1. Advances in Radiation Oncology:
Improvement and Outcome
Dr Ajeet Kumar Gandhi
MD (AIIMS), DNB (Gold Medalist)
UICCF (MSKCC,USA)
Assistant professor, Radiation oncology
Dr RMLIMS, Lucknow

2. Treatment modalities
• Surgery
• Radiotherapy
• Chemotherapy
• Hormone therapy
• Biological therapy/Immunotherapy
• Pain and palliative care therapy
• Alternative and Complimentary therapies

3. Radiation Therapy
• Ionizing Radiation: X-rays, Gamma rays,
electrons, protons

4. Dose (Gy)
Control
Complications
Goal of radiation therapy

5. Radiation therapy cures: Saves lives
• 40-50% of cancers are eliminated by
radiotherapy either alone or in combination
with other treatments:
– Head & Neck Cancers
– Lung Cancer
– Cancer of Uterine Cervix
– Prostate Cancer
– Others: Urinary bladder, Vagina, Penis, brain tumour

6. Radiation therapy cures: Saves lives
• Radiotherapy is given in combination with
surgery/systemic therapy:
– Brain tumors
– Head & Neck Cancers
– Breast Cancers
– Lung Cancer
– Gastrointestinal Cancer
– Genito-urinary Cancers
– Soft-tissue sarcoma
– Lymphoma, Myeloma, Leukemia

7. Radiation therapy cures: Saves lives
Benign Tumors
– Acoustic Neuromas
– Arteriovenous
Malformations
– Pituitary Adenomas
– Trigeminal Neuralgia
– Craniopharyngioma
– Fibromatosis
– Chordomas

8. Radiation therapy: Alleviates pain
and Improves QOL
• Neurological: Brain metastasis, Compressions
• Pain: Tumor, bone metastasis, Nodes
• Bleeding from tumor
• Respiratory and obstructive symptoms

9. Advances in Radiation Oncology:
Improving outcomes
• IMRT/ IGRT/VMAT
• RGRT
• SBRT
• Adaptive RT
• 4DRT
• Proton Beams and
heavy ions
• Image based
Brachytherapy
• IPSA
• Real time image
guided
brachytherapy-SWIFT
• Integrated
Brachytherapy Unit

10. Intensity Modulated
Radiotherapy is the key
Complex and Irregular Anatomy for the tumor
Different Nodal Volumes with
different prescription
Carcinoma Nasopharynx: c T4 N2c M0

11. Temporal Lobes
Parotids
Submandibular Glands
larynx
Brachial Plexus
Constrictor Muscles
Brain Stem
Optic Chaisma
Spinal Cord
OARs for Head and Neck Radiotherapy

12. Dose sculpting/painting

13. Advances in RO: Improving
outcomes

14. Advances in RO: Improving outcomes

15. Advances in RO: Improving outcomes
Cyberknife Tomotherapy

16. Advances in RO: Improving outcomes
MRI-Guided Radiation therapy

17. Advances in RO: Improving outcomes
Proton therapy

18. Technology transcends to practice
Advances in RO: Improving outcomes

19. Metabolism: 18F-FDG
11C-Met
Proliferation: 76Br-BFU (Bromo Fluro-deoxyuridine)
Hypoxia:18F-EF3 (2-Nitro
Imidazole marker)
Advances in RO: Improving outcomes
Biological targeting

20. Advances in RO: Brachytherapy

21. Advances in RO: Brachytherapy different sites
Ca Prostate
Ca Cervix: ISBT Soft Tissue Sarcoma
Ca Breast

22. Advances in RO: Intra-operative radiotherapy

23. Advances in RO: Surface Mold
Brachytherapy

24. Randomized Trials documenting superiority
Reference Design Site of
Disease
Primary
Endpoint
Results P Value
JCO,2007;2
5 (31), Nov
1
Prospective
Randomize
d [2D vs.
IMRT]
T1-2b N0-
1 M0
Nsophary
nx cancer
Severe
xerostomia
@ 1 Year
@ 1 year,
Severe
xerostomia:
39.3% vs. 82.1%
0.001
JCO,2008;2
6 (13),
May 1
Multicentric
,double
blinded
RCT [IMRT
vs. CRT]
Breast Moist
desquamati
on
Moist
Desquamation:
31.2% vs. 47.8%
0.003
Lancet
Oncology,
2011;12:12
7-36
Phase III,
Multi-
centric,
RCTs [IMRT
vs. CRT]
Head &
Neck
Cancers
Parotid
Sparing
[Grade 2 or
worse
xerostomia]
@ 12 Months-
Grade 2
Xerostomia:
38% vs. 74%
@24 Months-
29% vs. 83%
0.0027
0.0001

25. Randomized Trials documenting
superiority
Reference Design Site of
Disease
Primary
Endpoint
Results P Value
Lancet
1999;353:267-
72
Randomized
Trial
[Conformal
vs.
Conventional]
Prostate Radiation
induced
proctitis
and
bleeding
RTOG ≥ 1: 37%
vs. 56%
RTOG ≥ 2 : 5%
vs. 15%
0.004
0.01
JCO 2013; 31
(36): 4488-95
Randomized
controlled
trial [IMRT
vs. CRT]
Breast Overall
cosmesis &
Skin
Telengectas
ia
Overall
cosmesis better
with IMRT [OR
0.68] &
Telengectasia
[OR 0.58]
0.027
Radiotherapy
and
Oncology;
2012;103:305-
313
Prospective
Multicentric
Study [ 2D vs.
3D]
Carcinoma
Cervix
[PDR
Brachyther
apy]
3D Brachytherapy has improved local
control and half the toxicity with 2D
Dosimetry

26. prostate specific antigen relapse-free survival
Survival benefit: IGRT vs. Non-IGRT in Prostate Cance

27. Beadle BM, MDACC. Cancer, 2013 [Ahead of
Print]
 SEER Medicare analysis
[1999-2007]
 A total of 3172 patients
were identified. Median
follow-up of 40 months.
 CSS of IMRT vs. Non-
IMRT (84.1% versus
66.0%; P <.001) both
overall and subset wise.
 Difference persisted on
multivariable analysis

30.  India is sorely under equipped, having just
1machine per 21 lakh people and would need
1215 teletherapy machines by 2020
 2756 radiation oncologists, 1533 medical
physicists, and 4737 radiation therapists must
join the work force by 2020 to meet India’s
needs.

31. Radiation Oncology India: Challenges
& Opportunities
• Patients can wait up to 2months after diagnosis before
treatment is initiated in public hospitals. These delays
adversely affect patient outcomes
• More than 70% of India's population resides in rural
settings but only 40/640 districts have LINAC
• Wide regional disparity and public/private access to
radiotherapy

32. Cost
Amount
of Use
Health Policy
Decision
Indigenous
Production
and Design
Acceptance

33. Indigenous Design: Panacea
• Bhabhatron-II with MLC
• Integrated IGRT unit: G Ray
[Co-60 with 70 cm SSD]
• Karknidon: Ir-192
afterloader [20 Channels]
33

34. Inform
Govt and policy makers make radiotherapy a
central component of cancer care in policies,
planning and budget
Plan
Patient group and
media: Improve
general awareness
about radiotherapy
and it`s need
Harmonize
Multidisciplinary
cancer care: Fully
integrate
radiotherapy in
treatment planning
Integrate
Professional
Societies: Education
of radiotherapy
professionals
Invest
Investment in
research and use of
data for Innovation

35. THANK YOU
ajeetgandhi23@gmail.com
9560703223