1. The Health Roundtable 1-1b_HRT1215-Session_HEGI_JOHNSON_WESTMEAD_NSW Volumetric Modulated Arc Therapy for Stereotactic Body Radiotherapy in Early Lung Cancer. Dr Fiona Hegi-Johnson Westmead Hospital Innovation Poster Session HRT1215 – Innovation Awards Sydney 11 th and 12 th Oct 2012 1

2. The Health Roundtable KEY PROBLEM  Stereotactic body radiotherapy(SBRT) for early lung cancer results in excellent local control and potentially improved survival 1. 3D-conformal radiotherapy(3D-CRT) and intensity modulated radiation therapy( IMRT) delivery require long treatment times, increasing the risk of patient motion.  Volumetric arc therapy(VMAT) may result in improved dosimetric outcomes, and potentially reduced treatment time. 1. Chi et al. Radiotherapy and Oncology 94(2010): 1-11 2

3. The Health Roundtable AIM OF THIS INNOVATION  Assess dosimetric outcomes of implementing VMAT for SBRT lung  Quantify time required for treatment of SBRT lung patients 3

4. The Health Roundtable BASELINE DATA  Stereotactic Body Radiotherapy (SBRT) lung:  Very small volumes treated to high doses ( typically 48-54 Gy in 3- 5 fractions)  Demands high conformality of radiotherapy dose, with rapid fall-off from high dose region  Previous techniques in use:  3D-Conformal radiotherapy  Intensity modulated radiotherapy  Use 10-12 beams, often requiring non-coplanar beams  Up to 1 hour in treatment time  Uncomfortable for patients, and increases the risk of tumour motion during treatment. 4

5. The Health Roundtable KEY CHANGES IMPLEMENTED  Pinnacle VMAT plans compared to coplanar (CP) and non- coplanar (NCP) 3D-CRT and IMRT plans for delivery on Elekta Linacs and assessed for:  Target coverage with the prescribed dose and 98% coverage of the PTV  Low dose wash at 2 cm from target  V20 (volume of normal lung receiving 20 Gy).  3 patients included  All patients received 48 Gy in 4 fractions given twice weekly. 5

6. The Health Roundtable KEY CHANGES IMPLEMENTED ParameterVMAT3D-CRT CP3D-CRT NCP IMRT CPIMRT NCP PTV coverage 98.2%94.5%95.1%95.5%97.1% V206.0%5.6%4.5%5.5%5.1% D2cm26.9Gy33.4Gy28.9Gy29.4Gy25.4Gy 6

7. The Health Roundtable KEY CHANGES IMPLEMENTED Clinical treatment time: 35 minutes 7

8. The Health Roundtable OUTCOMES SO FAR  VMAT demonstrated to improve target coverage compared other techniques (>98% vs. 94-97%)  V20 higher with VMAT 6% vs. 4.1-5.6%.  Low dose wash superior to 3D-CRT (Co-planar and non- coplanar) and co-planar IMRT.  Treatment time reduced to 35 minutes. 8

9. The Health Roundtable LESSONS LEARNT  Choice of radiotherapy technique:  Consider technical factors  Ease of implementation  Need for further training  Future considerations:  VMAT funding significantly lower than other techniques, as reimbursement is based on the number of beams, and fractions delivered.  Currently under negotiation, but may make this expensive for departments to implement. 9