Conformal Therapy for Lung Cancer

1. Conformal Therapy for Lung Cancer B. Schicker, F.J. Schwab*, U. Götz Institute of Radiotherapy and Radiation Oncology St. Vincenz-Krankenhaus Limburg • *Clinic of Radiotherapy • University of Würzburg

2. Definition INTRODUCTION For lung cancer radiotherapy is an essential treatment mode. The major problem for the treatment planning is the fact that the target volume is surrounded by organs at risk. Acute or late reactions of the lung, the myelon and the heart are dose limiting factors. If curative doses are aspired the old fashioned opposed fields techniques are not applicable because of the high dose load to the organs at risk. Curative doses for lung cancer, however, usually exceed 70 Gy. Therefore conformal treatment techniques have to be developed aiming at the reduction of the normal tissue complication probability and the high tumor control probability.

3. ADJUVANT TREATMENT For local advanced tumor stages the postoperative irradiation of the regional lymphatics and of the bronchial stump is indicated. The mediastinum should always be included in the clinical target volume if involved nodes were found but no systematic lymph node dissection was performed. The supraclavicular lymph nodes are not included in the CTV for adjuvant treatment with curative intent. The involvement of these lymph nodes probably improves local control, whereas the improvement of survival remains questionable. The lymph nodes included in the CTV are: the intrapulmonary, the subcarinal, the tracheobronchial, the paratracheal and the preaortic group. For lower lobe primaries the inclusion of the lymph nodes along the ligamentum pulmonale and the paraesophageal nodes should be considered.

4. Radiotherapydecades ago

5. Conventional Opposed Fields Techniquebased on radiographs

6. Conventional Opposed Fields TechniqueChange from Radiograph to Target Volume Traditional irradiation portals recommended in textbooks for irradiation of lung cancer patients. selected clinical target volume based on the oncological prin-ciples (no inclusion of the supraclavicular and contra-lateral hilar lymph nodes in the CTV for curative RT).

7. first step: precise definiton of the planning target volume based on oncological criteria conformal treatment = precise irradiation of a precisely defined PTV Development of Conformal Treatment Techniques

8. Target Volume for adjuvant treatment Z +8 Z +3 Z +0 Z -2 Z -4 Z -8

9. Definition CONFORMAL RADIOTHRAPY A high dose to the PTV means a high tumour control probability were as a low dose to the normal tissue or organ at risk means a low normal tissue complication probability Low side effects = live quality for the Patient BENEFIT FOR PATIENT

10. Ideal Treatment vs. Reality Dose Distribution Ideal: D(PTV) = 100% D(NT,OAR) = 0% Real: D(PTV) ~ 100% D(NT,OAR) >> 0%

11. Ideal Treatment vs. Reality Dose Volume Histogram Volume [%] Volume [%] Normal Tissue, Organ at Risk 100 100 PTV 100 100 Dose [%] Dose [%]

12. High TCP and low NTCP: high dose within the PTV and a good protection of the OAR Reduction of the dose to the OAR below critical values (tolerance doses) Concentration of the therapeutic dose on the PTV: Dose homogeneity within the PTV (ICRU recommendations -5 % ... +7 %) Aim of the Optimization- minimum requirements -

13. Development of a 3-D Conformal Standard Technique for Lung Cancer From opposed fields to conformal technique => ???

14. Definition • 3 Dimensional Conformal • CT based Treatment planning • Slice distance 1.0 or 0.5 cm • Definition and delineation of PTV and Organ at risk in every slice • using other imaging procedures as MR, PET etc. • Calculation and optimisation of the dose distribution in every CT slice to achieve a homogenous dose distribution

