Nishant 08288022656, profile picture
Uploaded byNishant 08288022656
PPT, PDF320 views

Ca Cervix.ppt

This document discusses radiation therapy for carcinoma of the cervix. It provides details on epidemiology, anatomy, staging, imaging, and treatment options. Some key points: - Carcinoma of the cervix accounts for over 4700 new cases and over 71,000 deaths worldwide each year, with over 80% of cases occurring in developing countries. - Staging is done according to the FIGO system, which classifies tumors from Stage 0 (carcinoma-in-situ) to Stage IV (distant metastases). Imaging such as CT, MRI, and PET can help determine tumor size, parametrial invasion, and lymph node involvement to guide treatment planning. - Treatment options include surgery,

Embed presentation

Download to read offline
RADIATION THERAPY CARCINOMA CERVIX
CANCER CERVIX Estimated 4,70000 new cases per year worldwide > 80% cases in developing countries 27% cases occur in India 1,20000 cases annually 71,000 deaths 15.2% to 50% of all female cancers >80% of all cases present in advanced stages
ANATOMY PRIMARY SITE: Cancer Cervix originates - vaginal surface - cervical canal NODAL STATIONS: > parametrial,internal iliac(obturator- hypogastric) >External iliac, presacral & common iliac METASTATIC SITES: Paraaortic nodes Lungs Bone Liver Brain
PRE-TREATMENT EVALUATION Complete physical and gynaecological examination CBC , Biochemistry and urine analysis Chest X Ray USG or CT Scan/MRI abdo & pelvis Biopsy punch CPE for bladder involvement Colposcopy/ Barium Enema / Sigmoidoscopy / IVU PET-CT is optional
CERVICAL CA STAGING: 0: Carcinoma-in-situ I: Confined to cervix Ia: Microinvasive Ia1: Depth </= 3mm Width </= 7mm Ia2: “ - 3 – 5 mm “ “ Ib: Invasive – Clinically visible Ib1: <4cm dia Ib2: >4cm dia II: Beyond cervix but not to pelvic wall IIa: Upper 2/3 of vagina IIb: Parametrial involvement (not to PSW) III: Extension to PSW / Lower 1/3 rd Vagina / Hydronephrosis IIIa: Lower 1/3 of vagina IIIb: PSW or hydronephrosis IV: Extension beyond true pelvis / bladder / rectum IVa: Bladder or rectal mucosa IVb: Spread outside true pelvis / Distant metastases
1A 4B </=4cm > 4cm Upper 2/3 of vagina Parametrial involvement not to PSW Lower 1/3 of vagina PSW or hydronephrosis Bladder or rectal mucosa Spread outside true pelvis / Distant metasts
RULES FOR CLASSIFICATION FIGO guidelines: Clinical-Diagnostic staging: Staging based on clinical evaluation(EUA) Clinical Staging must NOT be changed because of subsequent findings If stage doubtful EARLIER stage allocated
FOLLOWING EXAMINATIONS PERMITTED Inspection Palpation Colposcopy Endocervical curettage Hysteroscopy Cystoscopy Proctoscopy IVU X Ray Chest Conization regarded as physical examination
FOLLOWING INVESTIGATIONS OPTIONAL Lymphangiography,Venography Laproscopy USG,CT Scan,MRI (planning therapy) > Not generally available > intepretation variable FNAC : scan detected LN (planning therapy)
IMPACT OF IMAGING ON TREATMENT DECISION AND PLANNING The choice of treatment depends on – - Tumor size - Parametrial invasion - Invasion to the ureter, bladder & rectum - Lymph node metastases , esp above the level of true pelvis & distant metastasis
METS TO PARA- AORTIC LN Stg IB 8% Stg IIA 18% Stg IIB 20-30% Stg IIIB 33-46% Stg IV 25 -50%
ROLE OF IMAGING -USG Delineates the location ,size and extent of tumor Hydronephrosis Determine nodal spread Follow up Sensitivity for Parametrial spread – 56 % and specificity is – 67 %
24/12/05 14/03/05
ROLE OF IMAGING – CT To determine extent of disease to aid in planning treatment Determine nodal and Parametrial spread Sensitivity to determine parametrial spread is 67 % and specificity is 70 % Assessment of patients with a persistent mass after treatment for cervical cancer to differentiate residual or recurrent disease from benign anatomical or post treatment changes Bulky I B / Lower uterine segment involved or Stage II / III B
