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I.G.R.T: I.M.R.T/ RAPIDARC (FIRST IN C.G) Image Guided Radiotherapy in Cancer
RAPIDARC UNIQUE VARIANLINEAR ACCELERATOR NEW RADIOTHERAPY SET-UPDR. PUNEET SETHM.B.B.S (Bhopal), M.D Radiotherapy (Indore)Consultant, Radiation Oncology,BSR Cancer & Research Institute,Apollo-BSR Hospital, Bhilai (C.G)Previously at:STT (Short term trained), I.R.C.H, A.I.I.M.S, New Delhi (Feb 2007) Registrar, Indraprastha Apollo Hospital , New Delhi (May 2007-Dec 2008)Senior Registrar, CBCC-USA Apollo, Ahmedabad,
ABOUT MY PAST 5 YRS WORK EXPERIENCE AT: I.R.C.H, A.I.I.M.S NEW DELHI 2007 IMRT/SRS/SRT Gamma knife ( Elekta/ Varian) INDRAPRASTHA APOLLO HOSPITAL, NEW DELHI 2007-2008 IMRT/SRS/SRT (Varian) CBCC-APOLLO, AHMEDABAD 2008 -2009 IGRT/IMRT/SRS/ Brachytherapy (Varian) G.R.MEDICAL COLLEGE, GWALIOR 2010 till Nov 2010 (BHABHATRONIC-II) 2D/3DCRT
Cancer’s Seven Warning SignalsCAUTION• Changes in bowel or bladder habits• A sore that does not heal• Unusual bleeding or discharge• Thickening or lump in breast or elsewhere• Indigestion or difficulty in swallowing• Obvious changes in warts or moles• Nagging cough or hoarseness
BackgroundEstimated new cancer cases each year is expectedto rise from 11 million (2002) to 16 million (2020). 60% (9.6 million) of all these new cases will occurin the less developed world.These individuals, their families will face thechallenge of understanding cancer, and how itaffects their lives.Providing quality & current cancer information tocancer patients, their families, laymen & healthcare givers is a key function
New cancer cases on the rise 10 16 9 millionnew cancer cases (millions) 8 developing in 2020 countries 7 a 50% 6 10 million increase! industrialized in 2000 countries 5 4 3 1990 1995 2000 2005 2010 2015 2020 year WHO (2003)
Issues Facing Developing World1. Patient Load. Specialized centers are few and overwhelmed with patients.2. Treatment Priorities Available agents e.g. chemotherapy and radiation facilities impose choice of management.3. Impact of existing health problems4. Hepatitis and nutritional status affect management significantly.5. Compliance Lack of interest in long term follow up due to economic, cultural and educational reasons.
6. Lack of communication between regional centers in patient follow up & management.7. Poor registration and follow up facilities.8. Lack of integrated aproach to: a)appropriate medical surveillance for late effects of treatment. b)counseling services. c) special needs concerning employment, disability, insurance, psychological support.
Obstacles/Barriers to Research1- Financial constraints:2-Lack of full time research career path.3- Lack of motivation towards research career pathway4- Variation in research interest/abilities within different centers
Membership in International Organizations• European organization for research and treatment of cancer (EORTC).• International Union Against Cancer (UICC)• World Health Organization (WHO)• International Atomic Energy Agency (IAEA)• International Network for Cancer Treatment and Research (INCTR)• Eastern Mediterannean Regional Office/World Health Organization (EMRO)
Novalis Body System (BrainLab, Hermstetten,Germany).
BSR CANCER HOSPITAL…June 2001 APOLLO BSR, BHILAI……..Sept 2007CENTRAL INDIA COMPREHENSIVE CANCER SET-UPRADATION ONCOLOGY (COBALT ATC-9.. MAY 2008 NEW SOURCE )SURG. ONCO, MED. ONCO, NUCLEAR MEDICINE, BLOOD BANK4000 + CANCER PATIENTS SUCCESSFULLY TREATED… NEW LINEAR ACCELERATOR.. UNIQUE 6 MV … IGRT/RAPIDARC INSTALLATION BY 2012 (DEC)…2013
UNIQUE linear accelerator• Millennium™ MLC• RapidArc® and dynamic IMRT• Small footprint• Patient protection system• Easy installation & commissioning• Exact couch carbon fiber table top• Enhanced dynamic wedge saves time
Linear Accelerator – 6MV• Treatment planning: CT• Quick and painless!• Multiple treatments fractions.• Dose and number of treatments depends on – Intent (Radical / Curative Palliative, Post op. Adjuvant) – Sensitivity of tumour – Sensitivity of normal tissues
The Tools for the Radiation Oncologist• Sophisticated treatment machines (dual energies, multileaf-collimator, 3 paired laser beams for patient set-up, integrated CT, IMRT, stereotactic treatment)• Tumor volume definition: CT-MRI-PET fusion imaging, dedicated planing CT• Treatment planing: Standardized dose prescription to tumor (maximal) and to normal tissue (minimal), dose-volume histogram for tumor and each organ at risk• Treatment delivery: fix RT-field(IMRT), moving RT- field (IMRT/RAPIDARC), image guidance, respiration correction• Fractionated (daily) radiotherapy to a defined total dose
Ionizing Radiation: The physical toolsPhotons: - High energy X-rays (MV for LINAC) - Skin sparing effect - Dose decrease 2-5% /cm tissueElectrons: - Charged light particles - No skin sparing effect, limited depth - Steep dose decrease after a few cm‘sProtons: - Charged heavy particles - unique dose distribution (matterhorn like – Bragg Peak)
Integration of Molecular Biology• Biology, Physics and Clinical Oncology are the 3 pillars of Radiation Oncology• Defined biologic model systems available: > 30 years experience in classic radiobiology• Molecular key targets for radiosensitization: (search) for novel RT-sensitizers... Past 10 years• Stem cell research, human genome project, microarray technology: Implications for clinical radiation oncology....Present and future
Pre-clinical research: Potential molecular targets for RT-sensitizers in lung cancer1970 Radiobiology 2008
PROTOCOL- Most of the patients are given chemotherapy (Cisplatin based) concurrently every week.- Patients are explained regarding IMRT/IGRT process, benefits & toxicities.- All patients undergo thorough clinical evaluation, staging & complete profile (bio- chemical & radiological).- Patients are evaluated at regular intervals during the treatment for tumour response & toxicities.
How much radiation? DOSE OF RT1 “rad” = 1 centiGray (cGy) 100cGy = 1 Gy 200 cGy / 2 Gy per day 5 days per week MON-FRI 1000 cGy/ 10 Gy per weekH N SCC 60-70 Gy in 6-7 WeekWeekly Chemo: SUN/MON 5-6 CYCLEMostly CISPLATIN 30 mg/m2 ( 50-60 mg)