Evolution of Radiotherapy in Modern Medicine
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The advancement in radiotherapy techniques and technologies
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Evolution of Radiotherapy in Modern Medicine
- 1. EVOLUTION OF RADIOTHERAPY IN MODERN MEDICINE LT COL SANKALP SINGH GD SPL (RADIOTHERAPY)
- 2. SEQUENCE OF PRESENTATION Historical aspect Science of Radiotherapy Therapeutic modalities Our experience Acute & Late effects
- 3. HISTORICAL ASPECT… WILHELM ROENTGEN Discovered X-rays in 1895 MARIECURIE Discovered natural Radioactivity in 1898 EMIL GRUBBE ?First used X-rays for treatment of a cancer patient in 1896
- 4. FIRST EVER X-RAYTREATMENT??? Jan 1896: Emile Grubbe therapeutically exposed a case of Carcinoma breast to a single treatment of x-rays for 1 hour
- 5. FIRST EVER CURE BY X-RAYS Nov 1896: Leopold Freund used fractionated X-ray therapy to treat a hairy nevus of a 5 year old girl child over 2 weeks.
- 6. FIRST CANCER CURE BY X-RAYS 1899-1900 Stenbeck and Sjorgen first to cure BCC &SCC of skin using X-rays
- 7. RADIUM THE PANACEA? • 1900: Radiumtherapy introduced by Danlos for treatment of lupus & other skin ailments • 1903 : Margaret A. Cleaves in NewYork directly applied radium intracavitarily for the treatment of carcinoma of the cervix. • 1905 : Robert Abbé, a NewYork surgeon, in 1905 implanted radium directly into a tumor.
- 10. RADIUM GIRLS OFTHEWATERBURY CLOCK COMPANY
- 11. “The Radium Water Worked Fine Until His Jaw Fell Off”
- 12. RADIOTHERAPY / RADIATION ONCOLOGYAS A SEPARATE DISCIPLINE IN 1922 It is a clinical modality that specializes in the use of ionizing radiation for treatment of patients suffering from cancer and other diseases. The radiation maybe delivered from a source placed outside the patient (Teletherapy/External beam radiotherapy) or a source placed within the patient’s tissues (Brachytherapy/Internal radiotherapy) Nuclear Medicine is a branch of medicine that utilizes the injection of radioactive substances (radiopharmaceuticals) into the patient’s bloodstream for diagnostic and therapeutic purposes.
- 13. SCIENCE OF RADIOTHERAPY: IONIZING RADIATION Ionizing radiation is radiation that carries enough energy to free electrons from atoms or molecules, thereby ionizing them.
- 14. SCIENCE OF RADIOTHERAPY: MECHANISM OF ACTION DNA within the cell nucleus is the primary target for radiation effects. SS B DS B
- 15. SCIENCE OF RADIOTHERAPY : MECHANISM OF EFFECT IONIZING RADIATIO N LETHAL DAMAGE SUB LETHAL DAMAGE CELL DEATH REPAIR MUTATIONS GENOMIC INSTABILITY MIS REPAIR NO EFFECT CARCINOGENE SIS
- 16. SCIENCE OF RADIATION : WHY FRACTIONATED THERAPY Time for REPAIR & REPOPULATION allows surrounding normal tissue to recover & reduces toxicity RE-OXYGENATION increases free radical levels in tissues, sensitising tumor cells to effects of radiation REASSORTMENT allows greater fraction of tumor cells to be irradiated in a radiosensitive
- 18. TELECOBALT-60 (1951) & LINEAR ACCELERATOR (1953)
