03 suh lung sbrt hyderabad feb 2013 (cancer ci 2013) john h. suh
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Stereotactic body radiation therapy (SBRT) is a form of high-precision radiotherapy that delivers large, precise radiation doses to tumors in just a few treatment sessions. Studies have shown SBRT provides excellent local tumor control of early stage non-small cell lung cancer comparable to surgery, with less invasive treatment. Ongoing and completed prospective studies continue to evaluate SBRT's long-term outcomes and toxicities compared to other standard treatments like surgery or conventional radiation therapy. SBRT is becoming an important treatment option for medically inoperable early stage lung cancer patients.
03 suh lung sbrt hyderabad feb 2013 (cancer ci 2013) john h. suh
- 1. Stereotactic Body Radiation Therapy for Non-small Cell Lung Cancer John H. Suh Professor and Chairman, Dept. of Radiation Oncology Taussig Cancer Institute Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center
- 2. Conflicts of interest • Abbott Oncology Consultant • Varian Travel stipend
- 3. Outline • Define lung stereotactic body radiation therapy • Review the historic outcomes with radiation therapy for early stage lung cancer • Discuss the advantages of lung SBRT compared to surgery • Highlight ongoing and completed prospective studies • Review the toxicities associated with lung SBRT
- 4. Sample case of lung SBRT • 77 year old female with left upper lobe lung adenocarcinoma, T1aN0M0, stage IA; medically inoperable due to impaired PFTs • Representative axial CT image at simulation • Representative axial CT image one year post SRS
- 5. What is lung SBRT? • Form of high precision radiotherapy delivery (1-8 fx) – Needs to account for tumor motion – Needs to be accurate – Needs to have reproducible setup prior to treatment – Has good patient compliance – Has good resource utilization • Represents one of the significant advances in the curative therapy of lung cancer • Also known as SABR (stereotactic ablative body radiotherapy)
- 6. Stereotactic Ablative Radiotherapy for Lung Cancer Treatment Planning Treatment Delivery Assessment of tumor motion Large doses per fraction Complex beam arrangement Monitoring of breathing Advanced planning Image-guided targeting algorithms Senan et al. 2012
- 7. SBRT can accomplish more than conventional XRT • Local Control Historic comparisons – SBRT 54 Gy in 3 fx, 98% (local), 91% (lobe) (RTOG 0236) – EBRT 60-66 Gy / 30-33 fx, ~50% (Qiao, Lung Cancer 2003) Beaumont experience (Lanni, Am J Clin Oncol 2011) – SBRT (48-60 Gy in 4-5 fx, n=45) vs. EBRT (70 Gy/ 35 fx, n=41) – 3y LC, 88% vs. 66% (p=0.10) • Meta-analysis (Grutters, Radiother Oncol 2010) SBRT (n=895) vs. EBRT (n=1326) – 2-year OS, 70% vs. 53% (p=<0.001) – 2-year DFS, 83.4% vs. 67.4% (p=0.006)
- 8. Stephans et al. l SBRT for Central Lung Tumors l 10/4/11 l 9
- 9. Stereotactic Radiation for Stage I NSCLC • Lung SBRT is gaining a track record of efficacy, now reaching the intermediate term, in more robust patients. – Japanese data with 10 year survivors – Long term IU and VUmc data – Multi-institutional RTOG 0236 data – Many single institutional series – Japanese, VUmc data for operable patients – Need larger, cooperative databases –Intermodality data, better matching
- 10. Peripheral Tumors Peripheral Tumors • Dealing primarily with “parallel” tissues, therefore there may be no point dose limit (if really only parallel). • Where does the dose-response curve plateau? Wulf et al., Radiother Oncol. 2005
- 11. Medically Inoperable: Peripheral Tumors
- 12. • 55 evaluable patients, 34 month med follow-up. • Only 1 local failure (3-year LC 97.6%) • 3 same-lobe failures (3-year lobar control 90.6%) • 2 nodal failures (3-year loco-regional control 87.2%) • 11 distant failures (3-year distant failure rate 22.1%) Timmerman R, et al. JAMA 303:1070-1076, 2010
- 13. Peripheral Tumors: The “Right” Dose Wulf et al., Radiother Oncol. 2005 Wash U, Olsen et al., IJROBP 2011 CCF early retrospective data (Stephans et al., JTO 2009)
