Peter Hirschi

My essay group in research methods is currently working on a case study in which a

patient presented with a non-resectable peripheral NSCLC that is abutted to the
chest wall. In most cases, a SBRT fractionation scheme of 5 fraction of a 1000cGy
would be prescribed. However, utilizing this SBRT fractionation scheme delivers an
unacceptable amount of dose to the chest wall. By using a traditional linear
quadratic model formula: BED = nd{1 + (d /
fractions, d = dose per fraction, and

/)\} , where n = number of

is a ratio representing inherent biological

characteristics of tissue, [1] a dose per fractionation scheme can be found to

maintain BED coverage of the tumor while lowering the BED to the chest wall. This
is done by taking advantage of the therapeutic ratio. In the formula just mentioned,
the

/ ratio

for late effect tissues like the chest wall is 3, while the

/ ratio for

acute reactions and tumor response is 10. This means as the number of fractions
increase the BED dose to the chest wall ( / = 3 Gy ) , should decrease faster than
the BED dose to the tumor ( / = 10 Gy ) . Table 1 was constructed using the BED
formula.
Table 1. Comparison of BED for various lung fractionation schedules.
Calculated BED* for Standard and Hypofractionated Treatment Schedules
Total Dose
Number of
Dose per Fraction BED Tumor (Gy) BED Chest Wall (Gy)
(Gy)
Fractions (n)
(d)(Gy)
(
( / = 3 Gy )

/ = 10 Gy )

70
69.92
70
70.04
50
*BED = nd{1 + (d

35
23
20
17
5
/ / }

2
3.04
3.5
4.12
10

84
91
94.5
99
100

117
141
152
166
217

Table 1 shows that increasing from 5 fractions to 17 fractions and lowering the
fraction dose from 10Gy to 4.12Gy per fraction maintained a tumor BED of 100
while the BED of the chest wall lowered from 217 to 166. The 17 fraction scheme
provides the same BED tumor coverage while lowering dose to the chest wall
making it a safer fractionation scheme in terms of chest wall toxicity levels.
A limitation to using the BED approach includes assuming an / ratio being equal
to 3 for the chest wall, and 10 for tumor response.[2]

References

Videtic GMM, Singh AK, Chang JY, et al. A randomized phase II study comparing 2
stereotactic body radiation therapy (SBRT) schedules for medically inoperable patients with
stage I peripheral non-small cell lung cancer. Radiation Therapy Oncology Group (RTOG).
https://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=0915. Published

2012. Accessed October 24, 2015.

Werts ED. The Radiation Biology of Dose Fractionation: Determinants of Effect.
https://uwlax.courses.wisconsin.edu/content/enforced/3015650UWLAC_2164_DYN_DOS_443_543_SEC501/werts_HISTORYrad%20biol%20of
%20fractionation.pdf?_&d2lSessionVal=6sYmgjtNtxQOCSv5oJw8ckkUG. Accessed
October 24, 2015.