1 PY Bondiau PhD. MD. Centre Antoine Lacassagne. Nice. France High Precision Radiotherapy Cyclotron/Cyberknife The management of lung cancer: from 3D to

1

PY Bondiau PhD. MD.

Centre Antoine Lacassagne. Nice. France

High Precision Radiotherapy

Cyclotron/Cyberknife

The management of lung cancer: from 3D to SBRT

EFEC 18/05/11

2

PlanPlan

• Introduction : – RT2-D– Definition SBRT (History)

• Technics and results– 3-D Linac– Rotational Radiotherapy– SBRT linac– Vero– Cyberknife

• Conclusion



• Conclusion

RT3D

SBRT

TechniquesResultsT1 lung cancer

3

PlanPlan



• Conclusion



• Conclusion

RT3D

SBRT

Techniques

4

From 2-D to 3-D [1] 2-D planning era.From 2-D to 3-D [1] 2-D planning era.

– Surgical resection of stage I (T1-2, NO) NSCLC

• 5 year survival rates 60-70%

– Patients medically inoperable treated RT2-D

• Field of irradiation :– primary tumor and regional lymphatics in the ipsilateral

hilum and mediastinum.

– poorly tolerated (with limited pulmonary reserve).

• In a report from the Netherlands, limited “postage stamp”

– Limitations:

• in visualizing the target => difficult to reduce high dose

volume

• selection of beam directions,

• computational algorithms describing deposited dose.

– Surgical resection of stage I (T1-2, NO) NSCLC

• 5 year survival rates 60-70%

– Patients medically inoperable treated RT2-D

• Field of irradiation :– primary tumor and regional lymphatics in the ipsilateral

hilum and mediastinum.

– poorly tolerated (with limited pulmonary reserve).

• In a report from the Netherlands, limited “postage stamp”

– Limitations:

• in visualizing the target => difficult to reduce high dose

volume

• selection of beam directions,

• computational algorithms describing deposited dose.

5

Result of 2-DResult of 2-D

• Duke experience 1980 1995

• 156 patients with Stage I medically inoperable

• non-small–cell lung cancer

• T1N0 54%, T2N0 46%

• Target– Median dose 64 Gy (50 to 80 Gy)– median size 3 cm (range 0.5 to 8)

• Overall survival – The 2- and 5-year was 39% and 13%

• Studies of dose escalation are warranted !

• Duke experience 1980 1995

• 156 patients with Stage I medically inoperable

• non-small–cell lung cancer

• T1N0 54%, T2N0 46%

• Target– Median dose 64 Gy (50 to 80 Gy)– median size 3 cm (range 0.5 to 8)

• Overall survival – The 2- and 5-year was 39% and 13%

• Studies of dose escalation are warranted !

6

PlanPlan

• Introduction : – RT2D– Definition SBRT (History)


• Conclusion



• Conclusion

RT3D

SBRT

TechniquesResultsT1 lung cancer

7

Revolution of 3-DRevolution of 3-D

• Due to CT scan– EMI 1972

• Possibility to multi slice

• 2-D to 3-D

• Due to CT scan– EMI 1972

• Possibility to multi slice

• 2-D to 3-D

CONTOUR:CONTOUR: - Manual - Manual

- Automatic- Automatic

VOLUMES DEFINITIONVOLUMES DEFINITION

GTVGTV CTVCTV PTVPTV VTVT VIVI

Beam ABeam A Beam BBeam B

Beam CBeam C

PTV

8

Patient

= ?

Contention

MEPTransfert

ContouringBalistic definition

DosimetryDRR

DosimetricCT scan

Mod

ifica

tions

?

9

Multileaf CollimatorMultileaf Collimator

Collimator

SourceMLC

10

From 2-D to 3-D: beamsFrom 2-D to 3-D: beams

11

RT2-D vs RT3-D M.D. Anderson (2005)RT2-D vs RT3-D M.D. Anderson (2005)

• Materials/Methods: – 200 patients stage I radiotherapy alone– 85 pts 3-D conformal radiotherapy

• T1N0 64%, T2N0 36%, squamous cell carcinoma 46%, non-squamous histology 54%

• median dose 66 Gy (45–90.3 Gy), median follow-up 19 months (3–77 months)

– 115 pts 2-D group: median age 69 (range 44–88)


• median dose 64 Gy (40–74 Gy), median follow-up 20 months (1–173 months)

• Materials/Methods: – 200 patients stage I radiotherapy alone– 85 pts 3-D conformal radiotherapy


