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The Royal Marsden

Implementing technology in the


radiotherapy treatment of lung
cancer

Dr. Maria A. Hawkins


MD, MRCP, FRCR
Consultant Clinical Oncology
The Royal Marsden Hospital NHS FT
St. Georges University Hospital London
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Disclosure

– received research funding from Elekta


The Royal Marsden

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

From Jemal, A. et al.


CA Cancer J Clin 2010;0:caac.20073v1
Copyright ©2010 American Cancer Society
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Spectrum of NSCLC
RT+Chemo+/-S

Locally
advanced

Surgically
resectable

Metastatic
Surgery+/- Chemo
or SBRT
Chemo+ palliative RT
and palliative care
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Stage Tumour Lymph nodes Metastases


Stage 1A T1a or T1b N0 M0
Stage 1B T2a N0 M0
T1a T1b T2a N1 M0
Stage 2A
T2b N0 M0
T2b N1 M0
Stage 2B
T3 N0 M0

Any T1a-T3 N2 M0
Stage 3A T3 N1 M0
T4 N0 or N1 M0
T4 N2 M0
Stage 3B
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 accelerated


radiotherapy) is superior to conventionally
fractionated 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

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


respiratory motion and set-up errors

– Toxicity during RT not permitting delivery of proposed


chemoRT schedule
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Locally advanced NSCLC


recent advances
– Better staging (PET, EBUS, MRI) and patient
selection

– Recognised genetic signature Kras, Braf….


– Incorporation of molecular targeted agents

– Technical advances in RT delivery-IGRT


– Target definition –PET
– Motion characterisation/management 4DCT,
Fluoro, ABC
– Volumetric imaging on the linear accelerator
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Strategies to improve local control

IMRT/VMAT/ 4D Radiotherapy
dose painting

Dose escalation
Toxicity prediction

Adaptive radiotherapy On-line 3D verification


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4D Radiotherapy

Encompass motion

Mean position
External surrogate
Gating
Internal surrogate

Breath Voluntary
hold Assisted
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4D Radiotherapy

Encompass motion

Mean position
External surrogate
Gating
Internal surrogate

Breath Voluntary
hold Assisted
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4D Radiotherapy

Encompass motion

Mean position
External surrogate
Gating
Internal surrogate

Breath Voluntary
hold Assisted
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4D Radiotherapy

Encompass motion

Mean position
External surrogate
Gating
Internal surrogate

Breath Voluntary
hold Assisted
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4D Radiotherapy

Encompass motion

Mean position
External surrogate
Gating
Internal surrogate

Breath Voluntary
hold Assisted
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4D radiotherapy
Technology Patient
simple
– Standard delivery – Free breathing

– 4DCT/fluoro – Coached breathing

– Gating in free – Voluntary breathold


breathing

– ABC
– Breathold

– Predictive tracking – Sedation

complex
– Real time tracking – Anaesthesia
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Active Breathing Control Device

Mirror
Abort button

Mouthpiece

Courtesy of Elekta
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Active Breathing Control Device=ABC

Breath hold
volume
(Threshold Vol)

Tidal volume

Breath
hold time
Standby
Active
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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

Free Breathing Scan ABC 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 patients mean age 68 yrs old


– 17/18 completed radical RT (32#)
– Median breathold 20 sec (range15-25 sec)

McNair, R&O, 2009


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Patient Questionnaire

How uncomfortable did you find the ABC device?

Very
much

Quite a
bit

A little

Not at all

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

Mean GTV center variation


mm(range)
SI RL AP

Intra# 1.7 1.7 1.5


(3CTs) (0.2-5) (0.1-6) (0-5.2)
Inter# 5.1 3.6 3.5
All CTs (0-2.5) (0-0.9) (0-1.6) Brock, IJROBP, 2010
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Tumour reproducibility

Week 1 •25% reduction


GTV volume
•5 pt GTV moved
Week 3 partially
Week 6 outside PTV

Week 6

Week 3

Week 1
Brock, IJROBP, 2010
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Treatment Delivery with ABC

Pt 1
Pt 2
50
Pt 3
45 Pt 4
40 Pt 5

35 Pt 6
Pt 7
30
Time

Pt 8
25 Pt 9
20 Pt 10
15 Pt 11
Pt 12
10
Pt 13
5 Pt 14
0 Pt 15
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32
Fraction
Overall Average 15.8 mins

McNair, R&O, 2009


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Normal lung volume manipulation- benefits?

max.
inhale

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


mm(range) CC 8 (0-21) 0.3 (0-1)
LR 5.1 (0-9) 0.6 (0-2)
MLD(Gy) 10+/-3 9+/-3
Mean+/-SD
V20 (%) 16+/-6 15+/-5
Mean+/-SD
V13 (%) 24+/-8 22+/-7
Mean+/-SD
Panakis, R&O, 2008
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Benefits: Dose escalation


28 patients free breathing CT, then ABC CT
Iso-toxic dose escalation= maintain MLD as standard plan
All OAR constraints maintained

64 Gy free breathing standard margins TCP = 15%

ABC Mean dose without reduced margins:


73.5 ± 6.8 Gy (both lungs) TCP = 30% ± 11%

ABC Mean dose with reduced margins


77.3 ± 7.4 Gy (patient specific margins) TCP = 32% ± 10%
77.1 ± 6.9 Gy (population-based margins) TCP = 36% ± 12%

Partridge, R&O, 2009


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Strategies to improve local control

IMRT/VMAT/ 4D Radiotherapy
dose painting

Dose escalation
Toxicity prediction

Adaptive radiotherapy On-line 3D verification


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Volumetric intensity modulated arc


therapy (VMAT) with ABC

Start arc in breathold


Stop arc in free breathing

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

Brock et al
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Strategies to improve local control

IMRT/VMAT/ 4D Radiotherapy
dose painting

Dose escalation
Toxicity prediction

Adaptive radiotherapy On-line 3D verification


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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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ABC for RT lung planning and delivery

– Tolerated by patients with lung cancer


– Does not necessarily increase RT appointment time
– Integrated with new technology
– Better tumour visualization
– Less dose to lung
– Opportunities for dose escalation
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Acknowledgements
William Beaumont Hospital

Prof. Mike Brada James Bedford


Helen McNair Jim Warrington
Juliet Brock Fiona McDonald
Merina Ahmed
Judith Christian
Diana Tait
Ellen Donovan
Phil Evans

RMH Physics
RMH radiographers
RMH Imaging
The Royal Marsden

Thank you

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