CHEST WALL TOXICITY IN SABR : PREDICTORS AND CONTOURING OF CHEST WALL
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Transcript of CHEST WALL TOXICITY IN SABR : PREDICTORS AND CONTOURING OF CHEST WALL
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Dr Vimoj J. Nair, SABR Fellow, Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
Chest Wall Toxicity In Stereotactic Ablative Body
Radiotherapy (SABR): Current Evidence
Dr Vimoj J NairSABR Fellow
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
Introduction
• Despite the increasing popularity of SBRT, concern persists regarding late normal tissue toxicity.
• Reports of increased frequency of rib fracture and chest wall pain after SABR treatment of peripherally located lesions compared to conventionally fractionated therapy
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
MAJOR CLINICAL TRIALS NO RIB CONSTRAINTS
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
Incidence of Chest wall Syndrome/Toxicity
Modality Incidence
Conventional radiotherapy 1-6%
Hypofractionated RT [Overgaard et al]
19%
SABRSevere chest wall pain 5-33%
rib fractures – 2-21%
Thoracotomy ~30-50%,
VATS None / mild 63%
Severe 6%
McKenna RJ, Houck W, Beeman Fuller C. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. The Annals of Thoracic Surgery, February 2006. 81(2):421-426.
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
Chest wall toxicity
• Dermatologic (erythema, ulceration and fibrosis)
• Chest wall pain – focal or neuropathic
• Rib fracture– symptomatic and
asymptomatic
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
Spectrum of CW toxicity
CTCAE v 3.0
Grade
Short name
1 2 3 4 5
Pain Mild pain not interfering with function
Moderate pain, pain or
analgesics interfering with
function, but not with ADL
Severe pain, pain or
analgesics severely
interfering with ADL
Disabling -
Fracture Asymptomatic, radiographic findings
only (e.g. Asymptomatic rib
fracture on plain x-ray, pelvic insufficinecy, fracture on MRI, etc)
Symptomatic, but not
displaced; immobilization
indicated
Symptomatic and displaced or open wound with bone exposure;
operative intervention
indicated
Disabling, amputation indicated
Death
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
• 61% Rib # asymptomatic, revealed ONLY through imaging• 19% of all episodes of CW pain coincided with a documented
rib fracture.
Andolino et al, IJROBP 2011
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
CHEST WALL CONTOURING
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
Studies Pros/Retr
o
N chest wall
{CW} lesion
definition
Chest wall Contouring
criteria
Dose fractionati
on
Median f/u
{mths}
Chest wall [Toxicity Pain and Fracture]
rates
Median Time of toxicity {mths}
1 Dunlap et al, Virginia/Colorado,
ASTRO 2008, IJROBP 2010
Retro
60 < 2.5 cm from CW OR Dmax >20 Gy
CW 3cm 60 Gy/30Fr
11 21% pain and 8% fractures
7.1
2 Voroney et al, Alberta,/PMH J
Thor Oncol 2009
Retro
42 NA NA 54-60 Gy /3 Fr
NA 21% rib #, 26% CW pain 1.5 to
5% rib .
17
3 Petterssen et al, Sweden,
Radiother Oncol, 2009
Retro
33 NA Individual Ribs
45Gy/3Fr 29 13 rib fractures 8.8
4 Welsh et al , MDACC, Astro 2009,
IJROBP 2010
Retro
265 (268 TX)
NA All soft tissue minus lungs
50Gy/4Fr 10.3 22% pain, 3% fractures
6
5 Stephans et al , Cleveland, IJROBP
2011
Retro
134 NA Unspecified arc of tissues
60Gy/3 18.8 7% chest wall toxicity ; # not
reported
8.8
6 Andolino et al, Indiana, IJROBP
2011
Retro
347 [203 CW]
CW within ≥
50% isodose
CW3cm + ribs
separately
54-60 Gy/ 2-5 Fr
19 CW 21%, NCW 3.5%
10% CW required
Prescription
8
7 Mutter et al, MSKCC, NY, 2011
Pros 126 NA CW2cm, CW 3cm
compared; 1.2 cm sup/inf
40-60Gy/3-5Fr
16 4% rib #, 51% grade 2 pain
9
Studies on chest wall toxicity in SABR
CW2cm correlated with toxicity
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
CHEST WALL CONTOURING
• 2-cm expansion in the LAT/ANT & POST from the lung edges
• Exclude lung volume, mediastinal soft tissue, and anterior vertebral body
• Include intercostal muscles and exclude other muscles and skin.
