Recommended Doses for Conventionally Fractionated Radiation Therapy

Treatment type	Total dose	Fraction size	Treatment duration
Postoperative after EPP
Negative margins	50–54 Gy	1.8–2 Gy	4–5 weeks
Microscopic-macroscopic positive margins	54–60 Gy	1.8–2 Gy	5–6 weeks
Palliative Chest wall pain from recurrent nodules Multiple brain or bone metastasis	20–40 Gy or 30 Gy 30 Gy	≥4 Gy 3 Gy 3 Gy	1–2 weeks 2 weeks 2 weeks
Prophylactic radiation to prevent surgical tract recurrence	21 Gy	7 Gy	1 week

After EPP, RT should only be considered for patients who meet the following criteria: ECOG PS ≤1; good functional pulmonary status; good function of contralateral kidney confirmed by renal scan; and absence of disease in abdomen, contralateral chest, or elsewhere. Patients who are on supplemental oxygen should not be treated with adjuvant RT.

Radiation Techniques

• Use of conformal radiation technology is the preferred choice based on comprehensive consideration of target coverage and clinically relevant normal tissue tolerance.

• CT simulation-guided planning using either intensity-modulated radiation therapy (IMRT) or conventional photon/electron RT is acceptable.⁷ IMRT is a promising treatment technique that allows for a more conformal high-dose RT and improved coverage to the hemithorax. IMRT or other modern technology (such as tomotherapy or protons) should only be used in experienced centers or on protocol. When IMRT is applied, the NCI and ASTRO/ACR IMRT guidelines should be strictly followed.^13,14 Special attention should be paid to minimize radiation to the contralateral lung,¹⁵ as the risk of fatal pneumonitis with IMRT is excessively high when strict limits are not applied.¹⁶ The mean lung dose should be kept as low as possible, preferably <8.5 Gy. The low-dose volume should be minimized.¹⁷

• The gross tumor volume (GTV) should include any grossly visible tumor. Surgical clips (indicative of gross residual tumor) should be included for postoperative adjuvant RT.

• The clinical target volume (CTV) for adjuvant RT after EPP should encompass the entire pleural surface (for partial resection cases), surgical clips, and any potential sites with residual disease.

• Extensive elective nodal irradiation (entire mediastinum and bilateral supraclavicular nodal regions) is not recommended.

• The planning target volume (PTV) should consider the target motion and daily setup errors. The PTV margin should be based on the individual patien’s motion, simulation techniques used (with and without inclusion motion), and reproducibility of each clinic’s daily setup.

See General Principles and Radiation Dose and Volume (MPM-D 1 of 3)

See References MPM-D (3 of 3)