Stereotactic MR-guided adaptive radiotherapy for central lung tumors. Professor Suresh Senan, VU University Medical Center
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1 Stereotactic MR-guided adaptive radiotherapy for central lung tumors Professor Suresh Senan, VU University Medical Center
2 Disclosures Research grants: Varian Medical Systems, ViewRay Inc. Advisory boards: Eli Lilly, AstraZeneca, Merck
3 Outline Patient selection for SMART Clinical workflow Illustrative cases What will not be discussed? Geometric accuracy of breath-hold SABR [van Sörnsen de Koste J, submitted] Adaptive treatment planning for lung tumors [Senan S, Proc ASTRO 2017] Daily on-table plan adaption [Bohoudi O, Radioth Oncology 2017]
4 SMART for thoracic tumors at VUMC Indications for SMART Moderately central tumors [fatal toxicity possible/likely in 7.5% of patients, Tekatli H, Radioth Oncol 2015] Interstitial lung disease [fatal toxicity in 15%, Chen H, IJROBP 2017] Re-irradiation for peripheral lung cancer [5-30% incidence of G3 or higher toxicity, De Bari B, Cancer Trt Rev 2015] Tumors adjacent to left hemi-diaphragm Paracardial tumors
5 SMART using breath-hold delivery (3mm margins) Moderately central tumors Ultracentral tumors SABR is feasible ASTRO guidelines [Videtic GMM, Prac Rad Onc 2017] SABR has higher toxicity [Haseltine JM, PRO 2016, Tekatli H, JTO 2016; Lindberg K, WCLC 2016]
6 SMART workflow at VUMC: Initial simulation Comfortable patient positioning (SMART takes up to 1 h) Image in MR-only mode in 3 planes Select respiratory phase for SMART 17 sec MR-sim in selected breathhold phase GTV tracking test 3D-CT scan in seclected breath-hold phase
7 SMART simulation: MR-only mode
8 SMART workflow at VUMC: Daily treatment Patient positioning 17 sec MR-sim in selected respiratory phase Recontour OAR s within 3 cm of GTV Create a plan of the day On-table plan QA SMART delivery
9 Central tumor Benchmark case (EORTC , LungTech) Adebahr S, VUMC SMART case
10 VUMC SMART case
11 SMART delivery (3 mm PTV margin)
12 SMART: patient-assisted gated delivery
13 Cardiac mortality in lung cancer Of all patients with lung cancer, 40 70% have COPD1 COPD patients have 2-5 fold higher risk of ischaemic heart disease, cardiac dysrhythmia, heart failure 2 A 5-8 fold higher risks of cardiovascular mortality is seen in some sub-groups of COPD 3 COPD patients have a 34% higher risk for sudden cardiac death 4 1Congleton J, Resp Med 2005; 2 Chen W, Lancet Resp Med 2015; 3 Lange P, AJRCCM 2012; 4 Lahousse L, Eur H J 2015
14 SMART: 2 nd case showing 4DCT simulation
15 Radiographic and clinical toxicity [data driven] 195 central tumors (585 bronchial structures); 12 fractions at 2 Dutch centers, between Doses recalculated to an equivalent dose of 2Gy with an α/β ratio of 3 Radiographic toxicity defined as: Airway stenosis Occlusion without atelectasis Occlusion with atelectasis Tekatli H, IJROBP 2017 Main stem bronchi (n=9), intermediate bronchus (n=8), upper lobe bronchi (n=25), middle lobe bronchi (n=6), and lower lobe bronchi (n=33)
16 Pooled analysis of central tumors: NTCP modelling Univariate logistic regression analyses of dosimetric parameters for clinical high grade pulmonary toxicity (n = 193) G3 toxicity (number of patients with toxicity = 24) Total D max,eqd Total V 65Gy,EQD Total V 80Gy,EQD Total V 90Gy,EQD Total V 100Gy,EQD Total V 130Gy,EQD OR % CI P-value <0.001 <0.001 <0.001 <0.001 <0.001 Tekatli, H, IJROBP 2017 ~ 5 fractions: 50.0 Gy ~ 8 fractions: 61.1 Gy
17 SMART: 2 nd case showing MR-simulation
18 SMART: 2 nd case showing 4DCT simulation
19 On-table quality assurance for SMART
20 SMART: 2 nd case showing treatment delivery
21 SMART: A new approach for central tumors Haasbeek CJA, J Thoracic Oncol 2011 Tekatli, H, Radioth Oncol 2015 Tekatli, H, J Thoracic Oncol 2016
22 SMART for thoracic tumors at VUMC Indications for SMART Moderately central tumors [fatal toxicity possible/likely in 7.5% of patients, Tekatli H, Radioth Oncol 2015] Interstitial lung disease [fatal toxicity in 15%, Chen H, IJROBP 2017] Re-irradiation for peripheral lung cancer [5-30% incidence of G3 or higher toxicity, De Bari B, Cancer Trt Rev 2015] Tumors adjacent to left hemi-diaphragm Paracardial tumors
23 Thank you for your attention
Chapter 6. H. Tekatli* M. Duijm* E. Oomen-de Hoop W. Verbakel W. Schillemans B. Slotman J. Nuyttens S. Senan
Normal tissue complication probability modeling of pulmonary toxicity after stereotactic and hypofractionated radiation therapy for central lung tumors H. Tekatli* M. Duijm* E. Oomen-de Hoop W. Verbakel
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