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Radiation therapy in wilms tumour


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Radiation therapy in wilms tumour

  1. 1. Radiation therapy in Wilms Tumor <ul><li>Dr. Lokesh Viswanath M.D </li></ul><ul><li>Professor, Department of Radiation Oncology </li></ul><ul><li>Kidwai Memorial Institute of Oncology </li></ul>
  2. 2. Radiation Therapy <ul><li>Wilms Tumors - high sensitivity – ionizing radiation </li></ul><ul><li>1940`s (all stages) 5yr survival </li></ul><ul><li>Surgery alone : 15-20% </li></ul><ul><li>Post OP RT : 47% </li></ul><ul><li>1970`s </li></ul><ul><li>CT - Distant relapses </li></ul><ul><ul><li>typically - large T size at presentation </li></ul></ul><ul><ul><li>propensity for metastasis (hematogenous) </li></ul></ul>
  3. 3. Roles of Radiotherapy <ul><li>Historical </li></ul><ul><ul><li>Definitive radiation therapy </li></ul></ul><ul><li>Contemporary </li></ul><ul><ul><li>Preoperative Radiation </li></ul></ul><ul><ul><ul><li>Flank </li></ul></ul></ul><ul><ul><ul><li>Whole Abdomen </li></ul></ul></ul><ul><ul><li>Postoperative Radiation </li></ul></ul><ul><ul><ul><li>Flank </li></ul></ul></ul><ul><ul><ul><li>Whole Abdomen </li></ul></ul></ul><ul><ul><ul><li>Lung bath </li></ul></ul></ul><ul><li>Treatment of recurrence </li></ul><ul><ul><li>Abdomen (localized abdominal recurrence) </li></ul></ul><ul><li>Treatment of metastasis </li></ul><ul><ul><li>Lung </li></ul></ul><ul><ul><li>Brain </li></ul></ul><ul><ul><li>Bone </li></ul></ul><ul><ul><li>Liver </li></ul></ul><ul><ul><li>Lymph nodes </li></ul></ul>
  4. 4. Indications <ul><li>Multimodality, stage and risk adapted approach is the standard of care </li></ul><ul><li>Radiation therapy is now a days indicated in a selected few to eliminate the risk of local recurrence </li></ul><ul><li>RT Management varies according to: </li></ul><ul><ul><li>Age of patient (avoided in < 6 months infants / <2yrs FH) </li></ul></ul><ul><ul><li>Preoperative extent on imaging </li></ul></ul><ul><ul><li>Operative stage </li></ul></ul><ul><ul><li>Post operative histology </li></ul></ul>
  5. 5. RT - Indications : Post OP RT <ul><li>WT - Favourable Histology </li></ul><ul><ul><li>Stage III: </li></ul></ul><ul><ul><ul><ul><li>residual T </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Gross/Micro </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>+ve Margin </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Local Infiltration Vital Structures </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Abd/Pelv -Ly N + </li></ul></ul></ul></ul><ul><ul><ul><ul><li>peritoneal surface </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Penetration </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Tumour implants </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>T Spillage (pre / intro OP) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Bx – trucut, Bx, FNAC </li></ul></ul></ul></ul><ul><ul><ul><ul><li>T removed in Pieces : eg - extn adrenal , T thrombus in renal vein </li></ul></ul></ul></ul><ul><ul><ul><li>Standard Risk FH WT without LOH at 1p & 16q </li></ul></ul></ul><ul><ul><ul><li>Higher Risk FH with LOH at 1p & 16q </li></ul></ul></ul><ul><ul><li>Stage IV </li></ul></ul><ul><ul><ul><li>Rapid responders of lung metastasis at week 6 on DD4A </li></ul></ul></ul><ul><ul><ul><li>(Possibility of no-RT to rapid complete responders on CT scan) </li></ul></ul></ul><ul><ul><ul><li>Slow responders (lungs) & non-pulmonary metastasis </li></ul></ul></ul><ul><li>WT Unfavourable Histology </li></ul><ul><ul><li>Anaplasia </li></ul></ul><ul><ul><ul><li>Stage I – diffuse </li></ul></ul></ul><ul><ul><ul><li>Stage II-IV – diffuse </li></ul></ul></ul><ul><ul><ul><li>Stage I-IV - Focal </li></ul></ul></ul><ul><ul><li>Clear cell CCSK </li></ul></ul><ul><ul><ul><li>Stage I-III </li></ul></ul></ul><ul><ul><ul><li>Stage IV </li></ul></ul></ul><ul><ul><li>Rhabdoid RTK </li></ul></ul><ul><ul><ul><li>Stage I -IV </li></ul></ul></ul>
  6. 6. RT Technique <ul><li>Timing of RT : not later than 9 days after surgery (max 14 days) </li></ul><ul><li>Delay of >10dys – significantly higher abdominal relapse rate , particularly UH. </li></ul>
  7. 7. RT Machines <ul><li>Telecobalt </li></ul><ul><li>Linear Accelerator </li></ul>