• median dose 66 Gy (45–90.3 Gy), median follow-up 19 months (3–77 months)

– 115 pts 2-D group: median age 69 (range 44–88)


• median dose 64 Gy (40–74 Gy), median follow-up 20 months (1–173 months)

2-year 5-year p

Overall survivals

3D 68% 36%

2D 47% 10% 0.001

Disease-specific survivals

3D 83% 68 %

2D 62% 29 % 0.008

Local-regional control rates

3D 77% 70%

2D 53% 34% 0.0006

12

Dose escalationDose escalation

• Hayman (University of Michigan)

• 104 patients with stages I-III treated by 3-DRT

• Dose escalation as high as 102.9 Gy with acceptable

toxicity. – 53 patients had disease progression

• 52% failing distantly

• 8% failing both distantly and PTV

• 2% failing in a distant site, the PTV and a nodal region outside the PTV

• 35% failing within the PTV alone.

• Hayman (University of Michigan)

• 104 patients with stages I-III treated by 3-DRT

• Dose escalation as high as 102.9 Gy with acceptable

toxicity. – 53 patients had disease progression

• 52% failing distantly

• 8% failing both distantly and PTV

• 2% failing in a distant site, the PTV and a nodal region outside the PTV

• 35% failing within the PTV alone.

13

Defining stereotactic body radiotherapy [1] Defining stereotactic body radiotherapy [1]

• Historical Developpement

– Lars Leksell Gammaknife

– Radiosurgery (1 fraction)

– 1967 Stockholm Karolinska Institut

• Radiosurgery

– High precision RT

– >100 converging mini-beam

– Target : 3 cm max

– millimetric accuracy

– Image matching PET/MRI and CT

– Mechanical accuracy => only intra cranial

• Historical Developpement

– Lars Leksell Gammaknife

– Radiosurgery (1 fraction)

– 1967 Stockholm Karolinska Institut

• Radiosurgery

– High precision RT

– >100 converging mini-beam

– Target : 3 cm max

– millimetric accuracy

– Image matching PET/MRI and CT

– Mechanical accuracy => only intra cranial

14

Defining stereotactic body radiotherapy [2]Defining stereotactic body radiotherapy [2]

• Beams– From cobalt 60 (gammaknife)

• Specific collimators– Conventional linac

• Specific collimator or multileaf– Dedicated linac (novalis, CK)

• Specific collimator or multileaf

• Raise of image processing matching tools– Integrated image system– Automatic matching

• Real Image = T ( DRR )

• movement = T ( table or device )

• Image processing accuracy replace mechanical accuracy

• Emergence of extra cranial indication

• Multiple fractions

• Beams– From cobalt 60 (gammaknife)

• Specific collimators– Conventional linac

• Specific collimator or multileaf– Dedicated linac (novalis, CK)

• Specific collimator or multileaf

• Raise of image processing matching tools– Integrated image system– Automatic matching

• Real Image = T ( DRR )

• movement = T ( table or device )

• Image processing accuracy replace mechanical accuracy

• Emergence of extra cranial indication

• Multiple fractions

TT

II JJ

15

Conventional RT

Conventional RT

70

RadiosurgeryRadiosurgery SBRTSBRT

?

Accuracy < cmAccuracy < cm

multiple fractionsmultiple fractions

Accuracy < mmAccuracy < mm

unique fractionunique fraction

Accuracy < mmAccuracy < mm

multiple fractionsmultiple fractions

16

PlanPlan


• Technics and results– 3D Linac– Rotational Radiotherapy– SBRT linac– Vero– Cyberknife

• Conclusion


• Technics and results– 3D Linac– Rotational Radiotherapy– SBRT linac– Vero– Cyberknife

• Conclusion

RT3D

SBRT

Techniques

17

Rotational radiotherapy [2]: TomotherapyRotational radiotherapy [2]: Tomotherapy

• FDA agreements for HI-ART in 2003

• Statif of 85 cm de diameter

• TomoHD

– TomoHD is a Hi-ART system

packageant

– new linac

– New detector

– Etc…

– system Hi-ART (2009) can be up

graded in TomoHD

– Mobile thomotherapy installed

in a truck

• FDA agreements for HI-ART in 2003

• Statif of 85 cm de diameter

• TomoHD

– TomoHD is a Hi-ART system

packageant

– new linac

– New detector

– Etc…

– system Hi-ART (2009) can be up

graded in TomoHD

– Mobile thomotherapy installed

in a truck

18

Rotational radiotherapy [3]: VARIAN Rotational radiotherapy [3]: VARIAN

• Rapid’ Arc– On board imager (OBI) and cône beam CT (CBCT)– Image guided radiotherapy– IMRT 360° – treatment time divided by 8 conventional IMRT– Dedicated software (ECLIPSE) or not (VMAT)

