA was substantial, suggesting that manual identification of cardiac substructures on planning CT scans is challenging. Future work in our institution will include automatic voxel-based methods to identify the sensitive cardiac substructures in NSCLC patients to explain previous observations.