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Rad onc presentation



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  • 1. Radiation Oncology 101Sewit Teckieteckies@mskcc.orgChief Resident, Department of Radiation OncologyMemorial Sloan-Kettering Cancer Center, New York, NYNote: The following material is intended for MSKCC internal medicine housestaff teaching purposesonly. The slides are courtesy of Dr. Sewit Teckie and were updated for the LibGuide in 2012-2013.
  • 2. Categories of RadiationExternal beam radiation (EBRT) Brachytherapy
  • 3. Physics• Electrons• Superficial treatments• Photons• IMRT• Protons• Optimal dosimetry• Not available at MSKCC• Neutrons
  • 4. RadiobiologyX-ray photonFree radicalDouble strand breakCell death Mitotic Apoptotic
  • 5. Terminology• Conventional: 2-dimensional• 3DCRT: 3-Dimensionalconformal RT• IMRT: Intensity ModulatedRadiation Therapy• IGRT: Image Guided RadiationTherapy• SRS: Stereotactic Radiosurgery• SBRT: Stereotactic Body RTAP FieldIMRT
  • 6. Treatment ProcessPatient seen in consultSimulation (CT or PET/CT)Treatment planningSet-upTreatment Start1 week1 week1 day
  • 7. Simulation• CT or PET/CT scan• Immobilization• Isocenter placement• Tattoo the patientH&N MaskPatient Marking
  • 8. Treatment Planning:Contouring• Contouring• Normal tissue• Tumor• Terminology• GTV: Gross tumor volume• CTV: Clinical target volume• PTV: Planning target volume
  • 9. Treatment Planning: TargetDelineation• GTV: Volume encompassing grossly visible tumor• CTV: Volume to account for uncertainties in suspectedmicroscopic spread• PTV: Volume to account for geometric and other non-biologic uncertaintiesGTVGTV CTV PTV
  • 10. Treatment Planning: TargetCoverageTarget volume• Dose-Volume Histogram
  • 11. Treatment Planning: PlanReviewAbide by set dose constraints for normal tissues:DVH
  • 12. Treatment Start: PatientSet-UpDRR / Sim film Portal film
  • 13. Patient Set-Up: IGRT
  • 14. Dose & Fractionation• Dose expressed in Gray, Gy (1 J/Kg)• Fractionation = # of treatments• Hypofractionation• Larger dose per fraction• Fewer total number of treatments• Hyperfractionation• Smaller dose per fraction• Increase total number of treatments
  • 15. Sites & DosesSite Dose (Gy) FractionsBreast 50-60 30Prostate 86 48Brain Tumor (Primary) 60 30H&N 70 33Rectal 50 28Post-Operative 50-60 30Palliative 30 10
  • 16. Breast Cancer• Prone vs. Supine• Breast alone vs. Breast + nodes• Post-mastectomy• Dose/Fractionation• 60 Gy / 30 - Standard• 52.4 Gy / 20 - CanadianTangents
  • 17. Prostate Cancer• Brachytherapy• Seeds alone – Iodine• HDR treatment (temporaryimplants) - Iridium• EBRT• 86.4 Gy / 48 fractions• Prostate/SV alone +/- nodes• Hormone therapy• Combination Therapy• Seeds + EBRTIMRT
  • 18. Seminoma: Stage I• Observation ~16% relapse• Target the pelvic andparaaortic lymph nodes• 25.5 Gy / 17 fractionsDog Leg Field
  • 19. GBM• Post-operative cavity• Fuse MRI with our CT scanto delineate edema andcontrast enhancement• 60 Gy concurrent withTemodarIMRT
  • 20. H&N Cancer: Subsites• Pharynx:• Oropharynx• Nasopharynx• Hypopharynx• Nasal cavity / Paranasalsinuses• Oral cavity• Larynx• Salivary glands• Thyroid
  • 21. H&N Cancer• Gross tumor, positivelymph nodes, and lymphnodes at risk• PET/CT simulation• Concurrent Cisplatin orCetuximab• 70 Gy / 33 fractionsTonsil Cancer
  • 22. Lung Cancer: SBRT• SBRT (Stereotactic BodyRadiation)• Early stage non-operable,peripheral cancers• 12 Gy x 4 or 9 Gy x 5 or 18Gy x 3“No Fly Zone”
