Stereotactic Body Radiation (SABR) principles, application, development and experiences.

1. UK SABR service
development experiences
Maria Hawkins
GenesisCare Consultant Clinical Oncologist
Honorary consultant Clinical Oncologist Oxford University Hospitals NHS FT

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Stereotactic body radiation principles
• Method to deliver a high dose radiation to target
• Single/few fraction treatment
• Rapid dose fall-off
• High precision
• Measures to account for motion
• Goal: tumour ablation
• Concept initially developed in 1951by Lars Leksell
(neurosurgeon!) allowing delivery of a single session of RT for cranial lesions
Int J Radiat Oncol Biol Phys 2004

4. Standard Radiation Therapy
• Delivered 5-6 wks, Mon-Fri
• Low dose RT/day (1.8 – 2Gy)
• Combined with chemo
• Normal tissue can repair
• Acute > Chronic toxicity
• Less Convenient (worse quality of
life)
• Good long term data (level1)
Stereotactic Radiation Therapy
• Delivered over one week
• High RT/day (5-30 Gy)
• No concurrent therapy
• More difficult for normal tissues to
repair the damage
• Chronic > Acute Toxicity
• Better quality of life
• Less data (level3)

5. Stereotactic body radiotherapy SBRT requirements
Highly specialized SBRT specific treatment
delivery systems and complex patient
immobilization
Linear Accelerators equipped with on treatment
imaging systems and conventional patient
immobilization

6. Stereotactic Radiation Requirements• Accurate imaging to define the target in 3D
• CT/4DCT
• MRI/PET
• Motion management/characterization
• Abdominal compression
• Breath hold techniques
• Tracking or gating
• 3D Localization during treatment
• Fiducial markers
• Cone beam CT (CBCT) imaging

7. Adoption of SBRT
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Pan Cancer 2011
Cumulative adoption United states

8. International survey >1000 Radiation Oncologists
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Lewis Am J CO 2015
42%US, 11%=Canada 10% Japan, 7% Western Europe 6% Australia, 3% S Korea

9. Indications for body SBRT-Primary tumours
Stage 1 inoperable lung cancer
Local Control rates >85% at 3 and 5 years dose >100Gy equiv in
2Gy fractions
Hepatocellular carcinoma not suitable for other ablative techniques
Less evidence: cholangiocarcinoma, renal cell carcinoma, pancreatic
cancer
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10. Lung 50Gy/5 fractions

11. The aim of SABR in patients with oligometastases is to:
• achieve local control at the metastatic site and prevent the clinical
sequelae of disease progression at that site
• improve disease free survival with the aim of enabling the patient to
defer systemic therapy, or at least delay time until the next systemic
therapy is required, thus maximising quality of life
• improve overall survival.
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12. Indications for body SBRT- metastatic disease
• Metastatic carcinoma with either a histologically or cytologically proven
primary site or a male patient with a PSA>50 and clinical evidence of
prostate cancer
• 1-3 sites of metastatic disease (defined after appropriate imaging) which can
be treated with stereotactic radiotherapy to a radical radiation dose.
• A maximum of two sites of spinal metastatic disease
• Maximum size of any single metastasis 6cm (5 cm for lung or liver
metastases)
• Disease free interval > 6 months; unless synchronous liver metastases from
colorectal primary (see liver metastases section)
• Not more than three oligometastatic sites treated in total per patient
• Expected life expectancy > 6 months
• Performance status ≤ 2
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13. Paraaortic node Spine pelvic side wall
30Gy/3# 27Gy/3# 30Gy/3#

14. Minimum technology requirements
• Imaging for planning: CT, contrast enhanced CT, MRI, PET, 4DCT
• Planning processed: advanced calculation algorithms, 6MV, beam
profile modelling for small field sizes to be undertaken
• Radiation beam delivery system: small MLC, high dose rate, size of
the mechanical isocenter sphere should be within 1 mm in radius.
• Immobilization of patient (comfortable and rigid), motion management
• Target definition- unambiguous, set-up margins well defined
• Geometric verification: on line imaging and repositioning
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15. Patient selection –MDT team
• Team: clinical oncologist, radiologist, medical physics, radiographer
• Patient selection – meet clinical criteria ?
• Immobilization, planning issues/solutions (tumour close to an organ
at risk, on treatment verification tolerances?
• Peer review of contours and plans
• Toxicity discussions
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Immobilization- abdominal compression

17. Workforce
• A multidisciplinary working party should develop,
implement and maintain the SBRT service
– Additional resources are needed (staffing, training, etc)
– Start with prospective risk assessment and timeline
– Clear documentation and short-term/long-term audit are essential
– Ongoing education is high priority (QA, planning, delivery and
verification technologies and techniques)
– Training in all likely treatment circumstances should be provided

