Radiation dose to sleep-relevant brain structures linked to impaired sleep quality in primary brain tumor patients

Figures & data

Table 1. Mean PSQI component and global scores and radiation doses to sleep- and wake-related brain structures.

Demographics and clinical characteristics	Value	Dichotomized
Number of participants, N (%)	78 (100)	–
Age (years), mean (SD)	51.53 (15.68)	–
Education (years), mean (SD)	14.44 (3.16)	–
Years since diagnosis, median (range)	6.67 (1–27)	–
Years since radiation therapy, median (range)	4.62 (1–9)	–
Gender, N (%)		–
Male	47 (60)	–
Female	31 (40)	–
Education in years, median (range)	14 (7–20)	–
Employment, N (%)		–
Working	36 (46)	–
Not working due to their illness	22 (28)	–
Retired	20 (26)	–
Karnofsky Performance Score, mean (range)	90 (70–100)	–
Tumor type, N (%)		–
Meningioma	22 (28)	–
Pituitary adenoma	16 (21)	–
Glioma grade I-III	28 (36)	–
Other brain tumors	12 (15)	–
EORTC QLQ-C30, mean (SD)	85.49 (13.22)	–
HADS
Depression	2.86 (3.41)	–
Anxiety	4.21 (3.65)	–
FACIT-Fatigue, mean (SD)	40.55 (9.48)	–
PSQI components	Mean (SD)	N (%)
Subjective sleep quality (poor, >1)	0.76 (0.71)	10 (13)
Sleep onset latency (long, >15 min)	0.94 (0.94)	47 (61)
Sleep duration (short, <7 hours)	0.69 (0.79)	40 (5)
Habitual sleep efficiency (poor, <85%)	0.49 (0.86)	23 (30)
Sleep disturbances (high, >1)	1.10 (0.57)	15 (19)
Use of sleep medication (yes)	0.26 (0.78)	9 (12)
Daytime dysfunction (poor, >1)	0.85 (0.76)	11 (14)
PSQI global score (impaired, >5)	5.13 (3.13)	29 (37)
Radiation dose to brain region (EQD2, Gy)	Mean (SD)
Brainstem	18.09 (14.33)	–
Hypothalamus	23.19 (17.62	–
Thalamus	20.01 (18.75)	–
Pineal gland	18.23 (19.12)	–
Pituitary gland	29.20 (18.62)	–

SD: standard deviation; NOS: not otherwise specified; EORTC QLQ-C30: European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire; HADS: The Hospital Anxiety and Depression Scale; FACIT-Fatigue: Functional Assessment of Chronic Illness Therapy Fatigue Scale; PSQI: Pittsburgh Sleep Quality Index; Gy: Gray.

Table 2. Radiation dose to sleep- and wake-relevant structures in patients with good and poor outcomes on PSQI components and global score.

