13. Statistics
• >9.7 million cases are detected each
year
• 6.7 million people will die from
cancer
• Every day, around 1700 Americans
die of the disease
• 20.4 million people living with
cancer in the world today
• 1 in 3 people will be diagnosed with
cancer in the UK and 1 in 4 will die
from their disease
20. Role of radiotherapy in various cancers
• Needed for all most head and neck cancer
• Radical-
– Naso-pharynx, laryx, hypopharynx etc.
• post-op-adjuvant
– MOSTLY ALL ORAL CANCERS except T1 lesions
• Palliative
– compression, bleeding, obstruction, pain
5/17/2019 6:11:10 PM 20
21.
22.
23. Radiotherapy procedure
1. Tumor board decision
2. Positioning And immobilization
3. Imaging
4. Target delineation
5. Planning
5/17/2019
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
23
24. IMAGE GUIDED RADIATION THERAPY
EQUIPMENT REQUIRED
CT-SCAN MRI PET-CT
5/17/2019 24
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
34. Treating Head & Neck with Sliding Windows
5/17/2019 6:11:10 PM 34
35. IMRT
• Divides each treatment field into
multiple segments
• Modulates beam intensity,
giving discrete dose to each
segment
• Uses multiple, shaped beams
(~9) and thousands of segments
IMRT Initiated in 1995
Reached the clinic in 2000
60. Plaque placement
• Under GA / LA
• Conjunctiva peritomy
• Tumor location marked on sclera
• Dummy plaque used to confirm
location
• Plaque placed & sutured to
sclera
• Conjunctiva sutured
• Patient is kept in isolation
Courtesy : Dr Vijay Anand P Reddy
91. Orbital lymphoma
• Lymphoid tumors -common despite the orbit not containing lymph nodes
or a well defined lymphatic vasculature.
• Incidence 13% of all orbital tumors.
• Primary or associated with systemic disease.
• Represents 8% of all extranodal NHL & 1 % of all NHL
• Approx 35% of patients with lymphoid tumors of orbital tumors will
eventually develop systemic lymphoma
• Presenting age- 15- 70 yrs
• Majority are low grade- 84%
92. • Biopsy
• Worked up for systemic disease
• Including a complete physical exam, a complete blood count,
bone marrow biopsy and CT scans of the thorax, abdomen and
pelvis.
• CSF examination
• CT scan -homogeneous mass with well defined borders that
does not destroy surrounding structures or bone.
• MRI – to assess extent ofdisease
• PET CT
97. Radiotherapy
• Stage I, II-RT main t/t
• - Whole orbit is to be
treated
• Energy- 1.25 Mv / 6Mv
• Supine
• Immobilise
• Ant & lat field using 45
wedges
• Looks into beam,
• dose- 25-30Gy@ 1.8- 2
Gy/#
• Bilateral disease- parallel
opposed fields
98. • If there is a forward displacement of eveball
• Involvement of post or anteromedial part of orbit
• Sup & inf oblique fields
99. Results: All patients had a complete response to RT. Intraorbital recurrence
developed in previously uninvolved areas not included in the initial target
volume in 4patients (33%) treated with partial orbit RT. All were salvaged by
repeat RT or surgery. No patient treated with whole orbit RT developed
intraorbital recurrence. The acute and long-term toxicity was similar in both
groups. All but 1 patient retained good vision.
Conclusion: Patients with orbital lymphoma should be treated to the entire
orbit.
100. Uveal melanoma
I. 3 Treatment Options:
Plaque vs Proton Beam vs Enucleation
III. 3 Clinical Questions, 3 Major Studies
102. • Work-up: fundus exam, ultrasound and
fluorescein angiography.
• Measurements: diameter by fundus exam,
thickness by ultrasound
• Biopsy: not done until after radiation for risk of
seeding.
Diagnosis
103. 3 Treatment Options
• Enucleation
Last resort
• Proton Beam
Useful when > 5 mm thickness
• Plaque Brachytherapy
Useful when < 5 mm thickness
104. • prior to 1970
• refractory
cases
Enucleation
109. Plaque
• Most common form of treatment
• Good for thin tumors, not thick tumors
• Commonly Iodine-
125 T1/2: 59.4 d
Av Energy: 35.5 keV
• Not possible over
optic nerve due to
anatomy
110. 3 Clinical Questions
I. Is radiation effective?
II. Does radiation cause vision loss?
III. Can prophylaxis prevent vision loss?
111. JAMAOphthalmology, Dec
2006
• Question: Is Radiotherapy as effective as
enucleation?
• Design: Randomized multi-center clinical trial of
iodine 125 brachytherapy vs enucleation.
• Conclusion: No difference in survival between
I-125 brachytherapy vs enucleation.
• Impact: Brachytherapy usually first line treatment.