- 20. EVOLUTION OF EBRT THERAPEUTIC TECHNIQUES
- 22. CT SIMULATION & 3D CONFORMAL RT
- 32. BRACHYTHERAPY – OTHER SITES
- 34. OUR EXPERIENCE AT CHCC
- 35. OUR EXPERIENCE (2008-2013) Total Patients treated On follow up Alive at 5 years DFS in N0 DFS in N+ OS at 5 years in N0 OS at 5 years in N+ 167 112 81 76% 54% 79% 62% Myers et al 88% 65% 75% 50% ORAL CAVITY CANCERS CERVICAL CANCERS Total Patients treated On follow up Alive at 5 years OS in IB2 OS in IIB OS in IIIA & IIIB OS in IVA 124 108 87 85% 76% 56% 31% FIGO 95% 77% 43% 18%
- 36. CARCINOMA SCALP CUTANEOUST-CELL LYMPHOMA MULTIPLE MYELOMA TELETHERAPY
- 37. PELVIC SARCOMA CARCINOMA DUODENUM CARCINOMA OESOPHAGUS CARCINOMA CERVIX TELETHERAPY
- 38. CARCINOMA NASOPHARYNX CARCINOMA BREAST CARCINOMA OESOPHAGUS SOFTTISSUE SARCOMAS BRACHYTHERAPY
- 41. TOXICITIES : LATE ENTEROCOLITIS PULMONARY FIBROSIS LARYNGEAL CHONDRONECROSIS SUBCUTANEOUS FIBROSIS CHRONIC ULCERATION XEROSTOMIA & CARIES
Editor's Notes
- Emil Grubbe was a student of Homeopathy in Chicago at the time Was a vaccum tube manufacturer At suggestion of Dr Ludlam Nearly 7000 doctors took training under him in the medical use of X-rays Died at the age of 85 in 1960 Underwent 100 surgeries for removal of cancerous lesions mostly from his hands
- Mrs Rose lee a 55 year old lady with recurrent inoperable breast cancer Referred by Dr Ludlum, Died a month later.
- 1899 : Stenbeck treated a 49 yr old patient with BCC on the nose (100 times over 9 months) – Patient alive & well after 30 years 1900 : Sjorgen treated a patient with squamous cell carcinoma of face (50 times over 50 months)
- Curies lent the tube after bequerel noticed accidental burns on his chest wall & Walkhoff reported these in a photography journal in 1900 Pierre produced experimental burns on his forerm Henri Danlos - Famous Dermatologist of Ehler-Danlos fame Studied effects of radium exposure on skin Used radiumtherapy for treatment of Lupus
- not only breast cancer, but also, diabetes, sciatica, uraemia, rheumatism, dandruff, and even impotence!
- During the early part of the 20th century, radium was believed to be a veritable cure-all with the ability to stimulate the endocrine system and improve an individuals strength, vitality and energy levels
- Dial painters - Lip dippers 90 Years Ago Workers At The Waterbury Clock Company Began falling sick in the 1920s and 30s and developing sore throat , anemia, weakness, spontaneous teeth loss and fractures, deterioration of the jaw and Dying After Painting Radium On Clock Dials The company is in Connecticut, USA- between 1926 and 1936 paid 90,000 USD in medical compensations The last Waterbury Radium Girl, Mae Keane, passed away at the age of 107 in March of 2014. She credited her long life to her love for laziness and eventually being placed in a different position at the Waterbury Clock Company. She worked as a dial painter for only a few months,but still lost all her teeth by the age of 30 and faced numerous battles with cancer.
