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PY Bondiau PhD. MD. Centre Antoine Lacassagne. Nice. France High Precision Radiotherapy

The management of lung cancer: from 3D to SBRT EFEC 18/05/11. PY Bondiau PhD. MD. Centre Antoine Lacassagne. Nice. France High Precision Radiotherapy Cyclotron/Cyberknife. Plan. Introduction : RT2-D Definition SBRT (History) Technics and results 3-D Linac Rotational Radiotherapy

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PY Bondiau PhD. MD. Centre Antoine Lacassagne. Nice. France High Precision Radiotherapy

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  1. The management of lung cancer: from 3D to SBRT EFEC 18/05/11 PY Bondiau PhD. MD. Centre Antoine Lacassagne. Nice. France High Precision Radiotherapy Cyclotron/Cyberknife

  2. Plan Introduction : RT2-D Definition SBRT (History) Technics and results 3-D Linac Rotational Radiotherapy SBRT linac Vero Cyberknife Conclusion RT3D Results T1 lung cancer Techniques SBRT

  3. Plan Introduction : RT2-D Definition SBRT (History) Technics and results 3-D Linac Rotational Radiotherapy SBRT linac Vero Cyberknife Conclusion RT3D Techniques SBRT

  4. From 2-D to 3-D [1] 2-D planning era. • Surgical resection of stage I (T1-2, NO) NSCLC • 5 year survival rates 60-70% • Patients medically inoperable treated RT2-D • Field of irradiation : • primary tumor and regional lymphatics in the ipsilateral hilum and mediastinum. • poorly tolerated (with limited pulmonary reserve). • In a report from the Netherlands, limited “postage stamp” • Limitations: • in visualizing the target => difficult to reduce high dose volume • selection of beam directions, • computational algorithms describing deposited dose.

  5. Result of 2-D • Duke experience 1980 1995 • 156 patients with Stage I medically inoperable • non-small–cell lung cancer • T1N0 54%, T2N0 46% • Target • Median dose 64 Gy (50 to 80 Gy) • median size 3 cm (range 0.5 to 8) • Overall survival • The 2- and 5-year was 39% and 13% • Studies of dose escalation are warranted !

  6. Plan Introduction : RT2D Definition SBRT (History) Technics and results 3-D Linac Rotational Radiotherapy SBRT linac Vero Cyberknife Conclusion RT3D Results T1 lung cancer Techniques SBRT

  7. Beam B Beam A PTV GTV PTV VT VI CTV Beam C Revolution of 3-D • Due to CT scan • EMI 1972 • Possibility to multi slice • 2-D to 3-D CONTOUR: - Manual - Automatic VOLUMES DEFINITION

  8. Patient Contention MEP Transfert Modifications ? Dosimetric CT scan = ? Balistic definition Dosimetry Contouring DRR

  9. Multileaf Collimator MLC Source Collimator

  10. From 2-D to 3-D: beams

  11. RT2-D vs RT3-D M.D. Anderson (2005) • Materials/Methods: • 200 patients stage I radiotherapy alone • 85 pts 3-D conformal radiotherapy • T1N0 64%, T2N0 36%, squamous cell carcinoma 46%, non-squamous histology 54% • median dose 66 Gy (45–90.3 Gy), median follow-up 19 months (3–77 months) • 115 pts 2-D group: median age 69 (range 44–88) • T1N0 51%, T2N0 49%, squamous cell carcinoma 47%, non-squamous histology 53% • median dose 64 Gy (40–74 Gy), median follow-up 20 months (1–173 months)

  12. Dose escalation • Hayman (University of Michigan) • 104 patients with stages I-III treated by 3-DRT • Dose escalation as high as 102.9 Gy with acceptable toxicity. • 53 patients had disease progression • 52% failing distantly • 8% failing both distantly and PTV • 2% failing in a distant site, the PTV and a nodal region outside the PTV • 35% failing within the PTV alone.

  13. Defining stereotactic body radiotherapy [1] • Historical Developpement • Lars Leksell Gammaknife • Radiosurgery (1 fraction) • 1967 Stockholm Karolinska Institut • Radiosurgery • High precision RT • >100 converging mini-beam • Target : 3 cm max • millimetric accuracy • Image matching PET/MRI and CT • Mechanical accuracy => only intra cranial

  14. Defining stereotactic body radiotherapy [2] • Beams • From cobalt 60 (gammaknife) • Specific collimators • Conventional linac • Specific collimator or multileaf • Dedicated linac (novalis, CK) • Specific collimator or multileaf • Raise of image processing matching tools • Integrated image system • Automatic matching • Real Image = T ( DRR ) • movement = T ( table or device ) • Image processing accuracy replace mechanical accuracy • Emergence of extra cranial indication • Multiple fractions T I J

  15. 70 ? SBRT Conventional RT Radiosurgery Accuracy < cm multiple fractions Accuracy < mm unique fraction Accuracy < mm multiple fractions

  16. Plan Introduction : RT2D Definition SBRT (History) Technics and results 3D Linac Rotational Radiotherapy SBRT linac Vero Cyberknife Conclusion RT3D Techniques SBRT

  17. Rotational radiotherapy [2]: Tomotherapy • FDA agreements for HI-ART in 2003 • Statif of 85 cm de diameter • TomoHD • TomoHD is a Hi-ART system packageant • new linac • New detector • Etc… • system Hi-ART (2009) can be up graded in TomoHD • Mobile thomotherapy installed in a truck

