Radiation therapy of oral cancers

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Radiation therapy of oral cancers

  1. 1. Radiation Therapy of Oral Cancers Dr. V. Lokesh M.D Professor & Head of Unit Department of Radiation Oncology, Kidwai Memorial Institute of Oncology, Bangalore
  2. 2. <ul><li>Radiation therapy is the art of using ionising radiation to destroy malignant tumours while being able to minimise damage to normal tissue. </li></ul>
  3. 3. Introduction <ul><li>Basics of Radiation Therapy </li></ul><ul><ul><li>Ionizing Radiation – X / γ Rays </li></ul></ul><ul><ul><li>Interaction of Radiation with matter </li></ul></ul>Transmission Attenuation Scatter Absorption Rad / Grey / cGy
  4. 4. Cancer Cell & Ionizing Radiation <ul><li>DNA is primary target </li></ul><ul><li>Double Strand breaks – Primary requisite </li></ul><ul><li>Reproductive Cell Death </li></ul>
  5. 5. RT is a Double Edge Sword
  6. 6. ↑ RT Dose ↓ RT Dose ↑ T – Control ↓ T – Control ↑ Normal Tissue Toxicitites ↓ Normal Tissue Toxicitites
  7. 7. <ul><li>Teletherapy </li></ul><ul><li>Telecobalt </li></ul><ul><li>Linear Accelerator </li></ul><ul><ul><li>Simple Teletherapy </li></ul></ul><ul><ul><li>SRS/SRT </li></ul></ul><ul><ul><li>3DCRT </li></ul></ul><ul><ul><li>IMRT </li></ul></ul><ul><ul><li>IGRT </li></ul></ul><ul><ul><li>Rapid Arc </li></ul></ul><ul><ul><li>True Beam </li></ul></ul><ul><li>Gamma Knife </li></ul><ul><li>Tomotherapy </li></ul><ul><li>Cyber Knife </li></ul><ul><li>Brachytherapy </li></ul><ul><ul><li>Intracavitory </li></ul></ul><ul><ul><li>Interstital </li></ul></ul><ul><ul><li>Mould </li></ul></ul><ul><li>Pre Loaded / Afterloading </li></ul><ul><li>Manual / Remote </li></ul><ul><li>LDR / HDR </li></ul>
  8. 8. Kilovoltage X-Ray 1920
  9. 9. Telecobalt 1970s
  10. 10. Linear Accelerator <ul><li>3DCRT </li></ul><ul><li>IMRT </li></ul>
  11. 11. True Beam
  12. 12. Brachytherapy
  13. 13. RT in Oral Cancer <ul><li>Management: </li></ul><ul><li>Treatment Outcome </li></ul><ul><li>Cosmesis </li></ul><ul><li>Organ Preservation & Function </li></ul><ul><li>Age </li></ul><ul><li>Quality of life </li></ul>
  14. 14. RT <ul><li>Radical RT </li></ul><ul><ul><li>RT: </li></ul></ul><ul><ul><ul><ul><li>Conventional (7-8 weeks) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hyperfractionation (5-6 weeks) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hypofractionation (1-2 Gap 1-2 weeks) </li></ul></ul></ul></ul><ul><ul><li>Pre Operative RT (2-5 weeks) </li></ul></ul><ul><ul><li>Post Operative RT (5-7 weeks) </li></ul></ul><ul><li>Palliative RT </li></ul><ul><ul><li>Short Course (1-2 weeks) </li></ul></ul><ul><ul><li>Saturation Technique (1-2 weeks gap 3-4 weks) </li></ul></ul>
