1 py bondiau phd. md. centre antoine lacassagne. nice. france high precision radiotherapy...
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1
PY Bondiau PhD. MD.
Centre Antoine Lacassagne. Nice. France
High Precision Radiotherapy
Cyclotron/Cyberknife
The management of lung cancer: from 3D to SBRT
EFEC 18/05/11
2
PlanPlan
• Introduction : – RT2-D– Definition SBRT (History)
• Technics and results– 3-D Linac– Rotational Radiotherapy– SBRT linac– Vero– Cyberknife
• Conclusion
• Introduction : – RT2-D– Definition SBRT (History)
• Technics and results– 3-D Linac– Rotational Radiotherapy– SBRT linac– Vero– Cyberknife
• Conclusion
RT3D
SBRT
TechniquesResultsT1 lung cancer
3
PlanPlan
• Introduction : – RT2-D– Definition SBRT (History)
• Technics and results– 3-D Linac– Rotational Radiotherapy– SBRT linac– Vero– Cyberknife
• Conclusion
• Introduction : – RT2-D– Definition SBRT (History)
• Technics and results– 3-D Linac– Rotational Radiotherapy– SBRT linac– Vero– Cyberknife
• Conclusion
RT3D
SBRT
Techniques
4
From 2-D to 3-D [1] 2-D planning era.From 2-D to 3-D [1] 2-D planning era.
– Surgical resection of stage I (T1-2, NO) NSCLC
• 5 year survival rates 60-70%
– Patients medically inoperable treated RT2-D
• Field of irradiation :– primary tumor and regional lymphatics in the ipsilateral
hilum and mediastinum.
– poorly tolerated (with limited pulmonary reserve).
• In a report from the Netherlands, limited “postage stamp”
– Limitations:
• in visualizing the target => difficult to reduce high dose
volume
• selection of beam directions,
• computational algorithms describing deposited dose.
– Surgical resection of stage I (T1-2, NO) NSCLC
• 5 year survival rates 60-70%
– Patients medically inoperable treated RT2-D
• Field of irradiation :– primary tumor and regional lymphatics in the ipsilateral
hilum and mediastinum.
– poorly tolerated (with limited pulmonary reserve).
• In a report from the Netherlands, limited “postage stamp”
– Limitations:
• in visualizing the target => difficult to reduce high dose
volume
• selection of beam directions,
• computational algorithms describing deposited dose.
5
Result of 2-DResult of 2-D
• Duke experience 1980 1995
• 156 patients with Stage I medically inoperable
• non-small–cell lung cancer
• T1N0 54%, T2N0 46%
• Target– Median dose 64 Gy (50 to 80 Gy)– median size 3 cm (range 0.5 to 8)
• Overall survival – The 2- and 5-year was 39% and 13%
• Studies of dose escalation are warranted !
• Duke experience 1980 1995
• 156 patients with Stage I medically inoperable
• non-small–cell lung cancer
• T1N0 54%, T2N0 46%
• Target– Median dose 64 Gy (50 to 80 Gy)– median size 3 cm (range 0.5 to 8)
• Overall survival – The 2- and 5-year was 39% and 13%
• Studies of dose escalation are warranted !
6
PlanPlan
• Introduction : – RT2D– Definition SBRT (History)
• Technics and results– 3-D Linac– Rotational Radiotherapy– SBRT linac– Vero– Cyberknife
• Conclusion
• Introduction : – RT2D– Definition SBRT (History)
• Technics and results– 3-D Linac– Rotational Radiotherapy– SBRT linac– Vero– Cyberknife
• Conclusion
RT3D
SBRT
TechniquesResultsT1 lung cancer
7
Revolution of 3-DRevolution of 3-D
• Due to CT scan– EMI 1972
• Possibility to multi slice
• 2-D to 3-D
• Due to CT scan– EMI 1972
• Possibility to multi slice
• 2-D to 3-D
CONTOUR:CONTOUR: - Manual - Manual
- Automatic- Automatic
VOLUMES DEFINITIONVOLUMES DEFINITION
GTVGTV CTVCTV PTVPTV VTVT VIVI
Beam ABeam A Beam BBeam B
Beam CBeam C
PTV
8
Patient
= ?