  18. Rotational radiotherapy [3]: VARIAN • Rapid’ Arc • On board imager (OBI) and cône beam CT (CBCT) • Image guided radiotherapy • IMRT 360° • treatment time divided by 8 conventional IMRT • Dedicated software (ECLIPSE) or not (VMAT) • Treatment • OBI and CBCT: positioning of tumor • Image comparision with CT scan • Patient matching • Treatment :1 to 2 rotations of 360° • Continus IMRT (field and intensity) • Results: publication

  19. Rotational radiotherapy [5]: ELEKTA • Same technique as VARIAN Rapid’arc • VMAT (Volumetric Modulated ArcTherapy). • Modification of rotation speed, leaf position, and dose debit • Fraction of 2mn • Dedicated software ERG or Monaco Vmat

  20. Plan Introduction : RT2D Definition SBRT (History) Technics and results 3D Linac Rotational Radiotherapy Linac SBRT Vero Cyberknife Conclusion RT3D Techniques SBRT

  21. AXESSE (ELEKTA) • Conventional RT and SBRT • High energy linac (4, 25 MV) • Isocenter accuracy: < 1 mm • Multileaf collimator (80 leaf) • Cone Beam CT » • Images • 2 XR at 90° • 2 flat panel (40x40 cm, pxl ? mm²) • Option VMAT • Gating ABC « Active Breathing Coordinator »

  22. SBRT: Local control

  23. Toxicity • Depends Modalities (?) • Oesophagitis • Dermatitis • Pneumonitis • Rib fracture • Pericardial • Chest wall pain

  24. RTOG 0236 [1] • A Phase II SBRT for Patients with Medically Inoperable Stage I/II Non-Small Cell Lung Cancer • R. Timmerman JAMA. 2010;303(11):1070-76. • 59 patients T1-T2N0M0 non-small cell tumors (<5 cm) • not allow surgical treatment. • May 2004 to October 2006 • data analyzed August 2009 • 1 end point: 2-year actuarial primary tumor control • 2 end points: disease-free survival • 55 evaluable pts with Median follow-up of 34.4 months

  25. RTOG 023 [2] • Presented in 51th ASTRO an update of RTOG 0236 • Only 1 primary tumor failure • Estimated 3-year primary tumor control rate: 97.6%. • Local-regional control rate: 87.2% • Disease-free survival at 3 years: 48.3% • Overall survival at 3 years: 55.8% • median overall survival: 48.1 months. • Primary tumour control at three years improved from 88 to 98% • Toxicity • grade 3 in 7 patients (12.7%), grade 4 in 2 patients (3.6%) • Conclusion • Median survival had not yet been reached (It had not been anticipated that this would happen) • Patient follow up has been amended from a total of 4 years to include annual follow up • Possibly be attributed to image-guidance techniques into the SBRT process.

  26. Plan Introduction : RT2D Definition SBRT (History) Technics and results 3D Linac Rotational Radiotherapy Novalis Vero Cyberknife Conclusion RT3D Techniques SBRT

  27. Vero [1] • System launched ESTRO 2010 meeting • MITSUBSHI and BRAINLAB collaboration • Combination of versatile imaging capabilities • real-time tumour tracking – • Statif of 4.17 m (1.25 m) 11 tons • Linac 6MV, • micro-multileaf of 60 leafs of 5mm at isocenter. • Field of 15X15 cm • O-ring can rotate ±60° about its vertical axis • isocentre accuracy of 0.1 mm.

  28. Vero [2] • Imaging • Two orthogonal kV attached to the O-ring at 30 i/s (fluoroscopy) • Cône Beam CT and software « HYBRID ARC », VERO can do rotational IMRT • Integrated ExacTrac infrared • Specific software: BRAINLAB iPLAN • Systems • 4 Vero in Japan • 1 European installation : UZ Brussels University Hospital • 300 patients already treated • Publicated Results: no

  29. Plan Introduction : RT2D Definition SBRT (History) Technics and results 3D Linac Rotational Radiotherapy Novalis Vero Cyberknife Conclusion RT3D Techniques SBRT

  30. 1 - Patient Positioning Robotic couch 3 rotations 3 translations Numeric X Rays 2 sources of X Rays with 2 flat panels at 90° Automatic. Discontinued 41 * 41 cm 1024 *1024 pxl Pxl : 0.4 mm²

  31. Fiducial or not? • For small tumor (<1,5cm) near spine/mediastinum : we prefer fiducial • Endoscopic • CT scan

  32. Mvt thorax/tumor Time Diods thorax Fiducials X Y Z

  33. Study Stage I NSCLC (T1 or T2 N0 M0). Histology proven : Only ADK and SCC lesions were included. For mets : primitive tumor controlled and slow growing. Maximal diameter : 6 cm. No other concomitant or postradiation treatment Indication of CK : Clinical case discussion Exclusion if pulmonary atelectasis, infection or pneumonitis problem of interpretation No MRI if no neurologic symptom

  34. 50-75 Gy 5 Fr 60 Gy / 3 F Treatments • Millimetric margins • Tumor tracking during breathing • CTV=GTV+5mm • Optical positioning system • « Synchrony » Software • Treatment time: 45-75 min

  35. Results • Median follow up 18.7 months • Mean fraction duration 65 min (G4) • First fraction longer than the others

  36. Results • Distant reccurence 62 (46.97%) • and 31 (23.48%) death • Local recurrence 18 (13.64%) • and 8 (6.06%) death

  37. Evaluation at 2 years (RECIst criteria) During the year : 10 Distant progression, 2 death of other cause, 2 NA CR 30 % PR 38 % ST 18 % L prg 14 % 86 %

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