Combined Deep Inspiration Breath Hold (DIBH)-Expiration Planning Technique in Patients With Lung Tumors in Close Proximity to the Chest Wall

  • End date
    Oct 1, 2023
  • participants needed
  • sponsor
    Indiana University
Updated on 26 January 2021
karnofsky performance status
lung cancer
stereotactic body radiation therapy
pulmonary metastasis
lung tumor
lung carcinoma


The purpose of this study is to evaluate a new radiation planning and treatment delivery technique called Deep Inspiration Breath Hold (DIBH) and expiration technique. This technique will be used to treat patients who have tumors close to the chest wall and are candidates for Stereotactic Body Radiation Therapy (SBRT). This study will assess the reduction of radiation to the chest wall during treatment using this technique.


Multiple studies have evaluated the efficacy of SBRT in patients with early stage lung cancer. The original Indiana University phase II trial evaluating three fraction SBRT with a total dose of 60-66 Gy for T1 and T2 (<7cm) lesions and median follow up of 50.2 months revealed a 3-year local failure rate of 5.7%. Tumor size and location did not impact tumor recurrence. [3]. RTOG 0236, which was a multi-institutional phase II trial evaluating the efficacy of three fraction SBRT for patients with peripherally located tumors, reported that 3-year local control rate was 98% with a median overall survival of 4 years and overall survival at 3 years of 56%. Long- term results of RTOG 0236 revealed a 5-year local failure rate of 7% and a 5-year overall survival rate of 40% [4, 5]. In addition, a pooled analysis of two randomized trials (Randomized study to Compare CyberKnife to Surgical Resection in Stage I Non-small Cell Lung Cancer [STARS] and the Trial of Either Surgery or Stereotactic Radiotherapy for Early Stage [IA] Lung Cancer [ROSEL]) comparing SBRT vs. lobectomy for operable stage I (T1-2aN0M0) NSCLC showed a 3-year overall survival for SBRT of 95% and for surgery of 79% (HR=0.14, p=0.037). There was no statistically significant difference between both groups in terms of 3-year rate of recurrence-free survival (HR = 0.69, p = 0.54) [5]. To evaluate the efficacy of SBRT (66 Gy in 3 fractions) compared to standard treatment (70 Gy in 35 fractions), 102 patients, with stage I inoperable NSCLC, were randomized to each treatment arm in the SPACE trial. The results were consistent with similar overall survival and progression free survival on both treatment groups. According to the TROG 09.02 CHISEL trial, stage I inoperable NSCLC patients treated with SBRT had superior local control of the primary disease (HR: 0.32) without an increase in major toxicity compared to patients treated with standard fractionation[6].

Pulmonary metastases frequently happen in patients with different types of cancer. Around 50% of patients who suffer from malignancy-related mortality have pulmonary metastasis at the time of autopsy [7]. In 1995, Hellman et al introduced the concept of oligometastases and the importance of aggressive surgical or ablative therapies to improve overall survival in this population [8]. As a result, SBRT technique has been widely used to treat pulmonary metastases. Multiple studies have evaluated this technique including a retrospective study evaluating 577 patients who undergo SBRT for pulmonary metastases that revealed 5-year local control of 46.3% and 5-year overall survival of 21.8% [9]. Based on the above findings, we propose a prospective feasibility trial evaluating the combined DIBH-expiration planning and delivery technique in patients with lung tumors in close proximity to the chest wall who are candidates to receive lung SBRT per their standard care.

Based on the observed respiration dependent movement during CT simulation we will assign patients into two cohorts: A) Tumors with no overlap between respiratory states and B) Tumors with up to 50% overlap between respiratory states. For A, we will have a composite plan delivering half the dose using DIBH plan and the other half using the expiration phase plan for each fraction. For B) the radiation target will be subdivided into different zones with different zones receiving different prescriptions. The study plan will be compared to a standard plan specifically designed for the same patient. We hypothesize that this technique will enable us to reduce chest wall V30 by 50% and deliver 54 Gy in 3 fractions while meeting all the dosimetric constraints. Cohorts A and B will be analyzed separately. Other dosimetric parameters will be evaluated in this trial.

Condition Pulmonary Disease, Metastasis, Lung Neoplasm, Bronchial Neoplasm, Liver Metastases, Bone Metastases, Brain Metastases, Cancer, Metastatic, Lung Cancer, Lung Disease, Metastatic Cancer, Neoplasm Metastasis, cancers metastatic, carcinoma lung, lung carcinoma, metastases, metastatic disease, secondary cancer, secondaries, metastatic tumor, metastasized
Treatment Treatment Planning using the DIBH Technique
Clinical Study IdentifierNCT04507828
SponsorIndiana University
Last Modified on26 January 2021


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Inclusion Criteria

Is your age greater than or equal to 18 yrs?
Gender: Male or Female
Do you have any of these conditions: Lung Neoplasm or Bronchial Neoplasm or Pulmonary Disease or Liver Metastases or Brain Metastases or Lung Cancer or Metastatic Cancer or Metastasis or ...?
Do you have any of these conditions: cancers metastatic or Pulmonary Disease or metastasized or Lung Cancer or Neoplasm Metastasis or Bronchial Neoplasm or Liver Metastases or Metastatic ...?
Age 18 at time of consent
Karnofsky Performance Status (KPS) > 40
Ability to provide written informed consent and HIPAA authorization
Clinical or pathological diagnosis of primary lung cancer or metastasis to the lung
Tumors must be located within 2 cm from the chest wall, defined as the inner border of the 2-cm lung expansion volume (per TG101)
Plan to receive Lung SBRT

Exclusion Criteria

Patients with tumors with > 50% overlap between respiratory states based on CT simulation will not be eligible for this study
Previous radiation therapy to the same site per investigator discretion
Inability to comply with treatment or standard of care follow up per investigator discretion
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