CHEST WALL TOXICITY IN SABR : PREDICTORS AND CONTOURING OF CHEST WALL

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CHEST WALL TOXICITY IN SABR : PREDICTORS AND CONTOURING OF CHEST WALL

  1. 1. Chest Wall Toxicity In Stereotactic Ablative Body Radiotherapy (SABR): Current Evidence Dr Vimoj J Nair SABR Fellow Dr Vimoj J. Nair, SABR Fellow, Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
  2. 2. Introduction <ul><li>Despite the increasing popularity of SBRT, concern persists regarding late normal tissue toxicity. </li></ul><ul><li>Reports of increased frequency of rib fracture and chest wall pain after SABR treatment of peripherally located lesions compared to conventionally fractionated therapy </li></ul>
  3. 3. MAJOR CLINICAL TRIALS NO RIB CONSTRAINTS
  4. 4. Incidence of Chest wall Syndrome/Toxicity McKenna RJ, Houck W, Beeman Fuller C. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. The Annals of Thoracic Surgery, February 2006. 81(2):421-426. Modality Incidence Conventional radiotherapy 1-6% Hypofractionated RT [Overgaard et al] 19% SABR Severe chest wall pain 5-33% rib fractures – 2-21% Thoracotomy ~30-50%, VATS None / mild 63% Severe 6%
  5. 5. Chest wall toxicity <ul><li>Dermatologic (erythema, ulceration and fibrosis) </li></ul><ul><li>Chest wall pain </li></ul><ul><ul><li>focal or neuropathic </li></ul></ul><ul><li>Rib fracture </li></ul><ul><ul><li>symptomatic and asymptomatic </li></ul></ul>
  6. 6. Spectrum of CW toxicity CTCAE v 3.0 Grade Short name 1 2 3 4 5 Pain Mild pain not interfering with function Moderate pain, pain or analgesics interfering with function, but not with ADL Severe pain, pain or analgesics severely interfering with ADL Disabling - Fracture Asymptomatic, radiographic findings only (e.g. Asymptomatic rib fracture on plain x-ray, pelvic insufficinecy, fracture on MRI, etc) Symptomatic, but not displaced; immobilization indicated Symptomatic and displaced or open wound with bone exposure; operative intervention indicated Disabling, amputation indicated Death
  7. 7. <ul><li>61% Rib # asymptomatic, revealed ONLY through imaging </li></ul><ul><li>19% of all episodes of CW pain coincided with a documented rib fracture. </li></ul>Andolino et al, IJROBP 2011
  8. 8. <ul><li>CHEST WALL CONTOURING </li></ul>
  9. 9. Studies on chest wall toxicity in SABR CW2cm correlated with toxicity Studies Pros/Retro N chest wall {CW} lesion definition Chest wall Contouring criteria Dose fractionation Median f/u {mths} Chest wall [Toxicity Pain and Fracture] rates Median Time of toxicity {mths} 1 Dunlap et al, Virginia/Colorado, ASTRO 2008, IJROBP 2010 Retro 60 < 2.5 cm from CW OR Dmax >20 Gy CW 3cm 60 Gy/30Fr 11 21% pain and 8% fractures 7.1 2 Voroney et al, Alberta,/PMH J Thor Oncol 2009 Retro 42 NA NA 54-60 Gy /3 Fr NA 21% rib #, 26% CW pain 1.5 to 5% rib . 17 3 Petterssen et al, Sweden, Radiother Oncol, 2009 Retro 33 NA Individual Ribs 45Gy/3Fr 29 13 rib fractures 8.8 4 Welsh et al , MDACC, Astro 2009, IJROBP 2010 Retro 265 (268 TX) NA All soft tissue minus lungs 50Gy/4Fr 10.3 22% pain, 3% fractures 6 5 Stephans et al , Cleveland, IJROBP 2011 Retro 134 NA Unspecified arc of tissues 60Gy/3 18.8 7% chest wall toxicity ; # not reported 8.8 6 Andolino et al, Indiana, IJROBP 2011 Retro 347 [203 CW] CW within ≥ 50% isodose CW3cm + ribs separately 54-60 Gy/ 2-5 Fr 19 CW 21%, NCW 3.5% 10% CW required Prescription 8 7 Mutter et al, MSKCC, NY, 2011 Pros 126 NA CW2cm, CW 3cm compared; 1.2 cm sup/inf 40-60Gy/3-5Fr 16 4% rib #, 51% grade 2 pain 9
  10. 11. CHEST WALL CONTOURING <ul><li>2-cm expansion in the LAT/ANT & POST from the lung edges </li></ul><ul><li>Exclude lung volume, mediastinal soft tissue, and anterior vertebral body </li></ul><ul><li>Include intercostal muscles and exclude other muscles and skin. </li></ul><ul><li>To avoid cumbersome contouring of the entire rib/chest wall, one can define the rib contours arbitrarily within a 3-cm limit from the PTV . </li></ul>