115. Conclusions
I. Wills Eye protocol for work-up of non-metastatic
melanoma differs from other tumors:
- No biopsy, CT or MRI
- Diagnosis via fundus exam
- Thickness measured by ultrasound
II. Isodose patterns of Plaque vs Proton:
- Plaque ➞ Steep gradient ➞ Thin tumors
- Proton Beam ➞ Wide plateau ➞ Thick tumors.
III. Radiotherapy cures ocular tumors, yet causes
maculopathy
IV. Bevacizumab expected minimize maculopathy
- Too early for long term studies
120. • Leucocoria
– Most common initial sign
– Retinoblastoma remains intraocular and
curable for 3–6 months after the first
sign of leucocoria
• Other signs
– Proptosis
– Swelling
– Strabismus
– Hypopyon
– Poor visual tracking
Clinical
Presentation
heterochromia
strabismus
122. • 90% show calcification
• Dense homogenous
• Extension to choroid,vitreous
& sclera not reliable.
• Detects intracranial disease
• 3D multiplanar capability.
• Hyperintense to vitreous on T1 &
markedly hypointense on T2
• Delineation of ON, IO & EO
spread
• Differentitates between tumor,
RD & subretinal fluid.
CT/MRI
125. Cryotherapy
Good local therapy. Leaves
Big scars
Photocoagulation Good local
therapy. Causes big scaring,
loses vascularization
Thermotherapy : Good
local therapy. Minimal
scaring
126. EYES PRESERVED
RE I to III RE IV to V
EBRT
ALONE
53% 45%
EBRT+SALV
AGE
96% 66%
CT ALONE 29% 11%
CT
+SALVAGE
94% 66%
CTRT - 75%
Eye Preservation
127. Vijay Anand P Reddy et al.
External Beam
Radiotherapy
134. • Retinoblastoma has been historically
treated with lateral beams to encompass
the affected retina(s), and spare the lens
anteriorly, if possible
• .
Radiation Therapy Techniques
141. Proton therapy
• The dosimetric advantage
of the Bragg-Peak, which
eliminates exit dose,
results in less low dose to
normal, uninvolved
tissue. The reduction in
peripheral dose as
compared with the IMRT
plan is highly desirable in
patients of this young
age, many of whom carry
a germline mutation,
predisposing them to the
development ofLee et al; Int J Radiat Oncol Biol Phys 63:362–372
142. • Reduces tumor volume
• Allows more focused, less damaging
therapeutic measures
Chemoreduction
161. CAUTION
C - Change in bowel or bladder habits
A - A sore that does not heal
U - Unusual bleeding or discharge
T - Thickening or lump in the breast or any part of the body
I - Indigestion or difficulty swallowing
O - Obvious change in a wart or mole
N - Nagging cough or hoarseness
205. TEAM OF EXPERTS IN SURGICAL ONCOLOGY
1. Dr.Murali Krishna Voonna M.S.,M.Ch.,
(Adyar Cancer Institute ,Chennai)
2. Dr.Karthik Chandra Vallam M.S., M.Ch,DNB.,
(TATA Memorial ,Mumbai)
3. Dr.M.P.S.Chandra Kalyan M.S,, M.Ch.,
(TATA Memorial ,Mumbai)
206. TEAM OF EXPERTS IN RADIATION ONCOLOGY
Dr. Kanhu Charan Patro M.D(RT).DNB(RT)
(ex. TATA Memorial ,Mumbai)
Dr. Partha Sarathi Bhattacharyya M.D (RT)
(ex. AIIMS,NEW DELHI)
Dr. Chittaranjan Kundhu M.D(RT)
(S.C.B.M.C ,Cuttack)
Dr. Venkata Krishna Reddy M.D (RT)
(ex.Christian Medical College ,Vellore)
207. TEAM OF EXPERTS IN MEDICAL ONCOLOGY
1. Dr. B.Rakesh Reddy M.D(Paed).,DM
(Medical Oncology) (AIIMS ,New Delhi)
208. TEAM OF EXPERTS IN CRITICAL CARE AND PAIN
1. Dr. K.V.D. Praveen M.D(Anesthesiology)
(PGIMER, Chandigarh)
2. Dr. A.Shirisha M.D (Anesthesiology)
(AMC ,Visakhapatnam)
3. Dr. Surendra Nadh D.A, DNB(Anesthesiology)
(ISPAT General Hospital, Odisha)
209. TEAM OF EXPERTS-- Radiology
1. Dr. P.Madhuri D.M.R.D
( AMC ,Visakhapatnam)
2. Dr. B.Revathi D.M.R.D
( RMC ,Kakinada)
213. EXPERTS FROM VARIOUS PRESTIGIOUS
INSTITUTIONS
1. ADYAR CANCER INSTITUTE, CHENNAI-1
2. TATA MEMORIAL HOSPITAL, MUMBAI-3
3. AIIMS,NEWDELHI-2
4. CMC-VELLORE-1
5. PGI-CHANDIGARH-2