• Treatment– OBI and CBCT: positioning of tumor– Image comparision with CT scan– Patient matching– Treatment :1 to 2 rotations of 360°– Continus IMRT (field and intensity)

• Results: publication

• Rapid’ Arc– On board imager (OBI) and cône beam CT (CBCT)– Image guided radiotherapy– IMRT 360° – treatment time divided by 8 conventional IMRT– Dedicated software (ECLIPSE) or not (VMAT)

• Treatment– OBI and CBCT: positioning of tumor– Image comparision with CT scan– Patient matching– Treatment :1 to 2 rotations of 360°– Continus IMRT (field and intensity)

• Results: publication

19

Rotational radiotherapy [5]: ELEKTARotational radiotherapy [5]: ELEKTA

• Same technique as VARIAN Rapid’arc

• VMAT (Volumetric Modulated ArcTherapy).

• Modification of rotation speed, leaf position, and dose debit

• Fraction of 2mn

• Dedicated software ERG or Monaco Vmat

• Same technique as VARIAN Rapid’arc

• VMAT (Volumetric Modulated ArcTherapy).

• Modification of rotation speed, leaf position, and dose debit

• Fraction of 2mn

• Dedicated software ERG or Monaco Vmat

20

PlanPlan


• Technics and results– 3D Linac– Rotational Radiotherapy– Linac SBRT– Vero– Cyberknife

• Conclusion


• Technics and results– 3D Linac– Rotational Radiotherapy– Linac SBRT– Vero– Cyberknife

• Conclusion

RT3D

SBRT

Techniques

21

AXESSE (ELEKTA) AXESSE (ELEKTA)

– Conventional RT and SBRT

– High energy linac (4, 25 MV)

– Isocenter accuracy: < 1 mm

– Multileaf collimator (80 leaf)

– Cone Beam CT »

• Images– 2 XR at 90°

– 2 flat panel (40x40 cm, pxl ? mm²)

– Option VMAT

– Gating ABC « Active Breathing Coordinator »

– Conventional RT and SBRT

– High energy linac (4, 25 MV)

– Isocenter accuracy: < 1 mm

– Multileaf collimator (80 leaf)

– Cone Beam CT »

• Images– 2 XR at 90°

– 2 flat panel (40x40 cm, pxl ? mm²)

– Option VMAT

– Gating ABC « Active Breathing Coordinator »

22

SBRT: Local controlSBRT: Local control

23

Papers Pts Tumors Survival Doses (Gy) Toxicity

Takeda et al

63 (11NoPath)

Stade IA : 38Stade IB : 25

At 3 years :-Stade IA : 90% (p=0,09%)-Stade IB : 63% (p=0,09%)At 5 years without pathology : -Stade IA : 82% (p=0,10%)-Stade IB : 63% (p=0,10%)

50 Gy in 5 fr

Uematsu et al

45 (66 t)

Loc I (IA : 9, IB : 11, IIA : 3Loc II : 26

Rate of de Survival ( ?) : 75 % 30 to 75 Gy in 3 à 15 fr

Timmerman et al

55 Primitives : stade IAbdominal pressure

global Survival at 2 years : 54% 60 to 66 Gy in 3 fr 20% (includes 6 possible grade 5 cases)

Onishi et al

245 Primitives :-Stade IA : 155-Stade IB : 90

SG at 3 years : 56%, at 5 years 47%specific at 3 and 5 years : 78%5 ans survival if BED ≥ 100 Gy : -Stade IA : 90%-Stade IB : 84%

18 to 84 Gy in 1 à 25 fr

5.4% lung1% oesophagitis1.2% dermatitis

Wulf et al 61 Loc I : 20 (IA : 2, IB : 10, IIA (T3) : 8Loc II :51

Primitives : Survival at 1 years : 52% Survival at 5 years : 18%Mets : Survival at 1 years : 85%

26 to 37,5 Gy in 1 à 3 fr

P. Baumann2009

57 Abdominal pressure if neededPeripheral

3 year 60% 45 Gy/3 fr 26% grade 32% grade 4

F.B. Zimmerman

68 Peripheral or central 3 year 53% 24–40 Gy/3–5 fr 6% pneumonitis3% rib fracture

R.C. McGarry

47 Abdominal pressurePeripheral or central

24 Gy/3 fr escalating to 72 Gy/3 fr

11% lung2% pericardial

J.Y. Chang

27 4-D CT planningCentral or superior

40–50 Gy/4 fr 11% grade 2–3 pneumontis/pain

24

Toxicity Toxicity

• Depends Modalities (?)

