Reducing heart dose with protons and cardiac substructure sparing for mediastinal lymphoma treatment

Kekoa Taparra, Scott C. Lester, W. Scott Harmsen, Molly Petersen, Ryan K. Funk, Miran J. Blanchard, Phillip Young, Joerg Herrmann, Ashley Hunzeker, Heather Schultz, Cynthia McCollough, Alexandria Tasson, Shuai Leng, James A. Martenson, Thomas J. Whitaker, Eric Williamson, Nadia N. Laack

Research output: Contribution to journalArticlepeer-review


Purpose: Electrocardiogram-gated computed tomography with coronary angiography can be used for cardiac substructure sparing (CSS) optimization, which identifies and improves avoidance of cardiac substructures when treating with intensity modulated radiotherapy (IMRT). We investigated whether intensity modulated proton therapy (IMPT) would further reduce dose to cardiac substructures for patients with mediastinal lymphoma. Patients and Methods: Twenty-one patients with mediastinal lymphoma were enrolled and underwent electrocardiogram-gated computed tomography angiography during or shortly after simulation for radiotherapy planning. Thirteen patients with delineated cardiac substructures underwent comparative planning with both IMPT and IMRT. Plans were normalized for equivalent (95%) target volume coverage for treatment comparison. Results: Thirteen patients met criteria for this study. The median size of the mediastinal lymphadenopathy was 7.9 cm at the greatest diameter. Compared with IMRT-CSS, IMPT-CSS significantly reduced mean dose to all cardiac substructures, including 3 coronary arteries and 4 cardiac valves. Use of IMPT significantly reduced average whole-heart dose from 9.6 to 4.9 Gy (P,.0001), and average mean lung dose was 9.7 vs 5.8 Gy (P,.0001). Prospectively defined clinically meaningful improvement was observed in at least 1 coronary artery in 9 patients (69%), at least 1 cardiac valve in 10 patients (77%), and whole heart in all 13 patients. Conclusions: For patients with mediastinal lymphoma, IMPT-CSS treatment planning significantly reduced radiation dose to cardiac substructures. The significant improvements outlined in this study for proton therapy suggest possible clinical improvement in alignment with previous analyses of CSS optimization.

Original languageEnglish (US)
Pages (from-to)1-12
Number of pages12
JournalInternational Journal of Particle Therapy
Issue number1
StatePublished - Jun 1 2021


  • Cardiac substructure sparing
  • Cardio-oncology
  • IMPT
  • Mediastinal lymphoma
  • Protons

ASJC Scopus subject areas

  • Atomic and Molecular Physics, and Optics
  • Radiology Nuclear Medicine and imaging


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