PY Bondiau PhD. MD. Centre Antoine Lacassagne. Nice. France High Precision Radiotherapy

1

PY Bondiau PhD. MD.

Centre Antoine Lacassagne. Nice. France

High Precision Radiotherapy

Cyclotron/Cyberknife

The management of lung cancer: from 3D to SBRT

EFEC 18/05/11

2

PlanPlan

• Introduction : – RT2-D– Definition SBRT (History)

• Technics and results– 3-D Linac– Rotational Radiotherapy– SBRT linac– Vero– Cyberknife

• Conclusion



• Conclusion

RT3D

SBRT

TechniquesResultsT1 lung cancer

3

PlanPlan



• Conclusion



• Conclusion

RT3D

SBRT

Techniques

4

From 2-D to 3-D [1] 2-D planning era.From 2-D to 3-D [1] 2-D planning era.

– Surgical resection of stage I (T1-2, NO) NSCLC

• 5 year survival rates 60-70%

– Patients medically inoperable treated RT2-D

• Field of irradiation :– primary tumor and regional lymphatics in the ipsilateral

hilum and mediastinum.

– poorly tolerated (with limited pulmonary reserve).

• In a report from the Netherlands, limited “postage stamp”

– Limitations:

• in visualizing the target => difficult to reduce high dose

volume

• selection of beam directions,

• computational algorithms describing deposited dose.

– Surgical resection of stage I (T1-2, NO) NSCLC

• 5 year survival rates 60-70%

– Patients medically inoperable treated RT2-D

• Field of irradiation :– primary tumor and regional lymphatics in the ipsilateral

hilum and mediastinum.

– poorly tolerated (with limited pulmonary reserve).

• In a report from the Netherlands, limited “postage stamp”

– Limitations:

• in visualizing the target => difficult to reduce high dose

volume

• selection of beam directions,

• computational algorithms describing deposited dose.

5

Result of 2-DResult of 2-D

• Duke experience 1980 1995

• 156 patients with Stage I medically inoperable

• non-small–cell lung cancer

• T1N0 54%, T2N0 46%

• Target– Median dose 64 Gy (50 to 80 Gy)– median size 3 cm (range 0.5 to 8)

• Overall survival – The 2- and 5-year was 39% and 13%

• Studies of dose escalation are warranted !

• Duke experience 1980 1995

• 156 patients with Stage I medically inoperable

• non-small–cell lung cancer

• T1N0 54%, T2N0 46%

• Target– Median dose 64 Gy (50 to 80 Gy)– median size 3 cm (range 0.5 to 8)

• Overall survival – The 2- and 5-year was 39% and 13%

• Studies of dose escalation are warranted !

6

PlanPlan

• Introduction : – RT2D– Definition SBRT (History)


• Conclusion



• Conclusion

RT3D

SBRT

TechniquesResultsT1 lung cancer

7

Revolution of 3-DRevolution of 3-D

• Due to CT scan– EMI 1972

• Possibility to multi slice

• 2-D to 3-D

• Due to CT scan– EMI 1972

• Possibility to multi slice

• 2-D to 3-D

CONTOUR:CONTOUR: - Manual - Manual

- Automatic- Automatic

VOLUMES DEFINITIONVOLUMES DEFINITION

GTVGTV CTVCTV PTVPTV VTVT VIVI

Beam ABeam A Beam BBeam B

Beam CBeam C

PTV

8

Patient

= ?

Contention

MEPTransfert

ContouringBalistic definition

DosimetryDRR

DosimetricCT scan

Mod

ifica

tions

?

9

Multileaf CollimatorMultileaf Collimator

Collimator

SourceMLC

10

From 2-D to 3-D: beamsFrom 2-D to 3-D: beams

11

RT2-D vs RT3-D M.D. Anderson (2005)RT2-D vs RT3-D M.D. Anderson (2005)

• Materials/Methods: – 200 patients stage I radiotherapy alone– 85 pts 3-D conformal radiotherapy

• T1N0 64%, T2N0 36%, squamous cell carcinoma 46%, non-squamous histology 54%

• median dose 66 Gy (45–90.3 Gy), median follow-up 19 months (3–77 months)

– 115 pts 2-D group: median age 69 (range 44–88)


• median dose 64 Gy (40–74 Gy), median follow-up 20 months (1–173 months)

• Materials/Methods: – 200 patients stage I radiotherapy alone– 85 pts 3-D conformal radiotherapy


