Advances in Radiotherapy for Lung Cancer

							Advances in Radiotherapy for
       Lung Cancer
             Joseph K. Salama, M.D.
                    Instructor
   Department of Radiation and Cellular Oncology
              University of Chicago
      What is Radiotherapy?
• Radiotherapy is a specialty devoted to the
  treatment of benign and malignant
  diseases in both adults and children with
  ionizing radiation
Modern Linear Accelerator
What Radiotherapy is not…
What Radiotherapy is not…
      Birth of Radiotherapy
      (November 5, 1895)




Wilhelm Roentgen   Roentgen’s laboratory
First known X-ray radiographs produced by Roentgen
 First Radiotherapist
(Chicago: Early 1896)




  Emil Grubbe (1875-1960)
 What Does a Radiotherapist Do?
• In practice, we design methods to focus x-
  rays on specific tumors or regions of the
  body
  – Goal is to eliminate tumors
  – Consider the effects of radiation on normal
    organs nearby
• Local treatment
  – Daily treatments for 2-7 weeks
                 Goals:
• To discuss recent technological advances
  in the planning and delivery of
  radiotherapy
• To discuss the role of a new radiotherapy
  technique in management of early stage
  lung cancer and advanced lung cancer
Early Treatment Machines

1 MeV Vicker’s Unit, St Bart’s →
Hospital London 1937




                                   ←1st Van de Graaf
                                   Generator, Royal
                                   Marsden Hospital,
                                   London, 1933
Old Radiotherapy Techniques
Modern 3-D Radiotherapy Planning
  Technological Improvements in
    Lung Cancer Radiotherapy
• Respiratory gating
• 4 dimensional radiotherapy planning
• Image guided radiotherapy
Free Breathing CT Scan
Respiratory Gating
                     Infrared camera
                     mounted on CT
                     couch

                       Infrared
                       marker block




                            Reflective
                            markers in
                            view-finder
100% inhalation




100% exhalation
Improved Planning with Respiratory Gating




Conventional             With respiratory gating
100% inhalation




100% exhalation
 Advantages to Respiratory Gating
• Improved delivery of radiotherapy to tumor
• Reduced normal lung receiving radiation
  Technological improvements in
          radiotherapy
• Respiratory gated radiotherapy
• 4 dimensional radiotherapy planning
• Image guided radiotherapy
 Advantages of 4 D Radiotherapy
           Planning
• Gives radiotherapist better understanding
  of tumor motion in breathing cycle
• Allows for more knowledgeable and
  accurate radiotherapy planning
4D CT Scan
Addition of Gating to 4D CT scan
  Technological improvements in
          radiotherapy
• Respiratory gated radiotherapy
• 4 dimensional radiotherapy planning
• Image guided radiotherapy
Traditional Linear Accelerator
Image Guided Radiotherapy
Image Guided Radiotherapy
      Benefits of Image Guided
           Radiotherapy
• Ensure proper daily alignment of patient
• Verify proper targeting of tumors
• Assess response of tumors during
  radiotherapy course
• Adapt treatment to the changing tumor
  during course of radiotherapy
       Innovative Radiotherapy
             Techniques
• Stereotactic body radiotherapy
  – delivers higher doses per radiation treatment
    for fewer treatments
  – Thought to be more effective biologically as
    more tumor cells will be killed with higher
    radiation doses
    Cyberknife               Tomotherapy




Novalis Shaped Beam System   Varian Trilogy
Stereotactic Body Radiotherapy
• Multiple individual
  fields are used to
  focus a few high
  doses of radiation on
  a single area
• Each radiation dose is
  5-10 times traditional
  daily dose of radiation
  Stereotactic Body Radiotherapy
• Diseases that this
  technique has been
  actively studied
  – Early Stage Lung
    Cancer
  – Patients with limited
    metastatic cancer
     • Lung
     • Liver
     • Multiple body sites
Stereotactic Body Radiotherapy
• Medically inoperable
  patients with early
  stage lung cancer
  – Traditional
    radiotherapy: 30-40%
    chance of controlling
    lung tumors
  – SBRT: 70-90%
    chance of controlling
    lung tumors
Stereotactic Body Radiotherapy
• Patients with metastatic cancer
  – Usual treatment is chemotherapy
• For patients with limited spread of cancer
  – Removal of tumors can be beneficial
  – For those that can’t be removed radiotherapy
    is being studied
Lung Cancer Patient with Adrenal
         Metastasis
Lung Cancer Patient with Adrenal
         Metastasis
Response of Adrenal Metastasis
              Conclusion
• Technological advances have improved
  the planning and delivery of radiotherapy
• New techniques of delivering radiation
  coupled with earlier detection of lung
  cancers may lead to better outcomes for
  patients not able to undergo surgery