- EBENEZER McBURNEY BYERS The son of industrialist Alexander Byers, Eben Byers was educated at St. Paul's School and Yale College,[1] where he earned a reputation as an athlete and ladies' man. He was the U.S. Amateur golf champion of 1906, after finishing runner-up in 1902[2] and 1903.[3] Byers eventually became the chairman of the Girard Iron Company, which had been created by his father.[1] In 1927, while returning via chartered train from the annual Harvard–Yale football game, Byers fell from his berth and injured his arm. He complained of persistent pain and a doctor suggested that he take Radithor, a patent medicine manufactured by William J. A. Bailey.[4] Bailey was a Harvard Universitydropout who falsely claimed to be a doctor of medicine and had become rich from the sale of Radithor. Bailey created Radithor by dissolving radium in water to high concentrations, claiming it could cure many ailments by stimulating the endocrine system. He offered physicians a 17% rebate on the prescription of each dose of Radithor.[5] Byers began taking enormous doses of Radithor, which he believed had greatly improved his health, drinking nearly 1,400 bottles.[6] By 1930, when Byers stopped taking the remedy, he had accumulated significant amounts of radium in his bones resulting in the loss of most of his jaw. Byers' brain was also abscessed, and holes were forming in his skull. His death on March 31, 1932, was attributed to "radiation poisoning" using the terminology of the time, but it was due to cancers, not acute radiation syndrome.[4][7] He is buried in Allegheny Cemetery in Pittsburgh, Pennsylvania, in a lead-lined coffin.[5] – His body wen exhumed in 1960 was still “hot””
- Radiation oncology as a clinical speciality introduced in 1922 Abbe considered father of rad onco
- The important characteristic of ionizing radiation is the localized release of large amounts of energy. The energy dissipated per ionizing event is about 33 eV, which is more than enough to break a strong chemical bond In biological effects, radiation is considered IONIZING if their energy is 124eV or more corresponding to a wavelength less than 10-6 cm.
- A dose of radiation that induces an average of one lethal event per cell leaves 37% still viable; is called the D0 dose and for mammalian cells, the x-ray D0 usually lies between 1 and 2 Gy. The number of DNA lesions per cell detected immediately after such a dose is approximately: Base damage, >1,000 Single-strand breaks, 1,000 Double-strand breaks, 40 Cell killing does not correlate at all with single-strand breaks but relates better to double-strand breaks. Free radicals produced by water radiolysis contribute to 70% of effect in photon therapy
- On irradiation of cell following happens: - No effect - Sublethal damage: DNA can be repaired - Lethal damage : Critical targets affected. Cell death. Cells unable to repair damage by next division die in mitotic phase. Cancer cells are most likely damaged & repair inefficiently Normal cells repair sublethal damage
- Early radiation therapy was empirical, unprotected and offered amazing results such as this 1899 pic of treatment for epithelioma of the nose Coolidge tube Single large dose to extirpate the tumor >> Significant dose to skin Radium BOMB Van de graff generator – 1933V 1st MeV machine – Vicker’s at ST Bart’s Hosp London
- 1951 – first telecobalt installed in Saskatoon , Saskatchewan, Canada - HE Johns 1953 – first LINAC in Hammersmith hosp, London – Dr Henry Kaplan Gordon Isaacs, the first patient treated with linear accelerator radiation therapy (in this case an electron beam) for retinoblastoma in 1957
- Beam incidence is based on experience of mentor Roughly shaped fields related to bony anatomy, radiographical projection of contrast or tumor High dose volume of basic shape
- It consisted of Tandem or the intrauterine tube made of flexible rubber and vaginal box made of lead or gold, application reported in terms of milligram hours(product of amount of radium used and duration of application),with unequal loading of radium in uterus and vagina. A fractionated course of treatment over a period of one month, usually 2-3 applications each lasting for 20-30 hours Version No: 0.1, dated 31 Dec 2012 Page 11 of 95 repeated 2-3 weekly to contribute a total prescribed dose of 6500-7100 milligram hours
- passive scattering proton therapy (PSPT), and intensity-modulated proton therapy (IMPT)
- HO Indications –Prophylactic”: MEDIUM TO HIGH RISK UNDERGOING THA (Past h/o, hip trauma with acetabular fracture, Hypertrophic osteoarthritis, ankylosing spondylitis) Adjuvant : After elective surgical excision in case of established symptomatic HO Dose – 7-8 Gy single # Periop (Preop 4 hrs or postop 72 hrs) PVNST INDICATION – RECURRENT (RADICAL OR ADJUVANT) Keloid – recurrent, inaccesible, marginal resection, aggressive (6 month growth)
- DOUBLE EDGED SWORD