• median dose 66 Gy (45–90.3 Gy), median follow-up 19 months (3–77 months)

– 115 pts 2-D group: median age 69 (range 44–88)


• median dose 64 Gy (40–74 Gy), median follow-up 20 months (1–173 months)

2-year 5-year p

Overall survivals

3D 68% 36%

2D 47% 10% 0.001

Disease-specific survivals

3D 83% 68 %

2D 62% 29 % 0.008

Local-regional control rates

3D 77% 70%

2D 53% 34% 0.0006

12

Dose escalationDose escalation

• Hayman (University of Michigan)

• 104 patients with stages I-III treated by 3-DRT

• Dose escalation as high as 102.9 Gy with acceptable

toxicity. – 53 patients had disease progression

• 52% failing distantly

• 8% failing both distantly and PTV

• 2% failing in a distant site, the PTV and a nodal region outside the PTV

• 35% failing within the PTV alone.

• Hayman (University of Michigan)

• 104 patients with stages I-III treated by 3-DRT

• Dose escalation as high as 102.9 Gy with acceptable

toxicity. – 53 patients had disease progression

• 52% failing distantly

• 8% failing both distantly and PTV

• 2% failing in a distant site, the PTV and a nodal region outside the PTV

• 35% failing within the PTV alone.

13

Defining stereotactic body radiotherapy [1] Defining stereotactic body radiotherapy [1]

• Historical Developpement

– Lars Leksell Gammaknife

– Radiosurgery (1 fraction)

– 1967 Stockholm Karolinska Institut

• Radiosurgery

– High precision RT

– >100 converging mini-beam

– Target : 3 cm max

– millimetric accuracy

– Image matching PET/MRI and CT

– Mechanical accuracy => only intra cranial

• Historical Developpement

– Lars Leksell Gammaknife

– Radiosurgery (1 fraction)

– 1967 Stockholm Karolinska Institut

• Radiosurgery

– High precision RT

– >100 converging mini-beam

– Target : 3 cm max

– millimetric accuracy

– Image matching PET/MRI and CT

– Mechanical accuracy => only intra cranial

14

Defining stereotactic body radiotherapy [2]Defining stereotactic body radiotherapy [2]

• Beams– From cobalt 60 (gammaknife)

• Specific collimators– Conventional linac

• Specific collimator or multileaf– Dedicated linac (novalis, CK)

• Specific collimator or multileaf

• Raise of image processing matching tools– Integrated image system– Automatic matching

• Real Image = T ( DRR )

• movement = T ( table or device )

• Image processing accuracy replace mechanical accuracy

• Emergence of extra cranial indication

• Multiple fractions

• Beams– From cobalt 60 (gammaknife)

• Specific collimators– Conventional linac

• Specific collimator or multileaf– Dedicated linac (novalis, CK)

• Specific collimator or multileaf

• Raise of image processing matching tools– Integrated image system– Automatic matching

• Real Image = T ( DRR )

• movement = T ( table or device )

• Image processing accuracy replace mechanical accuracy

• Emergence of extra cranial indication

• Multiple fractions

TT

II JJ

15

Conventional RT

Conventional RT

70

RadiosurgeryRadiosurgery SBRTSBRT

?

Accuracy < cmAccuracy < cm

multiple fractionsmultiple fractions

Accuracy < mmAccuracy < mm

unique fractionunique fraction

Accuracy < mmAccuracy < mm

multiple fractionsmultiple fractions

16

PlanPlan


• Technics and results– 3D Linac– Rotational Radiotherapy– SBRT linac– Vero– Cyberknife

• Conclusion


• Technics and results– 3D Linac– Rotational Radiotherapy– SBRT linac– Vero– Cyberknife

• Conclusion

RT3D

SBRT

Techniques

17

Rotational radiotherapy [2]: TomotherapyRotational radiotherapy [2]: Tomotherapy

• FDA agreements for HI-ART in 2003

• Statif of 85 cm de diameter

• TomoHD

– TomoHD is a Hi-ART system

packageant

– new linac

– New detector

– Etc…

– system Hi-ART (2009) can be up

graded in TomoHD

– Mobile thomotherapy installed

in a truck

• FDA agreements for HI-ART in 2003

• Statif of 85 cm de diameter

• TomoHD

– TomoHD is a Hi-ART system

packageant

– new linac

– New detector

– Etc…

– system Hi-ART (2009) can be up

graded in TomoHD

– Mobile thomotherapy installed

in a truck

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Rotational radiotherapy [3]: VARIAN Rotational radiotherapy [3]: VARIAN

