Advanced Radiotherapy Treatment

1. DR. PUNEET SETH
M.B.B.S, M.D. Radiotherapy
Consultant, Radiation Oncologist
Alexis Multi-speciality Hospital, Nagpur
ADVANCED
Radiotherapy
TREATMENT

4. M.D.RADIOTHERAPY
GOVT. SGPT CANCER HOSPITAL,
M.Y HOSPITAL, INDORE (M.P)
(2004 – 2007) Cobalt &HDR Brachy
APOLLO CBCC USA, AHMEDABAD (JCI)
(2009-10) Varian (Linac-ix) IGRT
SRS/IMRT/3DCRT
INDRAPRASTHA APOLLO HOSPITAL (JCI)
NEW DELHI (2007-08) Varian 21-Ex IMRT/SRS
APOLLO BSR, BHILAI (C.G) NABH
(2011-16) Varian (UNIQUE) RA/IMRT/3DCRT
HDR Brachy, First RAPIDARC in CG

6. 19 NOV 2016…NEW DESTINATION OF QUALITY
WORLD CLASS HEALTHCARE IN CENTRAL INDIA

9. (Central India)

11. 19 MARCH 2017…CANCER INAUGARATION

15. WARNING SIGNS & TRENDS IN CA

17. MEDICAL ONCO SURGEON
RADIATION ONCO

18. CARE COMPASSION CURE 3‘C’ CSR

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

22. Multidisciplinary Teamwork (MDT)
Fighting the Crab
Radiation Oncology
Surgery Oncology
Medical Oncology
Onco-Radiology, Onco-Genetics
Onco-Pathology, Histo-Pathologist
Onco-Psycology, Onco-Gynec,
Neuro-Onco, Dental, ENT, Optho,
Dietician, Rehabilitation (Speech,
Audiometry, Physiotherapy)

25. KEY RISK FACTORS FOR CANCER

27. CANCER CARE DELIVERY

28. COMPREHENSIVE CANCER CENTERS

31. DIRAC : IAEA 7600 RT CENTERS IN WORLD
• IAEA’s Directory of Radiotherapy Centres (DIRAC), which is
the world’s authoritative source of information on
radiotherapy infrastructure and centres. Database includes
more than 7600 radiotherapy centres and about 13000
teletherapy and 2600 brachytherapy in the world.
• In high income countries, one radiotherapy machine is
available for every 1,20,000 people.
• In middle income countries, one machine serves over 1
million people.
• In low income countries, about 5 million people over a
single radiotherapy machine.

33. THE ROENTGEN X-RAY: Oct 1895

34. HOW RADIOTHERAPY WORKS ?

36. Radiobiology : 5 R’S OF RADIOBIOLOGY

37. RT INFRA 2005 IN INDIA : LINAC 163 , COBALT 293
RT INFRA 2015 LINAC: 342 (+179 LINAC IN 10 YRS)

38. ADVANCED TECHNOLOGY ADOPTION IMPROVING IN INDIA

39. VENDORS: ELEKTA Vs VARIAN

40. TRUEBEAM LINAC

41. TOMO/Hi-ART

42. CYBERKNIFE

43. HIGH QUALITY CANCER CARE DELIVERY

44. ACE Access Culture Efficiency Quality

46. RADIOSURGERY
 First Ablative techniques:1951 Lars Leksell
Leksell Gamma thalamotomy in two cases of intractable pain.
Acta Chir Scand.
 GammaKnife:1989 201 Co-60 sources
Lunsford Stereotactic radiosurgery of the brain using the first US 201
Cobalt- 60 source Gamma Knife. Neurosurgery 24, 1989
 Linac Based 1985 F. Colombo
 CyberKnife 1997 Adler
The Cyberknife: a frameless robotic system for radiosurgery. Stereo &
Funct NeuroSurg 69, 1997

50. 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 FusionCerrobend
blocks
Computerized 3D CT
treatment planning
IMRT
dose-
painting
Stereotactic
Radiotherapy
IGRT
Multileaf collimator
Standard
collimator

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

54. MACHINE / TECHNOLOGY SELECTION

55. ADVANCED RADIOTHERAPY: VARIAN

56. HIGH PRECISION RADIOTHERAPY

57. TRUEBEAM Linear accelerator
• Quick and painless! Enhance patient Comfort
• RapidArc (VMAT), IGRT , SBRT, SRT & Dynamic IMRT
• IGRT couch, High Intensity Mode (FFF), CBCT OBI
• Advanced Computerized: ARIA TPS Eclipse 13.7
• CT Planning (SIEMENS) based Fuse with MRI 3 Tesla
• Patient protection, Short treatment time

58. PARTS OF LINEAR ACCELERATOR= LINAC
EPID Electronic Portal Imaging Device MV
PORTAL IMAGING IGRT (daily)
Multi Leaf-Collimator
SHAPE THE TUMOR VOLUME
GYANTRY
IGRT COUCH
Electron
Gun
BENDING
MAGNET
OBI Arms kv IGRT
COLLIMATOR

59. TRUEBEAM:4D-ITC CONSOLE

64. ADAPTIVE 4D RADIOTHERAPY

65. THERAPEUTIC RATIO

68. RADIOTHERAPY CHALLENGES

70. 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

72. INTENSITY MODULATED RADIOTHERAPY

73. VMAT/ RAPIDARC RADIOTHERAPY

74. 2 MIN IMAGING & TREATMENT

75. GATED RAPIDARC (VMAT)
• Next evolutionary step Compensates for tumor motion
• Expands application of RapidArc to moving tumors (lung)
• Enables fast treatments of tumors that move with
respiration Minimizes exposure to healthy tissues
• Provide more options for treating complex cancer cases
including lung, breast, liver, abdomen, head and neck
• IMRT, IGRT, RapidArc, Gated RapidArc, SBRT, SRS

76. RAPIDARC INDICATIONS

77. RAPIDARC INDICATIONS

78. RAPIDARC INDICATIONS

79. STEREOTACTIC RADIOTHERAPY/SBRT

82. Stereotactic Body Radiosurgery
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).

83. 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.

86. INDICATION FOR PORT IN HN CANCER

87. CA ETHMOID Optic apparatus Save!

89. PET-CT SCAN = METABOLIC FDG-18

90. DOSE VOLUME HISTOGRAM

91. INTENSITY MODULATED RT

94. GROSS & CLINICAL TARGET VOLUME

95. ORGAN AT RISK (OAR)

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

97. RAPIDARC EARLY GLOTTIC CA T1/2

98. Nasopharyngeal Ca

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

100. ANAL CANCER

102. 3DCRT/ FORWARD IMRT

103. POST LUMPECTOMY RT (BCT)

104. POST MRM RT INDICATIONS

105. CA B/L BREAST: RAPIDARC

107. CA CERVIX IIB-IVA RT+CT

110. HDR BRACHYTHERAPY VARIAN

111. LOCALLY ADVANCE CA CERVIX IGBT

115. IGRT, SBRT, RAPIDARC/VMAT TECHNOLOGY

116. TRUEBEAM SVC LINAC