1.Radiation for Lung CancerRobert Miller MD www.aboutcancer.com

2. NCCN.org 3. The treatment guidelines have become quite complex 4. NCCN.com 5. Treatment of Lung Cancer StageI and II surgery (if possible)and sometime postOp chemo orradiation (virtually all small cellcancer patients receivechemotherapy) Stage III usually chemo plusradiation, sometime followed bysurgery Stage IV chemo or radiation, 6. In the simulationprocess the CTand PET scanimages are usedto create acomputer plan 7. The CT images will be used to construct threedimensional reconstructions of the patients cancerand involved lymph nodes so they can be separatedfrom normal structures 8. In the treatmentthe lasers areused to line upthe beam and thepatient receivesthe radiationtreatment 9. Combine a CT scan and linear accelerator toultimate in targeting (IGRT) and ultimate indelivery (dynamic, helical IMRT) ability todaily adjust the beam (ART or adaptiveradiotherapy) 10. Computer generated images showing theradiation beam passing through the patient tohit the small lung cancer 11. Computer generated images of small lungcancer (in blue) in the left upper lung and theradiation target zone (green) that surrounds it 12. Computer generated images showing thevolume and dose of normal lung receivingradiationThe computer monitors the total lung dose tokeep it below a dose level that could causeproblems 13. Computergenerated lungcancer target inredand radiationzone (yellow)surrounds it 14. Computergeneratedimages willshow howclose thecancer is toother importantstructures (likethe spinal cord,the heart andthe liver, andhow muchnormal lung isnear 15. Using CTscans thecomputercangeneratethe targetfor acancer inthe upperpart of thelung 16. Using CTscans thecomputercangeneratethe targetfor a smallcancergrowinginside thetrachea 17. Computergenerated imagesto target the tumor 18. Tomotherapyimages showingthe radiation zonein red surroundsthe cancer area (inblue) and limits thedose of radiationthat hits the normallung, heart orspinal cord 19. PET Scan = local tumor. No nodes. These scans are not 100% accurate,but it may be possible to target only the cancer and not include the lymphnodes to limit the size of the radiation field. See Tomo plan on next slide 20. Tomotherapy plan targets just the mass, with a small margin. The target wasgenerated from multiple CT images in different breathing cycles to create a 4D(four dimensions including time and generating a larger target that accounts forinternal movement (called an ITV) 21. Radiation Dose 22. Radiation safe dose to normalstructures 23. Radiosurgery for Cancer 24. Cyberknife 25. Cyberknife for Lung Cancer 26. Commonly Used DoseRegimens for Radiosurgery 27. Maximum safe doses to normal structures with radiosurgery 28. Radiation ResultsSome lungcancers (likesmall cell)shrink quickly,other cancersmay take weeksor months toslowly regress 29. CT = large left upperlobe tumor invadingthe mediastinumCT Scan 3 years later= only scar tissueremains after chemo-radiation 30. With smaller cancers, the tumor may begone by Two Months after RadiationCT-PET Scan 31. PET Scans will show the response to radiation, thetumor should smaller and colder on the PET 32. Lung cancers shrinkslowly during theradiation,this picture from thedaily Tomotherapyimage shows goodregression only halfway through the courseof radiation allowingthe radiation targets tobe adjusted AdaptiveRadiotherapy) 33. Using Tomotherapy to Target Lung Cancer 34. Radiation and chemotherapy for NSCL, the mass may shrink significantly during thecourse of radiation cancer cancerCT Scan prior to radiationTomo image after only 19treatments 35. Tomotherapy Images 36. Daily CT imageson Tomo willallow for thephysician toadjust theradiation target ifthe cancerchanges in size orposition 37. CT scans willshow the slowshrinkage of non-small cell lungcancer, which cancontinue to shrinkfor months aftercompletingradiation 38. Large tumors may shrink slower and the scans may show radiation fibrosis (the PET will no longer be hot if the gray mass is