• Rapid’ Arc– On board imager (OBI) and cône beam CT (CBCT)– Image guided radiotherapy– IMRT 360° – treatment time divided by 8 conventional IMRT– Dedicated software (ECLIPSE) or not (VMAT)

• Treatment– OBI and CBCT: positioning of tumor– Image comparision with CT scan– Patient matching– Treatment :1 to 2 rotations of 360°– Continus IMRT (field and intensity)

• Results: publication

• Rapid’ Arc– On board imager (OBI) and cône beam CT (CBCT)– Image guided radiotherapy– IMRT 360° – treatment time divided by 8 conventional IMRT– Dedicated software (ECLIPSE) or not (VMAT)

• Treatment– OBI and CBCT: positioning of tumor– Image comparision with CT scan– Patient matching– Treatment :1 to 2 rotations of 360°– Continus IMRT (field and intensity)

• Results: publication

19

Rotational radiotherapy [5]: ELEKTARotational radiotherapy [5]: ELEKTA

• Same technique as VARIAN Rapid’arc

• VMAT (Volumetric Modulated ArcTherapy).

• Modification of rotation speed, leaf position, and dose debit

• Fraction of 2mn

• Dedicated software ERG or Monaco Vmat

• Same technique as VARIAN Rapid’arc

• VMAT (Volumetric Modulated ArcTherapy).

• Modification of rotation speed, leaf position, and dose debit

• Fraction of 2mn

• Dedicated software ERG or Monaco Vmat

20

PlanPlan


• Technics and results– 3D Linac– Rotational Radiotherapy– Linac SBRT– Vero– Cyberknife

• Conclusion


• Technics and results– 3D Linac– Rotational Radiotherapy– Linac SBRT– Vero– Cyberknife

• Conclusion

RT3D

SBRT

Techniques

21

AXESSE (ELEKTA) AXESSE (ELEKTA)

– Conventional RT and SBRT

– High energy linac (4, 25 MV)

– Isocenter accuracy: < 1 mm

– Multileaf collimator (80 leaf)

– Cone Beam CT »

• Images– 2 XR at 90°

– 2 flat panel (40x40 cm, pxl ? mm²)

– Option VMAT

– Gating ABC « Active Breathing Coordinator »

– Conventional RT and SBRT

– High energy linac (4, 25 MV)

– Isocenter accuracy: < 1 mm

– Multileaf collimator (80 leaf)

– Cone Beam CT »

• Images– 2 XR at 90°

– 2 flat panel (40x40 cm, pxl ? mm²)

– Option VMAT

– Gating ABC « Active Breathing Coordinator »

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SBRT: Local controlSBRT: Local control

23

Papers Pts Tumors Survival Doses (Gy) Toxicity

Takeda et al

63 (11NoPath)

Stade IA : 38Stade IB : 25

At 3 years :-Stade IA : 90% (p=0,09%)-Stade IB : 63% (p=0,09%)At 5 years without pathology : -Stade IA : 82% (p=0,10%)-Stade IB : 63% (p=0,10%)

50 Gy in 5 fr

Uematsu et al

45 (66 t)

Loc I (IA : 9, IB : 11, IIA : 3Loc II : 26

Rate of de Survival ( ?) : 75 % 30 to 75 Gy in 3 à 15 fr

Timmerman et al

55 Primitives : stade IAbdominal pressure

global Survival at 2 years : 54% 60 to 66 Gy in 3 fr 20% (includes 6 possible grade 5 cases)

Onishi et al

245 Primitives :-Stade IA : 155-Stade IB : 90

SG at 3 years : 56%, at 5 years 47%specific at 3 and 5 years : 78%5 ans survival if BED ≥ 100 Gy : -Stade IA : 90%-Stade IB : 84%

18 to 84 Gy in 1 à 25 fr

5.4% lung1% oesophagitis1.2% dermatitis

Wulf et al 61 Loc I : 20 (IA : 2, IB : 10, IIA (T3) : 8Loc II :51

Primitives : Survival at 1 years : 52% Survival at 5 years : 18%Mets : Survival at 1 years : 85%

26 to 37,5 Gy in 1 à 3 fr

P. Baumann2009

57 Abdominal pressure if neededPeripheral

3 year 60% 45 Gy/3 fr 26% grade 32% grade 4

F.B. Zimmerman

68 Peripheral or central 3 year 53% 24–40 Gy/3–5 fr 6% pneumonitis3% rib fracture

R.C. McGarry

47 Abdominal pressurePeripheral or central

24 Gy/3 fr escalating to 72 Gy/3 fr

11% lung2% pericardial

J.Y. Chang

27 4-D CT planningCentral or superior

40–50 Gy/4 fr 11% grade 2–3 pneumontis/pain

24

Toxicity Toxicity

• Depends Modalities (?)

