Yoshiya (Josh) Yamada MD FRCPC Department of Radiation Oncology

Why Should My Institution Start a SBRT Program and Steps in Setting Up a Spine SBRT Program

IAEA Singapore SBRT Symposium

Yoshiya (Josh) Yamada MD FRCPCDepartment of Radiation Oncology

Memorial Sloan Kettering Cancer Center

Disclosures

• Varian Medical Systems Consultant• Institute for Medical Education Speakers

Bureau

CONVENTIONAL FRACTIONATIONversus

HYPOFRACTIONATION versus

STEREOTACTIC BODY RADIOSURGERY (SBRT)

1 45

SBRT

5

Number of fractions

Fraction Size

>7 Gy 1.8-2.0 Gy

~35

ConventionalHypofractionation

Biological Rationale

Ablative?? N o r m a l ti s s u e s p a r i n g

Total Dose

~35-50 Gy ~75-85 Gy~50-75 Gy

Why SBRT?

• SBRT is better (tumor control, toxicity)

– Lung– Spine– Liver– Pancreas

Benefits of Image Guided Therapy• Precision of treatment ( Uncertainty)– Increased confidence to:• Reduce: –Margins– Reduce normal tissue exposure– Toxicity

• Biologic Effective Dose– Hypofractionate/ Single Fraction Treatment– Increase absolute dose

• IMPROVE OUTCOMES

4D RT

• Motion management– Lung– Liver– Pancreas– Prostate

• Adaptive RT

Week 1

Week 2

Week 3

Why SBRT?• SBRT is the only option:– Salvage RT:• Spine• H&N

– Lung

Why SBRT?

• SBRT is more efficient:– Prostate 5 fractions vs 48 fractions• SBRT 30 minutes of Linac time vs non SBRT 10 minutes• SBRT 150 minutes of Linac time vs 480 minutes• Brachytherapy requires OR time

– Pancreas 5 fractions vs 28 fractions• SBRT 150 minutes vs 280 minutes

SBRT for Prostate CancerCost

• 5 treatments vs. > 40 treatments• In US: SBRT $20,571 vs IMRT $36,837

CHEAPER

Courtesy Pat Kupelian MD

Why SBRT

• SBRT takes less time:• Patients who live away from center: 1 week away vs one-

two months away– Less impact on quality of life– Less time away from home and family– Less time away from work– Less expense

• Less interruption of chemotherapy treatment schedules

Why SBRT

• The demands of SBRT will raise the performance of department overall

• SBRT requires robust QA program which can be applicable in other department activities– MD– Physics– Therapists

The Ultimate Therapeutic Gain: Spine IGRT

• Improving the therapeutic ratio:

• Multimodality IGRT: The best of both worlds

• Reduce toxicity:

– Significant reduction in volume of volume sensitive toxicity

– Reduce dose to dose sensitive toxicity

• Improve tumor control:

– Tumor dose is critical

– Tumor control at ~ 90% level regardless of tumor phenotype or size

– Greatest therapeutic gain may be for radioresistant disease

Why SBRT Summary• Better tumor control

– Hypofractionation, dose escalation• Less toxicity

– Reduced margins, gating/adaptive RT• Faster

– More efficient• Cheaper• Improve processes throughout department• Provide avenues to establish multidisciplinary relationships• Multidisciplinary academic collaborations

SummarySpine radiosurgery is clinical proof of principle of the IGRT hypothesis↓ Toxicity• IGRT ↓ normal tissue volumes and dose• Clinically significant toxicity is extremely rare↑ Tumor control• High biologic impact of very high dose per

fraction/single fraction radiation• Dose response relationship• Redefining traditional radiobiologic constructs of

radiosensitivityChanged the management of spine tumors at MSKCC

Summary• IGRT:• You can’t always get what you

want…• But you get what you need!• With a little help from your

friends!

IGRT Quality Assurance is Critical

Why SBRT

• SBRT will provide mechanisms for multidisciplinary collaborations– Spine: Neurosurgery/Orthopedic

Surgery/Interventional Radiology/Medical Oncology

– Prostate: Urology-fiducial placement– Lung: Thoracic surgery/interventional radiology:• Fiducial placement

– Liver: Fiducial placement: Interventional radiology, biopsy

The Right Tools

Tools

• Be familiar actual with geometric uncertainties/capabilities of your equipment:– Gantry– Leaves– Table– Imaging uncertainty– Systematic and random errors

The Right People

• Radiation Oncologist• Medical Physicist• Medical Dosimetrist• Radiation Therapist• Other– Allied disciplines: Neurosurgery, Orthopedic

surgery, Interventional Radiology– Nursing

Getting Others Involved

• Familiarize yourself with the medical evidence in all related disciplines

• Encourage collaboration• Multidisciplinary management– Establish Multidisciplinary Treatment Protocols– Clinical Trials/Studies– Multidisciplinary clinics/joint patient

evaluation/assessment

Synergistic Academic Productivity

• Take advantage of individual expertise• Coordinate efforts• Team approach– Group research goals– Common data collection ie MDASI– Common definitions ie NOMS– MSKCC spine service has over 20 peer reviewed

publications in 2012

Learn from Others

• Fellowship training/special extended training• Attend specific meetings/conferences• Spend time with experts– Multidisciplinary• Radiation Oncology• Medical Physics• Allied disciplines

– Visit a high volume experienced center

Learn From Yourself

• Perform SBRT on specific protocols• In house, regional or national studies• Careful QA, chart review, toxicity assessment• Meticulous charting• Prospective database of outcomes

Spine SBRT: Where to Start

• Hypofractionation• Lumbar spine– Easiest to visualize– Easiest to immobilize– No spinal cord, no esophagus,

kidneys and bowel usually relatively distant• Post operative surgical hardware = excellent

fiducial markers

Registration -kVClinical procedure - continued

• Registration tools tightlyintegrated into operation of machine

• Only 1 registration perimage pair (anatomy match) is required

• Sup. / Inf. shifts linked in both images

• Calculated shifts canbe applied directly tocouch

DRR Window

Radiation OncologyJosh Yamada, M.D.

RadiologyEric Lis, M.D.George Krol, M.D.Sasan Karimi, M.D.Pierre Gobin, M.D.Athos Patsilides, M.D.

Orthopedic Surgery

Patrick Boland, M.D.

PhysiatryMichael Stubblefield,M.D.Jonas Sokolof, D.O.Christian Custodio, M.D.PT/OT

NursingJoan Zatcky, NPCynthia Correa, RNRuth Gargan-Klinger, NPJane Yoffe, NPSolange Inglis, NPMarie Marte, NP

NeurosurgeryMark Bilsky, M.D.Ilya Laufer, M.D.

NeurologyEdward Avila, D.O.Xi Chen, M.D.Sonia Sandhu, D.O

PainRoma Tickoo, M.D.Kenneth Cubert, M.D.Vinay Puttaniah, M.D.Amitabh Gulati, M.D.

MSKCC Spine Service

Summary: Steps to Starting Program

• Define program goals• Make it multidisciplinary• Acquire technical capabilities• QA process established• Acquire expertise– Learn from others and your self

• Start from simple and easy (post op lumbar never previously irradiated for hypofractionation)