- 14. Randomized Phase II Study Comparing Two SBRT Schedules for Medically Inoperable Patients with Stage I Peripheral NSCLC RTOG 0915 T1, T2 (< 5 cm) R R 34 Gy/1 fraction Clinically node A A negative by PET N Stratify N Peripherally D located T stage D 48 Gy/ 4 fractions Zubrod Primary endpoint: rate of 1-year grade 3 or higher AE Secondary endpoint: 1-year tumor control 1-year OS and DFS PET SUV changes PFT test
- 15. Central Tumors 3 year local control 92% JTO, Dec 2011
- 16. Central Tumors Central Tumors both parallel (target, normal lung), and • Now dealing with some serial tissue (trachea, bronchial tree, esophagus), as well as imperfectly categorized heart/great vessels. • Can we reach plateau without concerns of unreasonable normal tissue toxicity? (yes) Wulf et al., Radiother Oncol. 2005
- 17. Notes of Caution (Central Tumors) • 6 possibly treatment related deaths - 4 bacterial pneumonia - 1 pericardial effusion - 1 hemoptysis* (ascribed to carinal recurrence)
- 18. Central Tumors – Treated Safely with SBRT • Early Japanese data didn’t report significant toxicity. – Used smaller fraction sizes (typically 10-12 Gy/fx) – (Onishi et al., Onimaru et al, Uematsu et al., and Nagata et al). – These studies did not use any particular avoidance criteria for organs at risk. • VUmc experience in 63 patients (37 central, 26 “cardiac”) also demonstrates excellent safety profile. – 60 Gy in 8 fractions – Haasbeek et al. JTO 2011
- 21. Stage I NSCLC: Spectrum of Health Medically “High risk” Medically Operable Operable Inoperable Lobectomy SBRT
- 22. Potential Advantages of Surgical Resection • Confirmation of cancer diagnosis • Pathological staging • Nodal dissection • Information for adjuvant therapy • Clear measures of outcome to allow salvage
- 23. Pathological Staging and Node Dissection • ACOSOG study demonstrates no difference in OS between nodal sampling and dissection for early stage NSCLC (Darling et al. JTCVS) – This is different than no sampling, but improved radiographic staging and EBUS while not the same as surgical sampling allow improved non-invasive sampling (Okada 2005, Miller 2002, Meyers 2006, Crabtree 2010) • Even if nodal upstaging is 10% with dissection (2-17%), benefit of adjuvant chemo (provided the patient can tolerate) is only 5%. – ie. 10% * 5% = potential 0.5% OS benefit for population discovering occult node + disease.
- 24. Lack of biopsy in some SBRT series • Wash U data also suggests no difference by radiographic v pathological diagnosis – Robinson, IJROBP 2012 • Two separate Netherlands reports suggest same (Laagerward et al, ASTRO 2011), and worse (Palma JCO 2010) outcome in non-biopsied patients. Stephans, CCF, JTO 2010
- 25. Caveats for comparisons of SBRT and Surgery • Overall – What medical “risk” patient population? – Tumor stage / size? – Type of staging? • Surgery – Lobar? Sublobar? Both? – Open vs. VATS? – Skill set of surgeon/institution? • SBRT . . .rapidly learning. . .heterogeneity of data. . . – Dose / fractionation? – BED = Biologically Effective Dose – < 100 Gy10 results in worse LC and OS! – Dose / location relative to organs at risk? – Central tumors, Chest wall, Lung
- 26. Comparisons of SBRT and Surgery • Lowest level evidence – Raw comparisons of surgery and SBRT (i.e., my paper vs. your paper) – Easily confounded by imbalances in patient, tumor, and treatment factors. – As it turns out, also confounded by practices for coding failures. – The individual data itself is great, but comparisons are for now, nearly worthless, (it’s a start).
- 27. Comparisons of SBRT and Surgery • Reports of SBRT for “medically operable” pts? – Retrospective – Uematsu, et al (IJROBP 2001) – Onishi, et al (JTO 2007; IJROBP 2010) – Amsterdam (Senan et al, ASCO 2011) – Prospective (final results pending) – JCOG 0403 – Stage IA NSCLC. Phase II (n=65), 48 Gy /4 fx. – RTOG 0618 – Stage I/II NSCLC. Phase II (n=33), 60 Gy/ 3 fx.
