comprehensive cancer centre and hospice

1. DR. BEHGAL K.S. MD (AIIMS),DNB
director:
 Behgal cancer centre ph 5
mohali
 Behgal’s Radiation
Training Institute ph 8
mohali
 Department of Radiotherapy ph
1 mohali 1

2. RADIOTHERAPY
SURGERY CHEMOTHERAPY
HORMONE-THERAPY
IMMUNOTHERAPY
Cancer Treatment Options
BRACHYTHERAPY

3. There are five main reasons,
1. Curative or radical treatment
2. Palliative treatment
3. Neoadjuvant or induction treatment
4. Adjuvant treatment
5. Total Body Irradiation (TBI)
Why Radiotherapy is Used?

4. Behgal‘s cancer hospital and
radiation research institute
1. Behgal’s Radiation
Training Institute ph
8 mohali(2012)
2. Department of
Radiotherapy ph 1
mohali(2007)
3. Behgal cancer centre
ph 5 mohali(2000)
4.
 FREE STANDING RADIATION
ONCOLOGY
 STAFF:..1 RAD ONCOLOGIST
 ……………2 RSO physicist
 ……………1 dosimetrist
 ……………6 technicians

7.  External radiotherapy…
 COBALT
 LINEAR ACCELERATOR

 Brachytherapy
 Radiosurgery
 IMRT
 IGRT

8. Overview
3 DCRT
RadiationTherapy
Teletherapy
Brachytherapy
IMRT
IGRT DART
Electronic Brachytherapy
Tomotherapy
Image Assisted Brachytherpy
Stereotacticradiotherapy
Gamma Knife
LINAC based
Cyberknife

9. PGI-chd GMCH-32 Behgal:s RT GRECIAN MAX IVY
Cobalt +++++ +++++++ - - - -
Linear
accelerator
Varian - Siemens2008
Varian 2012
Varian1999 ELEKTA Varian2001
High energy √ - √ - - -
IMRT √ - √ - + √
Electrons √ _ √ - - _
radiosurgery Gamma knife - x- knife _ - _
Oncentra --- ---- √ - - _
BRACHYTHERAPY
+ + + - - -
IGRT ,RAPID
ARC
- - ++++++++ - - -

10. BEHGAL CANCER CENTRE….FACILITIES
45 BEDDED DEDICATED TO CANCER ONLY
SURGICAL ONCOLOGY
RADIATION ONCOLOGY
1)SIEMENS LINEAR ACCELERATOR
P R I M U S 6 & 1 5 M V W I T H E L E C T RO N S 6 - 2 2 M E V
… … 3 D C R T … I M R T … . . X K N I F E R A D I O S U RG E RY … . i n t r a o p e r at i ve
r a d i o t h e r a py
2 ) VA R I A N U N I Q U E I G R T R A P I D A RC . . 6 M V
… . . I M R T . . R a p i d a r c … . . I G R T … S T E R E OTAC T I C R A D I O S U RG E RY
3)E LE KTA/NUCLE T RON HDR BRACHYT HE RAP Y
4 ) … … P E R M A N E N T G O L D S E E D S F O R P RO S T R AT E
5)NUCLE AR M E DICINE (T HE RAP E UT IC)…
R A D I O
I O D I N E . . P H O S P H O RU S . . G O L D. . A M E R I C I U M . . S A M A R I U M . . S T ROT I U M

11. How to Plan CFRT
Patient positioning andImmobilization Volumetric Data acqusition Image Transfer to the TPS
TargetVolume Delineation
3D Model generation
Forward Planning
Inverse Planning
Dose distribution Analysis
Treatment QA Treatment Delivery

12. Concept

13. 4 D CT acqusition
Axial scans areacquired with the use of a RPM camera attached
to couch.
The“cine” mode of the scanner is used to acquiremultiple axialscans at predetermined phases of
respiratory cycle for each couch position

