Nathan Corradini, MS DABR SSRMP Clinica Luganese …...15% Mets 10% Prostate 10-15% Other RT...

Nathan Corradini, MS DABR SSRMPClinica Luganese Moncucco, Lugano, Switzerland

AERO Academy ● October 20 2018 ● San Antonio

• The views expressed in this presentation are those of the presenters and do not necessarily reflect the views or policies of Accuray Incorporated or its subsidiaries. No official endorsement by Accuray Incorporated or any of its subsidiaries of any vendor, products or services contained in this presentation is intended or should be inferred

• An honorarium is provided by Accuray for this presentation

Clinica Luganese MoncuccoCommunity hospital

Radiotherapy since 2010

Single-linac radiotherapy center (TomoTherapy®

System)

~250-300 new patients a year

30-35% Breast

15% GI-GU

15% H&N

15% Mets

10% Prostate

10-15%Other

RT anatomical sites treated

~ 80-90 breast RT patients/yr

80% Whole Breast

20% WB w/ LNs

TomoDirect™ (~75%)

TomoHelical™ (~25%)


http://www.google.ch/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://www.liberatv.ch/articolo/27890/ore-decisive-la-clinica-luganese-genolier-pole-position-120-milioni-fondazioni-ancora&ei=iGWKVd6hFcHxUMy5gMAF&bvm=bv.96339352,d.d24&psig=AFQjCNHzTOj6vF9Ga8o3y2pv9Gxd3R8GjQ&ust=1435219607898151

TomoDirect™ – Static field irradiation(IMRT or 3DCRT)

• Tangential fields used for breasttreatment

• Allows "flash" for respiratory motion

2-fld 4-fld


TomoDirect TomoHelical


Risk of major coronaryevent increases ~7% per Gy

Risk of heart diseasemortality increases~4% per Gy

Swedish/Danish registries, ~2200 women

Meta-analysis of various registries, ~195000 women


Estimating the Risks of Breast Cancer Radiotherapy: Evidence From Modern Radiation Doses to the Lungs and Heart and From Previous Randomized Trials.Taylor C, Correa C, Duane FK, Aznar MC, Anderson SJ, Bergh J, Dodwell D, EwertzM, Gray R, Jagsi R, Pierce L, Pritchard KI, Swain S, Wang Z, Wang Y, Whelan T, Peto R, McGale P; Early Breast Cancer Trialists’ Collaborative Group.J Clin Oncol. 2017 May 20;35(15):1641-1649.

Risk of ischemic heart disease in women after radiotherapy for breast cancer.Darby SC, Ewertz M, McGale P, Bennet AM, Blom-Goldman U, Brønnum D, Correa C, Cutter D, Gagliardi G, Gigante B, Jensen MB, Nisbet A, Peto R, Rahimi K, Taylor C, Hall P.N Engl J Med. 2013 Mar 14;368(11):987-98

• 5 patients selected w/ at least 3 yrs post-RT

• Patients did not receive chemotherapy

• RT data correlated with coronary CT

angiography results

Heart V25Gy & V30Gy correlated with number of lesions, not MHD!

….possible method for early diagnosis post-RT


Heart dosimetric analysis of three types of cardiac toxicity in patients treated on dose-escalation trials for Stage III non-small-cell lung cancer.Wang K, Pearlstein KA, Patchett ND, Deal AM, Mavroidis P, Jensen BC, Lipner MB, Zagar TM, Wang Y, Lee CB, Eblan MJ, Rosenman JG, Socinski MA, Stinchcombe TE, Marks LB. Radiother Oncol. 2017 Nov;125(2):293-300.


Radiation therapy for the whole breast: Executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based guideline.Smith BD, Bellon JR, Blitzblau R, Freedman G, Haffty B, Hahn C, Halberg F, Hoffman K, Horst K, Moran J, Patton C, Perlmutter J, Warren L, Whelan T, Wright JL, Jagsi R.Pract Radiat Oncol. 2018 May - Jun;8(3):145-152.

Is there an increased risk of local recurrence under the heart block in patients with left-sided breast cancer?Raj KA, Evans ES, Prosnitz RG, Quaranta BP, Hardenbergh PH, Hollis DR, Light KL, Marks LB. Cancer J. 2006 Jul-Aug;12(4):309-17.

