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Radiation for Lung Cancer
This document discusses the treatment of lung cancer with radiation. Stage I-II lung cancers are typically treated with surgery and sometimes post-operative chemotherapy or radiation. Stage III cancers usually receive chemotherapy and radiation, sometimes followed by surgery. Stage IV cancers are treated with chemotherapy or radiation. Advanced techniques like CT-guided planning, adaptive radiotherapy using daily CT images, and stereotactic body radiation therapy can help target radiation doses precisely to tumors while minimizing exposure to healthy lung tissue. Radiation is generally well-tolerated but can cause short-term effects like cough and long-term effects like fibrosis. Careful treatment planning aims to limit radiation doses to normal lungs.
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Radiation for Lung Cancer
- 1. Radiation for LungCancer Robert Miller MD www.aboutcancer.com
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- 4. The treatment guidelineshave become quite complex
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- 6. Treatment of LungCancer 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,
- 7. In the simulation processthe CT and PET scan images are used to create a computer plan
- 8. The CT imageswill be used to construct three dimensional reconstructions of the patient’s cancer and involved lymph nodes so they can be separated from normal structures
- 9. In the treatment thelasers are used to line up the beam and the patient receives the radiation treatment
- 11. Combine a CTscan and linear accelerator to ultimate in targeting (IGRT) and ultimate in delivery (dynamic, helical IMRT) ability to daily adjust the beam (ART or adaptive radiotherapy)
- 12. Computer generated imagesshowing the radiation beam passing through the patient to hit the small lung cancer
- 13. Computer generated imagesof small lung cancer (in blue) in the left upper lung and the radiation target zone (green) that surrounds it
- 14. Computer generated imagesshowing the volume and dose of normal lung receiving radiation The computer monitors the total lung dose to keep it below a dose level that could cause problems
- 15. Computer generated lung cancer targetin red and radiation zone (yellow) surrounds it
- 16. Computer generated images will show how closethe cancer is to other important structures (like the spinal cord, the heart and the liver, and how much normal lung is near
- 17. Using CT scans the computer can generate thetarget for a cancer in the upper part of the lung
- 18. Using CT scans the computer can generate thetarget for a small cancer growing inside the trachea
- 19. Computer generated images to targetthe tumor
- 20. Tomotherapy images showing the radiationzone in red surrounds the cancer area (in blue) and limits the dose of radiation that hits the normal lung, heart or spinal cord
- 21. 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 lymph nodes to limit the size of the radiation field. See Tomo plan on next slide
- 22. Tomotherapy plan targetsjust the mass, with a small margin. The target was generated from multiple CT images in different breathing cycles to create a 4D (four dimensions including time and generating a larger target that accounts for internal movement (called an ITV)
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- 24. Radiation ‘safe dose’to normal structures
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- 27. Cyberknife for LungCancer
- 28. Commonly Used Dose Regimensfor Radiosurgery
- 29. Maximum ‘safe doses’to normal structures with radiosurgery
- 30. Radiation Results Some lung cancers (like small cell) shrink quickly, other cancers may take weeks or months to slowly regress
- 31. CT = largeleft upper lobe tumor invading the mediastinum CT Scan 3 years later = only scar tissue remains after chemo- radiation
- 32. With smaller cancers,the tumor may be gone by Two Months after Radiation CT-PET Scan
- 33. PET Scans willshow the response to radiation, the tumor should smaller and ‘colder’ on the PET
- 34. Lung cancers shrink slowlyduring the radiation, this picture from the daily Tomotherapy image shows good regression only half way through the course of radiation allowing the radiation targets to be adjusted Adaptive Radiotherapy)
- 35. Using Tomotherapy toTarget Lung Cancer
- 36. Radiation and chemotherapyfor NSCL, the mass may shrink significantly during the course of radiation cancer cancer CT Scan prior to radiation Tomo image after only 19 treatments
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- 38. Daily CT images onTomo will allow for the physician to adjust the radiation target if the cancer changes in size or position
- 39. CT scans will showthe slow shrinkage of non- small cell lung cancer, which can continue to shrink for months after completing radiation
- 40. Large tumors mayshrink 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
- 41. PET Scan afterRadiation
- 42. PET Scan showingcomplete remission of the cancer in the left lung at 7 months
- 43. PET scan showingnear complete remission, 2 months after radiation alone for NSCL
- 44. PET Scan Advanced non- smallcell lung cancer before and 2 months after completing radiation
- 45. PET Scan showingchanges at 1 and 4 months after completing radiation for mediastinal lymph node
- 46. PET Scan 2-09 Adenocarcinoma of the right upper lung, before and 10 months after chemoradiation, 2-10 no longer hot on PET
- 47. Large NSCL ofthe RLL before and 3 months after chemoradiation CT 9-09 PET 9-09 CT 2-10 PET 2-10
- 48. Patient with advancedcancer had pre- operative chemoradiation. At the time of surgery there was no remaining cancer found
- 49. Very large lungcancer, prior to radiation
- 50. PET scan ofthe same patients, 2 years later, there is still a large density in the lung, but it is ‘cold’ on the PET scan, so just radiation fibrosis or scar tissue
- 51. Survival by Stage Stage Clinical 5 Year Pathologic 5 Year IA 60 months 50% 119 month 73% IB 43 43% 81 58% IIA 34 36% 49 46 IIB 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
- 52. Conventional Radiation forStage I and II NSCL Years Over All Cancer Specific Survival Survival 2 years 22 – 72% 54 – 93% 5 years 0 – 42% 13 - 39% Cochrane Database Syst Rev. 2001
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- 54. Radiosurgery Results Cause specific Survival Robert Timmerman IJROBP 2009;75:677 Months
- 55. Radiosurgery Results –Stage I Survival Years
- 56. Side Effects ofLung Radiation
- 57. Side Effects ribs lungs skin nerves heart esophagu s
- 58. 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
- 59. Long Term SideEffects 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.
- 60. CT Scan =Severe COPD
- 61. Many patients whoare smokers have severe damage to their normal lung tissue, making it important to target the radiation carefully and avoid as much ‘normal’ lung as possible
- 62. High dose radiationcan inflame (pneumonitis) or damage (fibrosis) normal lung tissue
- 63. Normal lung thatis hit by the radiation field (pink zone) will be inflamed by radiation (called radiation pneumonitis) these PET scans were done 2 months after completion (there is also volume loss on the left side due to some collapse)
- 64. Same patient at 18months, still volume loss and fibrosis less hypermeta- bolic activity (pneumonitis) and more chronic fibrosis
- 65. Long Term Effectsof Lung Radiation The PET scan shows an excellent response with the cancer gone and a small amount of radiation fibrosis (scar tissue) visible. Notice the lung looks smaller on the left from volume loss
- 66. Side Effects ofLung Radiation The cancer is visible as bright yellow on the first PET scan and the second image shows the radiation zone The third image (PET scan 4 months later) shows the cancer gone, but now there is a strip of abnormal tissue / radiation fibrosis in the posterior lung. It is important to keep the normal lung exposed to radiation as small as possible
- 67. By 7 monthsthe area of scarring or fibrosis is getting smaller and colder on PET
- 68. Radiation Fibrosis CT 9 months afterradiation, corresponding to the high dose radiation field
- 69. Radiation Fibrosis CT 9 months afterradiation, corresponding to the high dose radiation field
- 70. Radiation Fibrosis confinedbetter with SBRT
- 71. Radiation for LungCancer Robert Miller MD www.aboutcancer.com