sbrt and pancreas cancer la belle et la bête€¦ · – 23 lapc – 3 lrpc • mean age 70 (range...
TRANSCRIPT
![Page 1: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/1.jpg)
SBRT and Pancreas Cancer
La Belle et la Bête
Gert Meijer
![Page 2: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/2.jpg)
la Bête
![Page 3: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/3.jpg)
Controversial role of radiotherapy
• OS was not improved with CRT, 16.5 m vs. 15.3 m
(HR = 1.03[0.79-1.34], p=0.83)
![Page 4: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/4.jpg)
How about the radiotherapy in LAP07?
• All patients treated with 3D-CRT
• Margin on GTV was 3 cm sup-inf and 2 cm radially
• No prophylactic RT to the nodes
• The investigators conclude in the presentation that RT still has an important role in LAP, however they advocate for novel delivery modalities
![Page 5: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/5.jpg)
How about the SBRT?
• patient friendly • non-invasive • hypofractionated
• high dose to central • low dose to organs at risk
![Page 6: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/6.jpg)
How about the SBRT?
![Page 7: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/7.jpg)
How about the SBRT?
![Page 8: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/8.jpg)
How about the SBRT?
Can we cure all patients? - NO!
Can we cure a few patients? - Maybe…. How about palliation? - Hopefully…
![Page 9: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/9.jpg)
poor target definition
poor OAR definition
poor online image guidance
target moves
OARs move too
closeby radiosenstive OARs
What hurdles to take?
![Page 10: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/10.jpg)
poor target definition
poor OAR definition
poor online image guidance
target moves
OARs move too
closeby radiosenstive OARs
What hurdles to take?
![Page 11: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/11.jpg)
poor target definition
poor OAR definition
poor online image guidance
target moves
OARs move too
closeby radiosenstive OARs
What hurdles to take?
Heerkens et al. R&O 2014
![Page 12: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/12.jpg)
poor target definition
poor OAR definition
poor online image guidance
target moves
OARs move too
closeby radiosenstive OARs
What hurdles to take?
![Page 13: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/13.jpg)
Pancreas cancer has been identified as one of key tumor sites within MR-linac consortium
? Sept 2015 Houston
![Page 14: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/14.jpg)
MRI-guided SBRT with for locally advanced pancreatic cancer: a feasibility and safety study Add MRI for target definition and definition organs at risk
1
![Page 15: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/15.jpg)
MRI-guided SBRT with for locally advanced pancreatic cancer: a feasibility and safety study Use gold markers for image guidance during treatment
Acknowledgements Eelco Lens AMC Amsterdam
2
![Page 16: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/16.jpg)
MRI-guided SBRT with for locally advanced pancreatic cancer: a feasibility and safety study Use abdominal corset to reduce motion and measure residual motion with cine MRI
3
![Page 17: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/17.jpg)
MRI-guided SBRT with for locally advanced pancreatic cancer: a feasibility and safety study Create SBRT plan with 3-mm GTV-PTV margins to 3x8Gy
4
![Page 18: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/18.jpg)
MRI-guided SBRT with for locally advanced pancreatic cancer: a feasibility and safety study Blur dose with respiratory motion kernel to estimate effect breathing
breathing pattern 3 x breathing pattern 10 x breathing pattern
5
![Page 19: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/19.jpg)
MRI-guided SBRT with for locally advanced pancreatic cancer: a feasibility and safety study
6
![Page 20: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/20.jpg)
Results
![Page 21: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/21.jpg)
Results
80% intrafraction motion < 3 mm
![Page 22: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/22.jpg)
• 26 patients
– 23 LAPC
– 3 LRPC
• mean age 70 (range 50 -85)
• 13 patients died
• 7 patients developed metastases (1 is still alive)
• No treatment related grade 3 toxicity within 90 days
• One grade 2 pancreatitis due to seed procedure
Results
![Page 23: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/23.jpg)
• Our SBRT regimen is very well tolerated
• No improvement in LC/survival
• Increase dose!
So.....
![Page 24: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/24.jpg)
4D MRI Coronal
Sagittal
Transverse
CC
mo
tio
n (
mm
)
Pancreatic motion
1) Stemkens B et al. ISMRM, 2013 2) Roujol S et al. IEEE TMI, 2011
![Page 25: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/25.jpg)
Flow chart
Pre
-be
am
imag
ing
Rad
iati
on
Transform 3D volume, based on 2D images, using
motion model
Full FOV 3D motion
information (x,y,z,t)
4D MRI acquisition (x,y,z,φ) Motion model
Acquire 2D cine MR images
![Page 26: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/26.jpg)
Warped 3D volume (model)
2D coronal slice (acquired)
![Page 27: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/27.jpg)
![Page 28: SBRT and Pancreas Cancer La Belle et la Bête€¦ · – 23 LAPC – 3 LRPC • mean age 70 (range 50 -85) • 13 patients died • 7 patients developed metastases (1 is still alive)](https://reader034.vdocuments.us/reader034/viewer/2022052612/5f0f8a607e708231d444abc2/html5/thumbnails/28.jpg)
So in the end with the MR-linac we are working towards dose deliveries to pancreas tumors with the same accuracies as we currently do in brain Hopefully this will result in a clinical benefit for (a subset of) LAPC patients
Acknowledgements: Hanne Heerkens Bjorn Stemkens Rob Tijssen Marco van Vulpen
Baudouin Denis de Senneville Nico van den Berg Jan Lagendijk Eelco Lens (AMC)
Beth Erickson (MCW) William Hall (MCW)