Published on March 11, 2013
Radiation for Lung Cancer Robert Miller MD www.aboutcancer.com
The treatment guidelines have become quite complex
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,
In the simulationprocess the CTand PET scanimages are usedto create acomputer plan
The CT images will be used to construct threedimensional reconstructions of the patient’s cancerand involved lymph nodes so they can be separatedfrom normal structures
In the treatmentthe lasers areused to line upthe beam and thepatient receivesthe radiationtreatment
Combine a CT scan and linear accelerator toultimate in targeting (IGRT) and ultimate indelivery (dynamic, helical IMRT) ability todaily adjust the beam (ART or adaptiveradiotherapy)
Computer generated images showing theradiation beam passing through the patient tohit the small lung cancer
Computer generated images of small lungcancer (in blue) in the left upper lung and theradiation target zone (green) that surrounds it
Computer generated images showing thevolume and dose of normal lung receivingradiationThe computer monitors the total lung dose tokeep it below a dose level that could causeproblems
Computergenerated lungcancer target inredand radiationzone (yellow)surrounds it
Computergeneratedimages willshow howclose thecancer is toother importantstructures (likethe spinal cord,the heart andthe liver, andhow muchnormal lung isnear
Using CTscans thecomputercangeneratethe targetfor acancer inthe upperpart of thelung
Using CTscans thecomputercangeneratethe targetfor a smallcancergrowinginside thetrachea
Computergenerated imagesto target the tumor
Tomotherapyimages showingthe radiation zonein red surroundsthe cancer area (inblue) and limits thedose of radiationthat hits the normallung, heart orspinal cord
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 lymphnodes to limit the size of the radiation field. See Tomo plan on next slide
Tomotherapy plan targets just the mass, with a small margin. The target wasgenerated from multiple CT images in different breathing cycles to create a 4D(four dimensions including time and generating a larger target that accounts forinternal movement (called an ITV)
Radiation ‘safe dose’ to normalstructures
Radiosurgery for Cancer
Cyberknife for Lung Cancer
Commonly Used DoseRegimens for Radiosurgery
Maximum ‘safe doses’ to normal structures with radiosurgery
Radiation Results Some lung cancers (like small cell) shrink quickly, other cancers may take weeks or months to slowly regress
CT = large left upperlobe tumor invadingthe mediastinumCT Scan 3 years later= only scar tissueremains after chemo-radiation
With smaller cancers, the tumor may begone by Two Months after Radiation CT-PET Scan
PET Scans will show the response to radiation, the tumor should smaller and ‘colder’ on the PET
Lung cancers shrinkslowly during theradiation,this picture from thedaily Tomotherapyimage shows goodregression only halfway through the courseof radiation allowingthe radiation targets tobe adjusted AdaptiveRadiotherapy)
Using Tomotherapy to Target Lung Cancer
Radiation and chemotherapy for NSCL, the mass may shrink significantly during the course of radiation cancer cancerCT Scan prior to radiation Tomo image after only 19treatments
Daily CT imageson Tomo willallow for thephysician toadjust theradiation target ifthe cancerchanges in size orposition
CT scans willshow the slowshrinkage of non-small cell lungcancer, which cancontinue to shrinkfor months aftercompletingradiation
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
PET Scan after Radiation
PET Scan showing completeremission of the cancer in the left lung at 7 months
PET scan showing near completeremission, 2 months after radiation alone for NSCL
PET ScanAdvanced non-small cell lungcancer before and2 months aftercompletingradiation
PET Scan showing changes at 1 and 4months after completing radiation formediastinal lymph node
PET Scan 2-09 Adenocarcinoma of the right upper lung, before and 10 months after chemoradiation,2-10 no longer hot on PET
Large NSCL of the RLL before and 3 months after chemoradiation CT 9-09 PET 9-09 CT 2-10 PET 2-10
Patient with advanced cancer had pre-operative chemoradiation. At the time ofsurgery there was no remaining cancer found
Very large lung cancer, prior to radiation
PET scan of the samepatients, 2 years later,there is still a largedensity in the lung,but it is ‘cold’ on thePET scan, so justradiation fibrosis orscar tissue
Survival by StageStage Clinical 5 Year Pathologic 5 YearIA 60 months 50% 119 month 73%IB 43 43% 81 58%IIA 34 36% 49 46IIB 18 25% 31 36%IIIA 14 19% 22 24%IIIB 10 7% 13 9%IV 6 2% 17 13% J Thorac Oncol 2007; 2:706
Conventional Radiation for Stage I and II NSCLYears Over All Cancer Specific Survival Survival2 years 22 – 72% 54 – 93%5 years 0 – 42% 13 - 39% Cochrane Database Syst Rev. 2001
Radiosurgery Results Cause specific Survival Robert Timmerman IJROBP 2009;75:677 Months
Radiosurgery Results – StageI Survival Years
Side Effects of LungRadiation
Side Effects ribs lungs skin nerves heartesophagus
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
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.
CT Scan = Severe COPD
Many patients who are smokers have severedamage to their normal lung tissue, making itimportant to target the radiation carefully andavoid as much ‘normal’ lung as possible
High dose radiation can inflame(pneumonitis) or damage (fibrosis) normal lung tissue
Normal lung that is hit bythe radiation field (pinkzone) will be inflamed byradiation (called radiationpneumonitis) these PETscans were done 2 monthsafter completion (there isalso volume loss on theleft side due to somecollapse)
Same patient at18 months, stillvolume lossand fibrosis lesshypermeta-bolic activity(pneumonitis)and morechronic fibrosis
Long Term Effects of Lung RadiationThe PET scan shows an excellent response with the cancergone and a small amount of radiation fibrosis (scar tissue)visible. Notice the lung looks smaller on the left from volumeloss
Side Effects of LungRadiationThe cancer is visible as brightyellow on the first PET scan andthe second image shows theradiation zoneThe third image (PET scan 4months later) shows the cancergone, but now there is a strip ofabnormal tissue / radiation fibrosisin the posterior lung.It is important to keep the normallung exposed to radiation as smallas possible
By 7 months the area of scarring or fibrosisis getting smaller and colder on PET
RadiationFibrosisCT 9 monthsafter radiation,corresponding tothe high doseradiation field
RadiationFibrosisCT 9 monthsafter radiation,correspondingto the highdose radiationfield
Radiation Fibrosis confined better with SBRT
Radiation for Lung Cancer Robert Miller MD www.aboutcancer.com
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