6. Treatment of Lung Cancer
Stage I and II – surgery (if possible)
and sometime postOp chemo or
radiation (virtually all small cell
cancer patients receive
chemotherapy)
Stage III – usually chemo plus
radiation, sometime followed by
surgery
Stage IV – chemo or radiation,
8. The CT images will be used to construct three
dimensional reconstructions of the patient’s cancer
and involved lymph nodes so they can be separated
from normal structures
9. In the treatment
the lasers are
used to line up
the beam and the
patient receives
the radiation
treatment
10.
11. Combine a CT scan and linear accelerator to
ultimate in targeting (IGRT) and ultimate in
delivery (dynamic, helical IMRT) ability to
daily adjust the beam (ART or adaptive
radiotherapy)
12. Computer generated images showing the
radiation beam passing through the patient to
hit the small lung cancer
13. Computer generated images of small lung
cancer (in blue) in the left upper lung and the
radiation target zone (green) that surrounds it
14. Computer generated images showing the
volume and dose of normal lung receiving
radiation
The computer monitors the total lung dose to
keep it below a dose level that could cause
problems
20. Tomotherapy
images showing
the radiation zone
in red surrounds
the cancer area (in
blue) and limits the
dose of radiation
that hits the normal
lung, heart or
spinal cord
21. PET Scan = local tumor. No nodes. These scans are not 100% accurate,
but it may be possible to target only the cancer and not include the lymph
nodes to limit the size of the radiation field. See Tomo plan on next slide
22. Tomotherapy plan targets just the mass, with a small margin. The target was
generated from multiple CT images in different breathing cycles to create a 4D
(four dimensions including time and generating a larger target that accounts for
internal movement (called an ITV)
30. Radiation Results
Some lung
cancers (like
small cell)
shrink quickly,
other cancers
may take weeks
or months to
slowly regress
31. CT = large left upper
lobe tumor invading
the mediastinum
CT Scan 3 years later
= only scar tissue
remains after chemo-
radiation
32. With smaller cancers, the tumor may be
gone by Two Months after Radiation
CT-PET Scan
33. PET Scans will show the response to radiation, the
tumor should smaller and ‘colder’ on the PET
34. Lung cancers shrink
slowly during the
radiation,
this picture from the
daily Tomotherapy
image shows good
regression only half
way through the course
of radiation allowing
the radiation targets to
be adjusted Adaptive
Radiotherapy)
36. Radiation and chemotherapy for NSCL, the
mass may shrink significantly during the
course of radiation
cancer
cancer
CT Scan prior to radiation Tomo image after only 19
treatments
38. Daily CT images
on Tomo will
allow for the
physician to
adjust the
radiation target if
the cancer
changes in size or
position
39. CT scans will
show the slow
shrinkage of non-
small cell lung
cancer, which can
continue to shrink
for months after
completing
radiation
40. Large tumors may shrink slower and the scans may show radiation
fibrosis (the PET will no longer be ‘hot’ if the gray mass is just scar
tissue and not active cancer as seen on the pictures on the right)
Large NSCL Left Lung PET/CT 6 Months later
50. PET scan of the same
patients, 2 years later,
there is still a large
density in the lung,
but it is ‘cold’ on the
PET scan, so just
radiation fibrosis or
scar tissue
52. Conventional Radiation for Stage
I and II NSCL
Years Over All Cancer Specific
Survival Survival
2 years 22 – 72% 54 – 93%
5 years 0 – 42% 13 - 39%
Cochrane Database Syst Rev. 2001
57. Side Effects
ribs
lungs
skin
nerves
heart
esophagu
s
58. Short Term Side
Effects of Lung
Radiation (usually start
showing up after the
second week or
radiation)
Esophagus – sore throat or trouble
swallowing
Trachea or lungs – cough or shortness of
breath
Chest wall – tenderness
Skin – sunburn
Fatigue
59. Long Term Side Effects of
Lung Radiation, can show up
weeks or months after
completing radiation
Esophagus – sometimes there can be prolonged
irritation or stricture
Lungs – there can be scar tissue (fibrosis) that can
cause more shortness of breath or a delayed reaction
(radiation pneumonitis) with fever, cough and
shortness of breath.
Symptoms caused by acute radiation pneumonitis
usually develop approximately four to twelve weeks
following irradiation, whereas symptoms of late or
fibrotic radiation pneumonitis develop after six to
twelve months.
61. Many patients who are smokers have severe
damage to their normal lung tissue, making it
important to target the radiation carefully and
avoid as much ‘normal’ lung as possible
62. High dose radiation can inflame
(pneumonitis) or damage (fibrosis)
normal lung tissue
63. Normal lung that is hit by
the radiation field (pink
zone) will be inflamed by
radiation (called radiation
pneumonitis) these PET
scans were done 2 months
after completion (there is
also volume loss on the
left side due to some
collapse)
64. Same patient at
18 months, still
volume loss
and fibrosis less
hypermeta-
bolic activity
(pneumonitis)
and more
chronic fibrosis
65. Long Term Effects of Lung Radiation
The PET scan shows an excellent response with the cancer
gone and a small amount of radiation fibrosis (scar tissue)
visible. Notice the lung looks smaller on the left from volume
loss
66. Side Effects of Lung
Radiation
The cancer is visible as bright
yellow on the first PET scan and
the second image shows the
radiation zone
The third image (PET scan 4
months later) shows the cancer
gone, but now there is a strip of
abnormal tissue / radiation fibrosis
in the posterior lung.
It is important to keep the normal
lung exposed to radiation as small
as possible
67. By 7 months the area of scarring or fibrosis
is getting smaller and colder on PET