ROLE OF IMAGING - MR To determine extent of disease to aid in planning treatment Determine nodal and Parametrial spread Sensitivity to determine parametrial spread is 96 % and specificity is 92 % Recommended for assessment of depth of tumor/ Parametrial spread / tumor volume(> 40 cc worse prognosis) DURING THERAPY: During first 2 weeks provides tumor regression information especially for brachytherapy tailoring FOLLOW UP- Assessment of patients with a persistent mass after treatment for cervical cancer to differentiate residual or recurrent disease from benign anatomical or post treatment changes
CORELATION OF MRI WITH SURGICAL SPECIMEN
ROLE OF PET IMAGING Grigsby et al PET vs CT 2 yr PFS based on para-aortic positive nodes : - 64% in CT neg & PET neg - 18% in CT neg & PET + ve - 14% in CT + ve & PET + ve
ROLE OF PET – CA CERVIX Higher incidence of para – A LN positivity on PET when endometrial invasion present on D&C ( Grigsby et al) Planning for brachytherapy improving overall dose distribution & reduction of dose to sorrounding pelvis During therapy: Reduction in physiologic tumor volume of 50% within 20 days of Rx (Lin et al) Follow up
CT V/S MRI in cervical cancer
PROGNOSTIC FACTORS PATIENT: Age < 35 yrs have decreased survival European studies have shown the reverse TUMOR: Stage Tumor volume Vascular/ Lymphovascular Invasion
TREATMENT Choice of Treatment depends upon: 1. Stage of disease 2. Age 3. General Condition 4. Desire for fertility
RADIATION Radiotherapy uses megavoltage radiation Diagnostic Radiology uses kilovoltage radiation Radiation acts by interaction with patients tissues + reactions causing DNA damage
RADIATION – CA CERVIX EBRT : Whole pelvis + parametria + common iliac nodes + para- aortic LN Brachytherapy: Central disease for cervix , vagina, medail parametria
EBRT EBRT delivered before ICRT in patients : . Bulky cervical lesions to improve geometry for ICRT . Exophytic easily bleeding tumors . Tumors with necrosis / infection . Parametrial involvement
RADIOTHERAPY MODALITIES External Radiation: - Cobalt 60 gamma rays - Megavoltge Radiation with Linear Accelerator - Conventionl Fractionation 40-50Gy/25# to pelvis over 4 to 5 weeks Aim: Divide total dose over time Allows normal tissue to repair damage
EXTERNAL RADIOTHERAPY
TARGET VOLUME Whole Pelvis - encompassing extent of primary tumor - Lower margins vagina involved / not invov - Cover inguinal nodes if distal vagina involved - pelvic lymph nodes upto LV- 5 - precautions to keep min bowel in field Methods: - 2,3,4 Field 2-D RT - 3-D CRT - IMRT
TARGET VOLUME Post Operative RT: - extreme care for EBRT + ICRT . Bladder & rectum very close to sources . Vascular supply compromise by surgery
CONVENTIONAL TREATMENT Pelvic RT Paraaortic RT Mutic S et al IJROBP 55 (2003) 28 Region 2: 45Gy (para-aortic LN) Region 1: 45Gy + 5.4Gy EBT + brachytherapy boost
ROLE OF IMAGING FOR TARGET DEFINITION CT:  Treatment planning  Nodal assessment MRI:  Extra cervical spread  Design of lateral portals PET:  Lymph node involvement US/TRUS Mutic S et al IJROBP 55 (2003) 28
IMRT TO PELVIS
ROLE OF IMRT IN CERVIX CANCER For pelvic treatment sparing of normal structures (bone marrow, intestines) Potentially replace brachytherapy (80Gy possible with 0.5cm margin) - alternatively applicator based IMRT (Low et al 2002) Simultaneous integrated boost Lujan 2003
BRACHYTHERAPY – CA CERVIX LDR ( Low dose rate) 137 Cs 0.4 to 2 Gy/ hr HDR ( High Dose rate) 192 Ir > 12 Gy/ hr
BRACHYTHERAPY Intracavitary : Tandem and Ovoids Miniovoids Central Vaginal applicator Interstitial : Needles Ra , Cs Residual tumor, parametrial involvement
RADIATION THERAPY (BRACHYTHERAPY) ICRT: ( Done under GA ) Radical Boost ( Combined with EBRT ) Place applicators Vaginal packing radiopaque Radiographs using dummy sources Actual treatment Good application delivers high dose of RT to cervix, upper vagina, medial parametria without exceeding tolerance dose to bladder & rectum
HDR VS LDR LDR: 20 hrs continous application Admission to hospital Lesser number of applications (2) 30 Gy to pt A - 2nd week EBRT - after completion of EBRT HDR: Day procedure Treatment time 10 min 5 applications recommended 7 Gy to pt A – weekly starting week 2 of EBRT Lower toxicity (GI & GU) Control rates comparable
