1. Radiation for Lung Cancer
Robert Miller MD
www.aboutcancer.com

3. NCCN.org

4. The treatment guidelines have
become quite complex

5. NCCN.com

6. Treatment of Lung Cancer
 Stage I and II – surgery (if possible)
and sometime postOp chemo or
radiation (virtually all small cell
cancer patients receive
chemotherapy)
 Stage III – usually chemo plus
radiation, sometime followed by
surgery
 Stage IV – chemo or radiation,

7. In the simulation
process the CT
and PET scan
images are used
to create a
computer plan

8. The CT images will be used to construct three
dimensional reconstructions of the patient’s cancer
and involved lymph nodes so they can be separated
from normal structures

9. In the treatment
the lasers are
used to line up
the beam and the
patient receives
the radiation
treatment

11. Combine a CT scan and linear accelerator to
ultimate in targeting (IGRT) and ultimate in
delivery (dynamic, helical IMRT) ability to
daily adjust the beam (ART or adaptive
radiotherapy)

12. Computer generated images showing the
radiation beam passing through the patient to
hit the small lung cancer

13. Computer generated images of small lung
cancer (in blue) in the left upper lung and the
radiation target zone (green) that surrounds it

14. Computer generated images showing the
volume and dose of normal lung receiving
radiation
The computer monitors the total lung dose to
keep it below a dose level that could cause
problems

15. Computer
generated lung
cancer target in
red
and radiation
zone (yellow)
surrounds it

16. Computer
generated
images will
show how
close the
cancer is to
other important
structures (like
the spinal cord,
the heart and
the liver, and
how much
normal lung is
near

17. Using CT
scans the
computer
can
generate
the target
for a
cancer in
the upper
part of the
lung

18. Using CT
scans the
computer
can
generate
the target
for a small
cancer
growing
inside the
trachea

19. Computer
generated images
to target the tumor

20. Tomotherapy
images showing
the radiation zone
in red surrounds
the cancer area (in
blue) and limits the
dose of radiation
that hits the normal
lung, heart or
spinal cord

21. PET Scan = local tumor. No nodes. These scans are not 100% accurate,
but it may be possible to target only the cancer and not include the lymph
nodes to limit the size of the radiation field. See Tomo plan on next slide

22. Tomotherapy plan targets just the mass, with a small margin. The target was
generated from multiple CT images in different breathing cycles to create a 4D
(four dimensions including time and generating a larger target that accounts for
internal movement (called an ITV)

23. Radiation Dose

24. Radiation ‘safe dose’ to normal
structures

25. Radiosurgery for Cancer

26. Cyberknife

27. Cyberknife for Lung Cancer

28. Commonly Used Dose
Regimens for Radiosurgery

29. Maximum ‘safe doses’ to normal
structures with radiosurgery

30. Radiation Results
Some lung
cancers (like
small cell)
shrink quickly,
other cancers
may take weeks
or months to
slowly regress

31. CT = large left upper
lobe tumor invading
the mediastinum
CT Scan 3 years later
= only scar tissue
remains after chemo-
radiation

32. With smaller cancers, the tumor may be
gone by Two Months after Radiation
CT-PET Scan

33. PET Scans will show the response to radiation, the
tumor should smaller and ‘colder’ on the PET

34. Lung cancers shrink
slowly during the
radiation,
this picture from the
daily Tomotherapy
image shows good
regression only half
way through the course
of radiation allowing
the radiation targets to
be adjusted Adaptive
Radiotherapy)

35. Using Tomotherapy to Target Lung Cancer

36. Radiation and chemotherapy for NSCL, the
mass may shrink significantly during the
course of radiation
cancer
cancer
CT Scan prior to radiation Tomo image after only 19
treatments

37. Tomotherapy Images

38. Daily CT images
on Tomo will
allow for the
physician to
adjust the
radiation target if
the cancer
changes in size or
position

39. CT scans will
show the slow
shrinkage of non-
small cell lung
cancer, which can
continue to shrink
for months after
completing
radiation

40. Large tumors may shrink slower and the scans may show radiation
fibrosis (the PET will no longer be ‘hot’ if the gray mass is just scar
tissue and not active cancer as seen on the pictures on the right)
Large NSCL Left Lung PET/CT 6 Months later

