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10th Annual Lung Cancer
Conference
Radiation Oncology
Advances in Radiation Oncology
for Lung Cancer Treatment
ohn Mansueti, MD
RMC Radiation Oncology
Mar, 2015
Disclosures
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None, but always looking!
Objectives
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Describe the role of 4-dimension (4-D) CT
scanning in radiation lung treatment
planning.
Describe the two techniques of stereotactic
body radiation therapy: Non-coplanar
Intensity Modulated Radiation Therapy and
Volumetric Modulated Arc Therapy.
Compare the expected local control rates for
early stage lung cancer with SBRT and
surgery.
What is Radiation
Therapy?
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Using ionizing radiation to achieve
lethal damage to target tissues
The radiation causes lethal breaks in
the cells DNA
Linear Accelerator
(LINAC)
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Delivers high energy X-Rays (photons)
or electrons to the patient’s tumor
Our treatment plans try to maximize
dose to the tumor while minimizing
dose to normal tissue
Modern techniques include IMRT,
IGRT, SRS, SBRT
How does a LINAC Work
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Microwaves accelerate electrons to extremely high
speeds and slam them into a metal target
High energy x-rays are produced by this collision
The x-rays are shaped using several methods as
they exit the machine to conform to the target
Why do we need SBRT?
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LC with SBRT is 92-97%
Radiation Modality
5-year Overall
Survival
Conventional RT
20%
SBRT
42%
Radiother Oncol 2010
Problem
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Lung tumors move a lot with
respiration
≈40% lung tumors move >0.5cm
≈10-15% lung tumors move >1.0cm
How can we target a lung tumor more
accurately with tight margins to
minimize toxicity to normal lung?
Advanced Imaging
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4-D CT scan
4-D PET/CT
Cone Beam CT
MRI Fusion
4-D CT Scan
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Advances in technology have made CT
scanning much faster and accurate
Traditional CT scan only images the
tumor at one point of the breathing
cycle
Many 3-D CT sets are obtained
corresponding to a particular breathing
phase
4D CT
4-D CT Scan
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Over-sampling images at every
position of interest along the patients
axis
Images are tagged with breathing
signals
Images are sorted retrospectively
based on corresponding breathing
signal
MIP
(Maximum Intensity Projection)
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MIP reduces the multiple 3-D CT
images from a 4-D data set into a
single 3-D data set
MIP represents the maximum intensity
encountered by the corresponding
voxels in all the individual 3-D phase
image sets of the 4-D image set.
MIP
CT Slice
MIP
MIP
MIP
Cone Beam CT
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Acquires real-time 3D
images of the patient
while on the treatment
table with a single
rotation of the gantry
Patient can be adjusted
immediately to align
tumor target
Response of tumor to
treatment can be
monitored
Cone Beam CT
CT-PET/CT Fusion
Optimal Radiation
Treatment
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Encompass the tumor with a very
conformal dose cloud with rapid
dose fall-off outside your target
Minimize tumor motion to allow
smaller treatment field, thus
minimizing dose to normal tissue
Verify patient positioning with
immediate imaging
Modern Techniques
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IMRT-Intensity Modulated Radiation
Therapy
VMAT-Volumetric Arc Therapy
IGRT-Image Guided Radiation Therapy
SBRT-Stereotactic Body Radio-Therapy
SBRT
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Advances in hardware
(imaging), software
innovation (computational
algorithms), and faster
computer processors have
enable development of
SBRT techniques.
SBRT involves highly
precise, high dose, short
course treatments (3-5
fractions)
SBRT allows precise
targeting and techniques to
minimize tumor motion
Multiple Treatment
Directions
Highly Conformal Dose
Critical Structures
Avoided
RapidArc
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VMAT (Volumetric Modulated Arc
Therapy) is a new radiation technique
using sophisticated treatment plan to
deliver a continuous beam (arc) of
radiation as the linear accelerator
rotates around patient
RapidArc
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Planning optimization
algorithm that
simultaneously changes 3
parameters during
treatment
Shape of treatment
aperture
delivered dose intensity
Speed of gantry rotation
Treatment time is very
rapid
RapidArc Conformal Dose
RapidArc Conformal Dose
Patient E.D.
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68 y/o M was found to have a left
sided pulmonary nodule after
presenting with cough
Biopsy Lung Adenocarcinoma
Plan: 4800 cGy in 4 fractions (1200
cGy per fraction)
Local obliteration
CT 1-18-12
CT 10-20-14
Patient A.H.
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78 F had a COPD exacerbation and
imaging in Jan 2012 revealed RLL
nodule
Biopsy: Lung Adenocarcinoma
Plan: 5400 cGy in 3 fractions
CT February 2013
CT March2014
Patient E.M.
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73 y/o M with hx of LUL NSCLC s/p
resection in 2011 with new RUL 2cm
nodule in Jan 2013 (PET hot 5.3 SUV)
Biopsy caused penumothorax and path
showed atypical cells
Plan: 5000 cGy in 5 fractions (1000
cGy per fraction)
CT 7-5-13
CT 1-8-13
SBRT Results
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Phase 2 multicenter study of 59 pts
with T1 or T2 inoperable early stage
tumors (medical condition precluded resection)
3 SBRT treatments (18Gyx3=54 Gy)
Local control 97%
Local/Regional Control 87%
3-year OS 56%
Median OS 48 months
Timmerman et al., JAMA 2010
Summary
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Advanced Imaging has revolutionized
targeting in Radiation Oncology
Modern radiation techniques have
enabled dose escalation and excellent
local control
SBRT is an excellent option for
patients who are not surgical
candidates or refuse surgery
QUESTIONS?