Radiation for Lung Cancer

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Information about Radiation for Lung Cancer
Health & Medicine

Published on March 11, 2013

Author: doctorbobm

Source: slideshare.net

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 Dose

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

Tomotherapy Images

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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