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

1. Robert Sinha, M.D.
Radiation Oncologist
Western Radiation Oncolgy
Dorothy Schneider Cancer Center

2.  Incidence: Estimated 226,160 new cases in 2012
 Mortality: Estimated 160,340 deaths in 2012

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) will
be alive 5 years after dx

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. Step 1: Conventional simulator:
diagnostic quality xrays to design fields
Step 2: Fabricate custom
cerrobend blocks
Step 3: Perform Dose
Calculations
Typical radiation
portal for lung cancer
Step 4: Treat patient on linac with
mounted blocks

6.  CAT scan based planning
 3 Dimensional conformal Therapy
 IMRT – Intensity Modulated Radiotherapy
 IGRT – Image Guided Therapy

7. • Accuracy
• Less side effects – normal tissue sparing
• Dose escalation (60Gy to 70-74Gy)

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. 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. Treatment Planning PET-CT scans
Time of Flight PET/CT

13. 14 Institutions in Japan from 1993 to 2003
3yr OS 69% when BED>100 Gy
3yr OS for “operable” patients = 81% when BED> 100

14. IA
IB

15. 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

16. 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

17. • 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%

18. Local Control for Primary NSCLC
by Dose Fractionation Schemes
Reference BED LC% 3yr OS
RTOG 72 15%
RTOG 84 24% 32%
Bauman 113 >90% 60%
Historical Surgical
Onishi 100 >85% 80% Survival Stage I NSCLC
50-80%
Timmerman 180 >95% 56%
Emami 228 >95%
JCOG 0403 100 86% 76%

19. 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 IA
CLINICAL HISTORY:
 Referred by: Pulmonologist
 Previous Treatment: None
 Multiple medical co-morbidities (FEV1=1.12)

20. 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

21. NSCLC Left Upper Lung
TREATMENT 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

22. 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

23. Demographics:
• 67 yo s/p GTR resection 18 months prior, CAD &
FEV1=1.13
• Patient refused surgery after previous RML
surgery

24.  Rx 54 Gy to 85% isodose in 3 fractions
Pre-Treatment 1 mo post-CK 2 mo post-CK 6 mo post-CK
• Stable PFT’s & negative PET/CT >24 months after
SBRT

25. 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. total
migration 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 tx
Fig 1. Images from a right lower lobe (RLL) lesion before and after stereotactic body radiation therapy
(SBRT)
Copyright © American Society of Clinical Oncology

26. Fig 2. Actuarial local control in assessable patients
Rusthoven, K. E. et al. J Clin Oncol; 27:1579-1584 2009
Copyright © American Society of Clinical Oncology

27.  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

28.  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.

29.  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