- 28. Comparisons of SBRT and Surgery Uematsu, IJROBP 2001 – 50 pts w/T1 (n=24) or T2 (n=26) N0 NSCLC tx’d w/SBRT (10/94-06/99) – 29 pts were medically operable but refused surgery – Mix of SBRT doses, prior radiation, etc. All 50 29 medically operable 3y LC 94% CSS 88% OS 66% 3y OS 86%
- 30. Comparisons of SBRT and Surgery • Lagerwaard, IJROBP in-press – 177 pts w/medically operable, T1 (n=60%) or T2 (n=40%) N0 NSCLC tx’d w/SBRT from 2003-2010 in the Netherlands. – SBRT delivered using “risk adapted” scheme (60 Gy in 3, 5, or 8 fractions) – Median age 76 – Median F/U 32 mo – 3-year LC 93% – 3-year OS 84.7%, median OS 61.5 mo
- 31. Comparisons of SBRT and Surgery (source bias) Study Clinical Stage/Group OS Sugi (World J Surg 2000) IA; 52 open, 48 VATS 5y 85%/90% LCSG (Ginsberg, Ann Thorac IA; 122 wedge, 125 lobe 5y ~60%/~70% Surg 1995) AJCC 6th IA/IB 5y 61% (T1), 38% (T2) AJCC 7th IA/IB 5y 47-52% (T1), 36-43% (T2) Uematsu IA/IB (3y) 86% Onishi IA/IB 5y 76 (T1)%, 64% (T2) Amsterdam IA/IB (3y) 85%
- 32. Comparisons of SBRT and Surgery Crabtree, JTCVS 2010
- 33. Crabtree et al., Wash Univ, JTCVS 2010
- 34. Crabtree et al., Wash Univ, JTCVS 2010 All were not significant
- 35. • Analysis of patients with Gold’s III/IV COPD, or predicted post-op FEV1 <40% • 176 VUmc SBRT patients • Meta-analysis identified 75 additional SBRT patients, and 121 surgical patients from 4 studies meeting search and review criteria Palma IJROBP, March 2012
- 36. Palma et al., VUmc, IJROBP 2012
- 37. Markov Modeling Comparisons (Puri et al., JTCVS 2011, and Louie et al., IJROBP 2010) • Attempt to model a comparison of SBRT and surgery using available data – Demonstrate Surgery to be cost effective… – … However, outcome highly sensitive to surgical mortality rate • When surgical mortality exceeds 4% model favors SBRT (Louie) Low risk High risk (n=57) Operative 2.7% 7% Mortality Any 38% 43.8% complications Arrhythmia 22.7% 21% Respiratory 19.9% 27% Crabtree et al, Wash Univ data
- 38. PET scan after lung SBRT Henderson et al., IJROBP 2010 Mar 1;76(3)
- 39. RTOG 0618: Phase II trial of SBRT for patients with operable Stage I/II NSCLC
- 40. Quality of Life Comparisons: SBRT Videtic et al., CCF Data van der Voort van Zyp, IJROBP 2010 (Netherlands)
- 41. Comparisons of SBRT and Surgery • Highest level evidence – Randomized trials – None completed – Two trials of SBRT vs. lobectomy for medically operable pts – ROSEL – Terminated early – STARS – Struggling – Question asked too early. . .??? – One trial SBRT vs. sublobar resection for “high risk” operable pts –ACOSOG Z4099/RTOG 1021
- 42. Comparisons of SBRT and Surgery – Toxicity? SBRT Surgery • Skin toxicity? • Death? • Fatigue? • Post-op pain? • Chest wall toxicity? • Infection? • Pneumonitis? • Atrial fibrillation? • Brachial plexopathy? • Extended hospital stay? • Bleeding? • Decreased pulmonary • Fistula or stenosis? function? • Esophageal toxicity? • Post-thoracotomy pain?
- 43. Pulmonary Function • Studies have been mixed on PFT changes • IU Phase I protocol described transient decline followed by return to baseline - Timmerman et al., Chest 2003;124(5) • IU Phase II protocol showed no change in FEV1 but DLCO ↓ 1.11 mg/min/mm Hg/y - Henderson et al., IJROBP 2008 Oct 1;72(2) • RTOG 0236 showed 1 grade 4 (2%) and 8 grade 3 (15%) pulmonary/upper respiratory events (included PFT changes). - Timmerman et al., JAMA 2010 March 17;303(11)
- 44. Toxicity - Pneumonitis • Most studies report pneumonitis as 0-5%: • 25 patients treated at U. Tokyo to 48 Gy in 4 fractions prescribed to isocenter. - Grade 2-5 RP 29%, including 3 pt’s w grade 5 - RP correlated with high conformality index - In general had high conformality, 7 pts > 2.00 Yamashita et al., Rad Oncol 2007;2:21
- 46. IJROBP 2012 82:2
- 47. TE CT CHANGES (≤ 6 months) LATE CT CHANCES (> 6 months) Description Description Consolidation > 5 cm in largest Consolidation, loss of volume, Modified Diffuse dimension. The involved region bronchiectasis similar to conventional conventional consolidation contains more consolidation than radiation fibrosis, but usually less pattern aerated lung. extensive. May be associated with GGO. Well-circumscribed focal consolidation Consolidation ≤ 5 cm in largest dimension Patchy limited to area surrounding the tumor. and/or the involved region contains more Mass-like consolidation The abnormality must be larger than the consolidation than aerated lung. orginal tumor size > 5 cm of GGO, (without consolidation). Linear opacity in the region of the Diffuse GGO The involved region contains more Scar-like tumor, associated with loss of volume GGO than normal lung No new abnormalities. Includes patients ≤ cm of GGO, (without consolidation), No evidence of with tumors that are stable, regressing or Patchy GGO and/or the involved region contains increased resolved, or fibrosis in the position of the less GGO than normal lung density original tumor that is not larger than the original tumor Senan et al. 2012
- 48. Importance of the multi-disciplinary team • Radiation oncologist • Radiologists • Nuclear medicine physicians • Pulmonologists • Pathologists
- 49. Conclusions • Lung SBRT is an effective, efficient, and safe radiation technique for patients with early stage NSCLC • Peripheral lesions may be treated more aggressively compared to centrally located lesions • Clinical trials are underway to better understand the role of lung SBRT
- 50. Title of Presentation Arial Regular 22pt Single line spacing Up to 3 lines long Date 20pts Author Name 20pts Author Title 20pts