Extracranial SBRT: from technical availabilities to routine clinical opportunities. Pr. Eric F. LARTIGAU Centre Oscar Lambret, Lille France

Transcription

1 Extracranial SBRT: from technical availabilities to routine clinical opportunities Pr. Eric F. LARTIGAU Centre Oscar Lambret, Lille France

2 Disclosure consultant for : Accuray, Amgen, Astellas, Merck-Serono & Takeda

3 SBRT Definition Reference frame Precision < 1 mm (tracking) Multiple beams (non coplanar?) Specific dose Distribution (+ MC) Limited target volume = High dose/few fractions

4 SRS in Lille Saturne - Talairach s frame Betti s chair 1500 patients Gammaknife : intracranial 600 patients/year (<10 % mets) 14/06/2007 Cyberknife : extra cranial > 1800 patients

5 Academic radiotherapy department in D IG-IMRT STEREO Nucletron Oncentra Varian Clinac 1 Tomo HDA 1 CyberKnife Aquilab BRACHY Varian Clinac 2 Tomo HDA 2 Gammaknife SIMUL 1 HDR 3 PDR Tomo HDA 3 Toshiba Aquilion Nucletron Simulix

6 CyberKnife : what s different? Precision < 1 mm Dose Distribution +MC Tracking (real time)

7 Nb patients ACTIVITY 2012 HOSP RP_T Nb actes Nb patients Nb actes Clinac Clinac Cyberknife Darpac Primus Tomo Tomo TOTAL GammaKnife : + 622

8 TYPE of LESIONS 1774 patients treated 06/207 to 12/2012 Localisations Nb % 27% Head & Neck 157 9% Liver % Lung % Prostate 168 9% Spine 128 7% Brain % Bone 17 1% Nodes 124 7% Miscellanous (kydney, œsophagus, pancreas, melanoma, etc.) 32 2% TOTAL 1774

9 SBRT is a standard in many clinical situations Today : brain, spine, lung, retreatment Tomorrow : liver, prostate, partial breast After tomorrow : most of???

10 SPINE Spinal Mesothelioma metastase

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13 Lung tracking Fiducial Fiducial less Peripheral > 15 mm ITV

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15 Fiducial less 250 patients - about 40 % with xsight_lung - about 60 % with ITV

16 Lille, 51 patients, fiducial less Overall survival of patients with GTV>10cm 3 and patients with GTV<10 cm 3 treated with the Xsight Lung Tracking System (p=0.029). Local control rates of patients treated with 3 fractions (n=27) and patients treated with more than three fractions (n=24) with the Xsight Lung Tracking System (p=0.006).

17 Lung Ray-Tracing : 3 x 20 Gy Monte-Carlo : 63.5 Gy 60.0 Gy 50.0 Gy

18 LIVER TUMOURS 3 séances ambulatoires Biological effective dose 15 Gy x 3 = 45 Gy Real time tracking BED 95 Gy 32 faisceaux Tracking dynamique Toxicité = 0

19 Figure 1: Representative treatment planning image. Shown is the CyberKnife treatment plan for an 84 year-old male, Child A, cirrhotic patient with hepatic pain and an alpha foetoprotein value of 281. The lesion was larger than 6 cm. Lesion contouring (red) and isodose lines are shown.

20 120 patients / 153 Liver tumours Relapse free survival 153 targets HCC 48 Mets 99 Cholangio 6 Probability LC 1 year 84 % (CI 95% : %) Months Probability Relapse free survival 2 years 75 % (CI 95% : %) Months Liver Metastases HCC ICC

21 Toxicity Grade patients HCC + metastases Duodenal ulcer 6 5 % Othesr 6 5 % skin Liver pain Asthenia RILD 2?

22 RETREATMENT X Sight Spine 35 Skull 6D 10 Fiducials 1 6 Gy X 6 in 12 days Isodose 80% : 95% of PTV Cetuximab ( mg/m 2 x 4) Volume GTV cm 3 Median 29 Volume PTV cm 3 Median 60 Beams Collimato rs Duration Median 156 ( ) 1 Median 48 min (28-100) Int J Radiat Oncol Biol, 2012

23 Multicentric phase II Lille, Nancy, Nice Best response, n (%) N=49 Complete Response 24 (49.0) Partial Response 10 (20.4) Stable Disease 11 (22.5) Progressive Disease 4 (8.2) Median overall response duration was 7.9 months Overall objective best response rate : 69.4% [95% CI: %] Disease control rate : 91.8% [95% CI: %]

24 Safety Results Deaths One death from hemmorage and denutrition not related to study drug Serious adverse events

25 Overall survival The one-year OS rate is 47.5% (95%CI: ). The median survival is 11.8 months (95%CI: ) Submitted Radiother Oncol

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27 Median F Up 10,6 months LC & year 70%

28 OLIGOMETASTASES Local treatment : an issue? Concept of ablative treatments Surgery : (brain, liver) brings long survival. Radiosurgery/SBRT (brain), liver, lung, nodes.

29 Rational Cure is T N dependent When M : no cure! (solid tumours in adults) Successive treatment(ssss) (targeted) may bring long term local control of M (liver, lung, brain ) Role of combined/sequential systemic and loco-regional treatment (surgery/radiotherapy)??? When, how?

30 SBRT : liver/lung metastases SBRT experience in Lille 06/2007 to 06/2010 : 90 patients on 850 Median age : lesions 2/3 gastro intestinal primary

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32 1.00 Overall Survival Cyberknife treatment 0.75 Probability Number at risk Patients Months COL: hepatic lung 12 months months

33 Stranded Fiducials PROSTATE

34 Prospective multicentrique Phase II CKNO-PRO: 72 patients RT3D : 46 Gy en 23 x 2 Gy +/- IMRT Gap : 10 days RTS : 18 Gy en 3 x 6 Gy

35 PHRC 2007: ICHOROPRO : FLUOROMETHYLCHOLINE-(18F) in prostate cancer Philippe MAINGON, Gilles CREHANGE.

36 SBRT-IGRT Today : PACE Tomorrow : Partial treatment???

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38 Excellent tolerance in aging population

39 Radioresistant tumours Biology of High dose / fraction : BED > 100 Gy Melanoma Renal tumours Sarcomas

40 Renal metastase 3 x 15 Gy at 3 years

41 SILICON NANO TWEEZERS FOR REAL TIME BIOMECHANICAL ASSAY ON DNA DAMAGE BY THERAPEUTIC RADIATION BEAMS Dominique Collard1,4, Thomas Lacornerie2, Momoko Kumemura1,4, Nicolas Lafitte1,4, Herve Guillou1, Laurent Jalabert1, Eric Lartigau2, Teruo Fujii1,4, Fabrizio Cleri3, Hiroyuki Fujita1,4 1 LIMMS/CNRS-IIS, UMI2820, Japan 2 Centre Oscar Lambret, University of Lille 2, France 3 IEMN, UMR8520, CNRS, University of Lille 1, France 4 Institute of Industrial Science, The University of Tokyo, Japan

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43 SBRT with CK Routine practice Aded value for the staff (RTT s first ) An enlarged role in the treatment of cancer

44 Thanks to : X. MIRABEL, B. PREVOST Ph. NICKERS, L. SCHIAPPACASSE Th. LACORNERIE F. CROP