• Oesophagitis

• Dermatitis

• Pneumonitis

• Rib fracture

• Pericardial

• Chest wall pain

• Depends Modalities (?)

• Oesophagitis

• Dermatitis

• Pneumonitis

• Rib fracture

• Pericardial

• Chest wall pain

25

RTOG 0236 [1]RTOG 0236 [1]

• A Phase II SBRT for Patients with Medically Inoperable Stage I/II Non-Small Cell Lung Cancer

• R. Timmerman JAMA. 2010;303(11):1070-76. – 59 patients T1-T2N0M0 non-small cell tumors (<5 cm) – not allow surgical treatment.– May 2004 to October 2006– data analyzed August 2009– 1 end point: 2-year actuarial primary tumor control– 2 end points: disease-free survival

• 55 evaluable pts with Median

follow-up of 34.4 months

• A Phase II SBRT for Patients with Medically Inoperable Stage I/II Non-Small Cell Lung Cancer

• R. Timmerman JAMA. 2010;303(11):1070-76. – 59 patients T1-T2N0M0 non-small cell tumors (<5 cm) – not allow surgical treatment.– May 2004 to October 2006– data analyzed August 2009– 1 end point: 2-year actuarial primary tumor control– 2 end points: disease-free survival

• 55 evaluable pts with Median

follow-up of 34.4 months

26

RTOG 023 [2]RTOG 023 [2]

• Presented in 51th ASTRO an update of RTOG 0236– Only 1 primary tumor failure

– Estimated 3-year primary tumor control rate: 97.6%.

– Local-regional control rate: 87.2%

– Disease-free survival at 3 years: 48.3%

– Overall survival at 3 years: 55.8%

– median overall survival: 48.1 months.

– Primary tumour control at three years improved from 88 to 98%

• Toxicity– grade 3 in 7 patients (12.7%), grade 4 in 2 patients (3.6%)

• Conclusion– Median survival had not yet been reached (It had not been anticipated that this would happen)

– Patient follow up has been amended from a total of 4 years to include annual follow up

– Possibly be attributed to image-guidance techniques into the SBRT process.

• Presented in 51th ASTRO an update of RTOG 0236– Only 1 primary tumor failure

– Estimated 3-year primary tumor control rate: 97.6%.

– Local-regional control rate: 87.2%

– Disease-free survival at 3 years: 48.3%

– Overall survival at 3 years: 55.8%

– median overall survival: 48.1 months.

– Primary tumour control at three years improved from 88 to 98%

• Toxicity– grade 3 in 7 patients (12.7%), grade 4 in 2 patients (3.6%)

• Conclusion– Median survival had not yet been reached (It had not been anticipated that this would happen)

– Patient follow up has been amended from a total of 4 years to include annual follow up

– Possibly be attributed to image-guidance techniques into the SBRT process.

27

PlanPlan


• Technics and results– 3D Linac– Rotational Radiotherapy– Novalis– Vero– Cyberknife

• Conclusion



• Conclusion

RT3D

SBRT

Techniques

28

Vero [1]Vero [1]

• System launched ESTRO 2010 meeting

• MITSUBSHI and BRAINLAB collaboration

• Combination of versatile imaging capabilities

– real-time tumour tracking –

• Statif of 4.17 m (1.25 m) 11 tons– Linac 6MV,

– micro-multileaf of 60 leafs of 5mm at isocenter.

– Field of 15X15 cm

• O-ring can rotate ±60° about its vertical axis – isocentre accuracy of 0.1 mm.

• System launched ESTRO 2010 meeting

• MITSUBSHI and BRAINLAB collaboration

• Combination of versatile imaging capabilities

– real-time tumour tracking –

• Statif of 4.17 m (1.25 m) 11 tons– Linac 6MV,

– micro-multileaf of 60 leafs of 5mm at isocenter.

– Field of 15X15 cm

• O-ring can rotate ±60° about its vertical axis – isocentre accuracy of 0.1 mm.

