RADIOTHERAPY AND CANCER

1. DR KANHU CHARAN PATRO
RADIATION ONCOLOGIST
M.D,D.N.B[RT],FAROI[USA],MBA[ICFAI],PDCR,CEPC

2. O
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O L
Y
O
M
G
C
H
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P
E
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S P E C I
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T
Y
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VISAKHAPATNAM,1/7-MVP[AP]
2

4. 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

5. Lung
Breast
Colon/Rectum
Stomach
Liver
Prostate
Cervix uteri
Oesophagus
Bladder
Non-Hodgkin
Lymphoma
Leukaemia
Oral cavity
Pancreas
Kidney
Ovary
1000 800 600 400 200 0 200 400 600 8001000
Men Women
From: D.M. Parkin The Lancet Oncology 2: 533-543 (2001)
(Thousands)
Incidence
Mortality
337
293
105
0370
241
318
446
234
165
166
471
233
133
111
76
33
121
68
113
86
47
97
101
101
34
71
192
114
810
902
558
405
255
499
398
384
204
543
279
260
227
99
93
167
144
109
81
170
116
112
57
119
5.3 million cases
3.5 million deaths
4.7 million cases
2.7 million deaths
The Global Burden of Cancer 2000

6. ? ?
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10. Oncologist
Diagnosis
Treatment
Radiologist
Cytopathologist
Surgeon
HistopathologistMolecular
Pathologist
Geneticist
psychiatrist
Nursing
And
Support staff
Audit

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Radiation –Part of life

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Wilhelm Conrad Rontgen

13. History - radiation
1896 – Becquerel - Radioactivity
1898 – Madam Curie / Pierre Curie - Radium
1903 – Nobel Prize for Curie’s & Becquerel
1903 – First successful case of malignancy basal
cell carcinoma of face
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14. GOALS
High dose to tumor tissue-Tumor control
Normal tissue sparing
Minimize long and short term toxicities
Better Quality of life
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15. Treatment
• Delivered 5 days per week over 6-8 weeks
• Typical treatment takes around 5 minutes
• Treatment is painless--like having an X-ray taken
• No radioactive substances involved; beam goes
on/off
• Side effects usually temporary; controlled with
medication/diet
• Covered by Medicare and many other insurance
companies
•
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16. Role of radiotherapy in various cancers
• Needed for all most head and neck cancer
• Radical-
– Naso-pharynx, cervix,laryx,hypopharynx etc.
• post-op-adjuvant
– Rectum, cervix early, stomach, head and neck,
other abdominal malignancies
• Palliative
– compression, bleeding,obstruction,pian
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17. Types of radiotherapy
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TELETHERAPY
BRACHYTHERAPY

18. Radiotherapy procedure
1. Tumor board decision
2. Positioning And immobilization
3. Imaging
4. Target delineation
5. Planning
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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
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19. IMAGE GUIDED RADIATION THERAPY
EQUIPMENT REQUIRED
CT-SCAN MRI PET-CT
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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

20. Cobalt machine
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21. RADIOTHERAPY

23. • CONVENTIONAL
• 3DCRT
• IMRT
• IGRT
• VMAT/RAPIDARC
• PET GUIDED RADIOTHERAPY

24. Plaster of Paris Mould-older method
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25. Head & Neck
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27. Abdomen and Pelvis
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28. Vacuum Mould
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31. Evolution of Treatment Techniques
CUSTOMISED BLOCKS
MULTILEAF COLLIMATOR
BASED 3D-CRT
1990s1980s
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33. Treating Head & Neck with Sliding Windows
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34. 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

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39. Mesothelioma
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41. Small Volume Adjacent to Critical Structure
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42. 3D Dose Shaping - H&N and Brain
Brain
Stem
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43. Target Motion in
Radiotherapy
Caveman et al
Oops! The target
moves!
IGRT/GATED RT
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48. Where is the Target?
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Mahatmagandhi cancer hospital and
research institute
SPARE THE ROD AND SPOIL THE CHILD
DO NOT LOOSE SHIGHT OF FOREST [OAR]FOR THE TREE

