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This study evaluated a risk-adapted, dose-optimized esophagus-sparing (ES) strategy designed to reduce ARIE while maintaining adequate target coverage in high-risk patients.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Eighty patients with lung cancer treated with definitive TRT between May 2023 and January 2025 were enrolled. The injury-effective esophagus (IEE) was defined as the local high-risk esophageal segment consisting of the central-IEE and an additional 2-cm superior and inferior cranio-caudal expansion. The central-IEE encompassed all axial levels where PTV\u2013esophagus overlap was present, and the ES region was contoured as the portion of the IEE outside the PTV. Based on the degree of PTV\/central-IEE overlap (&lt;\u20091\/3, 1\/3\u20132\/3, &gt;\u20092\/3), the ES mean dose was constrained to 1\/3, 1\/2, and 2\/3 of the prescribed dose, respectively. ARIE was graded using Radiation Therapy Oncology Group (RTOG) criteria. Progression-free survival (PFS) was defined from initiation of the TRT to progression or death; overall survival (OS) was also evaluated.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 80 high-risk patients with the esophagus located within 5\u00a0mm of the clinical target volume (CTV), ARIE occurred in 24 patients (30.0%), including only one Grade 3 event and no Grade\u2009\u2265\u20094 toxicity. For contextual reference, the incidence of any-grade ARIE in a pre-ES historical benchmark cohort was 76.5%. In a paired dosimetric comparison of 10 cases, the ES strategy reduced esophageal dose exposure, particularly within the ES region, while substantially preserving target coverage and maintaining acceptable organ at risk (OAR) constraints. Exploratory univariable analyses suggested associations between ARIE and concurrent chemo-immuno-radiation therapy (CIRT), the geometric extent of the ES region, higher esophageal dose exposure, and failure to pass the ES-plan. Survival outcomes were descriptive only.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>This risk-adapted, dose-optimized segmental ES strategy appears feasible and may reduce clinically relevant ARIE with broadly preserved target coverage. Prospective validation is warranted.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s13014-026-02880-3","type":"journal-article","created":{"date-parts":[[2026,6,23]],"date-time":"2026-06-23T15:26:33Z","timestamp":1782228393000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["A risk-adapted, dose-optimized esophagus-sparing radiation therapy technique for high-risk patients with lung cancer: feasibility, dosimetry, and acute esophageal toxicity"],"prefix":"10.1186","volume":"21","author":[{"given":"Jia-Qi","family":"Huang","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shu-Yan","family":"Li","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Huan","family":"Li","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jing-Jing","family":"Cao","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jia-Yi","family":"Chen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wei-Xiang","family":"Qi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sheng-Guang","family":"Zhao","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,6,23]]},"reference":[{"key":"2880_CR1","doi-asserted-by":"publisher","first-page":"187","DOI":"10.1016\/S1470-2045(14)71207-0","volume":"16","author":"JD Bradley","year":"2015","unstructured":"Bradley JD, Paulus R, Komaki R, et al. 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