15. Infield Failure
All infield failures were located in GTV or CTV.

16. Linear Accelerators with features especially
suitable for SBRT
* Slide courtesy of Brian Kavanagh / University of Colorado

17. Why Brachytherapy?
Brachytherapy
Alternative:
Surgery
End resultCancer

18. Why Brachytherapy?
3-Fields External Beam AP-PA External Beam Brachytherapy
Highly conformal

19. Brachytherapy Delivery Methods
 Liquids
 Phosphorous (blood disorders)
 Strontium (bone cancer)
 Iodine (thyroid)
 Implants
 Permanent
(Au-198 or I-125 seeds for prostate)
 Temporary
(wires or afterloading techniques)

20. Treatments by Location
 Intracavitary techniques
(i.e. Vaginal, Rectum)
 Intraluminal techniques
(i.e. Lung)
 Interstitial techniques
(i.e. Breast, Prostate)
 Surface applications
(i.e. Skin)

21. ISOTOPES USED IN BRACHYTHERAPY can be embedded in
 Surface Applicator- placed directly on surface of tumor eg. Hard palate, skin, ocular
 Intracavitory- inserted into specially designed apparatus that is placed into body cavity eg.
Gynec.malign, nasopharynx
 Intraluminal- Various organs with lumen
(Oesophagus, endobronchial, biliary etc.)
 Interstitial- Directly through tissues encompassing tumor
 Intravascular- coronaries, peripheral art. internal mammary etc.

22. Image Guided Brachytherapy
Radiation Oncologist acquiringsectional USG
images
Contouring and dose planningbeing done on the
TPS Thefinalizedplan with the superimposed grid on the
template indicated the point of placement of each needle

23. Image Guided Brachytherapy
View of the B Mode Stepped USG device with the template for
insertionof the needles. Some needleshave been placed already
Final Seed
placement

24. Synergy with Brachytherapy
 Brachytherapy – External beam
 Brachytherapy – Surgery
 Per-operative
 Pre-operative (improves surgical outcome)
 Brachytherapy – Chemotherapy
 Brachytherapy - Hyperthermia

25. Pre-radiation 6 months post-
radiation
Radiographic Response

26. CLINICAL APPLICATIONS…
Ca Anorectum
 Indications: As boost to EBRT/ChemoRT
 If T.V. doesnot exceeds 1/2 circumference, 5 mm thick, 5 cm long i.e. T1-2 & small T3 lesions
 T1N0 adenocarcinoma of rectum 3-10 cm above anus
 T.V.: Visible palpable tumor+5 mm
 Dose: LDR 15-20 Gy at 0.3-0.6 Gy/hr
 Technique: Guide needle technique with template

27. Types of Radioisotopes depending
upon type of emission
 γ emitters : 226Ra,222Rn,60Co,137Cs,192Ir,198Au,
125I,103Pd,169Yb,145Sm,241Am.
 β emitters : 32P,90Sr,90Y,106Ru,49Va,166Ho,144Pr

28. Prostate HDR Brachytherapy

29. Breast HDR Brachytherapy

30. CLINICAL APPLICATIONS…

31. Lungs HDR Brachytherapy

32. BRONCHIAL CARCINOMA BRACHYTHERAPY

33. Esophagus HDR Brachytherapy

34. BRACHYTHERAPY ALONE WITH
PALLIATIVE INTENT

35. Cervix HDR Brachytherapy

37. Patient Preparation
 GA
 Lithotomy position
 Perineal area is disinfected
 Draping
 Catheterization

38. L/e •Applicator set is check for integrity and
completeness
•Uterine sounding
•Correct size of ovoid is selected and mounted
onto the ovoidtubes
•Dilatation of the cervix
•Length of uterus is measured

39. IU- Tube Insertion
 Correct length of IU-tube is
selected and inserted •Select proper size ovoids
•Fixate these to the ovoid tubes
•Insert one by one and attach to the fixing
mechanism

