D114 Implementing Technology in the Radiotherapy Treatment of Lung Cancer

8/7/2019 D114 Implementing Technology in the Radiotherapy Treatment of Lung Cancer

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Disclosure

received research funding from Elekta


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Ten Leading Cancer Types for the Estimated New Cancer Cases and Deaths by Sex, 2010

Co ri ht 2010 American Cancer Societ

From Jemal, A. et al.CA Cancer J Clin 2010;0:caac.20073v1


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Spectrum of NSCLC

Locally

advanced

RT+Chemo+/-S

Surgicallyresectable

MetastaticSurgery+/- Chemo

or SBRTChemo+ palliative RTand palliative care


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Stage Tumour Lymph nodes Metastases

Stage 1A T1a or T1b N0 M0

Stage 1B T2a N0 M0

Stage 2A

T1a T1b T2a N1 M0

T2b N0 M0

Stage 2BT2b N1 M0

Stage 3A

Any T1a-T3 N2 M0

T3 N1 M0

T4 N0 or N1 M0

Stage 3B

T4 N2 M0

Any T1aT4 N3 M0

Stage 4 Any T Any N M1a or M1b


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Dose, fractionation and chemoradiotherapy

Optimal schedule yet to be established

CHART (continuous hyperfractionated acceleratedradiotherapy) is superior to conventionallyfractionated radiotherapy to 60Gy (2Gy per fraction)

Chemoradiation superior to RT alone

Scheduling of chemotherapy - concurrent better,but

increased toxicity

Evidence of a dose response relationship in NSCLC


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Concurrent vs. sequential chemoradiotherapy

16% relative reduction in mortality

4.5% absolute benefit at 5 years Auperin JCO 2010


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Limiting toxicity: Pneumonitis

Seppenwolde et al IJROBP 55(3) 724-735MLD


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Local failure after RT-

Inadequate volume coverage caused by geographic miss

of the target

Inadequate planned dose because of dose limiting OAR

Inter and intra fraction uncertainties caused byrespiratory motion and set-up errors

Toxicity during RT not permitting delivery of proposedchemoRT schedule


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Strategies to improve local control

IMRT/VMAT/

dose painting

4D Radiotherapy

Dose escalation

Adaptive radiotherapy On-line 3D verification

Toxicity prediction


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4D Radiotherapy

Encompass motion

Mean position

External surrogate

Internal surrogate

a ng

Voluntary

Assisted

Breathhold


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4D Radiotherapy

Encompass motion

Mean position

External surrogate

Internal surrogate

a ng

Voluntary

Assisted

Breathhold


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4D Radiotherapy

Encompass motion

Mean position

External surrogate

Internal surrogate

a ng

Voluntary

Assisted

Breathhold


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4D Radiotherapy

Encompass motion

Mean position

External surrogate

Internal surrogate

a ng

Voluntary

Assisted

Breathhold


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4D radiotherapy

Technology

Standard delivery

4DCT/fluoro

Patient

Free breathing

Coached breathing

simple

breathing

Breathold

Predictive tracking

Real time tracking

o untary reat o

ABC

Sedation

Anaesthesiacomplex


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Active Breathing Control Device

Mouthpiece

Abort button

Mirror

Courtesy of Elekta


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Breath holdvolume(Threshold Vol)

Active Breathing Control Device=ABC

Breathhold time

Tidal volume

StandbyActive


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ABC for RT lung planning and delivery

Image acquisition for planning

Patients tolerability ABC reproducibility

RT delivery time

Possible benefits OAR sparing

Dose escalation

Integration with VMAT 3D verification


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Planning CT

ABC ScanFree Breathing Scan

CT artefacts

Inaccurate target and normal tissue volume

shape and position Inaccurate DVH

Inaccurate tumour dose and NTCP

Alters dose distribution Increase volume of normal tissue irradiated


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Tolerability- lung cancer patients

Position: moderate deep inhale breathold

83% (25 out of 30) tolerate ABC mean age ~70yrs old Mean breathold time 22 sec+/-6sec

Panakis, R&O, 2008

18 pat ents mean age 68 yrs o 17/18 completed radical RT (32#)

Median breathold 20 sec (range15-25 sec)

McNair, R&O, 2009


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ABC reproducibility

18 patients: induction chemo then radical RT 64Gy/30#,

treat each # with ABC

3 consecutive ABC planning CTs and 1 ABC CT mid RT, and 1ABC CT end RT

mm(range)

SI RL AP

Intra#

(3CTs)

1.7

(0.2-5)

1.7

(0.1-6)

1.5

(0-5.2)

Inter#

All CTs

5.1

(0-2.5)

3.6

(0-0.9)

3.5

(0-1.6) Brock, IJROBP, 2010


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Tumour reproducibility

Week 1

Week 3

25% reduction

GTV volume5 pt GTV movedpartially

Week 6

Week 1

Week 3

Week 6

Brock, IJROBP, 2010

outside PTV


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30

35

40

45

50

e

Pt 1

Pt 2

Pt 3

Pt 4

Pt 5

Pt 6

Pt 7

Pt 8

Treatment Delivery with ABC

0

5

10

15

20

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32Fraction

T

i Pt 9

Pt 10

Pt 11

Pt 12

Pt 13

Pt 14

Pt 15

Overall Average 15.8 mins

McNair, R&O, 2009


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max.inhale

Normal lung volume manipulation- benefits?

max.exhale

Courtesy of Mike Partridge


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Benefits: OAR dose reduction

12 patients 2 scans:free breathing-ABC

Parameter Free breathing ABC

Motion

mm(range)

AP 4.2 (0-9) 0.6 (0-3)

CC 8 (0-21) 0.3 (0-1)

Panakis, R&O, 2008

. - . -

MLD(Gy)

Mean+/-SD

10+/-3 9+/-3

V20 (%)

Mean+/-SD

16+/-6 15+/-5

V13 (%)

Mean+/-SD

24+/-8 22+/-7


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64 Gy free breathing standard margins TCP = 15%

Benefits: Dose escalation

28 patients free breathing CT, then ABC CT

Iso-toxic dose escalation= maintain MLD as standard plan

All OAR constraints maintained

ABC Mean dose without reduced margins:

73.5 6.8 Gy (both lungs)

ABC Mean dose with reduced margins77.3 7.4 Gy (patient specific margins)77.1 6.9 Gy (population-based margins)

TCP = 30% 11%

TCP = 32% 10%TCP = 36% 12%

Partridge, R&O, 2009


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IMRT/VMAT/

dose painting

4D Radiotherapy


Toxicity prediction


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Volumetric intensity modulated arc

therapy (VMAT) with ABC

Start arc in breathold

Stop arc in free breathing

Brock et al

60 Gy in 8 fractions of 7.5 GyAlternate days over 3 weeks


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IMRT/VMAT/

dose painting

4D Radiotherapy

Dose escalation


Toxicity prediction


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CBCT verification with ABC

2 strategies:

stop-go CBCT

Half scan

~70sec with patient in both breathold and free breathing filterS10/20, gantry starts 340-ends 180

Time spend in breathold during the scan 66%(52-81%)


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CBCT & on-line match

Pre match

Post match

On line match, radiographer, confirmed by a clinician


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Acknowledgements

Prof. Mike Brada

Helen McNairJuliet Brock

Judith Christian

James Bedford

Jim WarringtonFiona McDonaldMerina Ahmed

William Beaumont Hospital

Ellen DonovanPhil Evans

RMH Physics

RMH radiographers

RMH Imaging

The Royal Marsden


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Thank you

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D114 Implementing Technology in the Radiotherapy Treatment of Lung Cancer

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