18. Training requirements
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clinician Medical physicist Radiation therapy
technologist
General methods for SBRT Yes Yes Yes
Patient selection yes
Patient immobilization and
accounting for motion
Yes Yes
Imaging acquisition Yes Yes
Target definition yes
Dose planning yes
Dose prescription yes
Treatment delivery yes yes
Toxicity patterns
Follow-up
yes

19. NHS England’s Commissioning through Evaluation
• NHS England’s Commissioning through Evaluation (CtE) programme
enables a limited number of patients to access treatments that are
not funded by the NHS
There are two main phases to the programme
• Phase 1 – an agreed number of patients are recruited to a CtE
scheme within just a few selected centres across England. The
National Institute for Health and Care Excellence (NICE) helps to
identify the total number of patients who need to be recruited to the
scheme to support data analysis
• Phase 2 – the analysis phase will vary in length, depending on the
evaluation measures agreed
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20. SABR available via Commissioning through evaluation
programme
Oligometastic Disease 17 centres
• Barts Health NHS Trust
• Guy’s and St Thomas’ NHS Foundation Trust
• Leeds Teaching Hospitals NHS Trust
• Mount Vernon Cancer Centre (North and East Hertfordshire Foundation Trust)
• Newcastle upon Tyne Hospitals NHS Foundation Trust
• Nottingham University Hospitals NHS Trust
• Oxford University Hospital NHS Trust
• Royal Surrey County Hospital NHS Foundation Trust
• Sheffield Teaching Hospitals NHS Trust
• South Tees Hospitals NHS Foundation Trust
• The Christie NHS Foundation Trust
• The Clatterbridge Cancer Centre NHS Foundation Trust
• The Royal Marsden Foundation Trust
• University College London Hospitals NHS Foundation Trust
• University Hospitals Birmingham NHS Foundation Trust
• University Hospitals Bristol Foundation Trust
• University Hospitals of Leicester NHS Trust
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21. Re-irradiation of pelvis and spine
8 centres
• Barts Health NHS Trust
• Guy’s and St Thomas’ NHS Foundation Trust
• Leeds Teaching Hospitals NHS Trust
• Nottingham University Hospitals NHS Trust
• Mount Vernon Cancer Centre (North and
East Hertfordshire Foundation Trust)
• Oxford University Hospital NHS Trust
• The Royal Marsden NHS Foundation Trust
• University Hospitals Birmingham NHS
Foundation Trust
Hepatocellular carcinoma
7centres
• Barts Health NHS Trust
• Guy’s and St Thomas’ NHS Foundation Trust
• Leeds Teaching Hospitals NHS Trust
• Mount Vernon Cancer Centre (North and
East Hertfordshire Foundation Trust)
• Oxford University Hospital NHS Trust
• The Royal Marsden NHS Foundation Trust
• University Hospitals Birmingham NHS
Foundation Trust
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Potential benefits for SBRT
• Prospective studies proof feasibility and efficacy
• Local control 60-100%
• Favourable toxicity profile
• Non-invasive
• Convenient
• Possibly cost effective

23. SABR implementation
• Audit of toxicity and outcomes key to safe delivery
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Study & Service Evaluation
Prospective SBRT Clinical Outcomes study for metastatic disease GC16-01 (SBRT Mets)
Aim(s):
To prospectively collate clinical indications for SBRT delivered for metastatic disease within GC consortium and to
evaluate clinical patient outcomes for comparison to published literature.
This will require data provision of clinical indications and rationale for SBRT and clinical follow-up of the patient
using standard measurement tools for treatment related-toxicity, local control, patterns of failure, and disease free
survival.
A clinical SBRT proforma form will need to be completed and baseline status recorded.
Following completion of treatment, clinical review of disease control and toxicity will be completed at each follow-
up visit where appropriate at intervals of approximately 1 month, 3 months, 6 months, 9 months, 12 months then 6
monthly thereafter.
GCUK Service Evaluation for SBRT for Metastasis and
Development of a Prospective Database

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Primary Objective for Study 1
• Acute toxicity of SBRT as defined by CTCAE v. 4 treated in this service evaluation.
• Primary endpoint: Grade 2 toxicity at 3 months
Primary Objective for Study 2
• Late toxicity of SBRT as defined by CTCAE v. 4 treated in this service evaluation.
• Primary endpoint: Grade 2 toxicity at 12 months
Secondary Objectives
• To assess deliverability of SBRT and dose constraints achieved compared to published data.
• To evaluate local control of the clinical cohort
• To evaluate time to secondary therapy (DFS)
GCUK Service Evaluation for SBRT for Metastasis and
Development of a Prospective Database

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• Multidisciplinary team effort
• Communication
• Audit of practice, outcomes and technology
Key to success

27. Thank-you
References