Rad onc presentation

2,913 views
2,620 views

Published on

Published in: Health & Medicine
0 Comments
4 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,913
On SlideShare
0
From Embeds
0
Number of Embeds
1,596
Actions
Shares
0
Downloads
0
Comments
0
Likes
4
Embeds 0
No embeds

No notes for slide

Rad onc presentation

  1. 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. 2. Categories of RadiationExternal beam radiation (EBRT) Brachytherapy
  3. 3. Physics• Electrons• Superficial treatments i.e.skin• Photons• IMRT• Protons• Optimal dosimetry• Not available at MSKCC• Neutrons
  4. 4. RadiobiologyX-ray photonFree radicalDouble strand breakCell death Mitotic Apoptotic
  5. 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. 6. Treatment ProcessPatient seen in consultSimulation (CT or PET/CT)Treatment planningSet-upTreatment Start1 week1 week1 day
  7. 7. Simulation• CT or PET/CT scan• Immobilization• Isocenter placement• Tattoo the patientH&N MaskPatient Marking
  8. 8. Treatment Planning:Contouring• Contouring• Normal tissue• Tumor• Terminology• GTV: Gross tumor volume• CTV: Clinical target volume• PTV: Planning target volume
  9. 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. 10. Treatment Planning: TargetCoverageTarget volume• Dose-Volume Histogram
  11. 11. Treatment Planning: PlanReviewAbide by set dose constraints for normal tissues:DVH
  12. 12. Treatment Start: PatientSet-UpDRR / Sim film Portal film
  13. 13. Patient Set-Up: IGRT
  14. 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. 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. 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. 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. 18. Seminoma: Stage I• Observation ~16% relapse• Target the pelvic andparaaortic lymph nodes• 25.5 Gy / 17 fractionsDog Leg Field
  19. 19. GBM• Post-operative cavity• Fuse MRI with our CT scanto delineate edema andcontrast enhancement• 60 Gy concurrent withTemodarIMRT
  20. 20. H&N Cancer: Subsites• Pharynx:• Oropharynx• Nasopharynx• Hypopharynx• Nasal cavity / Paranasalsinuses• Oral cavity• Larynx• Salivary glands• Thyroid
  21. 21. H&N Cancer• Gross tumor, positivelymph nodes, and lymphnodes at risk• PET/CT simulation• Concurrent Cisplatin orCetuximab• 70 Gy / 33 fractionsTonsil Cancer
  22. 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. 23. Lung Cancer: SBRTTime (seconds)IGRT
  24. 24. Lung Cancer: SBRTTime (seconds)MarkerDisplacement(cm)Stereoscopic infra-redcameraMarker Locations- Left chest- Right chest- BellyRespiratory Gating
  25. 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. 26. Hodgkin Lymphoma: Fields1995 – Involved-Field Radiotherapy(IFRT)1970 – TotalLymphoid Irradiation(TLI)2008 – InvolvedNode Radiotherapy(INRT)
  27. 27. Hodgkin Lymphoma: FieldsMantle Neck Mediastinum
  28. 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. 29. Stomach MALT: 4D-CTSimulation
  30. 30. Treatment Plan3000 cGy
  31. 31. TBI & Transplant• AML pre-transplant• Doses: 13.75 Gy / 11 fractions• 3 / 3 / 3 /2 fractions per dayAP PA
  32. 32. Extramedullary LeukemiaLeukemia Cutis: TSEB 24 GyGranulocytic sarcoma: 24 Gy
  33. 33. Palliation: Brain MetsWBRT:• >3 brain mets• Opposed lateral fields• 30 Gy / 10 fractions
  34. 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. 35. Palliation: Cord CompressionConventional RT:• AP/PA• Vertebral levelsinvolved + 1 aboveand 1 below• 30 Gy / 10fractions
  36. 36. Palliation: Cord CompressionIGRT:• Re-treatments &radioresistanthistologies• 18-24 Gy definitiveor post-op• Conformal planGTV
  37. 37. Palliation: Bone metsConventional RT:• AP/PA• 3 Gy x 10 fractionsor 8 Gy x 1 fractionPET
  38. 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. 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. 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. 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. 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. 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. 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. 45. Questions??

×