The document discusses the incidence, mortality, and survival rates of lung cancer, emphasizing the importance of advanced treatment modalities like stereotactic body radiation therapy (SBRT) for patients with early-stage non-small cell lung carcinoma (NSCLC). It highlights detailed findings from various studies on treatment effectiveness, local control rates, and patient demographics, suggesting SBRT as a minimally toxic yet potent therapy compared to traditional methods. The conclusion advocates for SBRT's emerging role in the standard care of medically inoperable patients and suggests future research directions comparing SBRT with surgery.

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