Contention
MEPTransfert
ContouringBalistic definition
DosimetryDRR
DosimetricCT scan
Mod
ifica
tions
?
9
Multileaf CollimatorMultileaf Collimator
Collimator
SourceMLC
10
From 2-D to 3-D: beamsFrom 2-D to 3-D: beams
11
RT2-D vs RT3-D M.D. Anderson (2005)RT2-D vs RT3-D M.D. Anderson (2005)
• Materials/Methods: – 200 patients stage I radiotherapy alone– 85 pts 3-D conformal radiotherapy
• T1N0 64%, T2N0 36%, squamous cell carcinoma 46%, non-squamous histology 54%
• median dose 66 Gy (45–90.3 Gy), median follow-up 19 months (3–77 months)
– 115 pts 2-D group: median age 69 (range 44–88)
• T1N0 51%, T2N0 49%, squamous cell carcinoma 47%, non-squamous histology 53%
• median dose 64 Gy (40–74 Gy), median follow-up 20 months (1–173 months)
• Materials/Methods: – 200 patients stage I radiotherapy alone– 85 pts 3-D conformal radiotherapy
• T1N0 64%, T2N0 36%, squamous cell carcinoma 46%, non-squamous histology 54%
• median dose 66 Gy (45–90.3 Gy), median follow-up 19 months (3–77 months)
– 115 pts 2-D group: median age 69 (range 44–88)
• T1N0 51%, T2N0 49%, squamous cell carcinoma 47%, non-squamous histology 53%
• median dose 64 Gy (40–74 Gy), median follow-up 20 months (1–173 months)
2-year 5-year p
Overall survivals
3D 68% 36%
2D 47% 10% 0.001
Disease-specific survivals
3D 83% 68 %
2D 62% 29 % 0.008
Local-regional control rates
3D 77% 70%
2D 53% 34% 0.0006
12
Dose escalationDose escalation
• Hayman (University of Michigan)
• 104 patients with stages I-III treated by 3-DRT
• Dose escalation as high as 102.9 Gy with acceptable
toxicity. – 53 patients had disease progression
• 52% failing distantly
• 8% failing both distantly and PTV
• 2% failing in a distant site, the PTV and a nodal region outside the PTV
• 35% failing within the PTV alone.
• Hayman (University of Michigan)
• 104 patients with stages I-III treated by 3-DRT
• Dose escalation as high as 102.9 Gy with acceptable
toxicity. – 53 patients had disease progression
• 52% failing distantly
• 8% failing both distantly and PTV
• 2% failing in a distant site, the PTV and a nodal region outside the PTV
• 35% failing within the PTV alone.
13
Defining stereotactic body radiotherapy [1] Defining stereotactic body radiotherapy [1]
• Historical Developpement
– Lars Leksell Gammaknife
– Radiosurgery (1 fraction)
– 1967 Stockholm Karolinska Institut
• Radiosurgery
– High precision RT
– >100 converging mini-beam
– Target : 3 cm max
– millimetric accuracy
– Image matching PET/MRI and CT
– Mechanical accuracy => only intra cranial
• Historical Developpement
– Lars Leksell Gammaknife
– Radiosurgery (1 fraction)
– 1967 Stockholm Karolinska Institut
• Radiosurgery
– High precision RT
– >100 converging mini-beam
– Target : 3 cm max
– millimetric accuracy
– Image matching PET/MRI and CT
– Mechanical accuracy => only intra cranial
14
Defining stereotactic body radiotherapy [2]Defining stereotactic body radiotherapy [2]
• Beams– From cobalt 60 (gammaknife)
• Specific collimators– Conventional linac
• Specific collimator or multileaf– Dedicated linac (novalis, CK)
• Specific collimator or multileaf
• Raise of image processing matching tools– Integrated image system– Automatic matching
• Real Image = T ( DRR )
• movement = T ( table or device )
• Image processing accuracy replace mechanical accuracy
• Emergence of extra cranial indication
• Multiple fractions
• Beams– From cobalt 60 (gammaknife)
• Specific collimators– Conventional linac
• Specific collimator or multileaf– Dedicated linac (novalis, CK)
• Specific collimator or multileaf
• Raise of image processing matching tools– Integrated image system– Automatic matching
• Real Image = T ( DRR )
• movement = T ( table or device )
• Image processing accuracy replace mechanical accuracy
• Emergence of extra cranial indication
• Multiple fractions
TT
II JJ
15
Conventional RT
Conventional RT
70
RadiosurgeryRadiosurgery SBRTSBRT
?
