Carlos Jamis-Dow

Radical cyberknife radiosurgery with tumor tracking: an effective treatment for inoperable small peripheral stage I non-small cell lung cancer

ObjectiveCurative surgery is not an option for many patients with clinical stage I non-small-cell lung carcinoma (NSCLC), but radical radiosurgery may be effective.MethodsInoperable patients with small peripheral clinical stage I NSCLC were enrolled in this study. Three-to-five fiducial markers were implanted in or near tumors under CT guidance. Gross tumor volumes (GTVs) were contoured using lung windows. The GTV margin was expanded by 5 mm to establish the planning treatment volume (PTV). A dose of 42–60 Gy was delivered to the PTV in 3 equal fractions in less than 2 weeks using the CyberKnife radiosurgery system. The 30-Gy isodose contour extended at least 1 cm from the GTV. Physical examination, CT imaging and pulmonary function testing were completed at 6 months intervals for three years following treatment.ResultsTwenty patients with an average maximum tumor diameter of 2.2 cm (range, 1.1 – 3.5 cm) and a mean FEV1 of 1.08 liters (range, 0.53 – 1.71 L) were treated. Pneumothorax requiring tube thoracostomy occurred following CT-guided fiducial placement in 25% of the patients. All patients completed treatment with few acute side effects and no procedure-related mortality. Transient chest wall discomfort developed in 8 of the 12 patients with lesions within 5 mm of the pleura. The mean percentage of the total lung volume receiving a minimum of 15 Gy was 7.3% (range, 2.4% to 11.3%). One patient who received concurrent gefitinib developed short-lived, grade III radiation pneumonitis. The mean percent predicted DLCO decreased by 9% and 11% at 6 and 12 months, respectively. There were no local failures, regional lymph node recurrences or distant metastases. With a median follow-up of 25 months for the surviving patients, Kaplan-Meier overall survival estimate at 2 years was 87%, with deaths due to COPD progression.ConclusionRadical CyberKnife radiosurgery is a well-tolerated treatment option for inoperable patients with small, peripheral stage I NSCLC. Effective doses and adequate margins are likely to have contributed to the optimal early local control seen in this study.

Radical stereotactic radiosurgery with real-time tumor motion tracking in the treatment of small peripheral lung tumors

BackgroundRecent developments in radiotherapeutic technology have resulted in a new approach to treating patients with localized lung cancer. We report preliminary clinical outcomes using stereotactic radiosurgery with real-time tumor motion tracking to treat small peripheral lung tumors.MethodsEligible patients were treated over a 24-month period and followed for a minimum of 6 months. Fiducials (3–5) were placed in or near tumors under CT-guidance. Non-isocentric treatment plans with 5-mm margins were generated. Patients received 45–60 Gy in 3 equal fractions delivered in less than 2 weeks. CT imaging and routine pulmonary function tests were completed at 3, 6, 12, 18, 24 and 30 months.ResultsTwenty-four consecutive patients were treated, 15 with stage I lung cancer and 9 with single lung metastases. Pneumothorax was a complication of fiducial placement in 7 patients, requiring tube thoracostomy in 4. All patients completed radiation treatment with minimal discomfort, few acute side effects and no procedure-related mortalities. Following treatment transient chest wall discomfort, typically lasting several weeks, developed in 7 of 11 patients with lesions within 5 mm of the pleura. Grade III pneumonitis was seen in 2 patients, one with prior conventional thoracic irradiation and the other treated with concurrent Gefitinib. A small statistically significant decline in the mean % predicted DLCO was observed at 6 and 12 months. All tumors responded to treatment at 3 months and local failure was seen in only 2 single metastases. There have been no regional lymph node recurrences. At a median follow-up of 12 months, the crude survival rate is 83%, with 3 deaths due to co-morbidities and 1 secondary to metastatic disease.ConclusionRadical stereotactic radiosurgery with real-time tumor motion tracking is a promising well-tolerated treatment option for small peripheral lung tumors.

Thoracic Fiducial Placement via Flexible Bronchoscopy

CyberKnife® (Accuray Incorporated, Sunnyvale, CA) Frameless Image-Guided Radiosurgery [1, 2] with the Synchrony® Motion Tracking Module (Accuray Incorporated) [3, 4] is now available for the treatment of thoracic malignancies. Gold fiducial markers are required for the treatment planning and tracking of the tumor during each treatment. Fiducials have traditionally been placed percutaneously under CT-guidance. This chapter describes our center’s experience placing fiducials using flexible bronchoscopy with a transbronchial aspiration needle (TBNA).

CyberKnife frameless Image-Guided high-dose fractionated stereotactic radiosurgery with the synchrony motion tracking module in the treatment of single small peripheral lung tumors

Curative surgery is not an option for many patients with clinical stage I non-small-cell lung carcinoma (NSCLC) because of associated comorbidities. Stereotactic radiosurgery with the CyberKnife® (Accuray Incorporated, Sunnyvale, CA) tumor tracking system may be an option for many of these medically inoperable patients. Here we provide a concise overview of the standard treatment options for stage I lung cancer and a practical summary of the Georgetown University Hospital stereotactic radiosurgery treatment protocol. We review preliminary outcomes for single small peripheral lung tumors uniformly treated with the CyberKnife using the Synchrony® (Accuray Incorporated, Sunnyvale, CA) motion tracking module.