Table taken from Latty et al, “Review of DIBH techniques for the treatment of breast cancer,” JMRS (2015)


Is the lack of respiratory gating prejudicial for left breast TomoDirect treatments?Meyer P, Niederst C, Scius M, Jarnet D, Dehaynin N, Gantier M, WaissiW, Poulin N, Karamanoukian D.Phys Med. 2016 May;32(5):644-50

0

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25

7/1/2016 7/1/2017 7/1/2018

Mea

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ose

, MLD

(G

y)

Date

MLD, Lt-sided Breast Patients

7-10 Gy lung dose zone

0123456789

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7/1/2016 7/2/2017 7/2/2018

Mea

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eart

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se, M

HD

(G

y)

MHD, All Breast Patients

WB/Chestwall

WB/Chestwall + LNs

includes IMC

Helical TomoTherapy

3 Gy heart dose line

0123456789

10

7/1/2016 7/2/2017 7/2/2018

Mea

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HD

(G

y)

MHD, Lt-sided Breast Patients

WB/Chestwall


0123456789

10

7/1/2016 7/2/2017 7/2/2018

Mea

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eart

Do

se, M

HD

(G

y)

MHD, Lt-sided Breast Patients

WB/Chestwall

WB/Chestwall + LNs

includes IMC

Helical TomoTherapy


Clinica Luganese Moncucco, Jul 2016 – Jul 2018

• 164 pts treated (80 lt-sided, 82 rt-sided, 2 bilateral)

• 128 - WB

• 5 - CW

• 25 - WB+LNs (4 incl. IMC)

• 6 - CW+LNs (1 incl. IMC)


All breast patients# pts MHD (Gy) MLD (Gy)

Left/Right

2016 32 2.1±0.9/1.3±1.9 5.6±1.7

2017 81 1.8±0.7/0.9±0.9 5.4±1.8

2018 51 1.7±0.7/0.9±0.9 5.3±2.0

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7/1/2016 7/1/2017 7/1/2018

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, MLD

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MLD, All Breast Patients


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25

7/1/2016 7/1/2017 7/1/2018

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MLD, Lt-sided Breast Patients


TomoDirect™ Lt-Sided# pts MHD (Gy) MLD (Gy)

13 1.7±0.8 5.0±1.6

36 1.7±0.5 4.4±1.3

11 1.3±0.5 4.0±1.1

• 95 - 50Gy (25)

• 21 - 42.4Gy (16)

• 10 - 44Gy (16)

• 23 - 50/58.75Gy (25)

• 15 - 50/62.5Gy (25)

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0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0

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nts

(#)

Mean heart dose (Gy)

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(#)


Lt TomoDirect

Lt Helical Tomo

Rt TomoDirect

Rt Helical Tomo

Bil Helical Tomo


Involved BreastMHD (Gy)

mean (min-max) # Pts (# SIB)Lt WB 1.7 (0.5-3.6) 69 (13)Rt WB 0.6 (0.2-3.0) 60 (17)

Lt WB w/LN 2.7 (1.9-3.8) 9 (1)Rt WB w/LN 2.0 (0.4-4.5) 22 (6)

Rt WB w/LN incl. IMC 3.4 (2.2-4.1) 4 (1)Bilateral (1 incl. IMC) 3.8 (3.1-4.5) 2 (1)



• 128 - WB

• 5 - CW



• 95 - 50Gy (25)

• 21 - 42.4Gy (16)

• 10 - 44Gy (16)

• 23 - 50/58.75Gy (25)

• 15 - 50/62.5Gy (25)

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0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0

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(#)



mean (min-max) # Pts (# SIB)Lt WB TomoDirect™ 1.6 (0.5-3.6) 60 (10)Rt WB TomoDirect™ 0.4 (0.2-0.9) 54 (15)


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(#)


Lt TomoDirect

Rt TomoDirect



• 128 - WB

• 5 - CW



• 95 - 50Gy (25)

• 21 - 42.4Gy (16)

• 10 - 44Gy (16)

• 23 - 50/58.75Gy (25)

• 15 - 50/62.5Gy (25)

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25

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Mean Lung dose (Gy)

Lt TomoDirect

Rt TomoDirect




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Mean Lung dose (Gy)

Involved BreastMLD (Gy)




• 128 - WB

• 5 - CW



• 95 - 50Gy (25)

• 21 - 42.4Gy (16)

• 10 - 44Gy (16)

• 23 - 50/58.75Gy (25)

• 15 - 50/62.5Gy (25)


