New Radiation Treatment Modalities in the Treatment of Lung Cancer

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1 New Radiation Treatment Modalities in the Treatment of Lung Cancer David Perry, M.D. Chief, Radiation Oncology Medical Director, CyberKnife Radiosurgery Center Medstar Franklin Square Medical Center

2 Definitions SRS Stereotactic Radiosurgery SBRT Stereotactic Body Radiation Therapy SABR Stereotactic Ablative Radiotherapy Cyberknife Gammaknife

3 Definitions 3D-Conformal Radiotherapy VMAT (Volumetric Arc Radiotherapy) IMRT (Intensity Modulated Radiotherapy) Proton Radiotherapy MRI-guided VMAT/IMRT

4 Goals Reduce dose to normal tissues. Reduce the risk of radiation pneumonitis. Reduce cardiac toxicity. Increase dose to the tumor.

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6 The critical goals of modern RT are to maximize tumor control and to minimize treatment toxicity. A minimum technologic standard is CTplanned 3D-CRT.

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9 More advanced technologies are appropriate when needed to deliver curative RT safely. These technologies include (but are not limited to) 4D-CT and/or PET/CT simulation, IMRT/VMAT, IGRT, motion management, and proton therapy.

10 Nonrandomized comparisons of using advanced technologies versus older techniques demonstrate reduced toxicity and improved survival.

11 In a prospective trial of definitive chemo/rt for stage III NSCLC (RTOG 0617) IMRT was associated with a nearly 60% decrease in high-grade radiation pneumonitis and similar survival and tumor control outcomes. IMRT is preferred over 3D-CRT in this setting.

12 Definitions VMAT (Volumetric Arc Radiotherapy) IMRT (Intensity Modulated Radiotherapy) Proton Radiotherapy MRI-guided VMAT/IMRT

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14 VMAT Treatment Delivery

15 VMAT Treatment Delivery

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29 Protons Radiobiolgically equivalent to photons. Length of treatment course equivalent to photons. Tumor motion remains an issue.

30 Protons Critical in select situations. Data remains forthcoming. Cost, convenience, expectations.

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32 Radiosurgery Different radiobiology (hypofx) Highly effective local control Short course (3 5 treatments over one week)

33 Radiosurgery Ability to control for motion (Synchrony, Xsight Lung) Data established and growing Potential for abscopal effect in the treatment of oligometastatic disease

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37 CyberKnife Treatment with Synchrony *Reference: Dieterich S, Taylor D, Chuang C, Wong K, Tang J, Kilby W, Main W. The CyberKnife Synchrony Respiratory Tracking System: Evaluation of Systematic Targeting Uncertainty

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40 Synchrony Respiratory Tracking System Synchrony camera Synchrony tracking markers (LEDs) Tracks patient s respiratory motion Tumor motion tracked via fiducials

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42 SBRT for Early Stage Lung Cancer Surgery is the standard of care Inoperable patients have historically been offered external beam radiation for outpatient treatments EBRT - local control rates 30-40% EBRT - 3 year survival 20-35%

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44 NSCLC Stage I Selected N- Stage IIA SABR is recommended for patients who are medically inoperable or who refuse surgery after thoracic surgery evaluation. SABR has achieved primary tumor control rates and overall survival, comparible to lobectomy and higher than 3D-CRT in nonrandomized and population based comparisons in medically inoperable or older patients.

45 NSCLC Stage I Selected N- Stage IIA SABR is also an appropriate option for patients with high surgical risk (able to tolerate sublobar resection but not lobectomy [eg, age > 75 years], poor lung function. SABR and sublobar resection achieve comparable cancer-specific survival and primary tumor control.

46 NSCLC Stage I Selected N- Stage IIA A combined analysis of two randomized trials (that individually did not complete accrual) of SABR vs. lobectomy in operable patients found similar cancerspecific outcomes and improved toxicity profile and survival for SABR compared to surgery. Chang et al Lancet Oncology 2015, 16:

47 NSCLC Stage I Selected N- Stage IIA This analysis does not provide sufficient data to change the standard of care for good surgical candidates but strengthens the indication for SABR in patients with relative contraindications for surgery or who refuse surgery

48 NSCLC Left Upper Lung * RESULTS: Radiographic complete response in 15 weeks. A follow-up PET/CT scan at ten months post treatment was negative at the site of the primary tumor and showed no evidence of disease * Case provided courtesy of St. Joseph s Hospital, Phoenix, Arizona (USA)

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60 Summary Significant technologic advances over the last decade. Technology should best serve each individual patient. Inoperable early stage lung cancer can be cured

61 Summary Oligometastatic disease needs to be better understood and treated The connection between immunotherapy and radiosurgery is an exciting frontier worthy of further research.

62 Thank you!