  • 23. Lung Cancer: SBRTTime (seconds)IGRT
  • 24. Lung Cancer: SBRTTime (seconds)MarkerDisplacement(cm)Stereoscopic infra-redcameraMarker Locations- Left chest- Right chest- BellyRespiratory Gating
  • 25. Hodgkin Lymphoma: DosesDoses:• Early stage disease/PET neg 20 Gy• Unfavorable early stage (bulky): 30 Gy• Stanford V: All sites equal to or greaterthan 5cm: 36 Gy
  • 26. Hodgkin Lymphoma: Fields1995 – Involved-Field Radiotherapy(IFRT)1970 – TotalLymphoid Irradiation(TLI)2008 – InvolvedNode Radiotherapy(INRT)
  • 27. Hodgkin Lymphoma: FieldsMantle Neck Mediastinum
  • 28. Non-Hodgkin LymphomaDoses:• MALT: 30 Gy• DLBCL:• Pet negative: 180 cGy x 17• Uncertain response: 180 cGy x 25• Follicular lymphoma• Boom-Boom: 200 cGy x 2• Definitive: 24-30 Gy / If bulky 36 Gy
  • 29. Stomach MALT: 4D-CTSimulation
  • 30. Treatment Plan3000 cGy
  • 31. TBI & Transplant• AML pre-transplant• Doses: 13.75 Gy / 11 fractions• 3 / 3 / 3 /2 fractions per dayAP PA
  • 32. Extramedullary LeukemiaLeukemia Cutis: TSEB 24 GyGranulocytic sarcoma: 24 Gy
  • 33. Palliation: Brain MetsWBRT:• >3 brain mets• Opposed lateral fields• 30 Gy / 10 fractions
  • 34. Palliation: Brain MetsSRS:• 1-3 Mets• Less than 3 cm• 18-24 Gy in a single fraction• Simulation, planning, &treatment in one dayHead frame
  • 35. Palliation: Cord CompressionConventional RT:• AP/PA• Vertebral levelsinvolved + 1 aboveand 1 below• 30 Gy / 10fractions
  • 36. Palliation: Cord CompressionIGRT:• Re-treatments &radioresistanthistologies• 18-24 Gy definitiveor post-op• Conformal planGTV
  • 37. Palliation: Bone metsConventional RT:• AP/PA• 3 Gy x 10 fractionsor 8 Gy x 1 fractionPET
  • 38. Chemo-RT• Definitive/curative: Head and neck,locally advanced lung, brain, GI, Gyn,bladder• Post-operative: Head and neck, lung,brain, GI, Gyn• Pre-op: for tumor downstaging
  • 39. Major Acute Toxicities<90 days post RTRT Site Major Acute ToxicitiesBreast Skin: dry and moist desquamationProstate Urinary: frequency, urgency, obstructionGI/Rectal: Diarrhea, loose stoolsBrain Nausea, fatigue, hair lossGI Diarrhea, rectal painH&N Mucositis, xerostomia, loss of taste, skinBone /SpineMetsMarrow suppression if field is large enoughAll patients Fatigue
  • 40. Sub-Acute Toxicities• Lung: Pneumonitis (6 wks post RT)• Skin: Radiation recall• Occur months to years after radiation treatment• Follows recent administration of a chemotherapeuticagent• Occurs with the prior radiation port, characterized byfeatures of radiation dermatitis• Brain: fatigue, sluggishness, and mildneurocognitive effects
  • 41. Late Toxicities>6 months post RTRT Site Major Acute ToxicitiesBreast Cosmetic changes (skin, implants)Heart disease (minimized with modern planning techniques)Prostate UrinaryImpotencyRectalBrain Radiation necrosisH&N Xerostomia, skin changes, hearing
  • 42. Secondary Malignancy• Occur in or adjacent to the field of radiation• Latency of 7+ years for solid tumors• Earlier for leukemias• Type of secondary malignancy is dependenton site and tissue initially irradiated• Breast: Sarcoma• HL: Breast (in females)• Prostate: Bladder, colon, sarcoma• Absolute risk is small ~ 1%
  • 43. Follow-up• Typically see patients back 1 month followingtreatment• Follow-up is integrated between medicaloncology and surgical oncology• Length of follow-up is a function of disease
  • 44. Summary• How radiation works• Types of radiation therapy• How we contour and plan RT• Diseases we treat with radiation therapy• Dose and fractionation• Acute and long-term side effects
  • 45. Questions??