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  • Lower esophageal ACA status post esophagectomy and partial gastrectomy with gastric pull up. Blue: right kidney; Brown: left kidney; Red: clips; Pink: preoperative tumor volume; Yellow: gastric remnant; Green: Carina. An anterior inferior oblique field is used to spare the kidneys.
  • Mid-esophageal adenocarcinoma status post Ivor- Lewis esophagectomy. Red: stomach; Magenta: residual esophagus; Yellow: preoperative tumor volume; Blue: spinal cord. Anterior-posterior field demonstrated
  • How do you know this is a 3 field

Transcript

  • 1. HSC 340 12-19-10 Gastrointestinal Cancer Genitourinary Cancer Gynecological Cancer
  • 2. Gastrointestinal Cancer
    • Esophagus
    • Stomach
    • Pancreas
    • Rectum
    • Anus
  • 3. Esophageal Cancer
    • Usually squamous cell
    • Males more than females
    • Cure rates <10%
    • Accounts for 1% of all US cancers
  • 4. Esophageal Anatomy
    • Cervical esophagus
    • Upper thoracic
    • Middle thoracic
    • Lower thoracic
  • 5. Esophageal routes of spread
    • Spreads longitudinally through lymphatics
      • Upper
      • Middle
      • Lower
  • 6. Esophageal CA Treatment
    • Surgery only- poor control
    • External beam only- curative and palliative
    • Chemo, radiation
    • Chemo, radiation & surgery
    • Curative vs. Palliative
  • 7. Esophageal Radiation Therapy Techniques
    • Cervical Esophagus
      • Lateral opposed, Obliques
    • Thoracic Esophagus
      • AP:PA, Obliques or AP:PA & Obliques combo
  • 8.  
  • 9.  
  • 10. Esophageal Immobilization & Positioning Devices
    • Prone sometimes used to pull esophagus away from sc.
    • Supine more common
    • Arms above head, may-be hard to hold if elderly
    • Vac-lok, body casts
    • *problems w/arms at sides…3 pt set-up
  • 11. Esophageal Doses
    • Palliative
      • 30 Gy over two weeks to 50 Gy over five weeks
    • Preoperative + chemo
      • 30 Gy over three weeks to 45 Gy over five weeks
    • No surgery
      • Above dose with a boost to 60-65 Gy
    • HDR and LDR are options….
  • 12. Stomach Cancer
    • Majority Ulcerative Adenocarcinomas
    • High incidence in Japan
  • 13. Stomach Anatomy
    • Begins at Gastroesophageal Junction and ends at pylorus
    • Many critical structures surrounding organ
  • 14. Stomach CA Routes of Spread
    • Direct Extension
    • Widespread
  • 15. Stomach CA Treatment
    • Surgery & Post-op Radiation Therapy with Concurrent chemo
    • Radiation alone in palliative cases (unresectable)
  • 16. Stomach Radiation Therapy Techniques
    • AP:PA
    • Doses:
      • 40-45 Gy w/ 5FU
      • Boost to 50-55Gy if needed
  • 17.  
  • 18. Stomach Immobilization and Positioning
    • Supine
    • Arms above head
    • Vac-lok, body cast
    • Contrast?
  • 19. Pancreatic Cancer
    • Ductal adenocarcinoma
    • Occur in the head of pancreas
  • 20. Pancreas Anatomy
    • Three sections
      • Head, tail, body
      • L1-L2
  • 21. Pancreatic CA routes of spread
    • Direct extension
    • Lymphatics
  • 22. Pancreatic CA Treatment
    • Surgery (you want the cancer in the tail!)
    • Surgery, Post-op Radiation Therapy, Combination Chemotherapy
    • Unresectable tumors- palliative radiation therapy and chemotherapy
  • 23. Pancreatic radiation therapy techniques
    • Three field (AP, Lats), four field (AP:PA, Lats), IGRT –couch rotation used to create unique fields that spare structures
    • Doses
      • 45-50 Gy with combo chemo
      • Limit lateral fields to 18-20Gy to preserve kidneys
      • 60 Gy in 3 two week courses (20 Gy/week) for palliative with field reduction @ 45 Gy
  • 24.  