40. Applicator packing
 Insert gauze packing to push
rectum and bladder away
reducing the dose to these organs
 Radio opaque rectal marker
inserted

41. Verification X-ray
X-ray catheters

42. DOSE EVALUATION

43. Uterus HDR Brachytherapy

44. H&N HDR Brachytherapy

45. H&N HDR Brachytherapy

46. Rectal Brachytherapy

47. Templates

48. TRUS Guided Needles Insertion

49. MammoSite
MammoSite is Inflated to
Position the Tissue to
Receive Radiation Therapy
Design allows the 192Ir
Source to be Centrally
Positioned within the
Applicator
The192Ir Source is
Delivered Into the
MammoSite and
Radiation Therapy is
Delivered Per the
Treatment Plan

50. MammoSite

51. BEHGAL CANCER CENTRE….FACILITIES
45 BEDDED DEDICATED TO CANCER ONLY
SURGICAL ONCOLOGY
RADIATION ONCOLOGY
1)SIEMENS LINEAR ACCELERATOR
PRIMUS 6 & 15 MV WITH ELECTRONS 6-22MEV
……3DCRT…IMRT…..X KNIFE RADIOSURGERY….intraoperative radiotherapy
2) VARIAN UNIQUE IGRTRAPID ARC.. 6 MV
…..IMRT ..Rapid arc…..IGRT…STEREOTACTIC RADIOSURGERY
3)ELEKTA/NUCLETRON HDR BRACHYTHERAPY
4)……PERMANENT GOLD SEEDS FOR PROSTRATE
5)NUCLEAR MEDICINE (THERAPEUTIC)…
RADIO IODINE..PHOSPHORUS..GOLD..AMERICIUM..SAMARIUM..STROTIUM

52. OUR FIRST LINAC
 SIEMENS
 KLYSTRON BASED
 LOW AND HIGH ENERGY X rays
 6-15MV
 ELECTRONS
 5,7,8 ,10 ,12,14 MeV
IMRT
RADIOSURGERY
52

53. Behgal cancer centre”s new IGRT equipment – trubeam
XVI Imager
Multi-leaf collimator
ARTISTE
ARTISTE is the world’s first linear accelerator to feature integrated 3D-volume
imaging. This allows imaging of the tumor site with CT-like quality to be
acquired and reconstructed immediately before treatment, with the patient
already set-up in the treatment position.

54. Varian On-Board Imager
 Two robotic arms consisting of
kilovoltage Xray source and
detector
 Can obtain plain radiographs/
fluroscopic or with rotation can
obtain cone beam CT images.

55. Behgal cancer centre”s new IGRT equipment – VARIAN
UNIQUE IGRT &IGRS

56. Synergy provides:
 Two X-ray energies of 6 and 15 MV
 Four Electron energies: 6, 9, 12, 18 MeV
 Multi-leaf collimator
 Capable of Rotational Arc treatment capabilities for both photon and electron
beams
 Automated computer-controlled treatment
New technology introduced on Synergy:
 Incorporates digital X-ray and CT Imaging on the Linear accelerator
 Rotates 360 degrees around patient to produce a 3-D image
IMAGE GUIDED RADIATION THERAPY (IGRT)
ARTISTE ‘s IGRT Imaging capabilities

57. RADIATION Techniques
IMRT
Intensity-modulated radiation therapy
structures the dose to spare healthy tissue.
 RapidArc
two minutes or less.
IGRT
Image-guided radiation therapy pinpoints a
moving target.
DARTdynamic adaptive radiation therapy
IGBTImage-guided brachytherapy implants radiation
quickly and precisely.