15. Development of a Standard Technique for Lung Cancer PTV Lung Heart Myelon

16. Development of a Standard Technique for Lung Cancer PTV Lung Heart Myelon

17. Development of a Standard Technique for Lung Cancer PTV Lung Heart Myelon

18. Development of a Standard Technique for Lung Cancer PTV Lung Heart Myelon

19. Development of a Standard Technique for Lung Cancer PTV Lung Heart Myelon

20. Development of a Standard Technique for Lung Cancer PTV Lung Heart Myelon

21. Development of a Standard Technique for Lung Cancer PTV Lung Heart Myelon

22. Development of aStandard TechniqueStandard Beam Set up • - Isocenter – placed at the ventral tip of the vertebral body • - easy to find uneder X-Ray controll from 0° and also 90° gantry angle

23. Development of aStandard TechniqueStandard Beam Set up Aim of Field 1 is to spare a maximum volume of both lungs

24. F1 0°

25. Development of aStandard TechniqueStandard Beam Set up The gantry angle and blocking of field 2 (135°) was chosen to protect the myelon

26. F2 135°

27. Development of aStandard TechniqueStandard Beam Set up Field 3 (40°) reduce the high dose regions in the left lung and contribute to a better adaptation of the isodoses to the PTV

28. 3 fields: 0° fixed wedge (lung) ~ 140° fixed wedge (myelon) 40° ... 80° fixed or arc, wedge ? (heart, contralateral lung, myelon) start with dose contribution 1 : 1 : 1 field shaping using beams eye view good protection of the contra-lateral lung myelon dose (adjustable from 30% to 70%) below critical values for curative total doses Standard Techniqueat the ISRO Limburg

29. Clinical Case 1Adjuvant Treatment The 72 year old patient with a non small cell left localized lung cancer was operated. The primary lung cancer infiltrated the left pulmonary artery. A questionable R0 resection was performed. An adjuvant radiotherapy was indicated. From 12 examined lymph nodes 5 were found involved. A total dose of 66.6 Gy was applied in this clinical case. For the main series the target volume was treated with a dose of 50.4 Gy and for the boost technique a dose of 16.2 Gy was given. For both series a dose per fraction of 1.8 Gy was chosen.

30. ZV +4 cm

31. ZV -1 cm

32. ZV -3 cm

33. Clinical Case 1

34. Clinical Case 1 Field 3 (35°) and 4 (100°) reduce the high dose regions in the left lung and contribute a better adaption of the isodoses to the PTV.

35. Clinical Case 1 Full homogeneity over all slices requires two further fields (5 and 6).

36. Technique for Case 1Variation of the Standard Technique Conformal Therapy for Lung Cancer First International Symposium on Target Volume Definition F.Schwab

37. Clinical Case 1 HS +6 cm 95% 85% 70% 50%

38. Clinical Case 1 HS +4 cm 95% 85% 70% 50%

39. Clinical Case 1 HS 0 cm 95% 85% 70% 50%

40. Clinical Case 1 HS -1 cm 95% 85% 70% 50%

41. Clinical Case 1 HS -3 cm 95% 85% 70% 50%

42. Clinical Case 1 HS - 4 cm 95% 85% 70% 50%

43. 100% 95% 90% 85% 80% 70% 50% 30% 10% Clinical Case 1frontal / sagittal dose distribution sagittal frontal

44. Clinical Case 1DVH PTV Lung Myelon

45. Clinical Case 1DVH Box / 3 Field Technique PTV Lung Myelon

46. Clinical Case 1Boost

47. Clinical Case 1Boost – Beam Setup

48. BST -1 cm 95% 85% 70% 50%

49. Clinical Case 2Radiotherapy after Pneumonectomy A 46 year old male patient with a left located non small cell lung cancer of the upper lobe with infiltration of the upper lung vein. Nine involved nodes from 29 examined nodes were described. In many of the examined lymph nodes a capsule disruption was found. The CTV includes the paratracheal area, the upper mediastinum, the aortic pulmonary window, the left hilus and the subcarinal area. The lymph node capsule disruption and the infiltration of the upper pulmonary vein determine the necessity of a high total dose (at least 66 Gy).

50. Clinical Case 2