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What is QUANTEC?
Scientific project to establish radiation dose
tolerance for several organs
October 2007, Wisconsin, first QUANTEC
meeting, 57 participants
Scope: organ site-specific overviews of
quantitative dose-volume relationships
Results of this project published as a supplement
in Red Journal

Analyzing RT-related toxicity

Cancer survival has tripled in the last 30 years
Late treatment sequale becomes more important
NTCP modeling studies
Scoring toxicity
CTCAE- multiple symptomes and signs into a single grade
-loss of specificity in toxicity specific studies
SOMA (subjective,objective management ,analytic) scale
-components of toxicity are kept separate
Uniform, comprehensive reporting of side effects

From Emami to NTCP

Emami et al- concept of 1/3, 2/3, whole organ
exposure and RT tolerance
Lyman model- uniformly irradiated organ volumes
Kutcher et al. DVH reduction algorithm-nonuniform
dose distribution into partial volume
The combination of these two:
Lyman-Kutcher-Burman model the most
widely used NTCP-model
Allows representation of various dose-volume
dependencies

Limitation of DVH-based approach

DVH-based analyses assume organ function is
uniform
This in not true!
2 examples from animal experiences
1. lung base RT more pneumonitis than apex RT
2. Xerostomia more pronounced if excretory ducts
receive more RT
Beside NTCP models, clinical data are very
important to estimate RT toxicity.

Structure of QUANTEC publication

3 introductory papers
16 organ specific papers
5 vision papers
Each organ specific paper has 10 sections:
Clinical significance,
endpoints,
challenge defining volumes,
review of dose-volume data,
factors affecting the risk,
NTCP model, special situation
recommendation,
future studies, toxicity scoring

1. Clinical significance
RT to lungs in the treatment of
-lung cancer, RT-Pneumonitis risk 5-50%
-mediastinal tu, RP risk 5-10%
-breast cc, RP risk 1-5%

2. Endpoints
definition of RT induced lung injury

3. Definition of lung volume

Single paired organ total lung tissue
Most studies- lung defined while free breathing
Lung edge vary with CT window/level
Exclude GTV or PTV from the lung volume
Modification of lung volume due to tu. shrinkage during RT

Exact lung volume almost impossible to define !!!

4. Review of Dose-Volume Data

-more than 70 published articles studied
-the most used NTCP models
Lyman-Kutcher-Burman model with 3 parameters: position, steepness,
volume
MLD model- simple and efficient

Dose-volume treshold analyses

Various Vx values (percentage lung volume receiving x
or more than x Gy)
No sharp dose treshold below which there is no risk
Always technique dependent
Take account of high dose regions lower or uper lung

5. Factors affecting risk of RP

No association: GTV laterality, comorbidity,, gender
Association: age, surgery, smoking status, chemotherapy(docetaxel, gemcitabine)
6. Mathematic/ biologic models

7. Special situations
Whole lung RT (TBI, palliative hemibody, pulm mets)
Depends on TD, fraction size
If developes- 80% fatal
Hypofractionation
stereotactic RT, small volumes with high dose but large with low dose
Risk of RP 10-25%, if high dose peribronchial- stenosis
IMRT
MSKCC experience 11% grade 3 RP
Higher risk in mesothelioma patients

8. Recommended Dose/Volume limits

Acceptable risk level varies with clinical scenario
Its prudent to limit
V20 < 30-35% with conventional fr,
MLD<20-23 Gy
risk of RP <20%
Central airways <80 Gy

9. Future toxicity studies

Endpoint interaction
Impact of clinical factors
Organ interaction
Radiation response modifiers
Biomarkers

10. Toxicity scoring

use LENT-SOMA-type scoring

separate symptoms, function, radiographic endpoints