MHD = 4 Gy @ 30 yrs 0.3% 1.2%

MTLD = 5 Gy @ 30 yrs 0.3% 4.4%

Nonsmoker Smoker

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Mean lung dose (Gy)

Clinica Luganese MoncuccoJul 2016 – Jul 201880 lt-sided breast patients

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4.0 Gy (EBCTCG 2017)

1.8 Gy (All lt-sided pts, n = 80)

1.6 Gy (TD lt-sided pts, n = 60)

5.0 Gy (EBCTCG 2017)

2.6 Gy (All lt-sided pts, n = 80)

2.1 Gy (TD lt-sided pts, n = 60)

Estimating the Risks of Breast Cancer Radiotherapy: Evidence From Modern Radiation Doses to the Lungs and Heart and From Previous Randomized Trials.Taylor C, Correa C, Duane FK, Aznar MC, Anderson SJ, Bergh J, Dodwell D, Ewertz M, Gray R, Jagsi R, Pierce L, Pritchard KI, Swain S, Wang Z, Wang Y, Whelan T, Peto R, McGale P; Early Breast Cancer Trialists’ Collaborative Group. J Clin Oncol. 2017 May 20;35(15):1641-1649.

n = 20y = 12.608x + 115.3

R² = 0.692

y = 32.715x + 227.21R² = 0.5284

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0 20 40 60 80 100

Mea

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cGy)

Heart V50% (cc)

TomoDirect, n = 60

Helical TomoTherapy, n = 20



Rapid automated treatment planning process to select breast cancer patients for active breathing control to achieve cardiac dose reduction.Wang W, Purdie TG, Rahman M, Marshall A, Liu FF, Fyles A.Int J Radiat Oncol Biol Phys. 2012 Jan 1;82(1):386-93.

CLM TomoDirect 60 Breast/CW+/-Boost 1.6 (0.5-3.6)

Helical Tomo 11 Breast/CW+/-Boost 2.3 (1.7-3.0)

Helical Tomo 9 Breast/CW + SCF + AX 2.7 (1.9-3.8)

Helical Tomo 4 (rt) Breast/CW + SCF + AX + IMC 3.8 (2.2-4.1)


Review of deep inspiration breath-hold techniques for the treatment of breast cancer.Latty D, Stuart KE, Wang W, Ahern V.J Med Radiat Sci. 2015 Mar;62(1):74-81.

n = 227


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20

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859095100H

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PTV V93% [%]

x TomoDirect (n=60) o Helical TomoTherapy (n=20)


Improved heart, lung and target dose with deep inspiration breath hold in a large clinical series of breast cancer patients.Nissen HD, Appelt AL.Radiother Oncol. 2013 Jan;106(1):28-32.


98.3 (96.1-101.9)167 (50–314)0.4 (0-2.7)7.7 (1.1-14.8)


n = 20

Utility of Deep Inspiration Breath Hold for Left-Sided Breast Radiation Therapy in Preventing Early Cardiac Perfusion Defects: A Prospective Study.Zagar TM, Kaidar-Person O, Tang X, Jones EE, Matney J, Das SK, Green RL, Sheikh A, Khandani AH, McCartney WH, Oldan JD, Wong TZ, Marks LB.Int J Radiat Oncol Biol Phys. 2017 Apr 1;97(5):903-909.


In conclusion, TomoDirect™…

• continues to be an effective modality for breast radiotherapy

• provides excellent heart and lung dose sparing without sacrificing target dose coverage

• is a natural complement to helical TomoTherapy for complex cases requiring high modulation

TomoTherapy®

TomoTherapy®???

Cardiac dose sparing and avoidance techniques in breast cancer radiotherapy.Shah C, Badiyan S, Berry S, Khan AJ, Goyal S, Schulte K, Nanavati A, Lynch M, Vicini FA.Radiother Oncol. 2014 Jul;112(1):9-16.

Radiation therapy for the whole breast: Executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based guideline.Smith BD, Bellon JR, Blitzblau R, Freedman G, Haffty B, Hahn C, Halberg F, Hoffman K, Horst K, Moran J, Patton C, Perlmutter J, Warren L, Whelan T, Wright JL, Jagsi R.Pract Radiat Oncol. 2018 May - Jun;8(3):145-152

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Nathan Corradini, MS DABR SSRMP Clinica Luganese …...15% Mets 10% Prostate 10-15% Other RT...

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