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Int J Radiat Oncol Biol Phys. 2018 Nov 15;102(4):1357-1365. doi: 10.1016/j.ijrobp.2018.07.186. Epub 2018 Oct 18.

Interim Analysis of a Two-Institution, Prospective Clinical Trial of 4DCT-Ventilation-based Functional Avoidance Radiation Therapy.

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Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado. Electronic address:
Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado.
Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee.
Department of Radiation Oncology, Emory University, Atlanta, Georgia.
Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan.
Department of Radiology, University of Colorado School of Medicine, Aurora, Colorado.
Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
Department of Pediatrics and Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, Colorado.



Functional imaging has been proposed that uses 4DCT images to calculate 4DCT-based lung ventilation (4DCT-ventilation). We have started a 2-institution, phase 2 prospective trial evaluating the feasibility, safety, and preliminary efficacy of 4DCT-ventilation functional avoidance. The trial hypothesis is that the rate of grade ≥2 radiation pneumonitis could be reduced to 12% with functional avoidance, compared with a 25% rate of pneumonitis with a historical control. The trial employed a Simon 2-stage design with a planned futility analysis after 17 evaluable patients. The purpose of this work is to present the trial design and implementation, dosimetric data, and clinical results for the planned futility analysis.


Eligible patients were patients with lung cancer who were prescribed doses of 45 to 75 Gy. For each patient, the 4DCT data were used to generate a 4DCT-ventilation image using the Hounsfield unit technique along with a compressible flow-based image registration algorithm. Two intensity modulated radiation therapy treatment plans were generated: (1) a standard lung plan and (2) a functional avoidance treatment plan that aimed to reduce dose to functional lung while meeting target and normal tissue constraints. Patients were treated with the functional avoidance plan and evaluated for thoracic toxicity (presented as rate and 95% confidence intervals [CI]) with a 1-year follow-up.


The V20 to functional lung was 21.6% ± 9.5% (mean ± standard deviation) with functional avoidance, representing a decrease of 3.2% (P < .01) relative to standard, nonfunctional treatment plans. The rates of grade ≥2 and grade ≥3 radiation pneumonitis were 17.6% (95% CI, 3.8%-43.4%) and 5.9% (95% CI, 0.1%-28.7%), respectively.


Dosimetrically, functional avoidance achieved reduction in doses to functional lung while meeting target and organ at risk constraints. On the basis of Simon's 2-stage design and the 17.6% grade ≥2 pneumonitis rate, the trial met its futility criteria and has continued accrual.

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