  15. 15. RT Combinations <ul><li>RT alone </li></ul><ul><ul><li>Photons alone </li></ul></ul><ul><ul><li>Photons + Electrons </li></ul></ul><ul><ul><li>Recent adv - Photons + Particle (Protons/Neutorns/C ions) </li></ul></ul><ul><ul><li>RT + Radiation Sensitizers (CT drugs / BRM / CT+BRM) </li></ul></ul><ul><ul><li>RT + Radiation Protectors (Amifostine) </li></ul></ul><ul><li>RT + Brachytherapy </li></ul><ul><li>Brachytherapy alone </li></ul><ul><ul><li>Brachy type </li></ul></ul><ul><ul><ul><li>Single palne implant </li></ul></ul></ul><ul><ul><ul><li>Duble plane implant </li></ul></ul></ul><ul><ul><ul><li>Volume implants </li></ul></ul></ul>
  16. 16. Indications for RT in Oral Ca <ul><li>Radical RT </li></ul><ul><ul><li>T1, T2, T3, T4a </li></ul></ul><ul><ul><ul><li>Unresectable (Altered Fractionation HF/CB or RT + Radiation Sensitizer) </li></ul></ul></ul><ul><ul><ul><li>elderly, frail, comorbid conditions </li></ul></ul></ul><ul><ul><ul><li>refusal for surgery </li></ul></ul></ul><ul><ul><ul><li>prohibitive morbidity due to surgery </li></ul></ul></ul><ul><li>Pre OP RT : potentially inoperable </li></ul><ul><li>Post OP RT : (RT + Radiation Sensitizer) </li></ul><ul><ul><li>pT3/4 </li></ul></ul><ul><ul><li>Close & +ve margin </li></ul></ul><ul><ul><li>Multiple nodes </li></ul></ul><ul><ul><li>Perineural invasion </li></ul></ul><ul><ul><li>Lympho vascular space invasion </li></ul></ul><ul><ul><li>Extra Capsular extension </li></ul></ul><ul><ul><li>Level IV – V nodes </li></ul></ul>
  17. 17. RADIOTHERAPY DOSE <ul><li>1. External : </li></ul><ul><li>a. Alone : 7000 cGy to 7600 cGy /6-8 wks. </li></ul><ul><li> (microscopic - 4600 - 5000 cGy) </li></ul><ul><li>b. Pre-op. : 46-50 Gy/ 4 1/2 - 5 1/2 wks. </li></ul><ul><li>c. Post-op.: 60-66 Gy/ 6-7 wks. </li></ul><ul><li>2. Brachytherapy : </li></ul><ul><li>a. Alone : 6000 - 7000 cGy in 6 to 7 days. </li></ul><ul><li>b. External + Brachytherapy </li></ul><ul><li>Ext : 46-50 Gy in 4 1/2 - 5 1/2 wks. + </li></ul><ul><li>Brachy : 2000-3000 cGy in 2-3 days </li></ul>
  18. 18. pre- radiotherapy Dental Prophylaxis <ul><li>Extraction </li></ul><ul><li>Caries (non-restorable) </li></ul><ul><li>Active periapical disease (symptomatic teeth) </li></ul><ul><li>Moderate to severe periodontal disease </li></ul><ul><li>Lack of opposing teeth, compromised hygiene </li></ul><ul><li>Partial impaction or incomplete eruption </li></ul><ul><li>Extensive periapical lesions (if not chronic or well localized) </li></ul><ul><li>Start RT after 10 – 14 days </li></ul>
  19. 19. RT Techniques <ul><li>Simple Tele </li></ul><ul><li>3DCRT / IMRT </li></ul>
  20. 20. Mould Room <ul><li>Patient postioning : </li></ul><ul><ul><li>Supine </li></ul></ul><ul><ul><li>Neck – Extension / hyperflexion </li></ul></ul><ul><li>Immobilzation devises </li></ul><ul><ul><li>Head rest </li></ul></ul><ul><ul><li>Bite block </li></ul></ul><ul><ul><li>Tongue depressor </li></ul></ul><ul><ul><li>Thermoplastics </li></ul></ul>
  21. 21. Simulation <ul><li>Simulator X-Ray Machine </li></ul><ul><li>CT Scanner </li></ul><ul><li>An Isocentric Mounted Simulator X _Ray machine is used to simualte </li></ul><ul><li>Fields and Position before treatment </li></ul><ul><li>fields will be marked on a patient </li></ul>
  22. 22. Conventional 2D Planning