Accuracy < cmAccuracy < cm
multiple fractionsmultiple fractions
Accuracy < mmAccuracy < mm
unique fractionunique fraction
Accuracy < mmAccuracy < mm
multiple fractionsmultiple fractions
16
PlanPlan
• Introduction : – RT2D– Definition SBRT (History)
• Technics and results– 3D Linac– Rotational Radiotherapy– SBRT linac– Vero– Cyberknife
• Conclusion
• Introduction : – RT2D– Definition SBRT (History)
• Technics and results– 3D Linac– Rotational Radiotherapy– SBRT linac– Vero– Cyberknife
• Conclusion
RT3D
SBRT
Techniques
17
Rotational radiotherapy [2]: TomotherapyRotational radiotherapy [2]: Tomotherapy
• FDA agreements for HI-ART in 2003
• Statif of 85 cm de diameter
• TomoHD
– TomoHD is a Hi-ART system
packageant
– new linac
– New detector
– Etc…
– system Hi-ART (2009) can be up
graded in TomoHD
– Mobile thomotherapy installed
in a truck
• FDA agreements for HI-ART in 2003
• Statif of 85 cm de diameter
• TomoHD
– TomoHD is a Hi-ART system
packageant
– new linac
– New detector
– Etc…
– system Hi-ART (2009) can be up
graded in TomoHD
– Mobile thomotherapy installed
in a truck
18
Rotational radiotherapy [3]: VARIAN Rotational radiotherapy [3]: VARIAN
• Rapid’ Arc– On board imager (OBI) and cône beam CT (CBCT)– Image guided radiotherapy– IMRT 360° – treatment time divided by 8 conventional IMRT– Dedicated software (ECLIPSE) or not (VMAT)
• Treatment– OBI and CBCT: positioning of tumor– Image comparision with CT scan– Patient matching– Treatment :1 to 2 rotations of 360°– Continus IMRT (field and intensity)
• Results: publication
• Rapid’ Arc– On board imager (OBI) and cône beam CT (CBCT)– Image guided radiotherapy– IMRT 360° – treatment time divided by 8 conventional IMRT– Dedicated software (ECLIPSE) or not (VMAT)
• Treatment– OBI and CBCT: positioning of tumor– Image comparision with CT scan– Patient matching– Treatment :1 to 2 rotations of 360°– Continus IMRT (field and intensity)
• Results: publication
19
Rotational radiotherapy [5]: ELEKTARotational radiotherapy [5]: ELEKTA
• Same technique as VARIAN Rapid’arc
• VMAT (Volumetric Modulated ArcTherapy).
• Modification of rotation speed, leaf position, and dose debit
• Fraction of 2mn
• Dedicated software ERG or Monaco Vmat
• Same technique as VARIAN Rapid’arc
• VMAT (Volumetric Modulated ArcTherapy).
