Why Should My Institution Start a
SBRT Program and Steps in Setting
Up a Spine SBRT Program
IAEA Singapore SBRT Symposium
Yoshiya (Josh) Yamada MD FRCPC
Department of Radiation Oncology
Memorial Sloan Kettering Cancer Center
Disclosures
• Varian Medical Systems Consultant
• Institute for Medical Education Speakers
Bureau
CONVENTIONAL FRACTIONATION
versus
HYPOFRACTIONATION
versus
STEREOTACTIC BODY RADIOSURGERY (SBRT)
SBRT
Hypofractionation
Conventional
Number of fractions
1
5
~35
45
Fraction Size
>7 Gy
1.8-2.0 Gy
Total Dose
~35-50 Gy
~50-75 Gy
Biological Rationale
Ablative??
N o r m a l t i s s u e
s p a r i n g
~75-85 Gy
Why SBRT?
• SBRT is better (tumor control, toxicity)
– Lung
– Spine
– Liver
– Pancreas
Benefits of Image Guided Therapy
•  Precision of treatment ( Uncertainty)
– Increased confidence to:
• Reduce:
– Margins
– Reduce normal tissue exposure
–  Toxicity
•  Biologic Effective Dose
– Hypofractionate/ Single Fraction Treatment
– Increase absolute dose
• IMPROVE OUTCOMES
4D RT
Week 1
• Motion management
– Lung
– Liver
– Pancreas
– Prostate
Week 2
• Adaptive RT
Week 3
Why SBRT?
• SBRT is the only option:
– Salvage RT:
• Spine
• H&N
– Lung
Why SBRT?
• SBRT is more efficient:
– Prostate 5 fractions vs 48 fractions
• SBRT 30 minutes of Linac time vs non SBRT 10 minutes
• SBRT 150 minutes of Linac time vs 480 minutes
• Brachytherapy requires OR time
– Pancreas 5 fractions vs 28 fractions
• SBRT 150 minutes vs 280 minutes
SBRT for Prostate Cancer
Cost
• 5 treatments vs. > 40 treatments
• In US: SBRT $20,571 vs IMRT $36,837
CHEAPER
Courtesy Pat Kupelian MD
Why SBRT
• SBRT takes less time:
• Patients who live away from center: 1 week away vs onetwo months away
–
–
–
–
Less impact on quality of life
Less time away from home and family
Less time away from work
Less expense
• Less interruption of chemotherapy treatment schedules
Why SBRT
• The demands of SBRT will raise the
performance of department overall
• SBRT requires robust QA program which can
be applicable in other department activities
– MD
– Physics
– Therapists
The Ultimate Therapeutic Gain:
Spine IGRT
•
Improving the therapeutic ratio:
•
Multimodality IGRT: The best of both
worlds
•
Reduce toxicity:
– Significant reduction in volume of
volume sensitive toxicity
– Reduce dose to dose sensitive toxicity
•
Improve tumor control:
– Tumor dose is critical
– Tumor control at ~ 90% level regardless
of tumor phenotype or size
– Greatest therapeutic gain may be for
radioresistant disease
Why SBRT Summary
• Better tumor control
– Hypofractionation, dose escalation
• Less toxicity
– Reduced margins, gating/adaptive RT
• Faster
– More efficient
• Cheaper
• Improve processes throughout department
• Provide avenues to establish multidisciplinary
relationships
• Multidisciplinary academic collaborations
Summary
Spine radiosurgery is clinical proof of principle of the IGRT
hypothesis
↓ Toxicity
• IGRT ↓ normal tissue volumes and dose
• Clinically significant toxicity is extremely rare
↑ Tumor control
• High biologic impact of very high dose per fraction/single
fraction radiation
• Dose response relationship
• Redefining traditional radiobiologic constructs of
radiosensitivity
Changed the management of spine tumors at MSKCC
Summary
• IGRT:
• You can’t always get what you
want…
• But you get what you need!
• With a little help from your friends!
IGRT Quality Assurance is Critical
Why SBRT
• SBRT will provide mechanisms for
multidisciplinary collaborations
– Spine: Neurosurgery/Orthopedic
Surgery/Interventional Radiology/Medical
Oncology
– Prostate: Urology-fiducial placement
– Lung: Thoracic surgery/interventional radiology:
• Fiducial placement
– Liver: Fiducial placement: Interventional
radiology, biopsy
The Right Tools
Tools
• Be familiar actual with geometric
uncertainties/capabilities of your equipment:
– Gantry
– Leaves
– Table
– Imaging uncertainty
– Systematic and random errors
The Right People
•
•
•
•
•
Radiation Oncologist
Medical Physicist
Medical Dosimetrist
Radiation Therapist
Other
– Allied disciplines: Neurosurgery, Orthopedic
surgery, Interventional Radiology
– Nursing
Getting Others Involved
• Familiarize yourself with the medical evidence
in all related disciplines
• Encourage collaboration
• Multidisciplinary management
– Establish Multidisciplinary Treatment Protocols
– Clinical Trials/Studies
– Multidisciplinary clinics/joint patient
evaluation/assessment
Synergistic Academic Productivity
• Take advantage of individual expertise
• Coordinate efforts
• Team approach
– Group research goals
– Common data collection ie MDASI
– Common definitions ie NOMS
– MSKCC spine service has over 20 peer reviewed
publications in 2012
Learn from Others
• Fellowship training/special extended training
• Attend specific meetings/conferences
• Spend time with experts
– Multidisciplinary
• Radiation Oncology
• Medical Physics
• Allied disciplines
– Visit a high volume experienced center
Learn From Yourself
•
•
•
•
•
Perform SBRT on specific protocols
In house, regional or national studies
Careful QA, chart review, toxicity assessment
Meticulous charting
Prospective database of outcomes
Spine SBRT: Where to Start
• Hypofractionation
• Lumbar spine
– Easiest to visualize
– Easiest to immobilize
– No spinal cord, no esophagus,
kidneys and bowel usually relatively distant
• Post operative surgical hardware = excellent
fiducial markers
Clinical procedure - continued
Registration -kV
•
•
•
•
Registration tools tightly
integrated into operation
of machine
Only 1 registration per
image pair
(anatomy match)
is required
Sup. / Inf. shifts linked
in both images
Calculated shifts can
be applied directly to
couch
DRR Window
MSKCC Spine Service
Radiation Oncology
Josh Yamada, M.D.
Radiology
Eric Lis, M.D.
George Krol, M.D.
Sasan Karimi, M.D.
Pierre Gobin, M.D.
Athos Patsilides, M.D.
Orthopedic Surgery
Patrick Boland, M.D
.
Neurosurgery
Mark Bilsky, M.D.
Ilya Laufer, M.D.
Neurology
Edward Avila, D.O.
Xi Chen, M.D.
Sonia Sandhu, D.O
Pain
Roma Tickoo, M.D.
Kenneth Cubert, M.D.
Vinay Puttaniah, M.D.
Amitabh Gulati, M.D.
Physiatry
Michael Stubblefield,M.D.
Jonas Sokolof, D.O.
Christian Custodio, M.D.
PT/OT
Nursing
Joan Zatcky, NP
Cynthia Correa, RN
Ruth Gargan-Klinger, NP
Jane Yoffe, NP
Solange Inglis, NP
Marie Marte, NP
Summary: Steps to Starting Program
•
•
•
•
•
Define program goals
Make it multidisciplinary
Acquire technical capabilities
QA process established
Acquire expertise
– Learn from others and your self
• Start from simple and easy (post op lumbar never
previously irradiated for hypofractionation)