  11. 12. CHEST WALL CONTOURING 2cm
  12. 13. <ul><li>CHEST WALL TOXICITY PREDICTORS AND PARAMETERS: CURRENT EVIDENCE </li></ul>
  13. 14. Studies on chest wall toxicity in SBRT Studies Pros/Retro N chest wall {CW} vs NCW lesion definition Dose fractionation 1 Dunlap et al, Virginia/Colorado, ASTRO 2008, IJROBP 2010 Retro 60 < 2.5 cm from CW OR Dmax >20 Gy 60 Gy/30Fr <ul><li>Volume threshold of 30 cm3 </li></ul><ul><li>Recommended V30Gy < 30cc </li></ul>2 Voroney et al, Alberta,/PMH J Thor Oncol 2009 Retro 42 NA 54-60 Gy /3 Fr <ul><li>Median dose to # site 46-50 Gy </li></ul>3 Petterssen et al, Sweden, Radiother Oncol, 2009 Retro 33 NA 45Gy/3Fr <ul><li>Risk of # : 5% if D2CC =27Gy ; 50% if D2CC = 50Gy </li></ul><ul><li>37 % if V40 Gy > 2cc </li></ul>4 Welsh et al , MDACC, Astro 2009, IJROBP 2010 Retro 265 (268 TX) NA 50Gy/4Fr <ul><li>V30 Gy relevant </li></ul><ul><li>BMI >29 Doubles risk of c/c pain </li></ul>5 Stephans et al , Cleveland, IJROBP 2011 Retro 134 NA 60Gy/3 <ul><li>V30 ≤ 30cc & V60 ≤ 3cc ~ ≤10-15% risk of late chest wall toxicity </li></ul>6 Andolino et al, Indiana, IJROBP 2011 Retro 347 [203 CW] CW within ≥ 50% isodose 54-60 Gy/ 2-5 Fr <ul><li>10% if V30 Gy ≥ 15 cc and V40 Gy ≥ 5cc </li></ul><ul><li>30% risk of toxicity when V30 ≥ 40cc & V40 ≥ 15 cc. </li></ul><ul><li>Dmax >50Gy significant increase in pain and fracture. </li></ul>7 Mutter et al, MSKCC, NY, 2011 Pros 126 < 2.5 cm from CW 40-60Gy/3-5Fr <ul><li>CW2 V30 ≥ 70cc, significant correlation with Grade 2 CW pain </li></ul>
  14. 15. <ul><li>Prospective . 126 pts with primary, clinically node-negative NSCLC received 40–60 Gy / 3-5 # of SBRT </li></ul><ul><li>DVH dosimetry of CW3cm vs CW2cm. </li></ul><ul><li>Results: Median f/u 16 months, the 2-year estimated actuarial incidence of Grade 2 CW pain : 39%. </li></ul><ul><li>Median time to onset of Grade 2 CWpain was 9 months. </li></ul><ul><li>CW2cm consistently enabled better prediction of CW toxicity. </li></ul><ul><li>CW volume receiving 30 Gy (V30) as one of the strongest predictors (p < 0.001). </li></ul><ul><li>Physical dose of 30 Gy was received by >70cc -significant correlation with Grade 2 CW pain (p = 0.004) so keep V30<70cc </li></ul><ul><li>Only 19/126 pts met previous cutoff V 30 <30Gy </li></ul>
  15. 16. VUmc DATA <ul><li>Prospective </li></ul><ul><li>500 pts with T1-2N0 (2003-2009) </li></ul><ul><li>Median f/u 33 Months </li></ul>Chest wall toxicity following risk-adapted stereotactic radiotherapy for early stage lung cancer E. M. Bongers , C. J. Haasbeek , F. J. Lagerwaard , B. Slotman , S. Senan
  16. 18. <ul><li>Results will be presented in ASTRO 2011/IJROBP (in press) </li></ul>
  17. 19. Conclusion <ul><li>Tumor size and distance from chest wall is correlated to risk of chest wall toxicity. </li></ul><ul><li>Contour 2cm expansion upto 3 cm cranio-caudally. </li></ul><ul><li>V30Gy : useful as a guideline for estimating the likelihood of chest wall toxicity </li></ul><ul><ul><li><70cc optimum </li></ul></ul><ul><ul><li><30 cc ??? feasible </li></ul></ul><ul><li>Dmax 50Gy ~ above which pain and fracture increase. </li></ul><ul><li>Longer f/u needed – Late toxicity </li></ul>
  18. 20. CONCLUSION: STRATEGIES FOR CHEST WALL TOXICITY MANAGEMENT <ul><li>Reducing the total tumor dose </li></ul><ul><li>? Risk adapted fractionation/ increase no of Fr </li></ul><ul><li>Increasing the number of noncoplanar beams </li></ul><ul><li>Patient selection is vital </li></ul><ul><li>Tumor coverage and other normal tissue constraints should NOT be compromised. </li></ul>
  19. 21. HOWEVER THERE ARE SOME TOXICITIES THAT WE CAN’T AVOID
  20. 22. THANK YOU sports

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