29

Vero [2]Vero [2]

• Imaging– Two orthogonal kV attached to the O-

ring at 30 i/s (fluoroscopy)– Cône Beam CT and software «

HYBRID ARC », VERO can do rotational IMRT

– Integrated ExacTrac infrared

• Specific software: BRAINLAB iPLAN

• Systems– 4 Vero in Japan

– 1 European installation : UZ Brussels University Hospital

– 300 patients already treated

• Publicated Results: no

• Imaging– Two orthogonal kV attached to the O-

ring at 30 i/s (fluoroscopy)– Cône Beam CT and software «

HYBRID ARC », VERO can do rotational IMRT

– Integrated ExacTrac infrared

• Specific software: BRAINLAB iPLAN

• Systems– 4 Vero in Japan

– 1 European installation : UZ Brussels University Hospital

– 300 patients already treated

• Publicated Results: no

30

PlanPlan



• Conclusion



• Conclusion

RT3D

SBRT

Techniques

31

1 - Patient Positioning1 - Patient Positioning

• Robotic couch– 3 rotations

– 3 translations

• Numeric X Rays– 2 sources of X Rays with 2 flat

panels at 90°

– Automatic.

– Discontinued

– 41 * 41 cm 1024 *1024 pxl

– Pxl : 0.4 mm²

• Robotic couch– 3 rotations

– 3 translations

• Numeric X Rays– 2 sources of X Rays with 2 flat

panels at 90°

– Automatic.

– Discontinued

– 41 * 41 cm 1024 *1024 pxl

– Pxl : 0.4 mm²

32

33

34

35

36

37

38

39

40

41

42

43

Fiducial or not?

• For small tumor (<1,5cm) near spine/mediastinum : we prefer fiducial– Endoscopic– CT scan

• For small tumor (<1,5cm) near spine/mediastinum : we prefer fiducial– Endoscopic– CT scan

44

Mvt thorax/tumor Mvt thorax/tumor Mvt thorax/tumor Mvt thorax/tumor

X

Y

Z

Diodsthorax

Fiducials

Time

45

46

StudyStudy

• Stage I NSCLC (T1 or T2 N0 M0).

• Histology proven : Only ADK and SCC lesions were included.

• For mets : primitive tumor controlled and slow growing.

• Maximal diameter : 6 cm.

• No other concomitant or postradiation treatment

• Indication of CK : Clinical case discussion

• Exclusion if pulmonary atelectasis, infection or pneumonitisproblem of interpretation

• No MRI if no neurologic symptom

• Stage I NSCLC (T1 or T2 N0 M0).

• Histology proven : Only ADK and SCC lesions were included.

• For mets : primitive tumor controlled and slow growing.

• Maximal diameter : 6 cm.

• No other concomitant or postradiation treatment

• Indication of CK : Clinical case discussion

• Exclusion if pulmonary atelectasis, infection or pneumonitisproblem of interpretation

• No MRI if no neurologic symptom

47

Treatments Treatments

• Millimetric margins

• Tumor tracking during breathing

• CTV=GTV+5mm

• Optical positioning system– « Synchrony » Software

• Treatment time: 45-75 min

• Millimetric margins

• Tumor tracking during breathing

• CTV=GTV+5mm

• Optical positioning system– « Synchrony » Software

• Treatment time: 45-75 min

50-75 Gy5 Fr

60 Gy / 3 F

48

ResultsResults

• Median follow up 18.7 months

• Mean fraction duration 65 min (G4)

• First fraction longer than the others

• Median follow up 18.7 months

• Mean fraction duration 65 min (G4)

• First fraction longer than the others

Nb patient Nb Fr

3 1

78 3

5 4

42 5

49

ResultsResults

• Distant reccurence 62 (46.97%)

• and 31 (23.48%) death

• Local recurrence 18 (13.64%)

• and 8 (6.06%) death

• Distant reccurence 62 (46.97%)

• and 31 (23.48%) death

• Local recurrence 18 (13.64%)

• and 8 (6.06%) death

50

Evaluation at 2 years Evaluation at 2 years ((RECIst criteria)RECIst criteria)Evaluation at 2 years Evaluation at 2 years ((RECIst criteria)RECIst criteria)

During the year : 10 Distant progression,

2 death of other cause, 2 NA

CR 30 %

PR 38 %

ST 18 %

L prg 14 %

During the year : 10 Distant progression,

2 death of other cause, 2 NA

CR 30 %

PR 38 %

ST 18 %

L prg 14 %

86 %86 %86 %86 %

51

CT : Time EvolutionCT : Time Evolution

16/02/07

31/07/07

30/11/07

16/04/08

02/10/08

28/03/07

Matched images

12/03/10

14/09/09

20/09/10

52

PET evolutionPET evolution

24 January 08 05 January 10

Matched images

53

LRI : Results [1]LRI : Results [1]

• Recurrences: – same lobe 88.2% (15) same lung 11.8% (2).