58. Renal cell carcinoma
52 yr male with no surgery and bone mets
1.88 lakh monthly tab????????
6mth survival=0%
Pall IMRT to primary with tab geftinib
Pall rt to painful and weight bearing sites

59. ORAL CANCER
ALL SQUAMOUS CANCERS are irritatingly resistant to
chemo
Surgery and /or radiation remain the mainstay
With very very good results
At very very low cost

60. HOW TO MANAGE THEM?

61. RADICAL
LARYNGECTOM
Y

62. Cobalt radiation

63. ORAL CANCER
 CA TONSIL
 POST RT (COBALT recurrence)
 ?????????:?”…side effects outweigh benefits
Cobalt 60 facilities
Gmch 32 chandigarh
Pgi rohtak
IGMC shimla
Gmc patiala
& bikaner

64. BUCCAL MUCOSA CA

65. ORAL CANCER

68. Good surgery
incomplete radiation

70. ase of tongue……inaccessible to surgery

71. Supraglottic ca
over 2 yrs

72. RADIOSURGERY …AV
MALFORMATION

73. 73

74. Example of treatment
frontal lobe metastasis
several months after radiosurgery

75. Radiosurgery
Focused radiation beams
delivered to a specific tissue
volume
Multiple beams or multiple
passes (fractionated
treatment) that intersect

76. PONTINE GLIOMA

77. Automatic Image Fusion
for cranial Anatomy

78. PALLIATION

79. Inoperable to operable

80. CARCINOMA BREAST
80
Conventional Tangents
Co

81. PALLIATIVE RT TO AN 80 YR OLD

82. KELOIDS ELECTRONS

83. KELOID…….HYPERTHERMIA & ELECTRONS

84. Superior vena cava obstruction
5gy….single fraction

85. Nucletron brachytherapy unit _IRIDIUM
192

86. Intra operative brachytherapy for renal cell cc

87. IGRT CA LUNG

88. FLAP RECURRENCE 2010

89. The patient today

90. GOOD SURGERY NO RT …GIVEN ONLY
BRACHY…AS SALVAGE

91. BREAST CANCER

92. BASAL CELL CARCINOMA
 56Gy------30GY(5,10,22MeV electrons)+26Gy 6mv
Xrays

93. IMAGE GUIDED RADIOTHERAPY IN VARIOUS
CANCERS
IGRT is required in conditions where
critical organs are very close to the tumor
IMRT+IGRT is used when there is
negligible distance between the tumor and
surrounding normal tissues
93

94. PET-CT-MRI FUSION TECHNOLOGY
ONLY 4 SUCH FACILITIES IN INDIA

95. Radiotherapy can destroy small lung tumors while avoiding the
toxicity of thoracotomy
PET-GUIDEDRadiation Therapy in NSCLC
Pre-RT 2 Weeks
Post-RT
6 Months
Post-RT

97. PET IS IMPORTANT BUT COSTLY

98. CA PALATE IGRT _PET FUSION PLANNING

99. PET-CT-MRI FUSION TECHNOLOGY
ONLY 4 SUCH FACILITIES IN INDIA

101. BUCCAL MUCOSA CA
 DAY 22/33
AVASTIN
+PACLI

102. simulation scan

104. Tumor definition in radiotherapy
Process based on Computed Tomography (CT)

105. BUCCAL MUCOSA CA
 PREOP RAPID ARC TECHNIQUE….ONLY CISPLATIN
 DAY 7

106. BUCCAL MUCOSA CA
 DAY 22/33
AVASTIN
+PACLI…v v v costly
2.5 lakhs

107. BUCCAL MUCOSABEFORE
AFTER
Rs 40,000 rt and 4 chemo with cisplatin

108. NECK NODE

109. Srt GALL BLADDER CA

110. Renal cell carcinoma
 9th month
 SOS RT
 tamoxifen

111. GALL BLADDER CA.
24gy XKNIFE Stereotactic RADIOSURGERY

112. IMAGE GUIDANCE IN RT
 Availability of image guidance on treatment table
enhances the correctness of delivering radiation on target
 2D image guidance
112

113. DR. BEHGAL K.S. MD (AIIMS),DNB
director:
Department of Radiotherapy ph 1
mohali
Behgal cancer centre ph 5 mohali
Behgal’s Radiation Training Institute
ph 8 mohali
113