Chest Wall Volume Receiving >30 Gy Predicts Risk of Severe Pain and/or Rib Fracture After Lung Stereotactic Body Radiotherapy

Neal E. Dunlap, Jing Cai, Gregory B. Biedermann, Wensha Yang, Stanley H. Benedict, Ke Sheng, Tracey E. Schefter, Brian D. Kavanagh, James M. Larner

Research output: Journal article publicationJournal articleAcademic researchpeer-review

216 Citations (Scopus)


Purpose: To identify the dose-volume parameters that predict the risk of chest wall (CW) pain and/or rib fracture after lung stereotactic body radiotherapy. Methods and Materials: From a combined, larger multi-institution experience, 60 consecutive patients treated with three to five fractions of stereotactic body radiotherapy for primary or metastatic peripheral lung lesions were reviewed. CW pain was assessed using the Common Toxicity Criteria for pain. Peripheral lung lesions were defined as those located within 2.5 cm of the CW. A minimal point dose of 20 Gy to the CW was required. The CW volume receiving ≥20, ≥30, ≥40, ≥50, and ≥60 Gy was determined and related to the risk of CW toxicity. Results: Of the 60 patients, 17 experienced Grade 3 CW pain and five rib fractures. The median interval to the onset of severe pain and/or fracture was 7.1 months. The risk of CW toxicity was fitted to the median effective concentration dose-response model. The CW volume receiving 30 Gy best predicted the risk of severe CW pain and/or rib fracture (R2= 0.9552). A volume threshold of 30 cm3was observed before severe pain and/or rib fracture was reported. A 30% risk of developing severe CW toxicity correlated with a CW volume of 35 cm3receiving 30 Gy. Conclusion: The development of CW toxicity is clinically relevant, and the CW should be considered an organ at risk in treatment planning. The CW volume receiving 30 Gy in three to five fractions should be limited to <30 cm3, if possible, to reduce the risk of toxicity without compromising tumor coverage.
Original languageEnglish
Pages (from-to)796-801
Number of pages6
JournalInternational Journal of Radiation Oncology Biology Physics
Issue number3
Publication statusPublished - 1 Mar 2010
Externally publishedYes


  • chest wall
  • dose-response
  • fracture
  • lung
  • SBRT
  • Stereotactic body radiotherapy

ASJC Scopus subject areas

  • Radiation
  • Oncology
  • Radiology Nuclear Medicine and imaging
  • Cancer Research


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