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

3. MAJOR CLINICAL TRIALS NO RIB CONSTRAINTS

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%

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

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

12. CHEST WALL CONTOURING 2cm

21. HOWEVER THERE ARE SOME TOXICITIES THAT WE CAN’T AVOID

22. THANK YOU sports