High Precision Radiotherapy HPRT Focus on Organ Preservation

1. ‘‘ADVANCED HIGH PRECISION’’
RADIOTHERAPY: FOCUS ON ORGAN
PRESERVATION & QOL (QUALITY OF LIFE)

3. CARE COMPASSION CURE 3‘C’ CSR

4. MEDICAL ONCO SURGEON
RADIATION ONCO

5. CANCER TREATMENT OPTIONS:

6. HEALTHCARE SYSTEM.. ART / SCIENCE

10. FRACTIONATION IN RADIATION
• Standard fractionation:
@1.8-2.0 Gy a day, 5 days a week for 25-30 treatments
• Conventional hypofractionation:
@3-5 Gy a day, 5 days a week for 10-15 treatments
• Stereotactic radiotherapy SRT:
@15-25 Gy a day, 1-3 days a week for 1-5 treatments

11. THERAPEUTIC RATIO

12. HOW RADIOTHERAPY WORKS

13. EBO = EVIDENCE BASED ONCOLOGY
Organization/
Management
RADIATION
ONCOLOGY
SURGICAL
ONCOLOGY
MEDICAL
ONCOLOGY

14. 5 R’S OF RADIOBIOLOGY

15. TUMOR MICROENVIRONMENT

17. ORGAN PRESERVATION & QUALITY OF LIFE

18. TUMOR DELINIATION
• Gross Tumor Volume: GTV
• Clinical Target Volume: CTV
• Irradiated Target Volume: ITV
• Planning Target Volume: PTV
• Organ at Risk: OAR
• Planning Organ at Risk Volume: PRV

19. INDICATIONS OF CURATIVE RADIOTHERAPY

28. ORGAN PRESERVATION STRATEGIES IN CA LARYNX

29. ACE Access Culture Efficiency Quality

38. HIGH PRECISION RADIOTHERAPY

39. MACHINE SELECTION

40. VENDORS: ELEKTA (30%) Vs VARIAN (60%)

42. TOMO/Hi-ART

43. ADVANCED RADIOTHERAPY: ELEKTA 2013

44. ADVANCED RADIOTHERAPY: ELEKTA 2018

47. STEPS IN RT PLANNING: 1-2 DAYS
CT BASED WITH MOULD

48. ADAPTIVE 4D RADIOTHERAPY

51. RADIOTHERAPY GROWING MARKET

52.  No radiotherapy in 36 countries
 LMIC have less than 10% of
teletherapy serve almost 50% of the
world population.
 HIC have over 60% of all
teletherapy machines serve 16% of
the world population.
TELETHERAPY SHORTAGE LIC MIC

53. 7000 operational radiotherapy centers in 139
countries, 15 geographical regions.
14000 operational teletherapy Machines
~11500 linacs, ~2200 Co-60 units,
>100 particle accelerators
2500 brachytherapy units
6700 TPS treatment planning systems,
3700 simulators, 3600 CT systems
69000 staff 23600 radiation oncologists,
10700 medical physicists,
34700 radiation therapists

54. RT GLOBAL SKILLED MANPOWER NEED

56. ERA’S IN RADIOTHERAPY
DXT CRT IMRT IGRT Particle RT
ORTHO VOLTAGE
ERA
MEGA VOLTAGE
ERA
PARTICLE THERAPY
ERA
1950’S
COBALT-60 ERA
2000+ 2010+
LINAC ERA

59. IMRT, IGRT, SBRT, RAPIDARC, SRS, SRT

60. ADVANCED RADIOTHERAPY: VARIAN

64. TREATMENT DELIVERY TECHNIQUE
3D CONFORMAL THERAPY: DYNAMIC CONFORMAL/CONES
IMRT: INTENSITY MODULATED RADIOTHERAPY
VMAT/RAPIDARC: VOLUMETRIC MODULATED ARC THERAPY

65. Evolution of Radiation Therapy
• Drive to increase conformal delivery to irregular tumour
targets & to reduce toxicity.
1960 1970 1980 1990 2000 2010
First Linac Image Fusion
Cerrobend
blocks
Computerized 3D CT
treatment planning
IMRT
dose-
painting
Stereotactic
Radiotherapy
IGRT
Multileaf collimator
Standard
collimator

66. IMRT RADIOTHERAPY CHALLENGES

67. VMAT/ RAPIDARC RADIOTHERAPY

68. CRANIAL  SRS Vs EXTRACRANIAL SBRT

69. STEREOTACTIC RADIOTHERAPY/SBRT

70. BETTER LOCAL CONTROL SRS/SBRT

71. Stereotactic Body Radiosurgery SBRT
SBRT is the use of high doses of radiation delivered to
tumors in the liver, lung and spine.
Single dose or in a limited treatments (2-5 doses).

