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EP-1161: Cyberknife robotic SBRT for primary and secondary lung lesions: Clinical outcome of 129 patients with 157 lesions
ESTRO 33, 2014 resolved 4D CT (Philips Brilliance™) scan for treatment planning and after completion of treatment to investigate marker movement. Throughout treatment delivery MV electronic portal images (EPI) were acquired as well as kV and CBCT (Varian Medical System) images. Results: In one of the eight patients two markers were placed in adjacent airways (compare figure 1) and the remainder had a single marker placed within/adjacent to their peripheral tumour. No complications related to bronchoscopic marker implantation were observed. In one of the eight patients the marker (visicoil, left upper lobe) was lost between day 4 and 12 after the implant; no marker migration was observed for all other markers. Both types of markers were clearly visible in planar kV images; however, in EPI the markers could only be detected in selected beam directions where bony interference was minimal. 4D CT scanning was able to demonstrate the markers in great clarity and allowed easy assessment of motion (range 3 to 17mm in the patient cohort). The markers caused significant image artefacts in CBCT. The tumour motion pattern influenced the severity and type of artefact while CBCT technique (increase in kVp from 110 to 125kVp and reduction of field of view) did not reduce the artefacts appreciatively.
S41 Results: The median follow up time (FUP) was 20.6 months. To date the overall survival for the whole, primary, secondary and recurrent population is 72%, 73%, 82% and 59%, while for local control results are 79%, 83% 64% and 85% respectively. TheGTV and PTV volumes were (Mean±Standard deviation) 11±13 cm3 and33±26 cm3. We observed a correlation between the central/peripheral tumour locations versus local control rate in combination with H or L prescription (Table1). Grade 3+ acute and late toxicity were observed in 3 and 6 patients. Acute toxicities were pneumonitis (2 cases) and one G5 pulmonary haemorrhage. The late toxicitieswere G3 dyspnoea (3 cases, all of them presented with COPD Gold III prior to treatment); G3 sick sinus syndrome (1 case) required a pacemaker implantation; one with rib fracture associated with G3 pain, and one patient deceased of a possibly treatment-related pulmonary haemorrhage (possibly Grade 5 toxicity).Other toxicities observed consisted of: asymptomatic or moderately painful(< Grade 2) rib fracture (5 cases), Grade 2 recurrent laryngeal nerve palsy (1 case), Grade 2 late radiation pneumonitis (14 cases), and Grade 2 pneumothorax after transthoracic marker placement (6 cases).
Table 1. Localization versus local control rate combined with high or low dosage. Conclusions: In our mixed study population of primary and secondary, central and peripheral lung lesions,robotic SBRT showed overall survival and local control rates comparable to published data, especially in the high dose group. The rate of severe toxicity was low.
Conclusions: Our preliminary experience indicates bronchoscopic implantation of fiducial markers is safe. In most cases no marker migration was observed but it is prudent to wait at least one week before basing treatment approaches (such as gating) on the marker. The choice of marker is a compromise between trying to minimise CBCT artefacts while allowing visualisation during EPI imaging (which is better suited to verify gated radiotherapy delivery). EP-1161 Cyberknife robotic SBRT for primary and secondary lung lesions: Clinical outcome of 129 patients with 157 lesions L. Janvary1, N. Jansen1, E. Lenaerts1, M. Devillers1, V. Baart1, C. Ernst1, S. Cucchiaro1, A. Gulyban1, F. Lakosi1, P. Coucke1 1 Liege University Hospital, Department of Radiation Oncology, Liege, Belgium Purpose/Objective: To report the clinical outcome after robotic Stereotactic Body Radiotherapy (SBRT) for patients with lung lesions ineligible for surgery, or refusing surgical intervention. Materials and Methods: Between April 2010 and June 2012, one hundred and twenty nine patients with a total of 157 lung lesions were treated in our institution using Cyberknife (Accuray,Sunnyvale, US). Mean age at treatment was 68 years (range 40-93). Primary,secondary and recurrent NSCLC lesions accounted for 53 %, 22% and 25% of patients respectively. Standard prescriptions for peripheral lesions were 60 Gyin 3 fractions. Large or centrally located lesions were included using a risk adapted fractionation schemes, where prescription varied between 40 and 60 Gy in 3 or 5 fractions. For all patients a gross tumor volume (GTV) to planning target volume (PTV) margin of at least 5 mm was taken. In 41% of the lesions active intrafraction motion tracking was performed based on either implanted gold markers, or direct tumour contour recognition. Where active tumour tracking was not possible, an internal target volume (ITV) concept was applied. Histological confirmation was available in 61 % of the lesions. Toxicity was prospectively evaluated using CTCAE ver4. For the current analysis, treatments were classified in high dose (H, 69%) and low dose (L, 31%) groups in function of a biologically effective dose (BED) higher or lower than 120 Gy10.