• Modification of rotation speed, leaf position, and dose debit
• Fraction of 2mn
• Dedicated software ERG or Monaco Vmat
20
PlanPlan
• Introduction : – RT2D– Definition SBRT (History)
• Technics and results– 3D Linac– Rotational Radiotherapy– Linac SBRT– Vero– Cyberknife
• Conclusion
• Introduction : – RT2D– Definition SBRT (History)
• Technics and results– 3D Linac– Rotational Radiotherapy– Linac SBRT– Vero– Cyberknife
• Conclusion
RT3D
SBRT
Techniques
21
AXESSE (ELEKTA) AXESSE (ELEKTA)
– Conventional RT and SBRT
– High energy linac (4, 25 MV)
– Isocenter accuracy: < 1 mm
– Multileaf collimator (80 leaf)
– Cone Beam CT »
• Images– 2 XR at 90°
– 2 flat panel (40x40 cm, pxl ? mm²)
– Option VMAT
– Gating ABC « Active Breathing Coordinator »
– Conventional RT and SBRT
– High energy linac (4, 25 MV)
– Isocenter accuracy: < 1 mm
– Multileaf collimator (80 leaf)
– Cone Beam CT »
• Images– 2 XR at 90°
– 2 flat panel (40x40 cm, pxl ? mm²)
– Option VMAT
– Gating ABC « Active Breathing Coordinator »
22
SBRT: Local controlSBRT: Local control
23
Papers Pts Tumors Survival Doses (Gy) Toxicity
Takeda et al
63 (11NoPath)
Stade IA : 38Stade IB : 25
At 3 years :-Stade IA : 90% (p=0,09%)-Stade IB : 63% (p=0,09%)At 5 years without pathology : -Stade IA : 82% (p=0,10%)-Stade IB : 63% (p=0,10%)
50 Gy in 5 fr
Uematsu et al
45 (66 t)
Loc I (IA : 9, IB : 11, IIA : 3Loc II : 26
Rate of de Survival ( ?) : 75 % 30 to 75 Gy in 3 à 15 fr
Timmerman et al
55 Primitives : stade IAbdominal pressure
global Survival at 2 years : 54% 60 to 66 Gy in 3 fr 20% (includes 6 possible grade 5 cases)
Onishi et al
245 Primitives :-Stade IA : 155-Stade IB : 90
SG at 3 years : 56%, at 5 years 47%specific at 3 and 5 years : 78%5 ans survival if BED ≥ 100 Gy : -Stade IA : 90%-Stade IB : 84%
18 to 84 Gy in 1 à 25 fr
5.4% lung1% oesophagitis1.2% dermatitis
Wulf et al 61 Loc I : 20 (IA : 2, IB : 10, IIA (T3) : 8Loc II :51
Primitives : Survival at 1 years : 52% Survival at 5 years : 18%Mets : Survival at 1 years : 85%
26 to 37,5 Gy in 1 à 3 fr
P. Baumann2009
57 Abdominal pressure if neededPeripheral
3 year 60% 45 Gy/3 fr 26% grade 32% grade 4
F.B. Zimmerman
68 Peripheral or central 3 year 53% 24–40 Gy/3–5 fr 6% pneumonitis3% rib fracture
R.C. McGarry
47 Abdominal pressurePeripheral or central
24 Gy/3 fr escalating to 72 Gy/3 fr
11% lung2% pericardial
J.Y. Chang
27 4-D CT planningCentral or superior
40–50 Gy/4 fr 11% grade 2–3 pneumontis/pain
24
Toxicity Toxicity
• Depends Modalities (?)
• Oesophagitis
• Dermatitis
• Pneumonitis
• Rib fracture
• Pericardial
• Chest wall pain
• Depends Modalities (?)
• Oesophagitis
• Dermatitis
• Pneumonitis
• Rib fracture
• Pericardial
• Chest wall pain
25
RTOG 0236 [1]RTOG 0236 [1]
• A Phase II SBRT for Patients with Medically Inoperable Stage I/II Non-Small Cell Lung Cancer
• R. Timmerman JAMA. 2010;303(11):1070-76. – 59 patients T1-T2N0M0 non-small cell tumors (<5 cm) – not allow surgical treatment.– May 2004 to October 2006– data analyzed August 2009– 1 end point: 2-year actuarial primary tumor control– 2 end points: disease-free survival
• 55 evaluable pts with Median
follow-up of 34.4 months
• A Phase II SBRT for Patients with Medically Inoperable Stage I/II Non-Small Cell Lung Cancer
• R. Timmerman JAMA. 2010;303(11):1070-76. – 59 patients T1-T2N0M0 non-small cell tumors (<5 cm) – not allow surgical treatment.– May 2004 to October 2006– data analyzed August 2009– 1 end point: 2-year actuarial primary tumor control– 2 end points: disease-free survival
• 55 evaluable pts with Median
follow-up of 34.4 months
26
RTOG 023 [2]RTOG 023 [2]
• Presented in 51th ASTRO an update of RTOG 0236– Only 1 primary tumor failure
– Estimated 3-year primary tumor control rate: 97.6%.