just scar tissue and not active cancer as seen on the pictures on the right)Large NSCL Left Lung PET/CT 6 Months later 39. PET Scan after Radiation 40. PET Scan showing completeremission of the cancer in the leftlung at 7 months 41. PET scan showing near completeremission, 2 months after radiation alone for NSCL 42. PET ScanAdvanced non-small cell lungcancer before and2 months aftercompletingradiation 43. PET Scan showing changes at 1 and 4months after completing radiation formediastinal lymph node 44. PET Scan 2-09Adenocarcinomaof the right upperlung, before and10 months afterchemoradiation,2-10no longer hot onPET 45. Large NSCL of the RLL before and 3 monthsafter chemoradiation CT 9-09PET 9-09CT 2-10 PET 2-10 46. Patient with advanced cancer had pre-operative chemoradiation. At the time ofsurgery there was no remaining cancer found 47. Very large lung cancer, prior to radiation 48. PET scan of the samepatients, 2 years later,there is still a largedensity in the lung,but it is cold on thePET scan, so justradiation fibrosis orscar tissue 49. Survival by StageStage Clinical5 YearPathologic 5 YearIA60 months 50% 119 month 73%IB4343% 8158%IIA 3436% 4946IIB 1825% 3136%IIIA1419% 2224%IIIB107%139%IV6 2%1713% J Thorac Oncol 2007; 2:706 50. Conventional Radiation for Stage I and II NSCLYearsOver AllCancer Specific Survival Survival2 years22 72%54 93%5 years 0 42%13 - 39%Cochrane Database Syst Rev. 2001 51. Cyberknife 52. Radiosurgery ResultsCause specific SurvivalRobert Timmerman IJROBP 2009;75:677Months 53. Radiosurgery Results StageISurvival Years 54. Side Effects of LungRadiation 55. Side Effectsribslungsskinnerves heartesophagus 56. Short Term Side Effects of Lung Radiation (usually start showing up after the second week or radiation) Esophagus sore throat or troubleswallowing Trachea or lungs cough or shortness ofbreath Chest wall tenderness Skin sunburn Fatigue 57. Long Term Side Effects ofLung Radiation, can show upweeks or months aftercompleting radiation Esophagus sometimes there can be prolongedirritation or stricture Lungs there can be scar tissue (fibrosis) that cancause more shortness of breath or a delayed reaction(radiation pneumonitis) with fever, cough andshortness of breath. Symptoms caused by acute radiation pneumonitisusually develop approximately four to twelve weeksfollowing irradiation, whereas symptoms of late orfibrotic radiation pneumonitis develop after six totwelve months. 58. CT Scan = Severe COPD 59. Many patients who are smokers have severedamage to their normal lung tissue, making itimportant to target the radiation carefully andavoid as much normal lung as possible 60. High dose radiation can inflame(pneumonitis) or damage (fibrosis) normal lung tissue 61. Normal lung that is hit bythe radiation field (pinkzone) will be inflamed byradiation (called radiationpneumonitis) these PETscans were done 2 monthsafter completion (there isalso volume loss on theleft side due to somecollapse) 62. Same patient at18 months, stillvolume lossand fibrosis lesshypermeta-bolic activity(pneumonitis)and morechronic fibrosis 63. Long Term Effects of Lung RadiationThe PET scan shows an excellent response with the cancergone and a small amount of radiation fibrosis (scar tissue)visible. Notice the lung looks smaller on the left from volumeloss 64. Side Effects of LungRadiationThe cancer is visible as brightyellow on the first PET scan andthe second image shows theradiation zoneThe third image (PET scan 4months later) shows the cancergone, but now there is a strip ofabnormal tissue / radiation fibrosisin the posterior lung.It is important to keep the normallung exposed to radiation as smallas possible 65. By 7 months the area of scarring or fibrosisis getting smaller and colder on PET 66. RadiationFibrosisCT 9 monthsafter radiation,corresponding tothe high doseradiation field 67. RadiationFibrosisCT 9 monthsafter radiation,correspondingto the highdose radiationfield 68. Radiation Fibrosis confined better with SBRT 69. Radiation for Lung CancerRobert Miller MD www.aboutcancer.com