EP-1162 Carbon ion radiotherapy for lung cancer with idiopathic interstitial pneumonia M. Nakajima1, N. Yamamoto1, W. Takahashi1, H. Tsuji1, T. Kamada1 1 Research Center for Charged Particle Therapy, Radiation Oncology, Chiba City, Japan Purpose/Objective: Lung cancer is frequently complicated by idiopathic interstitial pneumonia (IIP). Treatments protocols for lung cancer patients with IIP have not been established as surgery, chemotherapy, and radiotherapy can all cause acute exacerbation of IIP. In this study we evaluated the toxicity and efficacy of carbon ion radiotherapy (CIRT) in patients with stage I-II non-small cell lung cancer (NSCLC) with IIP. Materials and Methods: Between January 2008 to July 2013, 15 patients who were diagnosed with NSCLC and IIP were treated with CIRT. All patients were ineligible for curative surgery and radiotherapy due of IIP. The presence of IIP was reviewed by two chest radiologists. The development of radiation pneumonitis (RP) was retrospectively evaluated using clinical symptoms and CT scans. CTCAE version 4.0 was used to score RP. The relationships between RP and clinical factors were investigated. Results: The 15 patients were male with a median age of 71 years (range, 62-86). Eleven patients were pathologically diagnosed with NSCLC, four patients were clinically diagnosed with lung cancer using CT and PET-CT. The mean tumor size was 34 mm (range, 17-58mm). There were six patients with stage IA, five patients with stage IB and two patients with stage IIA. One patient with stage IIB had a small metastatic nodule in the primary lobe. None of patients had regional lymph node metastasis. Four of the 15 patients had episodes of acute exacerbation of IIP prior to taking part in this study. Fourteen patients had high serum KL-6 values (>500 U/ml), and 11 patients had high SP-D values (>110ng/ml). The mean KL-6 value was 1167 (range, 456-2410) and the mean SP-D value was 157 (range, 31-502). The prescribed dose was 52.8 gray equivalent (GyE) in 4 fractions for 3 patients, 60.0 GyE in 4 fractions for 5 patients, 46.0 GyE in 1 fraction for one patient, 48.0 GyE in 1 fraction for 4 patients and 50.0 GyE in1 fraction for 2 patients. The median follow up period was 11.7 months (range,2.7-30.8 months). No patients suffered from acute exacerbation of IIP after CIRT. Six patients developed Grade 1 RP, 7 patients developed Grade 2 RP, and 2 patients developed Grade 3 RP. In all patients RP occurred within 3 months after CIRT, except for one patient who developed Grade 2 RP 6 months after CIRT. PTV, dosimetric factors of the lungs (V5, V10, V15, and V20), serum
S41 Results: The median follow up time (FUP) was 20.6 months. To date the overall survival for the whole, primary, secondary and recurrent population is 72%, 73%, 82% and 59%, while for local control results are 79%, 83% 64% and 85% respectively. TheGTV and PTV volumes were (Mean±Standard deviation) 11±13 cm3 and33±26 cm3. We observed a correlation between the central/peripheral tumour locations versus local control rate in combination with H or L prescription (Table1). Grade 3+ acute and late toxicity were observed in 3 and 6 patients. Acute toxicities were pneumonitis (2 cases) and one G5 pulmonary haemorrhage. The late toxicitieswere G3 dyspnoea (3 cases, all of them presented with COPD Gold III prior to treatment); G3 sick sinus syndrome (1 case) required a pacemaker implantation; one with rib fracture associated with G3 pain, and one patient deceased of a possibly treatment-related pulmonary haemorrhage (possibly Grade 5 toxicity).Other toxicities observed consisted of: asymptomatic or moderately painful(< Grade 2) rib fracture (5 cases), Grade 2 recurrent laryngeal nerve palsy (1 case), Grade 2 late radiation pneumonitis (14 cases), and Grade 2 pneumothorax after transthoracic marker placement (6 cases).
Table 1. Localization versus local control rate combined with high or low dosage. Conclusions: In our mixed study population of primary and secondary, central and peripheral lung lesions,robotic SBRT showed overall survival and local control rates comparable to published data, especially in the high dose group. The rate of severe toxicity was low.