TANDEM WITH OVOIDS
BRACHYTHERAPY UNDER MR
MR - BRACHYTHERAPY
AFTER LOADER, WITH 192 IR
RT - COMPLICATIONS Acute – EBRT GI GU ICA Cx of GA Perforation/Laceration Late – Hematuria Hematochesia Fistula
MANAGEMENT OF CA CERVIX Stage 0 ( Carcinoma in situ) Ectocervical Lesions: - Loop Electrosurgical Excision (LEEP) - Laser - Conisation - Cryotherapy Endocervical Canal Lesions: - Laser/Cryo (Fertility preservation) - TAH - Radiation Therapy > Single Intracavitary insertion 80 Gy vaginal surface dose (Grade B recommendation)
POST SURGICAL TREATMENT – PATHOLOGICAL STAGING Accurate assessment of disease extent Does not change clinical stage Helps decide adjuvant treatment post Sx
STAGE IA Stg IA1 (not >3mm depth, no wider than 7mm) (Lymph node mets < 1%) - Conisation - Total Abdominal Hysterectomy or - Intracavitary brachytherapy (2# upto 100 Gy VSD) if no LVI, then no EBRT Stg IA2 (Lymph node mets < 5%) - Radical Hysterectomy Type II with pelvic node dissection or - Radiation therapy Radical Intracavitary / EBRT + Intracavitary
POST OPERATIVE RISK GROUPING HIGH RISK: Lymph node involvement Parametrial invasion Positive surgical margins Management Adjuvant CT + RT Reduces local failure rate & improves PFS vs Surgery alone
POST OPERATIVE RISK GROUPING INTERMEDIATE RISK: Deep Stromal Invasion Lymphovascular space invasion Tumor size > 4 cm Management Adjuvant RT if 2 out of 3 on HPR Reduces local failure rate & improves PFS vs Surgery alone
POST OPERATIVE SURGICAL RISK GROUPING LOW RISK: All other patients No adjuvant therapy recommended Observation
ISODOSE DISTRIBUTIONS
STAGEIB/IIA Appropriate Investigations (Lymph node mets 10-20%) SURGERY: Type III Radical Hysterectomy + Pelvic lymphadenectomy Risk Grouping Low - Observe Intermediate- Pelvic RT High Risk -- Concurrent CT+ RT( weekly cisplatin) OR RADIOTHERAPY IB1: Radical Radiotherapy IB2: CT+ RT Comparable OAS for RT and Sx ( 80 to 90 %)
STAGE IIB TO IIIB Appropriate Investigations + Imaging (LN inv upto 40%) Radiotherapy is primary local treatment Primary RT OAS – Stage II B – 65 - 75 %(5 Yr survival) Stage III B – 35 - 50 %(5 Yr survival) Stage IV A – 15 -20 %(5 Yr survival) Para-aortic LN negative: - CT+RT - Radical RT Para-aortic LN positive: - Extended field RT+CT - Neoadj CT 2-3 cycles  Extended field RT
STAGE II B TO III B Radiation dose – II B – 40 Gy EBRT to Pelvis + MLB – 20 Gy HDR – 7 Gy / 5 # or LDR – 30 Gy / 2 # to Pt A III B – 50 Gy EBRT / 25 # HDR 7 Gy / 3# or LDR – 25 Gy / 1 # to Pt A
STAGE IVA (15 -20 % 5 YR SURVIVAL) Pelvic Exenteration Neo adj CT or CT+RT Palliative Radiotherapy(30 Gy / 10 #) - Effective pain relief in symptomatic mets.(Bone/Brain/LN’s) - Control of bleeding
LOCAL RECURRENCE FOLL SURGERY RT (Grade C Recommendation) CT+RT (Grade B Recommendation) Pelvic Exenteration (Gr C recommendation)
LOCAL RECURRENCE POST RT Central Recurrence: Pelvic exenteration Selection of patient - DFS > 6 months - Recurrent tumor < 3 cm - No pelvic sidewall fixation Pelvic Sidewall / Extrapelvic Recurrence Palliative Chemotherapy
INTERSTITIAL RT INDICATIONS – RECURRENCE VAULT RECURRENCE PARAMETRIAL RECURRENCE
INTERSTITIAL BRACHYTHERAPY GYNECOLOGICAL APPLICATOR
NEEDLES TROUGH A TEMPLATE
HDR – LDR EQUIVALENTS HDR dose LDR equivalent 6 Gy x 432 Gy 6 Gy x 540 Gy Taiwan (1996) -— "Determination of the appropriate fraction number and size of the HDR brachytherapy for cervical cancer." Liu WS et al. Gynecol Oncol. 1996 Feb;60(2):295-300. Detroit (1991) -— "Comparison of high and low dose rate remote afterloading for cervix cancer and the importance of fractionation." Orton CG et al. Int J Radiat Oncol Biol Phys. 1991 Nov;21(6):1425-34.  Analysis of 17,000 cervix cancer pts in 56 institutions using HDR.  Conversion of dose from LDR to HDR, use dose factor of 0.54.
BRACHYTHERAPY Three systems: Paris system Stockholm system Manchester system
