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Brachial Plexopathy Development in Stereotactic vs Conventional Radiotherapy

Radiation treatments of apical non-small cell lung tumors (NSCLC) are often in close

proximity to multiple critical structures that need to be identified in treatment planning in order

to keep total irradiation of the structure as minimal as possible. These structures can include

normal lung tissue, the heart, the spinal cord, nearby vasculature, and peripheral nerves. The

brachial plexus in particular sits very close to and is often affected by many of these apical

tumors. There have been multiple studies conducted to determine what the tolerance dose is for

this structure. Previous tolerance doses determined for the brachial plexus in these studies

showed to have constraints of 60-66 Gy and explained that when brachial plexopathy occurs it

often presents as the development of upper extremity pain, motor weakness, and/or sensory

abnormalities.1,2 The following studies went a step further to look for any differences in the onset

of brachial plexopathy based on the type of plan used for treatment.

When comparing the research of the following studies, the main purposes revolved

around what dosage of radiation the brachial plexus could tolerate before the onset of brachial

plexopathy. Two factors that each considered specifically included the volume of the treatment

fields and the dose per fraction. Both studies also choose to conduct this research off of previous

medical records involving patients with apical NSCLC of which 142 patients and 75 patients’

records were used by Eblan et al and Sood et al respectively. In the study conducted by Sood et

al, brachial plexopathy onset was researched based on SBRT treatments of apical lung tumors.

Since SBRTs use hyper fractionation the studies most common prescribed dose and fractionation

was 50 Gy in 5 fractions and it delivered fraction sizes ranged from 8 to 20 Gy.2 In the study

conducted by Eblan et al, the tumors were documented to be located within 1 cm of the apex of
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the lung and each of these patients received conventional therapy treatments to ≥50 Gy.1 In this

study, the patients most commonly received around 66 Gy and with the treatments being

conventional, the dose per fraction was likely less than that of the hyper fractionated dose per

fraction.

The results of the two studies revealed to have similarities in terms of the total tolerance

dose to the brachial plexus but also provided further information on whether the volumes and

dose per fraction were related to their patients’ cases. In the Eblan et al study it was determined

that the volume of the brachial plexus irradiated was in fact associated with the development of

brachial plexopathy and that delivering ≥76 Gy to more than 1 cc of the brachial plexus was

found to have the highest risk for developing brachial plexopathy.1 Furthermore, the study also

found that brachial plexopathy is a relatively uncommon complication of radiation treatment for

apical NSCLC tumors. The results of the SBRT study showed that a majority of its patients had

volumes of their brachial plexus receiving 70- 74 Gy or greater and similarly found that the risk

of brachial plexopathy increased significantly when the volume received greater than 74-76 Gy,2

It was also found that patients with brachial plexopathy appeared to have doses per fraction that

were greater than 10 and 12 Gy.2 With a larger number of fractions and a smaller dose per

fraction compared to SBRTs, there is not as great of a risk for developing brachial plexopathy

per fraction from irradiation in conventional treatments.

The purpose of both studies indicated the analysis of the volumes of brachial plexus

irradiated and the dosometric factors that were associated with brachial plexopathy in patients

with apical NSCLC. Likewise, each study exhibited that volumes of the brachial plexus that

could be irradiated without presenting with brachial plexopathy could reach as high of doses as
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70-74 Gy in SBRT and 76-78 Gy in conventional treatments. This demonstrates that the

tolerance to high doses of radiation to the brachial plexus is greater than historically proven.

Sood et al, however did recommend limiting the maximum dose per fraction to the brachial

plexus between 6 and 8 Gy for SBRTs depending on the number of fractions used for treatment

to ensure the tolerance point is not reached and to keep irradiation as low as possible.2. Eblan et

al also recommended treating primary apical tumors located in close proximity to the brachial

plexus to doses of 66-74 Gy while limiting hot spots in the brachial plexus to 78 Gy. The

conclusion that both studies come to is that the volume of the brachial plexus irradiated per

fraction as well as the dose per fraction are significant in determining the risks of developing

brachial plexopathy.
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Bibliography

1. Eblan MJ, Corradetti MN, Lukens JN, et al. Brachial plexopathy in apical non-small

cell lung cancer treated with definitive radiation: dosimetric analysis and clinical

implications. Internal Journal of Radiation Oncology*Biology*Physics. 2013; 85(1):175-

181. doi: 10.1016/j.ijrobp.2012.03.051.

2. Sood SS, McClinton C, Badkul R, Aguilera N, Wang F, Chen AM. Brachial plexopathy

after stereotactic body radiation therapy for apical lung cancer: Dosimetric analysis and

preliminary clinical outcomes. Advanced Radiation Oncology 2018.2017; 3(1):81-86.

doi: 10.1016/j.adro.2017.10.002.