73. INDICATION OF SBRT/ SRS
SBRT: Early Lung Ca, Metastatic Liver n Spine tumor,
Re-Radiation or Recurrent tumor, Localized Prostate Ca,
Pancreatic Ca, Brain metastases (5 or less).
SRS: AVM, Vestibular Schwannoma, Meningioma
Trigeminal neuralgia, Recurrent GBM, Acoustic neuroma
Pituitary adenoma, Glomus tumors, Hemangioblastoma.

74. Advantages of SBRT
Fewer fractions, more convenient.
Higher effective doses effective and durable
Less normal tissue Injury
Technically straight forward
Ability to retreat
But ……
Little margin for error,
Paucity of data on cord tolerance to single fraction
Potential complications: Mucositis, Laryngitis, Esophageal
stricture, and compression fracture

75. STEREO-TACTIC Meaning
“Stereotactic" OR “Stereotaxy“
Stereo- a prefix Greek word = solid
-taxis a suffix Greek taxis = arrangement, in order
SRS efficient, safe, and minimal invasive

76. RADIATION DELIVERY
• Conventional (3-5 beams)
• 3-D conformal radiation therapy
• Intensity modulated radiation therapy (IMRT) (3-9 Beams)
• Linac based radiation
• Tomotherapy
• Stereotactic Radiation Therapy (10+beams)
• Gamma Knife
• Linac based (isocenter)
• Cyberknife (non-isocenter)
• Proton Therapy (one beam repeated)

77. Hallmarks of Radiosurgery SRS
High Precision
High Accuracy (<1mm)
High dose conformity
Rapid fall off of
radiation dose
Minimizes dose to
normal tissues

78. POWER OF RADIOSURGERY: FFF
Fast Single day treatment ( less than hour)
Friendly Outpatient, Non-invasive
Focused Rapid & Durable local control,
Better sparing of surrounding tissue.
Allows for future surgical intervention if needed with
smaller chance for wound complications

80. RATIONALE FOR SRS
Spherical/pseudospherical
Generally non-infiltrative
Most < 3 cm
Grey-White location (“non-eloquent”)
Improved local control = Better survival
Need higher doses for local control
If surgery works, so should radiosurgery !

81. SRS: GK Vs LINAC

82. STEREOTACTIC RADIOSURGERY GK

84. CA ETHMOID Optic apparatus Save!

85. PET-CT SCAN = METABOLIC FDG-18

86. INTENSITY MODULATED RT

87. ORGAN AT RISK (OAR)

88. CA LARYNX (PFS)- ORGAN PRESERVATION T1/T2

89. RAPIDARC EARLY GLOTTIC CA T1/2

90. RESULTS OF RE-RT+CT :COMPLEX CASES
RECURRENT NODE, CA NASOPHARYNX (RT-CT) 3 MTHS POST RE-RT +CT

91. Nasopharyngeal Ca

92. ANAL CANCER

94. 3DCRT/ FORWARD IMRT IN BREAST

96. CA B/L BREAST: RAPIDARC

97. CA CERVIX : CONFORMAL RT

98. LOCALLY ADVANCE CA CERVIX IGABT

100. EVIDENCE DRIVEN ONCOLOGY

105. SUMMARY: CONCLUSION
• New technologies and innovations are constantly
changing and improving the way we do cancer
treatment and approach the problems.
ADVANCE RADIOTHERAPY
FAST SPEED
PIN POINT
ACCURACY
HIGH
PRECISION
LEAST SIDE
EFFECT TO
NORMAL
CELLS
CURE &
PROLONG
SURVIVAL
QOL.

107. #MIMS RAIPUR &
# MBH BHILAI
Cutting edge CANCER CARE
COMPREHENSIVE CARE CENTER
COMPASSIONATE ( HUMAN TOUCH )
CURE ( WITH QOL QUALITY OF LIFE )
ADVANCED ( IGRT, IMRT)
AFFORDABLE (AYUSHMAN PMJAY)
ACCESSABLE (RAIPUR, BHILAI)
8871523360
www.mittalhospital.in
drpuneetseth@gmail.com

109. LETS ALL HAVE BELIEVE & PATIENT COURAGE :
RADITING HOPE FOR CURE!