  8. 8. RT Techniques <ul><li>Flank RT </li></ul><ul><li>Whole Abdomen RT (WAI): </li></ul><ul><ul><li>Indicated – </li></ul></ul><ul><ul><ul><li>diffuse tumor spillage - Pre-OP / Intra OP Tumor Rupture </li></ul></ul></ul><ul><ul><ul><li>Peritoneal T seeding </li></ul></ul></ul><ul><ul><ul><li>Ascites +ve Cytology </li></ul></ul></ul><ul><li>Whole Lung RT </li></ul><ul><ul><li>Localized foci of lung disease persisting 2 weeks after 12 Gy can be excised or given additional 7.5 Gy </li></ul></ul><ul><ul><li>Treat both lungs regardless of the number or location of visible metastases </li></ul></ul><ul><ul><li>Patients with CT only pulmonary mets – at the discretion of the treating institution </li></ul></ul>
  9. 9. General Principles : RT planning <ul><li>Pt position : Supine </li></ul><ul><li>Immobilization: Vacuum Cushion </li></ul><ul><li>Sedation / Anesthesia during RT / Simulation </li></ul><ul><li>Simulation: </li></ul><ul><ul><li>Simulator – X –Ray + IVP (to Exclude Opposite kidney) </li></ul></ul><ul><ul><li>CT Simulation </li></ul></ul><ul><li>Ensure – Anesthesia & Patient monitoring equipments in the RT Bunker </li></ul><ul><li>Opposed AP:PA fields </li></ul><ul><ul><li>Field Shaping : 3DCRT / Contouring </li></ul></ul><ul><ul><li>Shielding opposite kidney & selected normal structures </li></ul></ul><ul><ul><li>Complete Vertebrae to be included in the RT field </li></ul></ul>
  10. 10. RT Dose CCSK Diffuse anaplasia Focal anaplasia Stage I-III FLANK RT : 10.8Gy , 180cGy/fx FH Stage III RTK Stage I-III FLANK RT : 19.8Gy (Infants -10.8Gy), 180cGy/fx Diffuse anaplasia Stage III
  11. 11. + 10Gy Renal Shielding / Limit the dose to remaining kidney <14.4Gy Residual Boost 19.8Gy in 11# Unresected Lymph nodes 12Gy WLI in 8# FH / UH Lung (mets.) 19.8Gy WLivI in 11# Liver (mets.) 10Gy, 150cGy/Fx FH Whole Abdomen RT 25.2 Gy in 14# Bone (mets.) 36.6Gy WB in 17# Or 21.6Gy WB + 10.8Gy IMRT /SRST Boost Brain (mets.)
  12. 12. Flank Radiation <ul><li>Treatment Portal design : </li></ul><ul><ul><li>Should encompass the tumor bed and the site of the excised kidney </li></ul></ul><ul><ul><li>2-3 cm margins should be given circumferentially </li></ul></ul><ul><li>3D Plans: PreOP CT/MRI – CTV : kidney + Tumor with 1cms Margin </li></ul><ul><li>Field sizes ~ 10 x 10 / 12 x 12 cms </li></ul><ul><li>Beam energy : 4-6 MV </li></ul>
  13. 13. Treatment Fields - Flank
  14. 14. Whole Abdomen Radiation <ul><li>Indicated in few patients now a days </li></ul><ul><li>energy - 4-6 MV photons </li></ul><ul><li>Shielding : </li></ul><ul><ul><li>Opposite kidney : Posterior 5 HVL shield </li></ul></ul><ul><ul><li>Acetabulum and femoral heads – both AP-PA shields </li></ul></ul><ul><li>Superior border : dome of diaphragm (nipples) </li></ul><ul><li>Inferior border : inferior border of the obturator foramen( pubis symphysis ) </li></ul><ul><li>Lateral border : to the lateral peritoneal reflection </li></ul>
  15. 17. Lung Irradiation <ul><li>Superior border : 3cm above the middle 1/3 rd of clavicle </li></ul><ul><li>Inferior border : ( below the costophrenic angles) Below the xiphisternum / level of L1 (transpyloric plane) </li></ul><ul><li>Lateral borders : Lateral border of areola of nipple </li></ul><ul><li>Shielding </li></ul><ul><ul><li>humeral head </li></ul></ul><ul><ul><li>larynx </li></ul></ul>
  16. 20. bilateral Wilms’ <ul><li>Dose to more than 1/3 of the contralateral kidney or residual kidney should not exceed 14.4 Gy </li></ul><ul><li>Inoperable Bilateral WT- role of Cyber Knife, Tomotherapy, Rapid Arc, True Beam, IMRT to be conscidered . PET based planning. </li></ul>
  17. 21. Long-term results of NWTS-3 and -4
  18. 22. Results – 4yrs – FH (NWTS 5) 93.9% 85.3% III Lung Mets, Pulm RT 74.6% IV 92% 83% II 98% 92% I EFS OS RFS Stage
  19. 23. Results UH (NWTS 5) <ul><li>Diffuse Anaplasia 2 y EFS </li></ul><ul><ul><li>Stage I 64.3 % </li></ul></ul><ul><ul><li>Stage II 79.5% </li></ul></ul><ul><ul><li>Stage III 62.7% </li></ul></ul><ul><ul><li>Stage IV 33.6% </li></ul></ul><ul><li>CCSK </li></ul><ul><ul><li>Stage I –IV 4y RFS 77.6% </li></ul></ul><ul><ul><li>6/9 Stage IV patients relapsed </li></ul></ul><ul><li>Rhabdoid Tumors </li></ul><ul><ul><li>Stage I 50% </li></ul></ul><ul><ul><li>Stage II 33.3% </li></ul></ul><ul><ul><li>Stage III 33.3% </li></ul></ul><ul><ul><li>Stage IV 21.4 % </li></ul></ul><ul><ul><li>Stage V 0% </li></ul></ul>
  20. 24. Conclusion <ul><li>WT at presentation is a large tumor and has a high propensity for distant metastasis </li></ul><ul><li>However the prognosis is excellent with modern day Multimodality Management </li></ul><ul><li>Surgery with chemotherapy is the mainstay of treatment </li></ul><ul><li>Radiation therapy given judiciously can reduce recurrences and improve QOL </li></ul>
  21. 25. Thank You