• Oesophagitis

• Dermatitis

• Pneumonitis

• Rib fracture

• Pericardial

• Chest wall pain

• Depends Modalities (?)

• Oesophagitis

• Dermatitis

• Pneumonitis

• Rib fracture

• Pericardial

• Chest wall pain

25

RTOG 0236 [1]RTOG 0236 [1]

• A Phase II SBRT for Patients with Medically Inoperable Stage I/II Non-Small Cell Lung Cancer

• R. Timmerman JAMA. 2010;303(11):1070-76. – 59 patients T1-T2N0M0 non-small cell tumors (<5 cm) – not allow surgical treatment.– May 2004 to October 2006– data analyzed August 2009– 1 end point: 2-year actuarial primary tumor control– 2 end points: disease-free survival

• 55 evaluable pts with Median

follow-up of 34.4 months

• A Phase II SBRT for Patients with Medically Inoperable Stage I/II Non-Small Cell Lung Cancer

• R. Timmerman JAMA. 2010;303(11):1070-76. – 59 patients T1-T2N0M0 non-small cell tumors (<5 cm) – not allow surgical treatment.– May 2004 to October 2006– data analyzed August 2009– 1 end point: 2-year actuarial primary tumor control– 2 end points: disease-free survival

• 55 evaluable pts with Median

follow-up of 34.4 months

26

RTOG 023 [2]RTOG 023 [2]

• Presented in 51th ASTRO an update of RTOG 0236– Only 1 primary tumor failure

– Estimated 3-year primary tumor control rate: 97.6%.

– Local-regional control rate: 87.2%

– Disease-free survival at 3 years: 48.3%

– Overall survival at 3 years: 55.8%

– median overall survival: 48.1 months.

– Primary tumour control at three years improved from 88 to 98%

• Toxicity– grade 3 in 7 patients (12.7%), grade 4 in 2 patients (3.6%)

• Conclusion– Median survival had not yet been reached (It had not been anticipated that this would happen)

– Patient follow up has been amended from a total of 4 years to include annual follow up

– Possibly be attributed to image-guidance techniques into the SBRT process.

• Presented in 51th ASTRO an update of RTOG 0236– Only 1 primary tumor failure

– Estimated 3-year primary tumor control rate: 97.6%.

– Local-regional control rate: 87.2%

– Disease-free survival at 3 years: 48.3%

– Overall survival at 3 years: 55.8%

– median overall survival: 48.1 months.

– Primary tumour control at three years improved from 88 to 98%

• Toxicity– grade 3 in 7 patients (12.7%), grade 4 in 2 patients (3.6%)

• Conclusion– Median survival had not yet been reached (It had not been anticipated that this would happen)

– Patient follow up has been amended from a total of 4 years to include annual follow up

– Possibly be attributed to image-guidance techniques into the SBRT process.

27

PlanPlan


• Technics and results– 3D Linac– Rotational Radiotherapy– Novalis– Vero– Cyberknife

• Conclusion



• Conclusion

RT3D

SBRT

Techniques

28

Vero [1]Vero [1]

• System launched ESTRO 2010 meeting

• MITSUBSHI and BRAINLAB collaboration

• Combination of versatile imaging capabilities

– real-time tumour tracking –

• Statif of 4.17 m (1.25 m) 11 tons– Linac 6MV,

– micro-multileaf of 60 leafs of 5mm at isocenter.

– Field of 15X15 cm

• O-ring can rotate ±60° about its vertical axis – isocentre accuracy of 0.1 mm.

• System launched ESTRO 2010 meeting

• MITSUBSHI and BRAINLAB collaboration

• Combination of versatile imaging capabilities

– real-time tumour tracking –

• Statif of 4.17 m (1.25 m) 11 tons– Linac 6MV,

– micro-multileaf of 60 leafs of 5mm at isocenter.

– Field of 15X15 cm

• O-ring can rotate ±60° about its vertical axis – isocentre accuracy of 0.1 mm.

