Incidence and dosimetric parameters for brainstem necrosis following intensity modulated radiation therapy in nasopharyngeal carcinoma

•The incidence of brainstem necrosis after IMRT for NPC patients is largely unknown.•Dose constraint recommendations for brainstem vary.•Brainstem necrosis is rare in NPC.•Current definitive criteria for brainstem dose constraint need to be updated.

ObjectivesTo clarify the incidence of brainstem toxicity and perform a dose-volume analysis for the brainstem after long-term follow-up of a large cohort of nasopharyngeal carcinoma (NPC) patients who underwent intensity-modulated radiation therapy (IMRT).Materials and methodsAll patients with NPC treated with IMRT at Sun Yat-sen University Cancer Center between April 2009 and March 2012 were retrospectively reviewed. A total of 1544 patients with follow-up >12 months and detailed treatment plan data were included. Radiotherapy was administered using the simultaneous integrated boost technique in 2.0-2.48 Gy per fractions/28-33 fractions. Brainstem necrosis was defined as lesions with high signal intensity on T2-weighted images and low signal intensity on T1-weighted images, with or without enhancement after administration of contrast in follow-up MRI.ResultsAfter median follow-up of 79.7 months (range, 12.2-85.6 months), 2/1544 (0.13%) patients developed brainstem necrosis after intervals of 12.3 and 18.5 months. Actuarial incidence of brainstem necrosis was 0.07%, 0.13%, 0.13% and 0.13% after 1, 2, 3 and 5 years, respectively. Overall, 384 (24.9%), 153 (9.9%), 67 (4.3%), 39 (2.5%), 78 (5.1%), and 114 (7.4%) patients had excessive doses of Dmax ≥ 64 Gy, D1 cc > 59 Gy, D2 cc > 59 Gy, aV50 > 5.9 cc, aV55 > 2.7 cc and aV60 > 0.9 cc respectively, of whom only two developed brainstem necrosis.ConclusionsBrainstem necrosis is rare in NPC. The definitive criteria based on conventional radiotherapy cannot accurately predict the occurrence of brainstem necrosis after IMRT, thus more flexible definitive criteria with strict restrictions need to be defined.