Conclusions: Our preliminary experience indicates bronchoscopic implantation of fiducial markers is safe. In most cases no marker migration was observed but it is prudent to wait at least one week before basing treatment approaches (such as gating) on the marker. The choice of marker is a compromise between trying to minimise CBCT artefacts while allowing visualisation during EPI imaging (which is better suited to verify gated radiotherapy delivery). EP-1161 Cyberknife robotic SBRT for primary and secondary lung lesions: Clinical outcome of 129 patients with 157 lesions L. Janvary1, N. Jansen1, E. Lenaerts1, M. Devillers1, V. Baart1, C. Ernst1, S. Cucchiaro1, A. Gulyban1, F. Lakosi1, P. Coucke1 1 Liege University Hospital, Department of Radiation Oncology, Liege, Belgium Purpose/Objective: To report the clinical outcome after robotic Stereotactic Body Radiotherapy (SBRT) for patients with lung lesions ineligible for surgery, or refusing surgical intervention. Materials and Methods: Between April 2010 and June 2012, one hundred and twenty nine patients with a total of 157 lung lesions were treated in our institution using Cyberknife (Accuray,Sunnyvale, US). Mean age at treatment was 68 years (range 40-93). Primary,secondary and recurrent NSCLC lesions accounted for 53 %, 22% and 25% of patients respectively. Standard prescriptions for peripheral lesions were 60 Gyin 3 fractions. Large or centrally located lesions were included using a risk adapted fractionation schemes, where prescription varied between 40 and 60 Gy in 3 or 5 fractions. For all patients a gross tumor volume (GTV) to planning target volume (PTV) margin of at least 5 mm was taken. In 41% of the lesions active intrafraction motion tracking was performed based on either implanted gold markers, or direct tumour contour recognition. Where active tumour tracking was not possible, an internal target volume (ITV) concept was applied. Histological confirmation was available in 61 % of the lesions. Toxicity was prospectively evaluated using CTCAE ver4. For the current analysis, treatments were classified in high dose (H, 69%) and low dose (L, 31%) groups in function of a biologically effective dose (BED) higher or lower than 120 Gy10.
EP-1162 Carbon ion radiotherapy for lung cancer with idiopathic interstitial pneumonia M. Nakajima1, N. Yamamoto1, W. Takahashi1, H. Tsuji1, T. Kamada1 1 Research Center for Charged Particle Therapy, Radiation Oncology, Chiba City, Japan Purpose/Objective: Lung cancer is frequently complicated by idiopathic interstitial pneumonia (IIP). Treatments protocols for lung cancer patients with IIP have not been established as surgery, chemotherapy, and radiotherapy can all cause acute exacerbation of IIP. In this study we evaluated the toxicity and efficacy of carbon ion radiotherapy (CIRT) in patients with stage I-II non-small cell lung cancer (NSCLC) with IIP. Materials and Methods: Between January 2008 to July 2013, 15 patients who were diagnosed with NSCLC and IIP were treated with CIRT. All patients were ineligible for curative surgery and radiotherapy due of IIP. The presence of IIP was reviewed by two chest radiologists. The development of radiation pneumonitis (RP) was retrospectively evaluated using clinical symptoms and CT scans. CTCAE version 4.0 was used to score RP. The relationships between RP and clinical factors were investigated. Results: The 15 patients were male with a median age of 71 years (range, 62-86). Eleven patients were pathologically diagnosed with NSCLC, four patients were clinically diagnosed with lung cancer using CT and PET-CT. The mean tumor size was 34 mm (range, 17-58mm). There were six patients with stage IA, five patients with stage IB and two patients with stage IIA. One patient with stage IIB had a small metastatic nodule in the primary lobe. None of patients had regional lymph node metastasis. Four of the 15 patients had episodes of acute exacerbation of IIP prior to taking part in this study. Fourteen patients had high serum KL-6 values (>500 U/ml), and 11 patients had high SP-D values (>110ng/ml). The mean KL-6 value was 1167 (range, 456-2410) and the mean SP-D value was 157 (range, 31-502). The prescribed dose was 52.8 gray equivalent (GyE) in 4 fractions for 3 patients, 60.0 GyE in 4 fractions for 5 patients, 46.0 GyE in 1 fraction for one patient, 48.0 GyE in 1 fraction for 4 patients and 50.0 GyE in1 fraction for 2 patients. The median follow up period was 11.7 months (range,2.7-30.8 months). No patients suffered from acute exacerbation of IIP after CIRT. Six patients developed Grade 1 RP, 7 patients developed Grade 2 RP, and 2 patients developed Grade 3 RP. In all patients RP occurred within 3 months after CIRT, except for one patient who developed Grade 2 RP 6 months after CIRT. PTV, dosimetric factors of the lungs (V5, V10, V15, and V20), serum