• Recurrences: – same lobe 88.2% (15) same lung 11.8% (2).

Previous treatment

CK treatment

Total

54

Papers Patients Tumor Survival Doses (Gy)

Collins et al 24 Primitives :-Stade I : 15Mets :-Dont 5 CBNPC

A 1 years : Primitives : 87%Mets : 78%

45 to 60 Gy in 3 fractions

Pennathur et al 32 Loc I : 27 ( StI : 11, II : 2, III : 2, IV : 1-Recurence : 11Mets : 5

A 1 year : Primitives :-Stade I-IV : 61%-Stade I : 91%-Recurrence 89 %Mets : 80%

20 Gy in 1 fraction

Christie et al 21 Stade I survival at 1 year : 90% 60 Gy in 3 fractions

W.T. Brown, 59 Peripheral or central 90% free from persistent or recurrent disease

15 to 67.5 Gy/1–5 fractions

van der Voort van Zyp

70 Synchrony respiratory tracking system

2 years 96% (60 Gy) or 78% (45 Gy) 45 or 60 Gy/3 fractions

Bondiau et al 53 (60T) 63% Stage I37% Metastatic lesion

2 years 86% 60 Gy in 3 fr or75 to 60 in 5 fr

Cyberknife resultsCyberknife results

55

Comparison to surgeryComparison to surgery

• International Protocol Phase III

• J. Roth (MD Anderson)

• Randomisation : CK vs

surgery

– T1-2 N0 M0,

– PET?

– Margin discussion 1cm?

– Dose discussion

• International Protocol Phase III

• J. Roth (MD Anderson)

• Randomisation : CK vs

surgery

– T1-2 N0 M0,

– PET?

– Margin discussion 1cm?

– Dose discussion

56

PlanPlan



• Conclusion



• Conclusion

RT3D

SBRT

Techniques

57

Nb beam Positioning Accuracy GTV irradiation DoseResults

LC

RT2D 6 Manual/ laser cm margin 66-70 30 % at 3

years

Conformal 3D 6-16 Manual/ laser cm Margin / Gating 66-70 60-70 % at 2

years

Rotational RT

Tomotherapy

Rapid arc

Vmat

360°

CT

(pxl>1,2mm²)

< cmMargin 66-70

Escalating dose study in progress

Accel/SBRT Novalis

Axess< 20 Beam 2 Xray

< mmGating ? 70-90% at 3

years

Vero Arc/Beam 2 Xray< mm

Tracking ? ? No

Cyberknife >1502 Xray

automatic< mm Tracking

150 Gy

BED

90-95% at 2 years

Compare Surgery

58

Conclusion: SBRT Conclusion: SBRT

• Overall accuracy < 1 mm

• Breaks through in the treatment lung tumor

• Hypofractionation– 1-5 fractions (1 week)

– "Rapid return to normal life"

• Major interest ++ lung tumor Stage 1 ( # surgery) Standard

of care of patient medically inoperable?

++ after pneumonectomy

++ of the re-irradiation capacity : Lung?

Clinical research : stage III boost?

• Overall accuracy < 1 mm

• Breaks through in the treatment lung tumor

• Hypofractionation– 1-5 fractions (1 week)

– "Rapid return to normal life"

• Major interest ++ lung tumor Stage 1 ( # surgery) Standard

of care of patient medically inoperable?

++ after pneumonectomy

++ of the re-irradiation capacity : Lung?

Clinical research : stage III boost?

RTCT 2008on CK-CT scan 2010

CK 2010 RTCT 2008CK 2010

59

Merci

G. ANGELIER (PhD)K. BENEZERY (MD)J. THARIAT (MD)

G. PALAMINI (radiotherapist)B. GRANIER (Secretary)S. MARCHAL (CR) P.Y. BONDIAU (MD. PhD)

Documents

PY Bondiau PhD. MD. Centre Antoine Lacassagne. Nice. France High Precision Radiotherapy