29

Vero [2]Vero [2]

• Imaging– Two orthogonal kV attached to the O-

ring at 30 i/s (fluoroscopy)– Cône Beam CT and software «

HYBRID ARC », VERO can do rotational IMRT

– Integrated ExacTrac infrared

• Specific software: BRAINLAB iPLAN

• Systems– 4 Vero in Japan

– 1 European installation : UZ Brussels University Hospital

– 300 patients already treated

• Publicated Results: no

• Imaging– Two orthogonal kV attached to the O-

ring at 30 i/s (fluoroscopy)– Cône Beam CT and software «

HYBRID ARC », VERO can do rotational IMRT

– Integrated ExacTrac infrared

• Specific software: BRAINLAB iPLAN

• Systems– 4 Vero in Japan

– 1 European installation : UZ Brussels University Hospital

– 300 patients already treated

• Publicated Results: no

30

PlanPlan



• Conclusion



• Conclusion

RT3D

SBRT

Techniques

31

1 - Patient Positioning1 - Patient Positioning

• Robotic couch– 3 rotations

– 3 translations

• Numeric X Rays– 2 sources of X Rays with 2 flat

panels at 90°

– Automatic.

– Discontinued

– 41 * 41 cm 1024 *1024 pxl

– Pxl : 0.4 mm²

• Robotic couch– 3 rotations

– 3 translations

• Numeric X Rays– 2 sources of X Rays with 2 flat

panels at 90°

– Automatic.

– Discontinued

– 41 * 41 cm 1024 *1024 pxl

– Pxl : 0.4 mm²

32

33

34

35

36

37

38

39

40

41

42

43

Fiducial or not?

• For small tumor (<1,5cm) near spine/mediastinum : we prefer fiducial– Endoscopic– CT scan

• For small tumor (<1,5cm) near spine/mediastinum : we prefer fiducial– Endoscopic– CT scan

44

Mvt thorax/tumor Mvt thorax/tumor Mvt thorax/tumor Mvt thorax/tumor

X

Y

Z

Diodsthorax

Fiducials

Time

45

46

StudyStudy

• Stage I NSCLC (T1 or T2 N0 M0).

• Histology proven : Only ADK and SCC lesions were included.

• For mets : primitive tumor controlled and slow growing.

• Maximal diameter : 6 cm.

• No other concomitant or postradiation treatment

• Indication of CK : Clinical case discussion

• Exclusion if pulmonary atelectasis, infection or pneumonitisproblem of interpretation

• No MRI if no neurologic symptom

• Stage I NSCLC (T1 or T2 N0 M0).

• Histology proven : Only ADK and SCC lesions were included.

• For mets : primitive tumor controlled and slow growing.

• Maximal diameter : 6 cm.

• No other concomitant or postradiation treatment

• Indication of CK : Clinical case discussion

• Exclusion if pulmonary atelectasis, infection or pneumonitisproblem of interpretation

• No MRI if no neurologic symptom

47

Treatments Treatments

• Millimetric margins

• Tumor tracking during breathing

• CTV=GTV+5mm

• Optical positioning system– « Synchrony » Software

• Treatment time: 45-75 min

• Millimetric margins

• Tumor tracking during breathing

• CTV=GTV+5mm

• Optical positioning system– « Synchrony » Software

• Treatment time: 45-75 min

50-75 Gy5 Fr

60 Gy / 3 F

48

ResultsResults

• Median follow up 18.7 months

• Mean fraction duration 65 min (G4)

• First fraction longer than the others

• Median follow up 18.7 months

• Mean fraction duration 65 min (G4)

• First fraction longer than the others

Nb patient Nb Fr

3 1

78 3

5 4

42 5

49

ResultsResults

• Distant reccurence 62 (46.97%)

• and 31 (23.48%) death

• Local recurrence 18 (13.64%)

• and 8 (6.06%) death

• Distant reccurence 62 (46.97%)

• and 31 (23.48%) death

• Local recurrence 18 (13.64%)

• and 8 (6.06%) death

50

Evaluation at 2 years Evaluation at 2 years ((RECIst criteria)RECIst criteria)Evaluation at 2 years Evaluation at 2 years ((RECIst criteria)RECIst criteria)

During the year : 10 Distant progression,

2 death of other cause, 2 NA

CR 30 %

PR 38 %

ST 18 %

L prg 14 %

During the year : 10 Distant progression,

2 death of other cause, 2 NA

CR 30 %

PR 38 %

ST 18 %

L prg 14 %

86 %86 %86 %86 %

51

CT : Time EvolutionCT : Time Evolution

16/02/07

31/07/07

30/11/07

16/04/08

02/10/08

28/03/07

Matched images

12/03/10

14/09/09

20/09/10

52

PET evolutionPET evolution

24 January 08 05 January 10

Matched images

53

LRI : Results [1]LRI : Results [1]

• Recurrences: – same lobe 88.2% (15) same lung 11.8% (2).

