Elsevier

Radiotherapy and Oncology

Volume 129, Issue 2, November 2018, Pages 196-208
Radiotherapy and Oncology

Systematic review
Functional lung imaging in radiation therapy for lung cancer: A systematic review and meta-analysis

https://doi.org/10.1016/j.radonc.2018.07.014Get rights and content

Abstract

Rationale

Advanced imaging techniques allow functional information to be derived and integrated into treatment planning.

Methods

A systematic review was conducted with the primary objective to evaluate the ability of functional lung imaging to predict risk of radiation pneumonitis. Secondary objectives were to evaluate dose–response relationships on post treatment functional imaging and assess the utility in including functional lung information into treatment planning. A structured search for publications was performed following PRISMA guidelines and registered on PROSPERO.

Results

814 articles were screened against review criteria and 114 publications met criteria. Methods of identifying functional lung included using CT, MRI, SPECT and PET to image ventilation or perfusion. Six studies compared differences between functional and anatomical lung imaging at predicting radiation pneumonitis. These found higher predictive values using functional lung imaging. Twenty-one studies identified a dose–response relationship on post-treatment functional lung imaging. Nineteen planning studies demonstrated the ability of functional lung optimised planning techniques to spare regions of functional lung. Meta-analysis of these studies found that mean (95% CI) functional volume receiving 20 Gy was reduced by 4.2% [95% CI: 2.3: 6.0] and mean lung dose by 2.2 Gy [95% CI: 1.2: 3.3] when plans were optimised to spare functional lung. There was significant variation between publications in the definition of functional lung.

Conclusion

Functional lung imaging may have potential utility in radiation therapy planning and delivery, although significant heterogeneity was identified in approaches and reporting. Recommendations have been made based on the available evidence for future functional lung trials.

Section snippets

Materials and methods

A systematic review was performed using structured search terms following the PRISMA guidelines [3]. This was prospectively registered on a systematic review database (PROSPERO, CRD42017077472).

The full review protocol is available attached in Appendix A. Publications were required to describe functional lung imaging in patients receiving treatment with radiation therapy in a peer reviewed journal. For the meta-analysis and descriptive tables, studies with less than 10 patients were excluded.

Results

A total of 114 publications met criteria for inclusion in the descriptive analysis [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65], [66], [67], [68], [69], [70], [71], [72], [73], [74],

Discussion

This is the first systematic review and meta-analysis of functional lung imaging in radiation therapy for lung cancer. Multiple prior reviews were noted in the literature searches with a main focus on the technical aspects of functional lung imaging methods. Meta-analysis demonstrated that improved sparing of fMLD (2.18 Gy) and fV20 (4.19%) is observed when plans are optimised to spare functional compared lung. Several studies were discarded prior to meta-analysis due to insufficient data and

Conclusions

Our review of 114 publications demonstrates that functional lung imaging may provide additional information to assist in identifying patients at greater risk of radiation pneumonitis. We found a consistent dose–response with post radiation therapy perfusion imaging illustrating the potential for functional lung imaging to be integrated into treatment planning to improve functional dose metrics. Meta-analysis of reduction in fV20 and fMLD has demonstrated that functionally optimised treatment

Funding

This research was supported by an Australian National Health and Medical Research Council Grant APP1122347. This research was supported by an Australian Government Research Training Program (RTP) Scholarship.

Conflicts of interest notification

No actual or potential conflicts of interest exist.

Acknowledgement

The authors would like to acknowledge the contribution of Smaro Lazarakis, Librarian at the Health Sciences Library at Royal Melbourne Hospital.

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