41. PET Scan after Radiation

42. PET Scan showing complete
remission of the cancer in the left
lung at 7 months

43. PET scan showing near complete
remission, 2 months after radiation
alone for NSCL

44. PET Scan
Advanced non-
small cell lung
cancer before and
2 months after
completing
radiation

45. PET Scan showing changes at 1 and 4
months after completing radiation for
mediastinal lymph node

46. PET Scan
2-09
Adenocarcinoma
of the right upper
lung, before and
10 months after
chemoradiation,
2-10 no longer hot on
PET

47. Large NSCL of the RLL before and 3 months
after chemoradiation
CT 9-09 PET 9-09
CT 2-10 PET 2-10

48. Patient with advanced cancer had pre-
operative chemoradiation. At the time of
surgery there was no remaining cancer found

49. Very large lung cancer, prior to radiation

50. PET scan of the same
patients, 2 years later,
there is still a large
density in the lung,
but it is ‘cold’ on the
PET scan, so just
radiation fibrosis or
scar tissue

51. Survival by Stage
Stage Clinical 5 Year Pathologic 5 Year
IA 60 months 50% 119 month 73%
IB 43 43% 81 58%
IIA 34 36% 49 46
IIB 18 25% 31 36%
IIIA 14 19% 22 24%
IIIB 10 7% 13 9%
IV 6 2% 17 13%
J Thorac Oncol 2007; 2:706

52. Conventional Radiation for Stage
I and II NSCL
Years Over All Cancer Specific
Survival Survival
2 years 22 – 72% 54 – 93%
5 years 0 – 42% 13 - 39%
Cochrane Database Syst Rev. 2001

53. Cyberknife

54. Radiosurgery Results
Cause specific Survival
Robert Timmerman IJROBP 2009;75:677
Months

55. Radiosurgery Results – Stage
I
Survival
Years

56. Side Effects of Lung
Radiation

57. Side Effects
ribs
lungs
skin
nerves
heart
esophagu
s

58. Short Term Side
Effects of Lung
Radiation (usually start
showing up after the
second week or
radiation)
 Esophagus – sore throat or trouble
swallowing
 Trachea or lungs – cough or shortness of
breath
 Chest wall – tenderness
 Skin – sunburn
 Fatigue

59. Long Term Side Effects of
Lung Radiation, can show up
weeks or months after
completing radiation
 Esophagus – sometimes there can be prolonged
irritation or stricture
 Lungs – there can be scar tissue (fibrosis) that can
cause more shortness of breath or a delayed reaction
(radiation pneumonitis) with fever, cough and
shortness of breath.
 Symptoms caused by acute radiation pneumonitis
usually develop approximately four to twelve weeks
following irradiation, whereas symptoms of late or
fibrotic radiation pneumonitis develop after six to
twelve months.

60. CT Scan = Severe COPD

61. Many patients who are smokers have severe
damage to their normal lung tissue, making it
important to target the radiation carefully and
avoid as much ‘normal’ lung as possible

62. High dose radiation can inflame
(pneumonitis) or damage (fibrosis)
normal lung tissue

63. Normal lung that is hit by
the radiation field (pink
zone) will be inflamed by
radiation (called radiation
pneumonitis) these PET
scans were done 2 months
after completion (there is
also volume loss on the
left side due to some
collapse)

64. Same patient at
18 months, still
volume loss
and fibrosis less
hypermeta-
bolic activity
(pneumonitis)
and more
chronic fibrosis

65. Long Term Effects of Lung Radiation
The PET scan shows an excellent response with the cancer
gone and a small amount of radiation fibrosis (scar tissue)
visible. Notice the lung looks smaller on the left from volume
loss

66. Side Effects of Lung
Radiation
The cancer is visible as bright
yellow on the first PET scan and
the second image shows the
radiation zone
The third image (PET scan 4
months later) shows the cancer
gone, but now there is a strip of
abnormal tissue / radiation fibrosis
in the posterior lung.
It is important to keep the normal
lung exposed to radiation as small
as possible

67. By 7 months the area of scarring or fibrosis
is getting smaller and colder on PET

68. Radiation
Fibrosis
CT 9 months
after radiation,
corresponding to
the high dose
radiation field

69. Radiation
Fibrosis
CT 9 months
after radiation,
corresponding
to the high
dose radiation
field

70. Radiation Fibrosis confined better with SBRT

71. Radiation for Lung Cancer
Robert Miller MD
www.aboutcancer.com