Esophageal cancer practical target delineation 2013 may
Novel RT techniques for treating lung cancer 1403
1. Novel RT Techniques
For Lung Cancer Treatment
Yong Chan Ahn, MD, PhD
Dept. of Radiation Oncology
Samsung Medical Center
Sungkyunkwan University School of Medicine
2.
3. Fundamental of RT
• To deliver high dose to tumor
• To limit dose to normal tissues
4. From Classic to Conformal
•
•
•
•
Better local control
Enhanced quality of life and reduced morbidity
Improve accuracy of every step!
Patient-specific:
– Individualized
– Customized
– Adaptive
5. RT Process
Steps in RT that can be represented by links in a chain.
Tx accuracy will be limited by the weakest link in the chain
21. Conventional RT
SABR
1.8~3.0 Gy
10~20 Gy
10~30 fractions
1~5 fractions
GTV, CTV, (ITV), PTV
GTV, CTV, ITV, PTV
(GTV CTV)
cm range
mm range
Need for mechanical
accuracy
Low to medium
Very high
Need for respiratory
motion control
Moderate
High
Radiobiology
Well understood
Still poorly understood
Interaction with
systemic therapy
Currently active
Will become active
Dose/fraction
Fraction number
Target delineation
Margins
22. Rationale of SABR in Stage I NSCLC
• RT is better than doing nothing.
• (+) dose-response relationship in local control.
• The smaller the tumor, the higher the local control
and survival by RT.
• LN metastasis incidence is very low.
• Shorter RT is better than protracted RT in survival.
31. Summary
• SBRT to lung cancer at SMC:
– High local control (90%)
– Favorable 5 year survival (primary/metastatic –
66.4%/53.8%)
– Very low risk of complication (Grade 2/3 –
3.4%/1.7%)
– Highly effective and curative modality to patients
who are unfit for surgery.
35. Summary
• SBRT for single or oligo-metastasis seems
quite effective and safe.
• Tumor size, disease-free interval, and presence
of extrathoracic disease are prognosticators for
survival.
46. Summary
• Limitations:
– Small number of patients
– Heterogeneous patient population
– Retrospective nature
• IMRT group:
– More extensive disease and larger CTV
– More frequent early distant metastasis
• Careful case selection and intensified systemic Tx
maybe considered
48. Why Proton Beam Therapy?
• Bragg peak (1946, Wilson et al. first proposed PBT)
• RBE=1.1
49. History of PBT
• 1950: 1st clinical application
to suppress pituitary
function and to reduce
metastases from breast ca
• 1950’s: Uppsala Group
(Sweden) pioneered proton
RT for cancer
• Early 1960’s: Harvard
Cyclotron Group (US)
developed most current
techniques
55. PBT for Stage III NSCLC
• Need for dose escalation:
– RTOG trials (X-rays): 8311 (+) and 0617 (-)
• Few dosimetric comparison studies:
– Advantage of PBT over X-rays seems more
significant in stage III than stage I
• Recent on-going trials of high-dose PBT with
concurrent chemotherapy
– Safe and effective
61. PBT for III NSCLC
• Need for dose escalation:
– RTOG trials (X-rays): 8311 (+) and 0617 (-)
• Few dosimetric comparison studies:
– Advantage of PBT over X-rays seems more
significant in stage III than stage I
• Recent on-going trials of high-dose PBT with
concurrent chemotherapy
– Safe and effective
62.
63.
64. Summary
• PBT can give excellent dose distribution using less
ports (Bragg peak)
• PBT maybe more widely applicable than SABR
even with pulmonary comorbidity and difficult
tumor location in stage I
• PBT may save more normal tissue in stage III
than in stage I
• Pencil beam scanning seems promising
• Dose-escalated PBT with concurrent CTx may be
safe and effective
69. Importance of Target Delineation
• Target contouring errors generate systematic errors
which no level of image guidance will eliminate.
• Target delineation accuracy cannot be overemphasized!