SBRT in early stage NSCLC

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1 SBRT in early stage NSCLC Optimal technique and tumor dose Frank Zimmermann Clinic of Radiotherapy and Radiation Oncology University Hospital Basel Petersgraben 4 CH 4031 Basel radioonkologiebasel.ch

2 Techniques in Radiation Therapy Conformal RT Intensity modulated RT (IMRT) Stereotactic RT (brain: SRT; body: SBRT / SABR) Image-guided RT (IGRT) Protons Heavy Ions Neutrons

3 Indications for stereotactic radiotherapy Brain metastases Recurrent glioma Non-small-cell lung cancer stage I (and II?) Lung metastases Liver metastases Pancreatic cancer Prostate cancer

4 Frame for - biopsies - radiosurgery Coming from neurosurgery

5 Definition of a 3-D-room Y Z X System creates a 3-D-area: - strong correlation of xyz-coordinates in patient and in frame - precise fixation of the patient!!!!

6 No Relevance Type of beam: Linac Cyberknife Tomotherapy Protons Neutrons Heavy particles

7 No Relevance Fractionation schedule: Conventional fractionation Hypofractionation Hyperfractionation

8 No relevance Beam: Shape Direction Number

9 Relevant Type of isocenter definition Type of immobilization

10 Isocenter definition and immobilisation Y Z X System creates a 3-D-area: - precise fixation of the patient!!!!

11 Navigation: Frame and Laser

12 Precision of SBRT-immobilization Yeung et al. IJROBP 2009

13 Techniques available Pure stereotactic treatment Pure image-guidance Mixed stereotactic positioning and imageguidance Breath-hold and 4-D-CT Nothing at all

14 SBRT and IGRT + Integrating image-guidance in treatment room: precision with bony landmarks about 2 mm! Need for special fixation? Only body mask systems!

15 Body fixation + Image-guided RT (IGRT) + Integrating image-guidance in treatment room or CT: precision around 3 mm Further techniques needed?

16 Competition and Problems Companies with their products Increasing speed of development of techniques we never asked for Quality assurance? Radiation-oncology institutions Internet-platform Pressure of re-financing Increasing number of systems Pure image-guidance increasing Patients demands Although not reasonable

17 SBRT: Immobilization Different systems: none proven superior!

18 SBRT: Immobilization systems in Japan Nagata Y, et al. IJROBP 2009

19 SBRT: documentation of pos. in Japan Nagata Y, et al. IJROBP 2009

20 Breath control + IGRT

21 Influence of breathing control in IGRT Masi et al. Acta Oncol 2008

22 Fractionation schedules in SBRT Hypofractionated RT (2-10 fractions) Single fraction (radiosurgery) But: In literature often not correct Combination with IGRT common

23 Radiosurgery: single fraction

24 Radiosurgery with Linac Gy in isocenter, 80%-Isodose surrounding 42 patients, median follow-up: 15 months Hof et al., Cancer 2007

25 Side effects 64,3 % lung tissue alterations 0 % toxizity CTC III-IV Hof et al., Cancer 2007

26 Radiosurgery with linac 30 Gy in isocenter Median follow-up: 20 months Local control: 81 % at 3 years Fritz et al., Lung Cancer 2008

27 Required dose: > 1 x 30 Gy PTV-including Timmerman et al., J Thorac Surg 2007

28 Fractionated SBRT

29 Importance of dose Local control rate 1 TTLP=1.6 +/- 1.4 y BED > 100 Gy (n=228) 5-y LC :84.3% p< BED < 100 Gy (n=72) 5-y LC : 57.1% Time (years) H Onishi et al. 2007

30 Mean results at 5 years worldwide Overall survival 47 % Cancer-specific survival 57 % Local control 86 % 35 studies between Median follow-up months 1000 patients BED > 100 Gy for T1 BED > 140 Gy for T2 Chi et al. Radiother Oncol 2010 Zimmermann et al. Sem RT 2010

31 RTOG Data Amerikanische Ergebnisse Necessary dose: 3 x Gy in including 80 %-isodose Timmerman et al., J Thorac Surg 2007

32 Side effects (%) Type RT 4 W 8 W 4 M 12 M Fatigue ,1 3,4 3,4 Shivering 5,7 1, Nausea 3,4 6, Dysphagia 1, Dermatitis 3,4 3,4 3,4 3,4 0

33 Pneumonitis ( % ) Grade RT 4 W 8 W 4 M 6 M > 12 M I 1,1 22,0 16,3 12,8 12,0 15,0 II 0 6,8 16,3 35,8 16,6 19,2 III ,6 2,8 3,0

34 More technique? More money! VOLUME PERCENT VOLUME PERCENT DOSE DOSE PERCENT

35 With very simple technique Immobilization free to usual local custom! Dose escalation by hypofractionation: Local control > 85 % Bogart et al. JCO 2010

36 Conclusion High local control: 1 x 40 Gy (not proven) 3 x 20 Gy (prosp. II-trial) 4 x 12 Gy (retrosp.) 5 x 11 Gy (prosp.) 10 x 7 Gy (not proven) Few side effects Immoblization reasonable More complex techniques not proven better

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