  23. 25. 3D CRT / IMRT
  24. 26. Laser setup
  25. 27. Virtual Simulation <ul><li>CT-based virtual simulation </li></ul><ul><li>use a full 3D image dataset </li></ul><ul><li>software tools </li></ul><ul><li>external laser system for marking </li></ul><ul><li>radiation therapy targets </li></ul>
  26. 29. PLANNING : ECLIPSE / HELIOS
  27. 30. CONTOURING
  28. 31. Fusion <ul><li>MRI </li></ul><ul><li>PET CT </li></ul><ul><li>Angio </li></ul><ul><li>others </li></ul>
  29. 32. IMRT: FIELD
  30. 33. IMRT : PLAN
  31. 34. Neck node Coverage
  32. 35. Acute side effects <ul><li>Skin – Hyper pigmentation, Dry and moist desqumation </li></ul><ul><li>Mucosa- Mucositis G2/3 </li></ul><ul><li>Pharynx – Odynophagia / dysphagia </li></ul><ul><li>Larynx – hoarseness of voice </li></ul><ul><li>Salivary - Xerostomia </li></ul>
  33. 36. 5 YR SURVIVAL STAGE 1 STAGE II STAGEIII STAGEIV T 3/4 Lip 90% <60-30% 30% Anterior Tongue 69% 41% 25% S+R - 35% 15% 33-60% Buccal Mucosa 77% 65% 27% 18% 33-67% Floor of the Mouth 97% 72% 51% 20% 33-67% Lower Gingiva Retromolar Trigone 70% 50-30% 30% 30-50% Upper Gingiva Hard Palate 75% 46% 36% 115
  34. 37. During radiotherapy <ul><li>Maintenance of good oral hygiene Brushing 2 to 4 times daily with soft-bristled brush; flossing daily </li></ul><ul><li>Daily topical fluoride Custom trays, brush-on prescription-strength fluoride </li></ul><ul><li>Frequent saline rinses </li></ul><ul><li>Lip moisturizer (non-petroleum based) </li></ul><ul><li>Passive jaw-opening exercises to reduce trismus </li></ul>
  35. 38. After radiotherapy <ul><li>Complete dental work that was deferred during radiotherapy </li></ul><ul><li>Maintain integrity of teeth Especially those in radiation fields </li></ul><ul><li>Frequent follow-up </li></ul>
  36. 39. Follow-up <ul><li>Clinical examination of head and neck mucosa (including fiberoptic ) and neck palpation / performance status / nutritional assessment </li></ul><ul><li>every 2 months (first 2 years), </li></ul><ul><li>every 6 months (years 3-5), </li></ul><ul><li>once a year (> 5 year) </li></ul><ul><li>Dental examination and orthopantomogram every 6 months </li></ul><ul><li>Chest X-ray every year </li></ul><ul><li>Chest spiral CT every year </li></ul><ul><li>Laboratory tests: TSH every year (if Radiotherapydelivered) </li></ul><ul><li>Evolution of late toxicity (EORTC/RTOG) scale </li></ul>
  37. 40. Salvage treatment for recurrent disease <ul><li>Lip, mobile tongue, floor of mouth: </li></ul><ul><ul><li>T1 N0 : </li></ul></ul><ul><ul><ul><li>Brachytherapy </li></ul></ul></ul><ul><ul><ul><li>Surgery </li></ul></ul></ul><ul><ul><li>Any other T, any other N </li></ul></ul><ul><ul><ul><li>Surgery + radical ND ± post-operative RxTh if not previously delivered </li></ul></ul></ul><ul><ul><ul><li>RxTh </li></ul></ul></ul><ul><li>Palliative care </li></ul><ul><li>Metastasis : </li></ul><ul><ul><li>Chemotherapy + best supportive care </li></ul></ul>
  38. 41. Thanking you

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