53. TRIPLE FUSION
PET
CTMRI
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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

54. Concept of triple-fusion
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Mahatmagandhi cancer hospital and
research institute

55. Target volume definition
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Research Institute,Visakhapatnanm

56. Imaging
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Research Institute,Visakhapatnanm
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57. IMAGING
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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

58. PET vs.MRI
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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

59. PET vs.MRI
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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

60. Avoid unnecessary toxicity
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Research Institute,Visakhapatnanm
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61. Unknown primary
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Research Institute,Visakhapatnanm
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62. Impact on radiotherapy
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Research Institute,Visakhapatnanm
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1.Elective nodal irradiation
2.Nodal boost

63. G.P., m, 46y; LN-Metastasis of Hypopharynxcarcinoma
Head and Neck Cancer: Example
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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

64. Interobservor variation
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Research Institute,Visakhapatnanm
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65. C. Messa et al.; Q J Nucl Med Mol Imaging 2006
NSCLC: PET/CT During Radiotherapy
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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

66. Adaptive –decrease toxicity
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Research Institute,Visakhapatnanm
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67. Pet CT planning
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Research Institute,Visakhapatnanm
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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

70. Tumor Volume
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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

71. Nodal Volume
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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

72. VN.C., f, 34y; Cancer of Cervix Uteri; Additional Retroperitoneal Metastases
Example: Increased Target Volume
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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

73. W.L., f, 61y; NSCLC; No Contralateral Involvement
Example: Decreased Target Volume
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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

74. Moureau et al. IJROBP 2005
Increased Target Volume in Oesophageal
Carcinoma
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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

75. PET-CT-WIN-WIN SITUATION
PARAMETER VOLUME
CHANNGE
T STAGE INCREASE
UPSTAGING
1. PREVENTS TUMOR TISSUE MISSING
2. CHANGES TT FROM CURATIVE TO PALLLIATIVE
DECREASE
DOWN STAGING
1. PREVENTS EXTRA DOSE TO NORMAL TISSUE
2. CHANGES TT. FROM PALLIATIVE TO CURATIVE
3. DOSE ESCALATION IS POSSIBLE
N STAGE INCREASE
UPSTAGING
1. PREVENTS TUMOR TISSUE MISSING
2. CHANGES TT FROM CURATIVE TO PALLLIATIVE
DECREASE
DOWN STAGING
1. PREVENTS EXTRA DOSE TO NORMAL TISSUE
2. CHANGES TT. FROM PALLIATIVE TO CURATIVE
3. DOSE ESCALATION IS POSSIBLE
M STAGE INCREASE CURATIVE-TO PALLIATIVE
DECREASE PALLIATIVE TO CURATIVE
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76. Bird’s eye view Eagle’s eye view
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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

78. ORGAN PRESERVATION

79. Penile conservation
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Research Institute,Visakhapatnanm
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Research Institute,Visakhapatnanm
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81. RADIOTHERAPY DELIVERY
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Research Institute,Visakhapatnanm
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82. • COSMETIC DEFECT
• FUNCTIONAL DEFECT
• IMPAIRED QUALITY OF LIFE
SURGERY
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BRACHYTHERAPY

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87. PROCEDURE
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88. TREATMENT DELIVERY

89. • HEAD AND NECK CANCERS
• BREAST CANCERS
• ESOPHAGUS CANCERS
• PENILE CANCER
• SOFT TISSUE SARCOMA
• BLADDER CANCERS
• CANAL CANCERS
ORGAN PRESERVATION
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90. ORGAN PRESERVATION FOR
BONE TUMORS
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94. ORGAN PRESERVATION FOR
BREAST CANCERS
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Intra- operative Brachytherapy
procedure

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Intra- operative Brachytherapy
procedure

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Intra- operative Brachytherapy
procedure

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Intra- operative Brachytherapy
procedure

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3D Brachytherapy Planning
CT Loading Dose distribution

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Dose prescription and Treatment
delivery
• Dose: 34Gy in 10 fraction bid
• Dose per fraction: 340cGy

