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Stereotactic Radiosurgery for Lung Cancer

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Robert Sinha, M.D., Radiation Oncologist .Western Radiation Oncology - Dorothy Schneider Cancer Center - 2013 Mills-Peninsula Health Services Cancer Symposium

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Stereotactic Radiosurgery for Lung Cancer

  1. 1. Robert Sinha, M.D. Radiation Oncologist Western Radiation OncolgyDorothy Schneider Cancer Center
  2. 2.  Incidence: Estimated 226,160 new cases in 2012 Mortality: Estimated 160,340 deaths in 2012
  3. 3. Stage TNM 5-yr OS Literature** IA-IB T1-T2N0M0 60-80% IIA-IIB T1-T2N1M0 25-50% IIIA T3N0-N1 or T1- 10-40% 3N2 IIIB Any T4 or any N3 5% IV M1=distant mets <5%**John D. Minna, Neoplasms of the Lung, in Harrison’s Principles of Internal Medicine, pt. 5§ 75, at 506-515 (Dennis L. Kasper, M.D. et al., eds, 16th ed 2005).Survival: Only 15-20% of all lung cancer patients (all stages) willbe alive 5 years after dx
  4. 4.  Palliation of symptoms for advanced disease  Brain and bone mets, local symptoms Curative Intent in Stage IIIA and IIIB disease  5 year survival rates of 10 to 30% Curative Intent for medically inoperable patients  Local control with traditional radiotherapy: 25-30%%  New techniques like SBRT have local control ~ 90%
  5. 5. Step 1: Conventional simulator: diagnostic quality xrays to design fields Step 2: Fabricate custom cerrobend blocks Step 3: Perform Dose CalculationsTypical radiationportal for lung cancer Step 4: Treat patient on linac with mounted blocks
  6. 6.  CAT scan based planning 3 Dimensional conformal Therapy IMRT – Intensity Modulated Radiotherapy IGRT – Image Guided Therapy
  7. 7. • Accuracy• Less side effects – normal tissue sparing• Dose escalation (60Gy to 70-74Gy)
  8. 8.  Target definition Target Motion  Respiratory motion/tracking Normal tissue tolerance/Increasing dose  Conventional XRT limited to 70Gy Duration of therapy  6 to 7 weeks for conventional therapy is difficult for medically inoperable patients
  9. 9. Stereotactic Body Radiosurgery (SBRT): The Ultimate “Targeted Therapy” Highly focused radiation concentrated on the tumor – with sub-millimeter accuracy Continuous tumor tracking – via respiratory gating Typically 5 or less treatments– high dose per treatment Biologic Equivalent doses greater than 120Gy at 2Gy/fx
  10. 10. Treatment Planning PET-CT scans Time of Flight PET/CT
  11. 11. 14 Institutions in Japan from 1993 to 20033yr OS 69% when BED>100 Gy3yr OS for “operable” patients = 81% when BED> 100
  12. 12. IAIB
  13. 13. Scandinavian Study:Baumann, P. et al. J Clin Oncol; 27:3290-3296 2009•57 patients•Median age 75•90% inoperable due to COPD/CAD•30% T2; 51% T1b; 19% T1a•Dose: 45Gy in 3 fxs (BED 113)•Local control at 3yrs = 93%•Distant mets at 3yrs = 16%•Overall survival @ 3yrs = 60%•DSS @ 3yrs = 88% Copyright © American Society of Clinical Oncology
  14. 14. RTOG 0236:• 59 patients• Median age 72• All pts inoperable•T1 – 80%; T2- 20%•Dose: 60Gy in 3 fxs (BED 180)Median FU 3 yrs:•Local control = 97.6%•Distant mets = 22.1%•Overall survival @3yrs = 55.8%•Median survival = 48 months
  15. 15. • Lancet 2012• 676 Patients, single institution• Stage I and II patients• 3 year survival 56%• Median survival: 41 months• Local Control @5yrs – 90%• Distant mets@5yrs – 20%
  16. 16. Local Control for Primary NSCLC by Dose Fractionation SchemesReference BED LC% 3yr OSRTOG 72 15%RTOG 84 24% 32%Bauman 113 >90% 60% Historical SurgicalOnishi 100 >85% 80% Survival Stage I NSCLC 50-80%Timmerman 180 >95% 56%Emami 228 >95%JCOG 0403 100 86% 76%
  17. 17. DEMOGRAPHICS & HISTOLOGY 76 yo Female, 1 month non-productive cough, mass on CXR CT and PET show no other areas of disease Histology: Poorly differentiated non-small cell lung carcinoma with squamous features . PET/CT staged as cT1N0M0 stage grouping IACLINICAL HISTORY: Referred by: Pulmonologist Previous Treatment: None Multiple medical co-morbidities (FEV1=1.12)
  18. 18. PreOp CT and Fiducial Placement: 1.0 mm CT slices with 1.5x2.0x2.1 cm tumor4 fiducials are placed within and near the tumor
  19. 19. NSCLC Left Upper LungTREATMENT PLANNING:• Axial, sagittal and coronal planning images showing the tumor, lung parenchyma and isodose curves TREATMENT DETAILS: • Rx Dose & Isodose: 60 Gy to 71%, 3 fractions QOD. • Tumor volume = 13.85 cc • Conformity Index (PIV/TV) = 1.37
  20. 20. RESULTS:• Near CR on CT 12 weeks post-treatment, PET negative at 3 months• PFTs unchanged at 3 months• Patient is NED at 3 years 3 months post Pre-treatment treatment
  21. 21. Demographics:• 67 yo s/p GTR resection 18 months prior, CAD & FEV1=1.13• Patient refused surgery after previous RML surgery
  22. 22.  Rx 54 Gy to 85% isodose in 3 fractionsPre-Treatment 1 mo post-CK 2 mo post-CK 6 mo post-CK• Stable PFT’s & negative PET/CT >24 months afterSBRT
  23. 23. Rusthoven, K. E. et al. J Clin Oncol; 27:1579-1584 2009•38 patients with 63 lesions•Dose: 48 to 60Gy in 3fxs•Tumor volume included ITV, i.e. totalmigration of tumor•Local control at 2yrs = 96%•Median survival = 19 mo.•Grade 3 toxicity 8% (almost all skin)•1 case of symptomatic pneumonitis Pre - tx Post txFig 1. Images from a right lower lobe (RLL) lesion before and after stereotactic body radiation therapy (SBRT) Copyright © American Society of Clinical Oncology
  24. 24. Fig 2. Actuarial local control in assessable patients Rusthoven, K. E. et al. J Clin Oncol; 27:1579-1584 2009Copyright © American Society of Clinical Oncology
  25. 25.  Systemic therapies are improving, prolonging survival But, systemic therapy still can’t durably control GROSS DISEASE (perhaps never will) Residual disease can “re-seed” SBRT: A minimally toxic yet potent local therapy to consolidate all gross disease
  26. 26.  SBRT is emerging as the new “standard of care” for medically inoperable early stage NSCLC patients Early data suggest that it may also achieve high local control and survival rates in operable patients SBRT is a promising treatment modality for patients with oligiometastatic dz to the lung.
  27. 27.  Randomized comparison of Surgery vs SABR for operable patients  ACOSOG Z4099/RTOG 1021 – Wedge vs SABR  STARS Trial – Lobectomy vs SABR for Stage I Can adjuvant systemic therapy improve outcomes for early stage inoperable patients?  CALGB/RTOG – SABR +/- chemo for 2-5cm T1 tumors

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