BRACHYTHERAPY Manchester system Point A dose definitions:  Allegedly, Point A corresponds to the paracervical triangle in the medial edge of the broad ligament where the uterine vessels cross the ureter  Original definition: draw a line connecting the superior aspects of the vaginal ovoids and measuring 2 cm superior along the tandem and then 2 cm perpendicular to this. (weakness: failure of localization radiographs to show the surface of the ovoids' caps)  Revised definition #1: 2 cm above the external cervical os and 2 cm lateral to midline  Revised definition #2 (1953, Tod & Meredith): 2 cm above the distal end of the lowest source in the tandem and 2 cm lateral to the tandem  Common variation: use flange at cervical os  Point B - 5 cm lateral from the midline at the same level as Point A
MANCHESTER SYSTEM The Manchester applicators consisted of a rubber tandem and two ellipsoid "ovoids" with diameters 2, 2.5, and 3 cm. No shielding in ovoids, so needed generous packing anteriorly and posteriorly. Used radium. Used 17.5, 20, and 22.5 mg Ra for the small, medium, and large ovoids, respectively. Designed such that: Point A dose rate was approximately 0.53 Gy/hr for all allowed applicator loadings Vaginal contribution to Point A was limited to 40% of the total dose The rectal dose should be 80% or less of the Point A dose Prescribed 80 Gy to point A in two applications, total of 144 hours, in the absence of external beam. Weakness: - Wide variation in Point A in respect to the ovoids. - Point A often occurs in a high-gradient region of the isodose distribution. Therefore, minor differences in position can result in large differences in dose.
ICRT - APPLICATORS Fletcher applicator Derives from the Manchester system. Added internal shielding in the colpostats. Afterloading ability. Colpostat has 2 cm diameter that can be increased to 2.5 or 3 cm by the addition of plastic caps. Minicolpostats are 1.6 cm and have a flat inner surface and have no shielding. Used 15, 20, and 25 mg Ra for small, medium, and large colpostats; use 10 for the minis. Tandems are available in three curvatures. Flange on the tandem avoids slippage past the cervical os, and a keel helps keep it from rotating. A yoke attaches the tandem and colpostats to maintain proper position. Loading of the tandem is 20 - 10 - 10 mgRaEq with Cs-137. Plastic Fletcher applicators are available to be compatible with CT simulation or MRI.
BRACHYTHERAPY PLANNING AP View  Tandem midline, unrotated  Tandem midway between colpostats  Keel (flange) in close proximity to gold seed markers  Colpostats high in the fornices along cervix Lateral View  Tandem bisects the colpostat  Sufficient anterior and posterior packing  Foley balloon firmly tugged down
BRACHYTHERAPY Good Insertion Characteristics American Brachytherapy Society (ABS) Recommend prescribing to Point H - Draw a line connecting the mid-dwell positions of the ovoids and find the point this line intersects the tandem. Follow 2 cm superior (along the tandem) plus the radius of the ovoids, then 2 cm perpendicular to the tandem. Note: This is basically 2 cm above the top of the ovoids.
BRACHYTHERAPY  Specification of image-guided GTV and CTV Osaka (Japan)(1983-1989) -- HDR fractional dose 7.5 Gy/fx vs. 6.0 Gy/fx  Randomized. 165 patients with cervix adenoCA, Stage IA-IV. Treated with 2 separated dose schedules depending on stage. Arm 1) EBRT + BT using 7.5 Gy/fx (either 37.5/5 or 30/4 or 22.5/3) vs. Arm 2) EBRT + BT using 6.0 Gy/fx (either 36/6 or 30/5 or 18/3).  5-years; 1994 -- "A prospective randomized study concerning the point A dose in high-dose rate intracavitary therapy for carcinoma of the uterine cervix. The final results." (Chatani M, Strahlenther Onkol. 1994 Nov;170(11):636-42.)  Outcome: 5-year CSS: Stage I 100% vs. 100%, Stage II 82% vs. 85%, Stage III 62% vs. 52%, Stage IV 22% vs. 31% (all NS). No difference in LRF or DM  Toxicity: No difference  Conclusion: No difference between the two treatment schedules; small number of fractions at 7.5 Gy/fx may be advantageous due to short duration