101. ORGAN PRESERVATION FOR
PENILE CANCERS
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107. ORGAN PRESERVATION FOR
SARCOMAS
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Research Institute,Visakhapatnanm
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114. ORGAN PRESERVATION FOR
CANCER CERVIX [STAGE
0,EARLY 1]
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117. ICA HDR application
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120. ORGAN PRESERVATION FOR
CANCER ANAL CANAL
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121. APR
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122. ANAL CANAL BRACHYTHERAPY
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123. ORGAN PRESERVATION FOR
CANCER TONGUE
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125. TONGUE IMPLANT IN PROGRESS
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126. TONGUE IMPLANT IN PROGRESS
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ORGAN PRESERVATION FORCANCER LIP

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131. Applicator in situ with IOP

132. Complete response –towards healing
hypo-pigmentation

133. Recent

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136. KELOIDS
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137. CANCER ESOPHAGUS
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138. ESOPHAGEAL BRACHYTHERAPY
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ILRT-dosimetry

140. BASE OF TONGUE
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141. PROSTATE CANCER
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149. OCULAR MELANOMA
RETINOBLASTOMA
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162. • GOOD COSMETIC
• FUNCTIONAL PRESERVATION
• GOOD QUALITY OF LIFE
• ESTABLISHED PROCEDURE
• EXPERTISE REQUIRED
• AVAILABLE LITERATURES
• LESS TOXIC
FACTS
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163. SMART THINKING
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165. Sharp gun-missed target
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167. Stage IV: Metastatic Breast Cancer

168. 171
METASTASIS
-please do not watch crying

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170. METASTASIS- give a smiling death
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171. Palliative radiation
Skeletal X-Ray
Bone scan
MRI
PET-CT

172. Spinal metastasis
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174. Brain metastasis
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176. Whole brain radiotherapy
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177. Choroidal metastasis
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178. Superscan-extensive bone mets
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179. Hemibody radiation
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180. Prophylactic radiation
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181. svco
184

182. 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

183. Change in bowel habits
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184. Change in bladder habits
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185. A sore that does not heal
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186. Unusual bleeding or discharge
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187. Thickening or lump in the
breast or any part of the body
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188. Indigestion or difficulty swallowing
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189. Obvious change in a wart or mole
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190. Nagging cough or hoarseness
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200. 203

201. Prevention-passive smoking

202. Liver cancer-
hepatitis B vaccine

203. Cervix cancer vaccine
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204. Promise-Stop drinking alcohol
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205. RELAX

206. Meditation
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207. 210
Dietary protective factors

208. Breast feeding

209. REGULAR CHECK-UP

210. Physical activity

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LOTS OF BLOOD REQUIRE

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TABLET FORMS

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All specialities under one roof

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222. Just “Doing It” is not good enough !
You must know “what” to do and “where” to do it !
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226. 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)

227. 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)

228. TEAM OF EXPERTS IN MEDICAL ONCOLOGY
1. Dr. B.Rakesh Reddy M.D(Paed).,DM
(Medical Oncology) (AIIMS ,New Delhi)
2. Dr. M.Vamshi Krishna M.D.,D.M., (Medical Oncology)
(Tata Memorial ,Mumbai)
3. Dr.R.Madhan Mohan M.D. (Hematology)
(AIIMS ,New Delhi)

229. 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)

230. TEAM OF EXPERTS-- Radiology
1. Dr. P.Madhuri D.M.R.D
( AMC ,Visakhapatnam)
2. Dr. B.Revathi D.M.R.D
( RMC ,Kakinada)

231. GYNAEC ONCOLOGY :
Dr.Jyoti Doki M.D. (Gynaec & Obg)
(AMC,Visakhapatnam)

232. Nuclear Medicine :
Dr. K.Raghava Kashyap M.D (Nuclear Medicine)
(PGIMER, Chandigarh)

233. 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

237. Radiation tumor board

238. DECISIONS IN TUMOR BOARD

239. EMPOWER
•EQUIPMENT
•EXPERT
•EXPERIENCE
•EASY ACCESSES

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Whenever not
possible,
make friends

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246. THANKS

247. 250
?

248. Guess
•What next