Residual Setup Errors Towards the Heart After Image Guidance Linked With Poorer Survival in Lung Cancer Patients: Do We Need Stricter IGRT Protocols?

PURPOSE: Image guided radiation therapy (IGRT) is widely used, but data directly relating set-up errors to patient outcome are scarce. This study investigates the relationship between residual IGRT shifts and overall patient survival and uses the observed relations to identify structures sensitive to radiation dose.

METHODS AND MATERIALS: Residual shift data for 780 patients with non-small cell lung cancer were summarized for each patient over the course of treatment by determining the mean shifts, standard deviations, and the vector shift in the direction of the heart. These variables were related to overall survival, and significant variables were used to produce Kaplan-Meier plots of survival. The effect of shift directionality was studied by splitting the cohort into left, right, anterior, posterior, superior, and inferior groups and by analyzing the vector shift in the direction of the heart. The observed relationship was independently validated in an esophageal cancer cohort (n = 177).

RESULTS: The shift data showed strong associations with survival. Left and right cohorts showed opposite directional shift effects, suggesting shifts toward the mediastinum have a negative effect on survival. Projection of the vector shift in the direction of the heart showed that patients with a residual shift toward the heart have significantly worse overall survival (P = .007, hazard ratio 1.091). The same effect was observed in the esophageal cancer cohort (P = .041, hazard ratio 1.164).

CONCLUSIONS: Residual shift metrics derived from IGRT data can categorize patients with non-small cell lung cancer and those with esophageal cancer into populations with significantly different survival times on the basis of the size of the residual shift in the direction of the heart, thus providing evidence of the importance of using strict IGRT protocols to spare organs at risk and highlighting the heart as a dose-sensitive organ.