– Local-regional control rate: 87.2%
– Disease-free survival at 3 years: 48.3%
– Overall survival at 3 years: 55.8%
– median overall survival: 48.1 months.
– Primary tumour control at three years improved from 88 to 98%
• Toxicity– grade 3 in 7 patients (12.7%), grade 4 in 2 patients (3.6%)
• Conclusion– Median survival had not yet been reached (It had not been anticipated that this would happen)
– Patient follow up has been amended from a total of 4 years to include annual follow up
– Possibly be attributed to image-guidance techniques into the SBRT process.
• Presented in 51th ASTRO an update of RTOG 0236– Only 1 primary tumor failure
– Estimated 3-year primary tumor control rate: 97.6%.
– Local-regional control rate: 87.2%
– Disease-free survival at 3 years: 48.3%
– Overall survival at 3 years: 55.8%
– median overall survival: 48.1 months.
– Primary tumour control at three years improved from 88 to 98%
• Toxicity– grade 3 in 7 patients (12.7%), grade 4 in 2 patients (3.6%)
• Conclusion– Median survival had not yet been reached (It had not been anticipated that this would happen)
– Patient follow up has been amended from a total of 4 years to include annual follow up
– Possibly be attributed to image-guidance techniques into the SBRT process.
27
PlanPlan
• Introduction : – RT2D– Definition SBRT (History)
• Technics and results– 3D Linac– Rotational Radiotherapy– Novalis– Vero– Cyberknife
• Conclusion
• Introduction : – RT2D– Definition SBRT (History)
• Technics and results– 3D Linac– Rotational Radiotherapy– Novalis– Vero– Cyberknife
• Conclusion
RT3D
SBRT
Techniques
28
Vero [1]Vero [1]
• System launched ESTRO 2010 meeting
• MITSUBSHI and BRAINLAB collaboration
• Combination of versatile imaging capabilities
– real-time tumour tracking –
• Statif of 4.17 m (1.25 m) 11 tons– Linac 6MV,
– micro-multileaf of 60 leafs of 5mm at isocenter.
– Field of 15X15 cm
• O-ring can rotate ±60° about its vertical axis – isocentre accuracy of 0.1 mm.
• System launched ESTRO 2010 meeting
• MITSUBSHI and BRAINLAB collaboration
• Combination of versatile imaging capabilities
– real-time tumour tracking –
• Statif of 4.17 m (1.25 m) 11 tons– Linac 6MV,
– micro-multileaf of 60 leafs of 5mm at isocenter.
– Field of 15X15 cm
• O-ring can rotate ±60° about its vertical axis – isocentre accuracy of 0.1 mm.
29
Vero [2]Vero [2]
• Imaging– Two orthogonal kV attached to the O-
ring at 30 i/s (fluoroscopy)– Cône Beam CT and software «
HYBRID ARC », VERO can do rotational IMRT
– Integrated ExacTrac infrared
• Specific software: BRAINLAB iPLAN
• Systems– 4 Vero in Japan
– 1 European installation : UZ Brussels University Hospital
– 300 patients already treated
• Publicated Results: no
• Imaging– Two orthogonal kV attached to the O-
ring at 30 i/s (fluoroscopy)– Cône Beam CT and software «
HYBRID ARC », VERO can do rotational IMRT
– Integrated ExacTrac infrared
• Specific software: BRAINLAB iPLAN
• Systems– 4 Vero in Japan
– 1 European installation : UZ Brussels University Hospital
– 300 patients already treated
• Publicated Results: no
30
PlanPlan
• Introduction : – RT2D– Definition SBRT (History)
• Technics and results– 3D Linac– Rotational Radiotherapy– Novalis– Vero– Cyberknife
• Conclusion
• Introduction : – RT2D– Definition SBRT (History)
• Technics and results– 3D Linac– Rotational Radiotherapy– Novalis– Vero– Cyberknife
• Conclusion
RT3D
SBRT
Techniques
31
1 - Patient Positioning1 - Patient Positioning
• Robotic couch– 3 rotations
– 3 translations
• Numeric X Rays– 2 sources of X Rays with 2 flat
panels at 90°
– Automatic.
