1. Emily Tanzler, MD Waseet Vance, MD
Stereotactic Ablative Radiation Therapy (SABR) for Early Stage Non-Small Cell Lung Cancer
Emily Tanzler, MD
Waseet Vance, MD

2. Treatment Options for Early Stage Lung Cancer
Surgical
Sub-Lobar Resection
Lobectomy
Non-Surgical
Conventional RT
SBRT
RFA

3. Clinical stage I NSCLC patients can be considered falling into three treatment groups:
Average-risk patients: typically treated with lobectomy
High-risk patients: typically treated with sublobar (segmental or wedge) resection
Medically inoperable patients: traditionally treated with external beam radiation therapy.

4. 5-year Overall Survival for stage I NSCLC
Surgical resection is the gold standard for treatment of patients with stage I and II operable lung cancer
5-year Overall Survival for stage I NSCLC
Clinical stage IA-61%
Pathologic stage IA-67%
Clinical stage IB-38%
Pathologic stage IB-57%
(Mountain CF. Semin. Surg. Oncol. 18:106–115, 2000)

5. Criteria for Resection
FEV1
ACCP threshold for lobectomy: 1-1.5L
Recent series demonstrated increased complications for FEV1 <47% predicted
DLCO
> 60% Preoperative recommended
< 40% Predicted Post-Op Associated with high morbidity/mortality
Exercise Tolerance

6. High Risk or “Marginally” Operable Patients
Substantial number (15-40%) of NSCLC patients present with impaired cardiopulmonary reserve
Increased risk of peri-operative complications and long-term disability with standard anatomic resections

7. High Risk or “Marginally” Operable Patients
Will have difficulty during and after a lobectomy or pneumonectomy
Getting off ventilator
Getting out of hospital
Readmissions
Decreased vitality/quality of life post-resection

8. Surgical Options – Lobectomy vs. Sublobar Resection
T1N0 (Negative mediastinoscopy)

9. Lobectomy vs. Sublobar Resection
Sem Thor and CT Surg 2003
LR ~10% with Lobectomy vs ~20-30% with sublobar resection

10. Medically Inoperable
Observation alone in these patients is not a good option
In a study of 75 Stage I medically inoperable patients treated with observation alone
Lung cancer cause of death in 53%
Death from other comorbidities was 30%
(McGarry, Chest 2002)

11. Radiofrequency Ablation
Placed percutaneously
Electrode heated to °
Coagulation Necrosis
Treat tumor + margin
Indications: Small (<3 cm) NSCLC or mets
Complications:
Pneumothorax (30%)
Fever/Pleurisy/Effusions
Radiology 2007

12. Conventional Radiation Therapy
IJROBP 1998
Local Control: 50 – 60%

13. Stereotactic Ablative Radiation Therapy (SABR) is the emerging standard in the management of non-small cell lung cancer for the medically inoperable patient.

14. Stereotactic Ablative Radiation Therapy (SABR)
Outpatient
Noninvasive/painless
No sedation or anesthesia required
Completed in 1-5 treatments
Entire course completed in 1-2 weeks
Each treatment only minutes
No limitation in activities or recovery downtime
Spares significant lung tissue

15. SABR vs Conventional RT
Local Control
Historic comparisons
SABR 54 Gy in 3 fx, 98% (local), 91% (lobe)
(RTOG 0236)
EBRT Gy / fx, ~50%
(Qiao, Lung Cancer 2003)
Beaumont experience comparing SABR vs EBRT
(Lanni, Am J Clin Oncol 2011)
SABR (48-60 Gy in 4-5 fx, n=45) vs. EBRT (70 Gy/35 fx, n=41)
3y LC: 88% vs. 66%
Meta-analysis (Grutters, Radiother Oncol 2010)
SABR (n=895) vs. EBRT (n=1326)
2y OS, 70% vs. 53%
2y DFS, 83.4% vs. 67.4%

16. Medically Inoperable: Peripheral Tumors- RTOG 0236
Timmerman et al. JAMA Mar 17;303(11):
55 patients with a median follow-up of 34.4 months
T1 tumors (44 patients)
T2 tumors (11 patients)
3-year primary tumor control rate was 97.6%
3-year rate of disseminated failure was 22.1%

17. Medically Inoperable: Peripheral Tumors- RTOG 0236
Disease-free survival at 3 years 48.3%
Overall survival at 3 years 55.8%
Median survival was 48.1 months
Toxicity
Grade 3 toxicity in 7 pts (12.7%); grade 4 in 2 pts (3.6%). No grade 5.
Rare rib fractures and dermatitis have been observed for chest wall tumors

18. MEDICALLY OPERABLE PATIENTS
SABR data from Japan in operable patients who declined surgery
87 patients with T1 (n=65) or T2 (n=22) tumors treated at 14 Japanese institutions
5 year survivals for stage IA and IB comparable to surgery
Stage IA=77%
Stage IB=68%
(Onishi, IJROBP 2010)

19. MEDICALLY OPERABLE PATIENTS
50 pts w with T1 (n=24) or T2 (n=26) tumors treated with SABR from 1994 to 1999.
29 pts were medically operable but refused surgery
Entire cohort of 50 patients:
3 year LC 94%
3 year CSS 88%
3 year OS 66%
Cohort of 29 operable patients
3 year OS 86%
(Uematsu, IJROBP 2001)

20. MEDICALLY OPERABLE PATIENTS
177 medically operable patients with T1 (60%) or T2 (40%) tumors treated with SABR from 2003 to 2010 in the Netherlands
SABR dose of 60 Gy delivered in 3, 5, or 8 fractions using a risk adapted scheme
3 year LC 93%
3 year OS 84.7%
(Lagerwaard, IJROBP 2012)

21. Treatment Toxicities Rates are generally low
> grade 3 pneumonitis, hypoxia: < 5%
Related to tumor location & fractionation schedule
Newer fractionation schemes and advanced treatment techniques have further improved toxicity profile

22. SABR Case

23. Treatment Response Timeline
Initial Treatment
4 months
Complete Radiographic Response
18 months
No Evidence of Disease

24. Conclusions Surgery is the gold standard for operable patients
For inoperable or marginally operable high risk patients with Stage I lung cancer SABR offers excellent local control and similar survival to surgical approaches
Randomized trials have failed to accrue for various reasons- patients and physicians

25. Thank You