DOSE CALCULATIONS - BRACHYTHERAPY ABS, Problem: What dose/fraction of HDR delivered in six fractions will be equivalent in terms of tumor control to 60 Gy delivered to Point A at 0.55 Gy h−1? Solution: Assume α/β (tumor) = 10 Gy, μ (tumor) = 0.46 h−1. Then: BED (LDR) = 60[1 + (2 × 0.55)/(0.46 × 10)] = 74.3 Equating this to the BED for 6 HDR fractions with dose/fraction d gives: 74.3 = 6d(1 + d/10) Solving this quadratic equation for d gives: d = 7.20 Gy. Conclusion: 6 fractions of 7.20 Gy with HDR is equivalent in terms of tumor control to 60 Gy delivered at 0.55 Gy h−1.
HDR dose LDR equivalent 6 Gy x 4 = 32 Gy 6 Gy x 5 = 40 Gy
Bladder point - on the surface of a Foley balloon filled with 7 cc of contrast; located at center of balloon on AP film, posterior surface of the balloon on a line through midballoon on lateral film Rectum point - 0.5 cm posterior to the posterior vaginal wall at the level of the bisection of the T&O. May also use barium + air contrast in rectum Vaginal mucosa - at surface of ovoids Pelvic sidewall, and external, common, and para-aortic LN points should be reported according to ICRU defintions Keep dose to rectum and bladder points below 80% of dose to Point H (ABS recommendation). Or, maximum dose to rectum, 75 Gy (avg dose 68 Gy); bladder, 80 Gy (avg 70 Gy); vagina, 120-140 (avg 125 Gy).
BRACHYTHERAPY - COMPLICATIONS Acute complications (1960-1992) - "Perioperative and postoperative complications of intracavitary radiation for FIGO stage I- III carcinoma of the cervix." Jhingran A et al. Int J Radiat Oncol Biol Phys. 2000; 46 (5):1177-83  Retrospective. 7662 intracavitary procedures in 4043 patients for FIGO I-III cervical CA  2.8% uterine perforation rate, 14% have fever >101 C during at least 1 admission, 0.1% fatal thromboembolism rate. Perforation did not affect DSS in stage I, II, but did lead to worse prognosis in stage III.
Late complications 1995 (1960-89) — "Time course and incidence of late complications in patients treated with radiation therapy for FIGO stage IB carcinoma of the uterine cervix." Eifel PJ et al. Int J Radiat Oncol Biol Phys. 1995 Jul 30;32(5):1289-300.  Retrospective. 1784 pts, FIGO stage IB. Grade 3 or higher complications occurred in 7.7% at 3 yrs and 9.3% at 10 yrs. After 10 yrs, 0.34% per year, so at 20 yrs, 14.4% risk.  Risk of rectal complications was the greatest, more than urinary complications.  Conclusion: low risk of major complications using brachytherapy.
BRACHYTHERAPY Guidelines Keep total duration (of EBRT + implants) to < 8 weeks. For HDR, this necessitates beginning brachytherapy while EBRT is ongoing. Usually give an HDR treatment once per week, not giving EBRT on that day. ABS recommendations LDR (2002) — "The American Brachytherapy Society recommendations for low-dose-rate brachytherapy for carcinoma of the cervix." Nag S et al. Int J Radiat Oncol Biol Phys. 2002 Jan 1;52(1):33-48. HDR (2000) — "The American Brachytherapy Society recommendations for high-dose-rate brachytherapy for carcinoma of the cervix." Nag S et al. Int J Radiat Oncol Biol Phys. 2000 Aug 1;48(1):201-11.
SCREENING FOR CANCER CERVIX NCCP – Priority for early detection & treatment No current screening programme- technical, financial, manpower constraints Aim: Reduce morbidity & mortality Detection of precancerous lesions HPV Vaccine – Primary prevention . It is a bivalent virus like particle against subtypes 16 & 18.Three doses at 0 , 1 & 6 mths. Efficacy – 100 % in preventing new and persistent infection of genital tract. Duration of protection – Not known
UNITS OF RADIATION Roentgen : Unit of exposure Absorbed Dose: Energy deposited by radiation as it passes thru tissue to create biological effects RAD: Represents absorption of 0.01J/Kg of absorbing material GRAY: Dose associated with absorption of 1J of energy / kg of absorbing material 1 RAD = 10 mGY
RADIATION UNITS Equivalent Dose(E): Diff types of radiation produce diff degree of biological damage SIEVERT = Measures dose equivalent Absorbed Dose (Gy) X Radiation weighting factor For this procedure: Your effective radiation dose is: Comparable to natural background radiation for: (CT)- Abdomen 10 mSv 3 years (IVP) 1.6 mSv 6 months (CT)-Head 2 mSv 8 months (CT)-Chest 8 mSv 3 years Radiography- Chest 0.1 mSv 10 days