– Discontinued
– 41 * 41 cm 1024 *1024 pxl
– Pxl : 0.4 mm²
• Robotic couch– 3 rotations
– 3 translations
• Numeric X Rays– 2 sources of X Rays with 2 flat
panels at 90°
– Automatic.
– Discontinued
– 41 * 41 cm 1024 *1024 pxl
– Pxl : 0.4 mm²
32
33
34
35
36
37
38
39
40
41
42
43
Fiducial or not?
• For small tumor (<1,5cm) near spine/mediastinum : we prefer fiducial– Endoscopic– CT scan
• For small tumor (<1,5cm) near spine/mediastinum : we prefer fiducial– Endoscopic– CT scan
44
Mvt thorax/tumor Mvt thorax/tumor Mvt thorax/tumor Mvt thorax/tumor
X
Y
Z
Diodsthorax
Fiducials
Time
45
46
StudyStudy
• Stage I NSCLC (T1 or T2 N0 M0).
• Histology proven : Only ADK and SCC lesions were included.
• For mets : primitive tumor controlled and slow growing.
• Maximal diameter : 6 cm.
• No other concomitant or postradiation treatment
• Indication of CK : Clinical case discussion
• Exclusion if pulmonary atelectasis, infection or pneumonitisproblem of interpretation
• No MRI if no neurologic symptom
• Stage I NSCLC (T1 or T2 N0 M0).
• Histology proven : Only ADK and SCC lesions were included.
• For mets : primitive tumor controlled and slow growing.
• Maximal diameter : 6 cm.
• No other concomitant or postradiation treatment
• Indication of CK : Clinical case discussion
• Exclusion if pulmonary atelectasis, infection or pneumonitisproblem of interpretation
• No MRI if no neurologic symptom
47
Treatments Treatments
• Millimetric margins
• Tumor tracking during breathing
• CTV=GTV+5mm
• Optical positioning system– « Synchrony » Software
• Treatment time: 45-75 min
• Millimetric margins
• Tumor tracking during breathing
• CTV=GTV+5mm
• Optical positioning system– « Synchrony » Software
• Treatment time: 45-75 min
50-75 Gy5 Fr
60 Gy / 3 F
48
ResultsResults
• Median follow up 18.7 months
• Mean fraction duration 65 min (G4)
• First fraction longer than the others
• Median follow up 18.7 months
• Mean fraction duration 65 min (G4)
• First fraction longer than the others
Nb patient Nb Fr
3 1
78 3
5 4
42 5
49
ResultsResults
• Distant reccurence 62 (46.97%)
• and 31 (23.48%) death
• Local recurrence 18 (13.64%)
• and 8 (6.06%) death
• Distant reccurence 62 (46.97%)
• and 31 (23.48%) death
• Local recurrence 18 (13.64%)
• and 8 (6.06%) death
50
Evaluation at 2 years Evaluation at 2 years ((RECIst criteria)RECIst criteria)Evaluation at 2 years Evaluation at 2 years ((RECIst criteria)RECIst criteria)
During the year : 10 Distant progression,
2 death of other cause, 2 NA
CR 30 %
PR 38 %
ST 18 %
L prg 14 %
During the year : 10 Distant progression,
2 death of other cause, 2 NA
CR 30 %
PR 38 %
ST 18 %
L prg 14 %
86 %86 %86 %86 %
51
CT : Time EvolutionCT : Time Evolution
16/02/07
31/07/07
30/11/07
16/04/08
02/10/08
28/03/07
Matched images
12/03/10
14/09/09
20/09/10
52
PET evolutionPET evolution
24 January 08 05 January 10
Matched images
53
LRI : Results [1]LRI : Results [1]
• Recurrences: – same lobe 88.2% (15) same lung 11.8% (2).
