Rationale in the Single Session Treatment of Lung Tumors Markus Kufeld Christoph Fürweger, Christian Drexler Berndt Wowra, Alexander Muacevic 1

Indication Treatment Tracking Results 2

Indication patient selection Karnofsky Score > 60 diagnosis NSCLC Stage Ia - Ib metastases small targets (< 4 cm max. diameter) no central lesions 3

Treatment Parameters target definition visible tumor volume (lung window) + 6 mm target volume 15 ccm median volume min 1,5 - max 129 ccm prescription 95% Conf. Int. 24 Gy median dose 22 - 24 70 % median isodose 70 - 75 Monte Carlo since June 2008 23 cases 4

Tracking number of lesions 10 Xsight Spine fixed paraspinal lesions 54 Synchrony fiducial tracking 10 Xsight Lung live image quality 2 x switching to marker tracking 5

Pt. 3577 Xsight Lung 6

Tracking fiducial placement percutaneous, CT guided one marker in the lesion complications 6 pneumothorax 11 % 3 bleedings (asymptomatic) 6 % setup Xsight Spine setup -> translation to lesion marker into the lesion 7

Monte Carlo 39 ray tracing 23 Monte Carlo since June 2008 physically consistent dose prescription 8

Results patients 62 patients in 4 years 27 female 65 yrs median age (min 22 - max 87 yrs) diagnosis 22 primary NSCLC 40 metastases follow up 11 months (median, min 0,5 - max 33 mths) Overall Survival: no significant difference between NSCLC and metastases, ray tracing and MC 9

Results actuarial local control crude local control Interval (mths) Failures Prop. Controlled 95% Conf. Int. 0 - 6 1 98 % 89.1 99.8 6 - 12 4 88 % 74.1 95.1 18 - 24 0 88 % 74.1 95.1 crude local control 92 % => 3 re-treatments (controlled) welche failures (Diag.), warum analyzed 10

Pt. 3864 spinal tracking: tumor fixed to chest wall => missed target ? 11

Proportion Controlled % Results Graph Local Control 1 4 Failures 98,4 89,1-99,8 88,4 74,1-95 Proportion Controlled % 12

Results n.s. local failure NSCLC metastases Total ray tracing 1 2 3 Monte Carlo 5 n.s. failures ? tumor size contouring spinal tracking Xsight Lung unknown 13

Results Graph Local Control Failures 92,8 81,9-97,2 80,3 65,1-89,3 4 5 3 1 Failures 92,8 81,9-97,2 80,3 65,1-89,3 68,5 49,8-81,5 62,8 42,2-77,8 Proportion Surviving % 1 4 Failures 98,4 89,1-99,8 88,4 74,1-95 Proportion Controlled % 14

Results adverse events after RS CTC Grade I 24 local pneumonitis (asymptomatic) CTC Grade II 1 symptomatic pneumonitis (dyspnea, cough: medication) no CTC Grade III to V toxicity no significant difference in toxicity between MC or Ray tracing 15

Pt. 1321 NSCLC pre RS 5 months post RS (24 Gy 70 %) pre RS 16

Results n.s. AE CTC I CTC II Total ray tracing 15 (38 %) 1 39 Monte Carlo 9 (39 %) 23 24 (38,7 %) 1 (1,6 %) 62 n.s. 17

Literature McGarry, Timmerman et al. (Red Journal 2005) Phase I dose escalation study: 3 fractions 20 Gy (80 % isodose) abdominal compression 18

Literature Hof et al. (Cancer 2007) single session 15,2 - 24 Gy (80 % isodose) abdominal compression 14 % local failure 64 % pneumonitic CT changes (CTC I + II) 19

Literature van der Voort van Zyp, Nuyttens et al. (Green Journal 2009) 3 fractions 15 -20 Gy (70 - 85 % isodose) multiple markers similar local control, overall survival similar toxicity 20

Images Pt. 2273 NSCLC control 15 months after RS 21

Conclusion Single session lung radiosurgery is a safe and effective treatment option for selected small tumors. 22