Radiation for Lung Cancer

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Radiation for Lung Cancer

  1. 1. Radiation for Lung Cancer Robert Miller MD www.aboutcancer.com
  2. 2. NCCN.org
  3. 3. The treatment guidelines have become quite complex
  4. 4. NCCN.com
  5. 5. Treatment of Lung Cancer Stage I and II – surgery (if possible) and sometime postOp chemo or radiation (virtually all small cell cancer patients receive chemotherapy) Stage III – usually chemo plus radiation, sometime followed by surgery Stage IV – chemo or radiation,
  6. 6. In the simulationprocess the CTand PET scanimages are usedto create acomputer plan
  7. 7. The CT images will be used to construct threedimensional reconstructions of the patient’s cancerand involved lymph nodes so they can be separatedfrom normal structures
  8. 8. In the treatmentthe lasers areused to line upthe beam and thepatient receivesthe radiationtreatment
  9. 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. 10. Computer generated images showing theradiation beam passing through the patient tohit the small lung cancer
  11. 11. Computer generated images of small lungcancer (in blue) in the left upper lung and theradiation target zone (green) that surrounds it
  12. 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. 13. Computergenerated lungcancer target inredand radiationzone (yellow)surrounds it
  14. 14. Computergeneratedimages willshow howclose thecancer is toother importantstructures (likethe spinal cord,the heart andthe liver, andhow muchnormal lung isnear
  15. 15. Using CTscans thecomputercangeneratethe targetfor acancer inthe upperpart of thelung
  16. 16. Using CTscans thecomputercangeneratethe targetfor a smallcancergrowinginside thetrachea
  17. 17. Computergenerated imagesto target the tumor
  18. 18. Tomotherapyimages showingthe radiation zonein red surroundsthe cancer area (inblue) and limits thedose of radiationthat hits the normallung, heart orspinal cord
  19. 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. 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. 21. Radiation Dose
  22. 22. Radiation ‘safe dose’ to normalstructures
  23. 23. Radiosurgery for Cancer
  24. 24. Cyberknife
  25. 25. Cyberknife for Lung Cancer
  26. 26. Commonly Used DoseRegimens for Radiosurgery
  27. 27. Maximum ‘safe doses’ to normal structures with radiosurgery
  28. 28. Radiation Results Some lung cancers (like small cell) shrink quickly, other cancers may take weeks or months to slowly regress
  29. 29. CT = large left upperlobe tumor invadingthe mediastinumCT Scan 3 years later= only scar tissueremains after chemo-radiation
  30. 30. With smaller cancers, the tumor may begone by Two Months after Radiation CT-PET Scan
  31. 31. PET Scans will show the response to radiation, the tumor should smaller and ‘colder’ on the PET
  32. 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. 33. Using Tomotherapy to Target Lung Cancer
  34. 34. Radiation and chemotherapy for NSCL, the mass may shrink significantly during the course of radiation cancer cancerCT Scan prior to radiation Tomo image after only 19treatments
  35. 35. Tomotherapy Images
  36. 36. Daily CT imageson Tomo willallow for thephysician toadjust theradiation target ifthe cancerchanges in size orposition
  37. 37. CT scans willshow the slowshrinkage of non-small cell lungcancer, which cancontinue to shrinkfor months aftercompletingradiation
  38. 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. 39. PET Scan after Radiation
  40. 40. PET Scan showing completeremission of the cancer in the left lung at 7 months
  41. 41. PET scan showing near completeremission, 2 months after radiation alone for NSCL
  42. 42. PET ScanAdvanced non-small cell lungcancer before and2 months aftercompletingradiation
  43. 43. PET Scan showing changes at 1 and 4months after completing radiation formediastinal lymph node
  44. 44. PET Scan 2-09 Adenocarcinoma of the right upper lung, before and 10 months after chemoradiation,2-10 no longer hot on PET
  45. 45. Large NSCL of the RLL before and 3 months after chemoradiation CT 9-09 PET 9-09 CT 2-10 PET 2-10
  46. 46. Patient with advanced cancer had pre-operative chemoradiation. At the time ofsurgery there was no remaining cancer found
  47. 47. Very large lung cancer, prior to radiation
  48. 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. 49. Survival by StageStage Clinical 5 Year Pathologic 5 YearIA 60 months 50% 119 month 73%IB 43 43% 81 58%IIA 34 36% 49 46IIB 18 25% 31 36%IIIA 14 19% 22 24%IIIB 10 7% 13 9%IV 6 2% 17 13% J Thorac Oncol 2007; 2:706
  50. 50. Conventional Radiation for Stage I and II NSCLYears Over All Cancer Specific Survival Survival2 years 22 – 72% 54 – 93%5 years 0 – 42% 13 - 39% Cochrane Database Syst Rev. 2001
  51. 51. Cyberknife
  52. 52. Radiosurgery Results Cause specific Survival Robert Timmerman IJROBP 2009;75:677 Months
  53. 53. Radiosurgery Results – StageI Survival Years
  54. 54. Side Effects of LungRadiation
  55. 55. Side Effects ribs lungs skin nerves heartesophagus
  56. 56. Short Term Side Effects of Lung Radiation (usually start showing up after the second week or radiation) Esophagus – sore throat or trouble swallowing Trachea or lungs – cough or shortness of breath Chest wall – tenderness Skin – sunburn Fatigue
  57. 57. Long Term Side Effects of Lung Radiation, can show up weeks or months after completing radiation Esophagus – sometimes there can be prolonged irritation or stricture Lungs – there can be scar tissue (fibrosis) that can cause more shortness of breath or a delayed reaction (radiation pneumonitis) with fever, cough and shortness of breath. Symptoms caused by acute radiation pneumonitis usually develop approximately four to twelve weeks following irradiation, whereas symptoms of late or fibrotic radiation pneumonitis develop after six to twelve months.
  58. 58. CT Scan = Severe COPD
  59. 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. 60. High dose radiation can inflame(pneumonitis) or damage (fibrosis) normal lung tissue
  61. 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. 62. Same patient at18 months, stillvolume lossand fibrosis lesshypermeta-bolic activity(pneumonitis)and morechronic fibrosis
  63. 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. 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. 65. By 7 months the area of scarring or fibrosisis getting smaller and colder on PET
  66. 66. RadiationFibrosisCT 9 monthsafter radiation,corresponding tothe high doseradiation field
  67. 67. RadiationFibrosisCT 9 monthsafter radiation,correspondingto the highdose radiationfield
  68. 68. Radiation Fibrosis confined better with SBRT
  69. 69. Radiation for Lung Cancer Robert Miller MD www.aboutcancer.com

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