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FIRST SBRT TREATMENT IN WINDSOR ONTARIO Ming Pan M.Sc., M.D., FRCPC

FIRST SBRT TREATMENT IN WINDSOR ONTARIO Ming Pan M.Sc., M.D., FRCPC Radiation Oncologist, Windsor Regional Hospital Cancer Program Adjunct Professor, Department of Oncology Schulich School of Medicine & Dentistry University of Western Ontario. Disclosure. I have no conflict of interest.

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FIRST SBRT TREATMENT IN WINDSOR ONTARIO Ming Pan M.Sc., M.D., FRCPC

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  1. FIRST SBRT TREATMENT IN WINDSOR ONTARIO Ming Pan M.Sc., M.D., FRCPC Radiation Oncologist, Windsor Regional Hospital Cancer Program Adjunct Professor, Department of Oncology Schulich School of Medicine & Dentistry University of Western Ontario

  2. Disclosure • I have no conflict of interest.

  3. Background • According to our 2010-2015 preliminary planning of Radiation Oncology Program, we should develop SBRT in Windsor before the 2015-2016 fiscal year. • This planning was delayed due to an inappropriate recommendation against the SBRT in our relatively small program by an expert external review in 2011. • Since then almost all other programs in Ontario have developed SBRT despite their size.

  4. Background • In these 5 years we developed IMRT, VMAT, IGRT with daily CBCT guidance, MRI simulation and 4D-CT simulation in our local cancer program, (almost all the state-of-the-art technology that other centers have dreamed of). • Our new cancer patient # seen by Rad Onc service increased from 1,235 to 1,509 per year. • But….we have been referring Windsor patients to London, Hamilton and even Toronto for SBRT. • We finally delivered the 1st SBRT to a lung cancer patient in October 2015.

  5. What is SBRT? • Stereotactic Body Radiation Therapy (SBRT) is a treatment procedure similar to central nervous system (CNS) stereotactic radiosurgery, except that it deals with tumors outside of the CNS. • A stereotactic radiation treatment for the body means that a specially designed coordinate-system is used for the exact localization of the tumors in the body in order to treat it with limited but highly precise treatment fields. • SBRT involves the delivery of a single high dose radiation treatment or a few fractionated radiation treatments (usually up to 5 treatments). http://radonc.ucla.edu/sbrt

  6. SRS: Stereotactic Radiosurgery. Stereotactic from “Stereotaxis” - Greek for “Solid” and “Orderly” - Originally for surgical path to cranial lesions. Then frame-based radio-surgery – frame used to target 'radio-ablation'

  7. SBRT: Stereotactic Body Radiotherapy 4D CT simulation

  8. How Did We Get Here? • CMEs • Lots of research • Site visit to JCC in Hamilton • New equipment purchases • Development of new policies and procedures • Staff training • Ongoing review and changes to process

  9. Challenges to Start SBRT • Improving immobilization and indexing to CT simulation and treatment bed • Scheduling (QA, SBRT treatment staff) • Time to create policies and procedures • Training staff on new equipment • Technical/software difficulties • Learning curve – become more efficient with each treatment

  10. 4D CT SIM - Immobilization • CT-SIM time for SBRT 90 mins(45 mins for CRT) • SBRT need Orfit immobilization device and Vacloc (vacuum bag) extend from above the shoulders to below the hip joint (4 therapists reqd) • Need maximizing comfort to ensure patient compliance and couch position reproducibility • CRT requires a vacloc and wingboard for shoulder and arm immobilization only (2 therapists minimum to form)

  11. Headboard (indexed in 2 locations) Knee and Foot Support (both indexed) Arm Support

  12. Long Vacloc Compression Plate Compression Arch

  13. CT SIM - Scanning • Patients have 2 CT scans (as do radical lung patients following the 4DCT protocol) • A respiratory tracking belt is placed around patient to track breathing • Physicist and physician will be present to assist, review the 4DCT, assess tumour size (max 5.0 cm) and motion • If tumour motion is > 1.0 cm, the 4DCT should be repeated with abdominal compression. • If size and motion acceptable, scanning continues with a second helical (3D scan)

  14. Treatment Planning ● Contouring is extensive – many structures required...

  15. Treatment Planning • Physicians contour tumor and Dosimetrists contour normal organs and structures • “Virtual” patient model built in treatment planning system (TPS) • Impact of different beam shapes, directions, intensities assessed • Goal is to reduce normal tissue damage risk, increase tumour control probability, by concentrating dose in tumour • Optimal “Treatment Plan” is then delivered to patient...

