PET-based dose painting in non-small cell lung cancer: Comparing uniform dose escalation with boosting hypoxic and metabolically active sub-volumes

Radiother Oncol. 2015 Aug;116(2):281-6. doi: 10.1016/j.radonc.2015.07.013. Epub 2015 Jul 31.


Background and purpose: We compared two imaging biomarkers for dose-escalation in patients with advanced non-small cell lung cancer (NSCLC). Treatment plans boosting metabolically active sub-volumes defined by FDG-PET or hypoxic sub-volumes defined by HX4-PET were compared with boosting the entire tumour.

Materials and methods: Ten NSCLC patients underwent FDG- and HX4-PET/CT scans prior to radiotherapy. Three isotoxic dose-escalation plans were compared per patient: plan A, boosting the primary tumour (PTVprim); plan B, boosting sub-volume with FDG >50% SUVmax (PTVFDG); plan C, boosting hypoxic volume with HX4 tumour-to-background >1.4 (PTVHX4).

Results: Average boost volumes were 507 ± 466 cm(3) for PTVprim, 173 ± 127 cm(3) for PTVFDG and 114 ± 73 cm(3) for PTVHX4. The smaller PTVHX4 overlapped on average 87 ± 16% with PTVFDG. Prescribed dose was escalated to 87 ± 10 Gy for PTVprim, 107 ± 20 Gy for PTVFDG, and 117 ± 15 Gy for PTVHX4, with comparable doses to the relevant organs-at-risk (OAR). Treatment plans are available online (

Conclusions: Dose escalation based on metabolic sub-volumes, hypoxic sub-volumes and the entire tumour is feasible. Highest dose was achieved for hypoxia plans, without increasing dose to OAR. For most patients, boosting the metabolic sub-volume also resulted in boosting the hypoxic volume, although to a lower dose, but not vice versa.

Keywords: Dose painting; FDG; HX4; NSCLC; Positron emission tomography; Radiotherapy.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Carcinoma, Non-Small-Cell Lung / diagnostic imaging
  • Carcinoma, Non-Small-Cell Lung / pathology
  • Carcinoma, Non-Small-Cell Lung / radiotherapy*
  • Cell Hypoxia
  • Female
  • Humans
  • Lung Neoplasms / diagnostic imaging
  • Lung Neoplasms / pathology
  • Lung Neoplasms / radiotherapy*
  • Male
  • Middle Aged
  • Positron-Emission Tomography / methods*
  • Radiotherapy Dosage
  • Radiotherapy Planning, Computer-Assisted / methods