tips and tricks to safely treat central lung tumors · aman sharma, m.d. j. nuyttens, m.d., ph.d....
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Tips and tricks to
safely treat central lung tumors
Aman Sharma, M.D.
J. Nuyttens, M.D., Ph.D.
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Disclosure & Disclaimer
An honorarium is provided by Accuray for this presentation
The views expressed in this presentation are those of the presenters and do not necessarily reflect the views or policies of Accuray Incorporated or its subsidiaries. No official endorsement by Accuray Incorporated or any of its subsidiaries of any vendor, products or services contained in this presentation is intended or should be inferred.
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Definition of Central tumors
2 cm from …
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Synchrony® Respiratory Tracking System
Tracking for tumors impacted by respiratory motion Patient wears a vest with optical markers that serve as a surrogate for tumor
position. Camera system monitors position of implanted fiducial markers.
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Reducing margins ?
Population based margins (PBM) utilized to account for tumour motion were
typically 5 mm radially and 8–10 mm longitudinally.
For : CK: margins: GTV+5-7 mm = PTV
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Reducing marginsITV based target volume Real-time tumor tracking
with the
CyberKnife® System
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Reducing margins: how ?
Xsight® Lung System
Placing markers
endo-bronchoscopic
percutaneous intrapulmonary
intravascular
Endo-echo
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Dose and dose volume constraints
Our fractionation schedules with MC
Central lung tumors : 11Gy * 5 fractions
For tumors close to esophagus or <6mm from pericardium : 7.5 Gy *7 fractions
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Fractionation Schedules and Results
Close to esophagus:
6 *8 Gy -> 7*7 Gy
Close to main bronchi only:
5 * 9 Gy -> 5 * 10 Gy -> 5 *12 Gy
2yr Survival:
NSCLC -------53%
Metastases----75%
Nuyttens et al 2012
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Use of appropriate BED
Nuyttens et al 2012
2-years LC
85% with a BED >100 Gy
60% BED <100 Gy.
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Fractionation schedules and results
Nuyttens et al 2012
2-years LC
NSCLC ---------85%
Metastases ----64%
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Dose to organs and toxicity
No severe acute or late toxicity Nuyttens et al 2012
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Duijm et al 2016
Dose and Volume of the Irradiated Main Bronchi and Related Side Effects
N=134 690 bronchial structures delineated Bronchial structures divided1) (T) trachea2) (MI) mainstem bronchus and
intermediate bronchus 3) (UML) upper-, middle-, and lower- lobe
bronchi4) (SB) segmental bronchi (branches of
the upper-,middle-, and lower bronchi) Side effects scored1) stenosis2) occlusion without atelectasis in the
same segment3) occlusion with atelectasis in the same
segment.
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Dose and Volume of the Irradiated Main Bronchi and Related Side Effects in the Treatment of Central Lung Tumors With Stereotactic Radiotherapy
Duijm et al 2016
No side effects found in the
trachea
Stenosis : main bronchus and
bronchus intermedius.
Higher grades of side effects
(occlusion and atelectasis) :
upper, middle and lower bronchi
and the segmental bronchi
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Duijm et al 2016
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Oesophagus toxicity
Nuy
ttens
, Sem
Rad
Onc
, 201
6
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Primary Lung cancer & Pulmonay oligometastasis Dose 6*8 Gy Post RT (15 months)
Pre-RT
Post RT (30 months)• Dose: 6*8 Gy
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Conclusions
Fractionation of 5 or more fractions with the CyberKnife® System is safe.
BED of ≥100Gy associated with excellent local control
Reducing margins is very import and so is the treatment associated with
no mortality, limited toxicity.
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J. Nuyttens
J. Praag
R. De Boer
I. Antonisse
S. Aluwini
L. Baartman
N. Van der Voort
J-B. Prevost
M. Hoogeman
H. Marijnissen
E. De Klerck
L. Luthart
D. De La Bije
C. De Pan
H. Joosten