  16. Quality Assurance • Every morning, standard quality assurance tests are performed on each linear accelerator from 6-7am by a radiation therapist • On SBRT days, additional SBRT-specific “Winston Lutz” QA (WLQA) is done directly after regular morning QA from 7-8am by a therapist on the SBRT team • Once WLQA is complete, a physicist double checks the results and gives the go-ahead for treatment that day • Isocentre alignment becomes more and more critical as target sizes become very small, as is the case for SBRT (WLQA tolerance = 1.6mm vs. 2mm for regular QA) • An additional monthly QA test is also performed by physics

  17. Treatment Delivery • SBRT lung booking = 60 min(CRT=15min) • First day patient education/ongoing patient care • MRTTs set up Orfit immobilization device (5-10 min) • Patients are brought into the room and positioned (15-20 min) • CBCT – treat – CBCT = approx. 20-25 min • Physician present to approve CBCT prior to Tx delivery and perform abdominal compression if required • Physicist present for Tx delivery for troubleshooting

  18. Daily Cone Beam CT=IGRT

  19. LUSTRE trial • A Randomized Trial of Medically-Inoperable Stage I Non-Small Cell Lung Cancer Patients Comparing Stereotactic Body Radiotherapy Versus Conventional Radiotherapy (LUSTRE) • Protocol Number: OCOG-2013-LUSTRE

  20. LUSTRE trial • To determine if SBRT is more effective than CRT for patients with stage I NSCLC who prefer radiation due to high operable risk, or are deemed medically inoperable. • Primary end point is rate of local control. Secondary objectives for comparison include survival, quality of life, and toxicities. • Multi-centre randomized controlled trial, to be conducted at 16-20 centres across Canada. • Eligible patients will be randomized to receive SBRT or CRT in a 2:1 ratio, and treatment is to follow as soon as possible, and within 3 wks post randomization.

  21. LUSTRE Sample Size and Feasibility • NCIC BR25 (60Gy/15): 2-yr LC 88% with estimated 3 yr LC 75% at best with CRT. • We expected SBRT result in a minimal clinically important increase of 12.5% in 3-year LC to 87.5%. • Min 59 events: 85% power to detect a difference of this magnitude (HR=0.46) with a two sided α=0.05 and a 2:1 (SBRT:CRT) randomization • Assuming 3 years for patient recruitment with an additional 2 years of follow-up, we would require a total sample size of 308 patients. • Add 5% inflation factor for non-compliance and losses to F/U, we need a total of 324 patients (216 SBRT and 108 CRT patients).

  22. LUSTRE trial • Experimental arm (SBRT) receives 48 Gy in 4 fractions of 12 Gy, separated by at least 24 hrs. If the tumour is not peripheral, then a modified dose of 60 Gy in 8 fractions of 7.5 Gy will be used. The overall SBRT treatment course will be given over 4-14 days. • Control arm (CRT), 3D conformal or IMRT is allowed. The prescribed dose is 60 Gy in 15 fractions of 4 Gy delivered daily over 3 weeks. • In both cases, the preferred technique at WRCC will be VMAT with multiple arcs, or multi-field 3D-CRT, if necessary.

  23. LUSTRE trial

  24. Case #1 • 81-year-old lady with presumed non-small cell lung cancer in the left lingula that had doubled in size on CT scan over one year. • PET scan from May 1, 2015 showed SUV 10.5 in the left lingula nodule that measured 1.2 x 1.6 cm in size. There was no evidence of any distant or lymph node metastases. • Long history of severe COPD, chronic bronchitis and emphysema. On home oxygen all the time. • Multiple hospital admissions for COPD exacerbations. • Not candidate for biopsy or surgery.

  25. Case #1 • Participated in OCOG-2013-LUSTRE trial after informed consent. • Randomized into SBRT arm. • Had 4-D CT simulation followed by SBRT 4,800 cGy in four fractions between October 28 and November 4, 2015. • Tolerated treatment well with no significant side effects.

  26. 1st Follow up in January • First post-treatment CT scan of the chest from December 29, 2015 showed excellent response. • Primary cancer almost completely disappeared on mediastinal window, with no measurable tumor. • Lung window:Scaring appearance measuring 1.4x1.3cm • Previously it measured 2.4 x 1.7 cm on September 8, 2015.

  27. Pre- and Post-SBRT CT CT: 8 weeks before and after SBRT

  28. Pre- and Post-SBRT CT CT: Lung window

  29. Follow up in April 2016 • She has been doing very well since SBRT. • No new respiratory symptoms or worsening symptoms. • Continues to have shortness of breath due to her known COPD, chronic bronchitis and emphysema. • She is still on home oxygen. • ECOG=1

  30. Pre- and Post-SBRT CT CT: 2 months before and 5 months after SBRT

  31. Conclusions • SBRT is finally available in WRH Cancer Program. • Our 1st SBRT outcome is favorable. • We will continue LUSTRE trial (had 5 cases now). • No need for central review after 4 cases SBRT. • Next step is to start SBRT as standard treatment off clinical trial, along with other new technology including IMRT, VMAT, and IGRT.

  32. Question 1 • Which of the following treatments can Windsor Regional Hospital Cancer Program provide to treat lung cancer? • A) 3D-CRT • B) IMRT/VMAT • C) IGRT • D) SBRT • E) All of the above

  33. Question 2 • What is the expected local control rate at 3 years for stage 1 non-small cell lung cancer treated with SBRT in LUSTRE trial? • A) 50-70% • B) 75% • C) 87.5% • D) 88% • E) 100%

  34. Thank you!

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