We sought to systematically review and summarize dosimetric factors associated with radiation-induced brachial plexopathy (RIBP) after stereotactic body radiation therapy (SBRT) or hypofractionated image guided radiation therapy (HIGRT). From published studies identified from searches of PubMed and Embase databases, data quantifying risks of RIBP after 1- to 10-fraction SBRT/HIGRT were extracted and summarized. Published studies have reported ∼10% risks of RIBP with maximum doses (Dmax) to the inferior aspect of the brachial plexus of 32 Gy in 5 fractions and 25 Gy in 3 fractions. For 10-fraction HIGRT, risks of RIBP appear to be low with Dmax < 40 to 50 Gy. For a given dose value, greater risks are anticipated with point volume-based metrics (ie, D0.03-0.035cc: minimum dose to hottest 0.03-0.035 cc) versus Dmax. With SBRT/HIGRT, there were insufficient published data to predict risks of RIBP relative to brachial plexus dose-volume exposure. Minimizing maximum doses and possibly volume exposure of the brachial plexus can reduce risks of RIBP after SBRT/HIGRT. Further study is needed to better understand the effect of volume exposure on the brachial plexus and whether there are location-specific susceptibilities along or within the brachial plexus structure. 

Hypofractionated Stereotactic Radiation Therapy Dosimetric Tolerances for the Inferior Aspect of the Brachial Plexus: A Systematic Review.

Radiation-Induced Inferior Brachial Plexopathy after Stereotactic Body Radiotherapy: Pooled Analyses of Risks.

<h3>Purpose/Objective(s)</h3> Radiation-induced brachial plexopathy (RIBP) is quality of life impairing, with uncertain dosimetric limits for stereotactic body radiation therapy (SBRT) in lung cancer. This study aimed to examine its relationship with the dosimetric factors of brachial plexus (BP) and determine the effect of BP definition. <h3>Materials/Methods</h3> The primary study population started from an institutional database of 6291 patients. Lesions with PTV ≤2 cm from the BP treated with SBRT from Jan 2016 to Feb 2021 were eligible. All patients had simulation CT scans on 1.25-mm-thickness. BP was delineated according to the atlas of RTOG1106. The primary endpoint was radiation-induced brachial plexopathy (RIBP), with symptoms graded by LENT-SOMA scales. The primary dosimetric variable of our interest was the maximum BP dose (BP-Dmax). The best constraint for BP was determined using logistic regression and the Youden index. <h3>Results</h3> At a median follow-up of 30. 5 months (range 10.9 - 71.0), 126 patients (128 lesions) were eligible for this study. Nine out of 126 patients (7.1%) experienced grade 1-3 (G1-3) RIBP (4 grade 1, 4 grade 2, and 1 grade 3). For patients with RIBP-related symptoms, the median maximum BP dose (BP-Dmax) reached 45.7Gy (range 36.4 - 61.5) with 4-6 fractions (61.5Gy/4f, 42.23-53.11Gy/5f, 41.80-58.13Gy/6f). The best-estimate of fitting variables for logistic regression was BEDmax (α/β=3, LQ model) of BP (BP-BEDmax), and generated a best cut-off BEDmax of 159.44 Gy, with AUC of 0.859 (95% CI: 0.774-0.943). The 2-year Kaplan-Meier risk of RIBP was 33.5% vs 2.0% (p < 0.001) for BP-BEDmax more or less than 159.44 Gy, respectively. Using subclavian vein (SV) for the BP surrogate, the maximum dose was significantly lower than that of the BP defined according to RTOG1106. This underestimation was significantly greater for lesions with PTV ≤ 1 cm from the BP (median dose difference 9.42Gy, range -13.22-43.20). <h3>Conclusion</h3> This study demonstrated that the BP-BEDmax threshold of 150 Gy (less than 36Gy/4F, 40Gy/5F, 43Gy/6F) and improperness of using vascular bundle as a surrogate BP for dosimetric assessment as this severely underestimated the maximum point dose received by anatomic BP 

Dosimetric Analysis of Radiation-Induced Brachial Plexopathy after Stereotactic Body Radiotherapy: The Contouring of Brachial Plexus Matters

<h3>Purpose/Objective(s)</h3> SBRT is a guideline-recommended treatment for patients with early-stage NSCLC who are medically unfit or unwilling to undergo surgery, while some patients can still develop distant failure. The goal of this work is developing and validating a radiomics model for predicting distant failure in early-stage NSCLC patients treated with SBRT. <h3>Materials/Methods</h3> receiving SBRT were enrolled. In total, 103 CT radiomic features and 103 PET radiomic features were extracted from the pretreatment PET-CT images of each lung lesion. Patients with inoperable NSCLC treated with SBRT and have dicome format imaging available were eligible. A CT-based radiomics signature and a PET-based radiomics signature were established in one dataset and independently validated in other datasets by logistic regression after feature selection. Multivariable logistic regression analysis was then used to develop a radiomics model incorporated in the radiomics signature and independent clinical predictor. The performance of the model was assessed by its discrimination, calibration, and clinical usefulness with internal (first center), and external (other two centers) validation. <h3>Results</h3> A total of 174 patients (with 174 lung lesions; 126, 21, and 27 from three individual institutions) were enrolled. Median follow-up was 30.7 (1.9-97.8) months. Radiomics signature was built by combining features selected from the feature pool. A model of combining CT and PET radiomic signatures with clinically significant factors like gender by logistic regression had AUC of 0.804 in the training set of first center. This model was then tested from data of first center and other two centers which showed AUC 0.785 and 0.712, respectively. <h3>Conclusion</h3> The presented radiomics model, available as an online calculator, can serve as a user-friendly tool for individualized prediction of the distant failure in early-stage NSCLC patients treated with SBRT. 

A PET-CT Radiomics Model for Predicting Distant Metastasis in Early-Stage Non–Small Cell Lung Cancer Patients Treated with Stereotactic Body Radiotherapy: A Multicentric Study

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Dosimetric Analysis of Radiation-Induced Brachial Plexopathy after Stereotactic Body Radiotherapy: The Contouring of Brachial Plexus Matters

A PET-CT Radiomics Model for Predicting Distant Metastasis in Early-Stage Non–Small Cell Lung Cancer Patients Treated with Stereotactic Body Radiotherapy: A Multicentric Study