  • 25. Pancreatic Immobilization & Positioning
    • Supine
    • Arms above head
    • Vac-lok, alpha cradle, body cast
    • Contrast- swallowed and/or injected (to see kidneys)
  • 26. Rectal Cancer
    • Adenocarcinomas
    • Men = Women
    • Rectal bleeding
    • 2 nd most common cause of CA death in US
  • 27. Rectal Anatomy
    • 13-15 cm long
    • Upper, middle and lower valves divide into sections
  • 28. Rectal CA routes of spread
    • Direct extension
    • Wide spread dissemination
  • 29. Rectal CA Treatment
    • Surgery
    • Surgery + Radiation Therapy + Chemo
    • Pre-op, post-op, pre-op & post-op
  • 30. Rectal CA Radiation Therapy
    • Three field (PA and lats) patient prone
    • IGRT
    • Doses
      • 45 Gy
      • May boost to 50Gy
  • 31.  
  • 32. Rectal Immobilization and Positioning
    • Prone
    • Belly board (to help “drop” small bowel)
    • Arms above head
    • Contrast- Oral for sm. Bowel, rectal
    • Rectal marker
    • Anal marker
    • Vaginal marker
  • 33. Anal Cancer
    • Squamous cell
    • 3cm in length
  • 34. Anal CA Routes of Spread
    • Direct Extension, Lymphatics, Blood stream
  • 35. Anal CA Treatment
    • Surgery
    • Chemo and Radiation
  • 36. Anal CA Radiation Therapy
    • AP:PA, IGRT
    • Doses
      • 45 Gy with Chemo
      • Boost to 50-55 Gy if large tumor
      • 60-65 Gy radiation only
      • e- beams may be used if inguinal nodes have disease
  • 37.  
  • 38. Anal CA Immobilization and Positioning
    • Supine
    • Vac-lok, body cast
    • Marker on lowest pt. of tumor
    • Vaginal marker
  • 39. Genitourinary Cancer
    • Bladder
    • Prostate
  • 40. Bladder Cancer
    • Blood in urine
    • Cigarette smoke common cause
    • Transitional cell carcinoma
  • 41. Bladder CA Routes of Spread
    • Direct Extension
    • Lymphatics
  • 42. Bladder CA Radiation Therapy
    • Radiation therapy alone
    • Surgery & Radiation Therapy
    • Surgery, Chemo & Radiation Therapy
    • 3 most common:
      • Preop radiation followed by cystectomy
      • Radiation after transurethral resection
      • Transurethral resection, chemo, radiation
  • 43. Bladder CA Radiation Therapy Techniques
    • Four field technique, IGRT
    • Dose:
      • Pre-op 45-50Gy
      • No chemo, no surgery 45-50 Gy with a boost to 65-70 Gy
      • Trials
  • 44.  
  • 45.  
  • 46.  
  • 47. Bladder CA Immobilization & Positioning
    • Supine
    • Contrast- Bladder (air introduced to see anterior surface of bladder)
    • Arms on chest
  • 48. Prostate Cancer
    • Most common cancer in men
    • Adenocarcinoma
    • 60+
    • PSA, Gleason Score
  • 49. Prostate CA Routes of Spread
    • Local invasion
    • Lymphatics
    • Bone
  • 50. Prostate CA Treatments
    • Observation
    • Radical Prostatectomy
    • Implant Therapy
    • External Therapy
    • Combination Implant & External
    • Hormone Therapy for Metastatic disease
  • 51. Prostate CA Radiation Therapy Techniques
    • Four field, IGRT
    • Doses:
      • 75-81Gy with conedown off rectum if possible
      • Post-op 60-66 Gy
  • 52. Prostate CA Positioning and Immobilization
    • Supine/Prone (study done)
    • Vac-lok
    • Arms on chest holding ring
    • Contrast- bladder, nodal, rectal**, sm. Bowel
  • 53.  
  • 54.  
  • 55. Gynecological Cancer
    • Uterine Cervix
  • 56. Uterine Cervix
    • Squamous cell
    • Incidence of Invasive CA decrease due to PAP smear detection
  • 57. Uterine Cervix Routes of Spread
    • Direct extension
    • Lymphatics
  • 58. Uterine Cervix Treatment
    • Surgery (TAH)
    • Radiation Therapy (external & implant)
    • Surgery, Radiation Therapy, Chemo
  • 59. Uterine Cervix Radiation Therapy Treatment
    • Four field to 40-45Gy
    • Boost intercavitary
  • 60.  
  • 61.  
  • 62. Uterine Cervix Positioning and Immobilization
    • Anal marker
    • Rectal barium
    • Vaginal marker
    • Bladder contrast
    • Prone w/belly board to move sm.bowel