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Disclosure
received research funding from Elekta
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Ten Leading Cancer Types for the Estimated New Cancer Cases and Deaths by Sex, 2010
Co ri ht 2010 American Cancer Societ
From Jemal, A. et al.CA Cancer J Clin 2010;0:caac.20073v1
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Spectrum of NSCLC
Locally
advanced
RT+Chemo+/-S
Surgicallyresectable
MetastaticSurgery+/- Chemo
or SBRTChemo+ palliative RTand palliative care
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Stage Tumour Lymph nodes Metastases
Stage 1A T1a or T1b N0 M0
Stage 1B T2a N0 M0
Stage 2A
T1a T1b T2a N1 M0
T2b N0 M0
Stage 2BT2b N1 M0
Stage 3A
Any T1a-T3 N2 M0
T3 N1 M0
T4 N0 or N1 M0
Stage 3B
T4 N2 M0
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 acceleratedradiotherapy) is superior to conventionallyfractionated 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
Seppenwolde et al IJROBP 55(3) 724-735MLD
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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 byrespiratory motion and set-up errors
Toxicity during RT not permitting delivery of proposedchemoRT schedule
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Strategies to improve local control
IMRT/VMAT/
dose painting
4D Radiotherapy
Dose escalation
Adaptive radiotherapy On-line 3D verification
Toxicity prediction
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4D Radiotherapy
Encompass motion
Mean position
External surrogate
Internal surrogate
a ng
Voluntary
Assisted
Breathhold
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4D Radiotherapy
Encompass motion
Mean position
External surrogate
Internal surrogate
a ng
Voluntary
Assisted
Breathhold
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4D Radiotherapy
Encompass motion
Mean position
External surrogate
Internal surrogate
a ng
Voluntary
Assisted
Breathhold
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4D Radiotherapy
Encompass motion
Mean position
External surrogate
Internal surrogate
a ng
Voluntary
Assisted
Breathhold
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4D radiotherapy
Technology
Standard delivery
4DCT/fluoro
Patient
Free breathing
Coached breathing
simple
breathing
Breathold
Predictive tracking
Real time tracking
o untary reat o
ABC
Sedation
Anaesthesiacomplex
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Active Breathing Control Device
Mouthpiece
Abort button
Mirror
Courtesy of Elekta
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Breath holdvolume(Threshold Vol)
Active Breathing Control Device=ABC
Breathhold time
Tidal volume
StandbyActive
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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
ABC ScanFree Breathing 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 pat ents mean age 68 yrs o 17/18 completed radical RT (32#)
Median breathold 20 sec (range15-25 sec)
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
mm(range)
SI RL AP
Intra#
(3CTs)
1.7
(0.2-5)
1.7
(0.1-6)
1.5
(0-5.2)
Inter#
All CTs
5.1
(0-2.5)
3.6
(0-0.9)
3.5
(0-1.6) Brock, IJROBP, 2010
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Tumour reproducibility
Week 1
Week 3
25% reduction
GTV volume5 pt GTV movedpartially
Week 6
Week 1
Week 3
Week 6
Brock, IJROBP, 2010
outside PTV
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30
35
40
45
50
e
Pt 1
Pt 2
Pt 3
Pt 4
Pt 5
Pt 6
Pt 7
Pt 8
Treatment Delivery with ABC
0
5
10
15
20
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32Fraction
T
i Pt 9
Pt 10
Pt 11
Pt 12
Pt 13
Pt 14
Pt 15
Overall Average 15.8 mins
McNair, R&O, 2009
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max.inhale
Normal lung volume manipulation- benefits?
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
mm(range)
AP 4.2 (0-9) 0.6 (0-3)
CC 8 (0-21) 0.3 (0-1)
Panakis, R&O, 2008
. - . -
MLD(Gy)
Mean+/-SD
10+/-3 9+/-3
V20 (%)
Mean+/-SD
16+/-6 15+/-5
V13 (%)
Mean+/-SD
24+/-8 22+/-7
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64 Gy free breathing standard margins TCP = 15%
Benefits: Dose escalation
28 patients free breathing CT, then ABC CT
Iso-toxic dose escalation= maintain MLD as standard plan
All OAR constraints maintained
ABC Mean dose without reduced margins:
73.5 6.8 Gy (both lungs)
ABC Mean dose with reduced margins77.3 7.4 Gy (patient specific margins)77.1 6.9 Gy (population-based margins)
TCP = 30% 11%
TCP = 32% 10%TCP = 36% 12%
Partridge, R&O, 2009
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Strategies to improve local control
IMRT/VMAT/
dose painting
4D Radiotherapy
Adaptive radiotherapy On-line 3D verification
Toxicity prediction
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Volumetric intensity modulated arc
therapy (VMAT) with ABC
Start arc in breathold
Stop arc in free breathing
Brock et al
60 Gy in 8 fractions of 7.5 GyAlternate days over 3 weeks
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Strategies to improve local control
IMRT/VMAT/
dose painting
4D Radiotherapy
Dose escalation
Adaptive radiotherapy On-line 3D verification
Toxicity prediction
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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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Th R l M d6
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Acknowledgements
Prof. Mike Brada
Helen McNairJuliet Brock
Judith Christian
James Bedford
Jim WarringtonFiona McDonaldMerina Ahmed
William Beaumont Hospital
Ellen DonovanPhil Evans
RMH Physics
RMH radiographers
RMH Imaging
The Royal Marsden
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Thank you
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