Radiation Oncology specialist, Dr. Kuczer




Respiratory Motion Management

Conventional (ITV-based)
– Contour and treat full tumor ROM

Accelerator beam gating
– Patient breathes normally; beam only on while patient is in a certain phase of the respiratory cycle

Active breathing control
– Patient holds breath in a certain position; beam only on in that phase of the respiratory cycle

Dynamic tumor tracking
– Patient breathes normally; tumor is tracked; beam always on and moves with tumor

Regardless of the motion management used, an additional “CTV/PTV” margin around our target is needed to ensure that we hit it.



Curative Indication - NCCN Guidelines – NSCLC


Curative Indication - NCCN Guidelines – NSCLC

  • Surgical resection is the preferred local treatment
    – An anatomical resection with lobectomy or segmentectomy is preferred to wedge resection
    – Includes sampling of at-risk ipsilateral hilar and mediastinal LN
  • SBRT for patients who are medically inoperable or refuse surgery
    Limitations: High volume (DM > 5cm) and  “ultra-central” tumors should be treated more cautiously (e.g. 10 instead of 3 fractions)
    –Limited data yet supporting the addition of systemic therapy to SBRT

Potential SBRT Toxicity Depends on Tumor Site

Risk of toxicity can be reduced through risk-adapted dose-fractionation


Outcomes of SBRT for Early Stage NSCLC


Take Home Pearl and Further Indications of SBRT for NSCLC


Reirradiation of Recurrent disease


  • Feasibility of treating with curative intent depends on site of primary (P) and recurrent (R) tumors
  • Advanced treatment techniques are particularly useful for sparing normal tissue (e.g., IMRT, SBRT, protons)
    – Reirradiating central structures (e.g., esophagus, airway) most challenging
    – Long-term toxicity is the major concern – impacted by dose/fraction

SBRT in the Management of Stage IV NSCLC

Palliative Radiation For Symptom Relief

  • Pain
    –Bone metastases
  • Neurologic symptoms
    –Spinal cord compression
    –Brain metastases
  • Bleeding
    –Endobronchial tumor
  • Dyspnea/Dysphagia
    –Tumor obstruction causing SVC, respiratory distress or esophageal narrowing

Is all metastatic disease the same?

  • No! Lung cancer has M1a, M1b and M1c designations because the metastatic state at diagnosis impacts prognosis; a small subset of patients may be cured
  • Oligometastaticrefers to a situation where distant metastases may be limited in number (typically defined as < 5 mets in < 3 organs), and potentially curative treatment can be delivered prior to the development of widespread disease


UT Southwestern Randomized Phase II Trial

  • Iyengar et al, JAMA Oncol, 2018
  • 29 patients, oligometastatic NSCLC with < 5 sites of disease (EGFR/ALK negative), PR or SD after induction chemo, randomized to +/- SAbR
  • SAbR à ↑ M-PFS (3.5à9.7mo)


SABR-COMET Randomized Phase II Trial

  • Palma et al, Lancet, 2019
  • 99 patients, variety of oligometastatic cancers with < 5 sites of disease, PR/SD on systemic therapy, randomized 1:2 to +/- SAbR (at ablative doses)
    – Most common histologies: breast, lung, colorectal, prostate
  • SAbR à ↑ M-PFS (6à12mo, p<0.001) & M-OS (28à41mo, p=0.09)
    – Also ↑ G2 or higher toxicity, but no difference in QOL


Multi-Institutional Randomized Phase II Trial

  • Gomez et al, J Clin Oncol, 2019
  • 49 patients with oligometastatic NSCLC with < 3 sites of disease, SD/PR after Pt-based doublet or EGFR/ALK inhibitor, randomized to maintenance systemic therapy +/- local consolidative surgery/RT
  • RT à ↑ M-PFS (4.4à14.2mo) and M-OS (17à41mo, p=0.02)


The Future…

Immunotherapy May Change Our Approach to Locoregional Management Too

A stronger immune response may be elicited by leaving a tumor in and irradiating it, rather than removing the largest source of antigenic stimulation.




The Future……Aktive Protokolle


Inclusion Criteria

  • Clinical Stage I/II node negative (T1 – T3 N0)
  • Medically inoperable or refuse surgery
  • ECOG PS 0-2
  • All comers for histology and PDL-1 status
  • Sync/Metach allowed

The Future…A Few Examples of Active Clinical Trials in Lung Cancer

CAVE: Not all new substances proofed to be safe with SBRT. Additional surveys needed!

  • NRG LU002: Adds RT (to all sites of disease) to systemic therapy for oligometastatic NSCLC
  • NRG LU004: Adds immunotherapy to IMRT or 3-D CRT for stage II-III NSCLC with high PD-L1 expression (instead of chemotherapy)
  • PACIFIC 4 and NRG/S1914: Adds consolidative immunotherapy to SBRT for stage I NSCLC
  • AEGEAN: Adds neoadjuvant immunotherapy to surgery for resectable stage II-III NSCLC
  • ALCHEMIST: Evaluating adjuvant use of targeted agents for resected NSCLC
  • RTOG 1308: Compares proton therapy to photon therapy for LA-NSCLC
  • NRG LU005: Adds immunotherapy to chemoradiation for limited-stage SCLC
  • NRG CC003: Hippocampal avoidance PCI for SCLC




Radiotherapy uses high-energy beams to kill prostate cancer cells. It is a treatment option for nearly all cancer stages, from early-stage tumours to more advanced and metastatic prostate cancer.

Our radiation oncology team at Amethyst Radiotherapy, represents the largest pan-European network of high-tech radiotherapy centres. Our doctors are committed to providing cutting-edge radiation therapy treatments that effectively target cancer while minimising the risk of side effects. One of these innovative methods is hydrogel spacers.

This technique involves the use of an absorbable gel that temporarily creates a gap between the prostate and rectum, significantly reducing the risk of bowel radiation during treatment. Hydrogel spacers also improve tumor targeting, reducing the total number of treatment sessions from 39 to 7.

This means that you can complete your treatment in 2.5 weeks instead of 8 weeks. The method is used for localised prostate cancer and is performed on an outpatient basis every 2nd working day. A treatment takes about 10 minutes and is painless.

Attached is the example of the first patient we treat using this method. You can see the dose by the very precise color that surrounds the prostate, as well as the white color of the spacer gel that pushes the rectum away from the prostate.

Radiation techniques available at Amethyst Radiotherapy include:

Image guided VMAT radiation therapy

Volumetric modulated arc therapy (VMAT) is one of the most advanced techniques of external radiotherapy. It involves the use of a linear accelerator machine that rotates around the patient while he lies down. The machine precisely delivers radiation doses to the tumor site while limiting the amount of radiation received by the healthy tissues surrounding it.

Stereotactic Body Radiotherapy (SBRT)

Amethyst Radiotherapy is among the few private centres in Europe offering SBRT radiotherapy, and the only one in Austria. SBRT is a cutting-edge radiotherapy technique that can comprise the radiotherapy treatment into a few sessions, by delivering higher radiation doses safely and efficiently. SBRT is an efficient treatment option both for metastasis/lymph nodes as well as for small PET positive relapses for patients that had radiotherapy previously.

Author: Dr. David Kuczer
Literature: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31131-6/fulltext