John Mansueti, MDPRMC Radiation Oncology12 Mar, 2015

10th Annual Lung Cancer Conference

Radiation Oncology

Advances in Radiation Oncology for Lung Cancer

Treatment

DisclosuresDisclosures

None, but always looking!None, but always looking!

ObjectivesObjectives Describe the role of 4-dimension (4-D) CT Describe the role of 4-dimension (4-D) CT

scanning in radiation lung treatment scanning in radiation lung treatment planning.planning.

Describe the two techniques of stereotactic Describe the two techniques of stereotactic body radiation therapy: Non-coplanar body radiation therapy: Non-coplanar Intensity Modulated Radiation Therapy and Intensity Modulated Radiation Therapy and Volumetric Modulated Arc Therapy.Volumetric Modulated Arc Therapy.

Compare the expected local control rates Compare the expected local control rates for early stage lung cancer with SBRT and for early stage lung cancer with SBRT and surgery.surgery.

What is Radiation What is Radiation Therapy?Therapy?

Using ionizing radiation to Using ionizing radiation to achieve lethal damage to target achieve lethal damage to target tissues tissues

The radiation causes lethal breaks The radiation causes lethal breaks in the cells DNAin the cells DNA

Linear Accelerator Linear Accelerator (LINAC)(LINAC)

Delivers high energy X-Rays Delivers high energy X-Rays (photons) or electrons to the (photons) or electrons to the patient’s tumorpatient’s tumor

Our treatment plans try to Our treatment plans try to maximize dose to the tumor while maximize dose to the tumor while minimizing dose to normal tissue minimizing dose to normal tissue

Modern techniques include IMRT, Modern techniques include IMRT, IGRT, SRS, SBRTIGRT, SRS, SBRT

How does a LINAC How does a LINAC WorkWork Microwaves accelerate electrons to extremely Microwaves accelerate electrons to extremely

high speeds and slam them into a metal targethigh speeds and slam them into a metal target High energy x-rays are produced by this collisionHigh energy x-rays are produced by this collision The x-rays are shaped using several methods as The x-rays are shaped using several methods as

they exit the machine to conform to the targetthey exit the machine to conform to the target

Why do we need Why do we need SBRT?SBRT?

LC with SBRT is 92-97%LC with SBRT is 92-97%

Radiation Modality

5-year Overall Survival

Conventional RT 20%

SBRT 42%

Radiother Oncol 2010

ProblemProblem

Lung tumors move a lot with Lung tumors move a lot with respirationrespiration

≈≈40% lung tumors move >0.5cm40% lung tumors move >0.5cm ≈≈10-15% lung tumors move >1.0cm10-15% lung tumors move >1.0cm How can we target a lung tumor How can we target a lung tumor

more accurately with tight margins more accurately with tight margins to minimize toxicity to normal lung?to minimize toxicity to normal lung?

Advanced ImagingAdvanced Imaging

4-D CT scan4-D CT scan 4-D PET/CT4-D PET/CT Cone Beam CTCone Beam CT MRI FusionMRI Fusion

4-D CT Scan4-D CT Scan

Advances in technology have made Advances in technology have made CT scanning much faster and CT scanning much faster and accurateaccurate

Traditional CT scan only images the Traditional CT scan only images the tumor at one point of the breathing tumor at one point of the breathing cyclecycle

Many 3-D CT sets are obtained Many 3-D CT sets are obtained corresponding to a particular corresponding to a particular breathing phasebreathing phase

4D CT4D CT

4-D CT Scan4-D CT Scan

Over-sampling images at every Over-sampling images at every position of interest along the position of interest along the patients axispatients axis

Images are tagged with breathing Images are tagged with breathing signalssignals

Images are sorted retrospectively Images are sorted retrospectively based on corresponding breathing based on corresponding breathing signalsignal

MIPMIP (Maximum Intensity (Maximum Intensity

Projection)Projection) MIP reduces the multiple 3-D CT MIP reduces the multiple 3-D CT

images from a 4-D data set into a images from a 4-D data set into a single 3-D data setsingle 3-D data set

MIP represents the maximum MIP represents the maximum intensity encountered by the intensity encountered by the corresponding voxels in all the corresponding voxels in all the individual 3-D phase image sets individual 3-D phase image sets of the 4-D image set.of the 4-D image set.

MIPMIP

MIPCT Slice

MIPMIP

MIPMIP

Cone Beam CTCone Beam CT

Acquires real-time 3D Acquires real-time 3D images of the patient images of the patient while on the treatment while on the treatment table with a single table with a single rotation of the gantryrotation of the gantry

Patient can be adjusted Patient can be adjusted immediately to align immediately to align tumor targettumor target

Response of tumor to Response of tumor to treatment can be treatment can be monitoredmonitored

Cone Beam CTCone Beam CT

CT-PET/CT FusionCT-PET/CT Fusion

Optimal Radiation Optimal Radiation TreatmentTreatment

Encompass the tumor with a very Encompass the tumor with a very conformal dose conformal dose cloud with cloud with rapid rapid dose fall-offdose fall-off outside your target outside your target