More Related Content

PPTX
Prophylactic cranial irradiation
byShreya Singh
 
PPTX
Radiotherapy in benign disease.
byParag Roy
 
PPTX
carcinoma breast RADIOTHERAPY TECHNIQUES
byNabeel Yahiya
 
PPTX
Accelerated partial breast irradiation
byHimanshu Mekap
 
PPT
Nasopharyngeal brachytherapy
byAshutosh Mukherji
 
PPTX
image guided brachytherapy carcinoma cervix
byIsha Jaiswal
 
PPTX
Radiotherapy planning for vulvar cancer September 2020
byGebrekirstos Hagos Gebrekirstos, MD
 
PPTX
ICRU CONCEPT
byKanhu Charan
 
Prophylactic cranial irradiation
byShreya Singh
 
Radiotherapy in benign disease.
byParag Roy
 
carcinoma breast RADIOTHERAPY TECHNIQUES
byNabeel Yahiya
 
Accelerated partial breast irradiation
byHimanshu Mekap
 
Nasopharyngeal brachytherapy
byAshutosh Mukherji
 
image guided brachytherapy carcinoma cervix
byIsha Jaiswal
 
Radiotherapy planning for vulvar cancer September 2020
byGebrekirstos Hagos Gebrekirstos, MD
 
ICRU CONCEPT
byKanhu Charan
 

What's hot

PPTX
CA ENDOMETRIUM-KIRAN.pptx
byKiran Ramakrishna
 
PPTX
EBRT IN CARCINOMA CERVIX
byIsha Jaiswal
 
PPTX
Cervix landmark trials- kiran
byKiran Ramakrishna
 
PPT
Brachytherapy Final
byPGIMER, AIIMS
 
PPTX
Conventional Brachytherapy in carcinoma cervix
byIsha Jaiswal
 
PPTX
TIME DOSE & FRACTIONATION
byIsha Jaiswal
 
PDF
Cervix External Beam Radiotherapy techniques
byAnimesh Agrawal
 
PPTX
Icru – 83 dr. upasna
byUpasna Saxena
 
PPTX
Radiation for Cervix Cancer
byRobert J Miller MD
 
PPTX
Radiotherapy breast
byvrinda singla
 
PPTX
Plan evaluation in RADIOTHERAPY
byKanhu Charan
 
PPTX
Quantec dr. upasna saxena (2)
byUpasna Saxena
 
ODP
radiotherapy planning of CA maxilla
byAnil Gupta
 
PDF
Radiotherapy techniques for Breast Cancer
byAnimesh Agrawal
 
PPTX
beam modifying devises
bysaikishore15
 
PPTX
Principals of brachytherapy shk
byShashank Bansal
 
PPTX
MOTION MANAGEMENT IN RADIOTHERAPY
byKanhu Charan
 
PPTX
Radiotherapy in ca esophagus
byIsha Jaiswal
 
PPTX
Intraoperative Radiotherapy (IORT)
byVictor Ekpo
 
PPTX
Rectal cancer Preoperative Radiotherapy- Short vs long course
byGaurav Kumar
 