• To avoid cumbersome contouring of the entire rib/chest wall, one can define the rib contours arbitrarily within a 3-cm limit from the PTV.
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
CHEST WALL CONTOURING
2cm
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
CHEST WALL TOXICITY PREDICTORS AND PARAMETERS: CURRENT EVIDENCE
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
Studies Pros/Retro
N chest wall {CW} vs NCW
lesion definition
Dose fraction
ation
1 Dunlap et al, Virginia/Colorado,
ASTRO 2008, IJROBP 2010
Retro 60 < 2.5 cm from CW OR Dmax
>20 Gy
60 Gy/30Fr
•Volume threshold of 30 cm3 •Recommended V30Gy < 30cc
2 Voroney et al, Alberta,/PMH J
Thor Oncol 2009
Retro 42 NA 54-60 Gy /3 Fr
•Median dose to # site 46-50 Gy
3 Petterssen et al, Sweden, Radiother Oncol,
2009
Retro 33 NA 45Gy/3Fr •Risk of # : 5% if D2CC =27Gy ; 50% if D2CC = 50Gy • 37 % if V40 Gy >2cc
4 Welsh et al , MDACC, Astro 2009,
IJROBP 2010
Retro 265 (268
TX)
NA 50Gy/4Fr •V30 Gy relevant •BMI >29 Doubles risk of c/c pain
5 Stephans et al , Cleveland,
IJROBP 2011
Retro 134 NA 60Gy/3 •V30 ≤ 30cc & V60 ≤ 3cc ~ ≤10-15% risk of late chest wall toxicity
6 Andolino et al, Indiana, IJROBP
2011
Retro 347 [203
CW]
CW within ≥ 50% isodose
54-60 Gy/ 2-5
Fr
•10% if V30 Gy ≥ 15 cc and V40 Gy ≥ 5cc•30% risk of toxicity when V30 ≥ 40cc & V40 ≥ 15 cc. •Dmax >50Gy significant increase in pain and fracture.
7 Mutter et al, MSKCC, NY, 2011
Pros 126 < 2.5 cm from CW
40-60Gy/3-
5Fr
•CW2 V30 ≥ 70cc, significant correlation with Grade 2 CW pain
Studies on chest wall toxicity in SBRT
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
• Prospective . 126 pts with primary, clinically node-negative NSCLC received 40–60 Gy / 3-5 # of SBRT
• DVH dosimetry of CW3cm vs CW2cm.
• Results: Median f/u 16 months, the 2-year estimated actuarial incidence of Grade 2 CW pain : 39%.
• Median time to onset of Grade 2 CWpain was 9 months.
• CW2cm consistently enabled better prediction of CW toxicity.
• CW volume receiving 30 Gy (V30) as one of the strongest predictors (p < 0.001).
• Physical dose of 30 Gy was received by >70cc -significant correlation with Grade 2 CW pain (p =
0.004) so keep V30<70cc
• Only 19/126 pts met previous cutoff V30<30Gy
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
VUmc DATA
• Prospective • 500 pts with T1-2N0 (2003-2009)• Median f/u 33 Months
Chest wall toxicity following risk-adapted stereotactic radiotherapy for early stage lung cancer E. M. Bongers, C. J. Haasbeek, F. J. Lagerwaard, B. Slotman, S. Senan
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
• Results will be presented in ASTRO 2011/IJROBP (in press)
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
Conclusion
• Tumor size and distance from chest wall is correlated to risk of chest wall toxicity.
• Contour 2cm expansion upto 3 cm cranio-caudally.
• V30Gy : useful as a guideline for estimating the likelihood of chest wall toxicity– <70cc optimum– <30 cc ??? feasible
• Dmax 50Gy ~ above which pain and fracture increase.
• Longer f/u needed – Late toxicity
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
CONCLUSION: STRATEGIES FOR CHEST WALL TOXICITY MANAGEMENT
• Reducing the total tumor dose
• ? Risk adapted fractionation/ increase no of Fr
• Increasing the number of noncoplanar beams• Patient selection is vital• Tumor coverage and other normal tissue
constraints should NOT be compromised.
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
HOWEVER THERE ARE SOME TOXICITIES THAT WE CAN’T AVOID
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Dr Vimoj J. Nair MBBS MD Department of Radiation Oncology, The Ottawa Hospital Cancer Centre, ON, Canada
THANK YOU
sports