Brain region	Pittsburgh Sleep Quality Index components and global score
	Component 1 Subj. sleep quality		Component 2 Sleep latency		Component 3 Sleep duration		Component 4 Sleep efficiency		Component 5 Sleep disturbance		Component 6 Sleep medicine		Component 7 Daytime dysfunction		Global PSQI
	Good ≤1 n = 68 (67%)	Poor >1 n = 10 (13%)	Normal ≤15 min n = 30 (39%)	Long >15 min n = 47 (61%)	Normal ≥7 h n = 38 (49%)	Short <7 h n = 40 (51%)	High ≥85% n = 55 (71%)	Low <85% n = 23 (29%)	Low ≤1 n = 63 (81%)	High >1 n = 15 (19%)	No n = 69 (88%)	Yes n = 9 (12%)	No ≤1 n = 67 (86%)	Yes >1 n = 11 (14%)	Unimpaired ≤5 n = 49 (63%)	Impaired >5 n = 29 (37%)
Brainstem
Dmean (Gy)	17.76	20.38	15.32	20.20	18.67	17.54	17.61	19.25	17.75	19.51	18.53	14.71	16.44	28.18	18.14	18.02
SD	14.70	11.89	14.85	13.77	15.01	13.82	14.93	13.02	14.88	12.09	14.17	16	14.04	12.25	15.43	12.51
ES (d)	–0.18		–0.34		0.08		–0.11		–0.12		0.27		–0.85		0.01
95% CI	[–0.85, 0.48]		[–0.80, 0.12]		[–0.37, 0.52]		[–0.60, 0.37]		[–0.69, 0.44]		[–0.43, 0.96]		[–1.50, –0.20]		[–0.45, 0.47]
p Value	.49		.16		.74		.65		.64		.48		.006**		.98
Hypothalamus
Dmean (Gy)	23.32	22.24	23.07	23.73	23.45	22.93	22.05	25.91	23.06	23.73	24.12	15.99	21.04	36.22	22.82	23.79
SD	17.43	19.85	17.11	18.00	18.16	17.32	17.35	18.34	17.00	20.68	18.00	12.97	16.60	18.78	17.11	18.73
ES (d)	0.06		–0.04		0.03		–0.22		–0.04		0.46		–0.90		–0.06
95% CI	[–0.60, 0.73]		[–0.50, 0.42]		[–0.42, 0.47]		[–0.71, 0.27]		[–0.60, 0.53]		[–0.24, 1.16]		[–1.55, –0.24]		[–0.51, 0.41]
p Value	.87		.87		.90		.36		.92		.09		.01*		.82
Thalamus
Dmean (Gy)	21.04	12.99	21.77	19.29	20.31	19.72	18.11	24.55	21.19	15.04	20.67	14.90	18.44	29.58	21.34	17.75
SD	18.80	17.80	16.39	20.21	17.85	19.80	17.48	21.22	18.53	19.52	18.78	18.84	18.59	17.60	17.60	20.69
ES (d)	0.43		0.13		0.03		–0.35		0.33		0.31		–0.60		0.19
95% CI	[0.24, 1.10]		[–0.33, 0.59]		[–0.41, 0.48]		[–0.83, 0.15]		[–0.24, 0.89]		[–0.39, 1.00]		[–1.25, 0.04]		[–0.27, 0.65]
p Value	.19		.56		.90		.21		.28		.39		.046*		.47
Pineal
Dmean (Gy)	19.19	11.77	18.10	18.70	18.72	17.78	16.20	23.10	19.27	13.88	18.65	15.03	16.79	27.02	19.52	16.06
SD	19.43	16.28	17.18	20.46	19.39	19.10	18.37	20.40	19.27	18.49	19.02	20.77	18.78	19.74	18.86	19.69
ES (d)	0.39		–0.03		0.05		–0.36		0.28		0.19		–0.54		0.18
95% CI	[–0.28, 1.05]		[–0.49, 0.43]		[–0.40, 0.49]		[–0.85, 0.13]		[–0.28, 0.85]		[–0.51, 0.88]		[–1.18, 0.10]		[–0.28, 0.63]
p Value	.18		.90		.84		.18		.32		.62		.11		.48
Pituitary
Dmean (Gy)	28.24	36.11	24.54	32.60	30.23	28.33	29.32	29.10	27.39	37.09	29.96	23.81	27.66	38.93	26.11	34.57
SD	18.83	16.30	20.30	16.99	19.30	18.14	19.06	17.91	18.76	16.30	18.13	22.47	18.60	16.25	18.13	18.52
ES (d)	–0.42		–0.44		0.10		0.01		–0.53		0.33		–0.62		–0.46
95% CI	[–1.10, 0.24]		[–0.90, 0.03]		[–0.34, 0.55]		[–0.48, 0.50]		[–1.10, 0.04]		[–0.37, 1.03]		[–1.26, 0.03]		[–0.93, 0.003]
p Value	.13		.08		.64		.96		.048*		.41		.03*		.05

Dmean: mean radiation dose; CI: confidence interval; ES: effect Size; Gy: gray; SD: standard deviation; PSQI: Pittsburgh Sleep Quality Index.

Between-group differences with ESs (d) exceeding ±0.4 corresponding to small to medium differences are highlighted as follows: bold indicates that scores exceeding PSQI subcomponent cutoffs are associated with higher Dmean; italicized indicates that scores not exceeding PSQI subcomponent score cutoffs are associated with higher Dmean.

Statistical significance (unadjusted): *p < .05, **p < .01.

Figure 1. Individual (iDVH) and mean dose volume histograms (DVH) for good (blue) and poor (red) daytime dysfunction across selected brain structures.

Data availability statement

The data that support the findings are available from the corresponding author, AA, upon reasonable request.