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

2. Indication Treatment Tracking Results2

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

4. 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 % median isodose Monte Carlo since June cases 4

5. 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

6. Pt Xsight Lung 6

7. 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

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

9. Results
patients 62 patients in 4 years 27 female 65 yrs median age (min 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

10. Results actuarial local control crude local control
Interval (mths) Failures Prop. Controlled 95% Conf. Int % % %
crude local control
92 % => 3 re-treatments (controlled)
welche failures (Diag.), warum analyzed 10

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

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

13. 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

14. Results Graph Local Control Failures 92,8 81,9-97,2 80,3 65,1-89,34 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

15. 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

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

17. 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

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

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

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

21. Images
Pt NSCLC control 15 months after RS 21

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