• Recurrences: – same lobe 88.2% (15) same lung 11.8% (2).

Previous treatment

CK treatment

Total

54

Papers Patients Tumor Survival Doses (Gy)

Collins et al 24 Primitives :-Stade I : 15Mets :-Dont 5 CBNPC

A 1 years : Primitives : 87%Mets : 78%

45 to 60 Gy in 3 fractions

Pennathur et al 32 Loc I : 27 ( StI : 11, II : 2, III : 2, IV : 1-Recurence : 11Mets : 5

A 1 year : Primitives :-Stade I-IV : 61%-Stade I : 91%-Recurrence 89 %Mets : 80%

20 Gy in 1 fraction

Christie et al 21 Stade I survival at 1 year : 90% 60 Gy in 3 fractions

W.T. Brown, 59 Peripheral or central 90% free from persistent or recurrent disease

15 to 67.5 Gy/1–5 fractions

van der Voort van Zyp

70 Synchrony respiratory tracking system

2 years 96% (60 Gy) or 78% (45 Gy) 45 or 60 Gy/3 fractions

Bondiau et al 53 (60T) 63% Stage I37% Metastatic lesion

2 years 86% 60 Gy in 3 fr or75 to 60 in 5 fr

Cyberknife resultsCyberknife results

55

Comparison to surgeryComparison to surgery

• International Protocol Phase III

• J. Roth (MD Anderson)

• Randomisation : CK vs

surgery

– T1-2 N0 M0,

– PET?

– Margin discussion 1cm?

– Dose discussion

• International Protocol Phase III

• J. Roth (MD Anderson)

• Randomisation : CK vs

surgery

– T1-2 N0 M0,

– PET?

– Margin discussion 1cm?

– Dose discussion

56

PlanPlan



• Conclusion



• Conclusion

RT3D

SBRT

Techniques

57

Nb beam Positioning Accuracy GTV irradiation DoseResults

LC

RT2D 6 Manual/ laser cm margin 66-70 30 % at 3

years

Conformal 3D 6-16 Manual/ laser cm Margin / Gating 66-70 60-70 % at 2

years

Rotational RT

Tomotherapy

Rapid arc

Vmat

360°

CT

(pxl>1,2mm²)

< cmMargin 66-70

Escalating dose study in progress

Accel/SBRT Novalis

Axess< 20 Beam 2 Xray

< mmGating ? 70-90% at 3

years

Vero Arc/Beam 2 Xray< mm

Tracking ? ? No

Cyberknife >1502 Xray

automatic< mm Tracking

150 Gy

BED

90-95% at 2 years

Compare Surgery

58

Conclusion: SBRT Conclusion: SBRT

• Overall accuracy < 1 mm

• Breaks through in the treatment lung tumor

• Hypofractionation– 1-5 fractions (1 week)

– "Rapid return to normal life"

• Major interest ++ lung tumor Stage 1 ( # surgery) Standard

of care of patient medically inoperable?

++ after pneumonectomy

++ of the re-irradiation capacity : Lung?

Clinical research : stage III boost?

• Overall accuracy < 1 mm

• Breaks through in the treatment lung tumor

• Hypofractionation– 1-5 fractions (1 week)

– "Rapid return to normal life"

• Major interest ++ lung tumor Stage 1 ( # surgery) Standard

of care of patient medically inoperable?

++ after pneumonectomy

++ of the re-irradiation capacity : Lung?

Clinical research : stage III boost?

RTCT 2008on CK-CT scan 2010

CK 2010 RTCT 2008CK 2010

59

Merci

G. ANGELIER (PhD)K. BENEZERY (MD)J. THARIAT (MD)

G. PALAMINI (radiotherapist)B. GRANIER (Secretary)S. MARCHAL (CR) P.Y. BONDIAU (MD. PhD)

Documents

1 PY Bondiau PhD. MD. Centre Antoine Lacassagne. Nice. France High Precision Radiotherapy Cyclotron/Cyberknife The management of lung cancer: from 3D to