SBRT LUNG Tayler-Jo Mullins

• 5fx or less
• At least 500cGy/fx
• More rigid immobilization
SBRT • Motion management
INDIC ATORS
• Smaller treatment volumes/margins
• More frequent/elaborate imaging
• Physician and physics oversight
 SBRT LUNG PLAN

• Male
• Single lung lesion
• Left lower lobe
• Lateral
• At level with heart
• Near diaphragm
• NSCLC
• squamous cell carcinoma
• T1bN0M0 (Stage1B)
• Treated on Vault 5 in Sept. 2018
 SBRT IMMOBILIZATION

WHAT? REFERENCE MARKS

• Civco Stereotactic board • CT zero (isocenter)
• With board numbers • 5cm superior
• Arm shuttle • 5cm inferior
• With HR and hand bars • 10cm posterior
• Red knee sponge • Lateral mark on bag underneath patient
• SBRT vac-bag • Clearance issues
• Form top section around arms
• Form bottom section around thorax and pelvis
• Clam-lok cushion
• Respiratory plate
• Used for chests
• Has a greater effect than the compression belt
PT’S IMMOBILIZATION
 4D CT SCAN
PURPOSE
• To visualize motion of the tumor volume
• Indicate if gating is needed for treatment
• Guide in drawing target volumes
PROCESS
• Performed without contrast
• Typically performed before free-breathing scan with
contrast
• 10 images per slice, making 10x the number of images in
complete scan compared to FB scan
• Meaning 10x the radiation exposure
• Cine time is based off the time of patient’s full respiratory
cycle
• Need the whole cycle to be included in scan or else data will be
missing for planning purposes
• MIP: maximum HU of all images combined and shows
largest tumor motion range
• Ave: average HU of all images (not used for planning)
 MOTION MANAGEMENT

GATING DAMPENING
• Beam on only during a specific segment • Abdominal compression
of the respiratory cycle
• Breathe hold
• 0-5mm tumor motion range = gating is
not needed during treatment
• 5-10mm range = gating is decided by
physician CHASING
• >1cm range = gating is recommended for • Cyberknife
treatment
• If gating is chosen, gold fiducial(s) placed
in tumor with a bronchoscope for
imaging purposes during treatment
• Complications possible
 LUNG LESIONS

• Central/Proximal Lesions = No Fly Zone

• Includes trachea, carina, and primary bronchi with 2mm margin
• Will treat in 5-8 fractions
• Must spare non-adjacent wall of airway
• less than 105% of Rx dose
• Peripheral Lesions
• Outside this region
• Able to treat in 5 fractions or less
 TARGET VOLUMES

• GTV: drawn from the free-breathing scan

• ITV: volume including the GTV’s full range of motion during the 4D scan
• GTV should fit into the ITV at ALL TIMES
• PTV: expansion of ITV and GTV
• 5mm radially and 7mm sup-inf
 PT’S PRESCRIPTION

• Free-breathing
• Abdominal compression
• No gating or fiducials
• 4fx to 5000cGy (1250cGy/fx)
• 6MV photons
 CRITICAL STRUCTURES

• Esophagus
• Great Vessels (Aorta)
• Ribs
• Chest wall
• Liver
• Airway (Bronchi)
 PLANNING OBJECTIVES

• No hotspots outside of PTV

• No limit on how hot, as long as within the
GTV and ITV
• 95% of PTV receives minimum 100% of Rx
dose
• 99% of PTV receives minimum of 90% of Rx
dose
• Maximum dose at any direction 2cm from
the PTV should be <50% of Rx dose
• More realistic goal is <60% of Rx dose
• Rapid dose fall off
 BEAM ARRANGEMENTS

• FFF to increase the rate that

dose can be delivered and better
dose fall off
• Must be a small field size
• Non-coplanar beams
• Half arcs to spare the other lung
 DYNAMIC CONFORMAL ARCS

• Field shaped to the target throughout entire treatment, NEVER

covering the target volume
• When there is more tumor motion, this is a better option over
IMRT/VMAT
• Greater chance of missing the target
• Planning process includes fitting the MLCs to the PTV, no
optimization used
• Planning PTVs are used instead, cropped to reduce dose to OARs
and expanded to better cover the target
• PTV cropped to reduce dose to chest wall and ribs
 RIBS
CHEST WALL
HEART
ESOPHAGUS
GREAT VESSEL
DVH
SPINAL CORD
MAIN BRONCHUS
GTV

ITV

PTV
 TREATMENT PROCEDURE

• Daily alignment to tattoos/green marks and shifts to blue marks.

• MD CBCT daily. Align to PTV, make sure tumor is within ITV.
• Retract imagers completely for treatment. Does not clear at T90.
• Physicist present for entire treatment.
• Sign off on QA, CBCT and shifts, treatment arcs with gantry and couch angles, MU,
energy, and completion of treatment
• Physician present for timeout, apply compression, and imaging approval.