CA ENDOMETRIUM-KIRAN.pptx
byKiran Ramakrishna
 
EBRT IN CARCINOMA CERVIX
byIsha Jaiswal
 
Cervix landmark trials- kiran
byKiran Ramakrishna
 
Brachytherapy Final
byPGIMER, AIIMS
 
Conventional Brachytherapy in carcinoma cervix
byIsha Jaiswal
 
TIME DOSE & FRACTIONATION
byIsha Jaiswal
 
Cervix External Beam Radiotherapy techniques
byAnimesh Agrawal
 
Icru – 83 dr. upasna
byUpasna Saxena
 
Radiation for Cervix Cancer
byRobert J Miller MD
 
Radiotherapy breast
byvrinda singla
 
Plan evaluation in RADIOTHERAPY
byKanhu Charan
 
Quantec dr. upasna saxena (2)
byUpasna Saxena
 
radiotherapy planning of CA maxilla
byAnil Gupta
 
Radiotherapy techniques for Breast Cancer
byAnimesh Agrawal
 
beam modifying devises
bysaikishore15
 
Principals of brachytherapy shk
byShashank Bansal
 
MOTION MANAGEMENT IN RADIOTHERAPY
byKanhu Charan
 
Radiotherapy in ca esophagus
byIsha Jaiswal
 
Intraoperative Radiotherapy (IORT)
byVictor Ekpo
 
Rectal cancer Preoperative Radiotherapy- Short vs long course
byGaurav Kumar
 

Similar to Ca Cervix.ppt

PPTX
Management of Carcinoma cervix
byDrrajan Paliwal
 
PPTX
Management of carcinoma cervix
byVarshu Goel
 
PPTX
Ca Cervix Dr Naresh Jakhotia
bydrnareshjakhotia
 
PPTX
CA CX TREATMENT NEW.pptx for mbbs students
byDeepaliBhat6
 
PPT
carcinoma-cervix2.ppt
byRevantAgarwal2
 
PPT
carcinoma_cervix2222222222222222222222222222222.ppt
bymousaderhem1
 
PPT
carcinoma_cervix2.ppt
bypatelbhavinnarayanbh
 
PPT
carcinoma_cervix2.ppt
byrobinson405376
 
PPTX
Ca cervix—standards of care
byDrAnkitaPatel
 
PPTX
Ca cervix—standards of care
byDrAnkitaPatel
 
PPT
Radiotherapy in carcinoma cervix
byDebarshi Lahiri
 
PPTX
carcinoma of cervix and its presentations, treatment
bychetnatrivedi3
 
PPTX
Carcinoma cervix by Maj shahed oncologist .pptx
bybabulakter74254
 
PPTX
cervical cancer lecture- management and staging
byPooja Agarwal
 
PDF
contouring guidelines ca cervix.pdf
byMAMC,Delhi
 
PPTX
management of carcinoma cervix- 2021
byDr. Naina Kumar Agarwal
 
PPTX
Radiotherapy practices in GYN malignancies
byAjeet Gandhi
 
PPTX
Carcinoma cervix management : 2022 nccn guidelines
byDr. Naina Kumar Agarwal
 
PPTX
Advanced Radiotherapy for Cervical cancers for physicians
byKanhu Charan
 
PPTX
Managment of Cervical Cancer
byAjay Sasidharan
 
Management of Carcinoma cervix
byDrrajan Paliwal
 
Management of carcinoma cervix
byVarshu Goel
 
Ca Cervix Dr Naresh Jakhotia
bydrnareshjakhotia
 
CA CX TREATMENT NEW.pptx for mbbs students
byDeepaliBhat6
 
carcinoma-cervix2.ppt
byRevantAgarwal2
 
carcinoma_cervix2222222222222222222222222222222.ppt
bymousaderhem1
 
carcinoma_cervix2.ppt
bypatelbhavinnarayanbh
 
carcinoma_cervix2.ppt
byrobinson405376
 
Ca cervix—standards of care
byDrAnkitaPatel
 
Ca cervix—standards of care
byDrAnkitaPatel
 
Radiotherapy in carcinoma cervix
byDebarshi Lahiri
 
carcinoma of cervix and its presentations, treatment
bychetnatrivedi3
 
Carcinoma cervix by Maj shahed oncologist .pptx
bybabulakter74254
 
cervical cancer lecture- management and staging
byPooja Agarwal
 
contouring guidelines ca cervix.pdf
byMAMC,Delhi
 
management of carcinoma cervix- 2021
byDr. Naina Kumar Agarwal
 
Radiotherapy practices in GYN malignancies
byAjeet Gandhi
 
Carcinoma cervix management : 2022 nccn guidelines
byDr. Naina Kumar Agarwal
 
Advanced Radiotherapy for Cervical cancers for physicians
byKanhu Charan
 
Managment of Cervical Cancer
byAjay Sasidharan
 

Recently uploaded

PPTX
Types of Communication Disorders SLP lecture 3.pptx
byDr Zonera Khalid PT
 
PPTX
Seminar on Ebola virus , سیمینارێکی ئامادەکراو لەسەر Ebola virus
bydanaShalal2
 
PPTX
"SUPER FLU": TRUTH VS HYPE - WHAT CLINICIANS MUST KNOW
byArchitMehta11
 
PDF
RETINAL VEIN OCCLUSION; CRVO & BRVO types, pathophysiology, diagnosis & manag...
bySamikshaRai22
 
PPTX
Mental Health Awareness Campaign 2025 PPT.PPTX
byBirendra Bhatt
 
PPTX
Historical background and development of profession of pharmacy pptx
byGulam Muheyuddeen
 
PPTX
Pressure ulcer Internal KPIs results for July,2024.pptx
byprofyasser95
 
PPTX
Management of TB in adults.pptx by Dr.Momen Mukhtar Abdalla MD,FCCP
bymomen14
 
PPTX
Neurogenic oropharyngeal dysphagia in stroke 2025.pptx
byHeba El Saeid
 
PPTX
Imaging of benign focal lesions of the Liver
byDr. Aryan (Anish Dhakal)
 