• Recurrences: – same lobe 88.2% (15) same lung 11.8% (2).
Previous treatment
CK treatment
Total
54
Papers Patients Tumor Survival Doses (Gy)
Collins et al 24 Primitives :-Stade I : 15Mets :-Dont 5 CBNPC
A 1 years : Primitives : 87%Mets : 78%
45 to 60 Gy in 3 fractions
Pennathur et al 32 Loc I : 27 ( StI : 11, II : 2, III : 2, IV : 1-Recurence : 11Mets : 5
A 1 year : Primitives :-Stade I-IV : 61%-Stade I : 91%-Recurrence 89 %Mets : 80%
20 Gy in 1 fraction
Christie et al 21 Stade I survival at 1 year : 90% 60 Gy in 3 fractions
W.T. Brown, 59 Peripheral or central 90% free from persistent or recurrent disease
15 to 67.5 Gy/1–5 fractions
van der Voort van Zyp
70 Synchrony respiratory tracking system
2 years 96% (60 Gy) or 78% (45 Gy) 45 or 60 Gy/3 fractions
Bondiau et al 53 (60T) 63% Stage I37% Metastatic lesion
2 years 86% 60 Gy in 3 fr or75 to 60 in 5 fr
Cyberknife resultsCyberknife results
55
Comparison to surgeryComparison to surgery
• International Protocol Phase III
• J. Roth (MD Anderson)
• Randomisation : CK vs
surgery
– T1-2 N0 M0,
– PET?
– Margin discussion 1cm?
– Dose discussion
• International Protocol Phase III
• J. Roth (MD Anderson)
• Randomisation : CK vs
surgery
– T1-2 N0 M0,
– PET?
– Margin discussion 1cm?
– Dose discussion
56
PlanPlan
• Introduction : – RT2D– Definition SBRT (History)
• Technics and results– 3D Linac– Rotational Radiotherapy– Novalis– Vero– Cyberknife
• Conclusion
• Introduction : – RT2D– Definition SBRT (History)
• Technics and results– 3D Linac– Rotational Radiotherapy– Novalis– Vero– Cyberknife
• Conclusion
RT3D
SBRT
Techniques
57
Nb beam Positioning Accuracy GTV irradiation DoseResults
LC
RT2D 6 Manual/ laser cm margin 66-70 30 % at 3
years
Conformal 3D 6-16 Manual/ laser cm Margin / Gating 66-70 60-70 % at 2
years
Rotational RT
Tomotherapy
Rapid arc
Vmat
360°
CT
(pxl>1,2mm²)
< cmMargin 66-70
Escalating dose study in progress
Accel/SBRT Novalis
Axess< 20 Beam 2 Xray
< mmGating ? 70-90% at 3
years
Vero Arc/Beam 2 Xray< mm
Tracking ? ? No
Cyberknife >1502 Xray
automatic< mm Tracking
150 Gy
BED
90-95% at 2 years
Compare Surgery
58
Conclusion: SBRT Conclusion: SBRT
• Overall accuracy < 1 mm
• Breaks through in the treatment lung tumor
• Hypofractionation– 1-5 fractions (1 week)
– "Rapid return to normal life"
• Major interest ++ lung tumor Stage 1 ( # surgery) Standard
of care of patient medically inoperable?
++ after pneumonectomy
++ of the re-irradiation capacity : Lung?
Clinical research : stage III boost?
• Overall accuracy < 1 mm
• Breaks through in the treatment lung tumor
• Hypofractionation– 1-5 fractions (1 week)
– "Rapid return to normal life"
• Major interest ++ lung tumor Stage 1 ( # surgery) Standard
of care of patient medically inoperable?
++ after pneumonectomy
++ of the re-irradiation capacity : Lung?
Clinical research : stage III boost?
RTCT 2008on CK-CT scan 2010
CK 2010 RTCT 2008CK 2010
59
Merci
G. ANGELIER (PhD)K. BENEZERY (MD)J. THARIAT (MD)
G. PALAMINI (radiotherapist)B. GRANIER (Secretary)S. MARCHAL (CR) P.Y. BONDIAU (MD. PhD)
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