Minimize tumor motion Minimize tumor motion to allow to allow smaller treatment field, thus smaller treatment field, thus minimizing dose to normal tissueminimizing dose to normal tissue

Verify patient positioning with Verify patient positioning with immediate imagingimmediate imaging

Modern TechniquesModern Techniques

IMRT-Intensity Modulated IMRT-Intensity Modulated Radiation TherapyRadiation Therapy

VMAT-Volumetric Arc TherapyVMAT-Volumetric Arc Therapy IGRT-Image Guided Radiation IGRT-Image Guided Radiation

TherapyTherapy SBRT-Stereotactic Body Radio-SBRT-Stereotactic Body Radio-

TherapyTherapy

SBRTSBRT

Advances in hardware Advances in hardware (imaging), software (imaging), software innovation innovation (computational (computational algorithms), and faster algorithms), and faster computer processors computer processors have enable development have enable development of SBRT techniques.of SBRT techniques.

SBRT involves highly SBRT involves highly precise, high dose, short precise, high dose, short course treatments (3-5 course treatments (3-5 fractions)fractions)

SBRT allows precise SBRT allows precise targeting and techniques targeting and techniques to minimize tumor motionto minimize tumor motion

Multiple Treatment Multiple Treatment DirectionsDirections

Highly Conformal DoseHighly Conformal Dose

Critical Structures Critical Structures AvoidedAvoided

RapidArcRapidArc

VMAT (Volumetric Modulated Arc VMAT (Volumetric Modulated Arc Therapy) is a new radiation Therapy) is a new radiation technique using sophisticated technique using sophisticated treatment plan to deliver a treatment plan to deliver a continuous beam (arc) of continuous beam (arc) of radiation as the linear accelerator radiation as the linear accelerator rotates around patientrotates around patient

RapidArcRapidArc

Planning optimization Planning optimization algorithm that algorithm that simultaneously changes simultaneously changes 3 parameters during 3 parameters during treatmenttreatment

Shape of treatment Shape of treatment apertureaperture

delivered dose intensitydelivered dose intensity Speed of gantry rotationSpeed of gantry rotation Treatment time is Treatment time is

very rapidvery rapid

RapidArc Conformal RapidArc Conformal Dose Dose

RapidArc Conformal RapidArc Conformal DoseDose

Patient E.D.Patient E.D.

68 y/o M was found to have a left 68 y/o M was found to have a left sided pulmonary nodule after sided pulmonary nodule after presenting with coughpresenting with cough

Biopsy Lung AdenocarcinomaBiopsy Lung Adenocarcinoma Plan: 4800 cGy in 4 fractions Plan: 4800 cGy in 4 fractions

(1200 cGy per fraction)(1200 cGy per fraction)

Local obliterationLocal obliteration

CT 1-18-12CT 1-18-12 CT 10-20-14CT 10-20-14

Patient A.H.Patient A.H.

78 F had a COPD exacerbation 78 F had a COPD exacerbation and imaging in Jan 2012 revealed and imaging in Jan 2012 revealed RLL noduleRLL nodule

Biopsy: Lung AdenocarcinomaBiopsy: Lung Adenocarcinoma Plan: 5400 cGy in 3 fractions Plan: 5400 cGy in 3 fractions

CT February 2013CT February 2013 CT March2014CT March2014

Patient E.M.Patient E.M.

73 y/o M with hx of LUL NSCLC s/p 73 y/o M with hx of LUL NSCLC s/p resection in 2011 with new RUL resection in 2011 with new RUL 2cm nodule in Jan 2013 (PET hot 2cm nodule in Jan 2013 (PET hot 5.3 SUV)5.3 SUV)

Biopsy caused penumothorax and Biopsy caused penumothorax and path showed atypical cellspath showed atypical cells

Plan: 5000 cGy in 5 fractions Plan: 5000 cGy in 5 fractions (1000 cGy per fraction)(1000 cGy per fraction)

CT 1-8-13CT 1-8-13

CT 7-5-13

SBRT ResultsSBRT Results Phase 2 multicenter study of 59 pts Phase 2 multicenter study of 59 pts

with T1 or T2 inoperable early stage with T1 or T2 inoperable early stage tumors tumors (medical condition precluded resection)(medical condition precluded resection)

3 SBRT treatments 3 SBRT treatments (18Gyx3=54 Gy)(18Gyx3=54 Gy) Local control 97%Local control 97% Local/Regional Control 87%Local/Regional Control 87% 3-year OS 56%3-year OS 56% Median OS 48 monthsMedian OS 48 months

Timmerman et al., JAMA 2010

SummarySummary

Advanced Imaging has revolutionized Advanced Imaging has revolutionized targeting in Radiation Oncologytargeting in Radiation Oncology

Modern radiation techniques have Modern radiation techniques have enabled dose escalation and enabled dose escalation and excellent local controlexcellent local control

SBRT is an excellent option for SBRT is an excellent option for patients who are not surgical patients who are not surgical candidates or refuse surgerycandidates or refuse surgery

QUESTIONS?QUESTIONS?