PPTX
Slenderiiz Dual Drops: Slenderiix & Xceler8 Insider Guide
byDualDrops.com
 
PPTX
Structural Elucidation of Squalene of AMC
bySumitSharma743530
 
PPTX
SPS_PE_LAB 2_Liquid Operation-Centrifugation.pptx
bysupriyabhagwatsps
 
PPTX
Pharmacology and Toxicology Multiple Choice Questions (MCQs) Part 3
byVanarajRabari
 
PPTX
EYELID TUMOURS . CLINICAL FEATURES . DIAGNOSIS . SURGICAL MANAGEMENT
byDr Aarushi Choudhary
 
PPTX
Unit- II (Bioavaliability & Bioequivalence).pptx
byUditiHanda
 
PPTX
MICROSPORIDIAL KERATITIS , CLINICAL FEATURES , TREATMENT
byDr Aarushi Choudhary
 
PPTX
NUCLEAR CARDIOLOGY2025bbbbbbbbbbbbbbbbbb.pptx
byhospital
 
PPT
Many Roads to Myeloma Remission: Making Sequential Choices With BCMA and Non-...
byPVI, PeerView Institute for Medical Education
 
PPTX
OBSTRUCTED LABOR - Edward Mwansa.LGH.pptx
byedwardmwansa4
 
Types of Communication Disorders SLP lecture 3.pptx
byDr Zonera Khalid PT
 
Seminar on Ebola virus , سیمینارێکی ئامادەکراو لەسەر Ebola virus
bydanaShalal2
 
"SUPER FLU": TRUTH VS HYPE - WHAT CLINICIANS MUST KNOW
byArchitMehta11
 
RETINAL VEIN OCCLUSION; CRVO & BRVO types, pathophysiology, diagnosis & manag...
bySamikshaRai22
 
Mental Health Awareness Campaign 2025 PPT.PPTX
byBirendra Bhatt
 
Historical background and development of profession of pharmacy pptx
byGulam Muheyuddeen
 
Pressure ulcer Internal KPIs results for July,2024.pptx
byprofyasser95
 
Management of TB in adults.pptx by Dr.Momen Mukhtar Abdalla MD,FCCP
bymomen14
 
Neurogenic oropharyngeal dysphagia in stroke 2025.pptx
byHeba El Saeid
 
Imaging of benign focal lesions of the Liver
byDr. Aryan (Anish Dhakal)
 
Slenderiiz Dual Drops: Slenderiix & Xceler8 Insider Guide
byDualDrops.com
 
Structural Elucidation of Squalene of AMC
bySumitSharma743530
 
SPS_PE_LAB 2_Liquid Operation-Centrifugation.pptx
bysupriyabhagwatsps
 
Pharmacology and Toxicology Multiple Choice Questions (MCQs) Part 3
byVanarajRabari
 
EYELID TUMOURS . CLINICAL FEATURES . DIAGNOSIS . SURGICAL MANAGEMENT
byDr Aarushi Choudhary
 
Unit- II (Bioavaliability & Bioequivalence).pptx
byUditiHanda
 
MICROSPORIDIAL KERATITIS , CLINICAL FEATURES , TREATMENT
byDr Aarushi Choudhary
 
NUCLEAR CARDIOLOGY2025bbbbbbbbbbbbbbbbbb.pptx
byhospital
 
Many Roads to Myeloma Remission: Making Sequential Choices With BCMA and Non-...
byPVI, PeerView Institute for Medical Education
 
OBSTRUCTED LABOR - Edward Mwansa.LGH.pptx
byedwardmwansa4
 

Ca Cervix.ppt

  • 1.
  • 2.
    CANCER CERVIX Estimated 4,70000new cases per year worldwide > 80% cases in developing countries 27% cases occur in India 1,20000 cases annually 71,000 deaths 15.2% to 50% of all female cancers >80% of all cases present in advanced stages
  • 3.
    ANATOMY PRIMARY SITE: Cancer Cervixoriginates - vaginal surface - cervical canal NODAL STATIONS: > parametrial,internal iliac(obturator- hypogastric) >External iliac, presacral & common iliac METASTATIC SITES: Paraaortic nodes Lungs Bone Liver Brain
  • 4.
    PRE-TREATMENT EVALUATION Complete physicaland gynaecological examination CBC , Biochemistry and urine analysis Chest X Ray USG or CT Scan/MRI abdo & pelvis Biopsy punch CPE for bladder involvement Colposcopy/ Barium Enema / Sigmoidoscopy / IVU PET-CT is optional
  • 5.
    CERVICAL CA STAGING: 0:Carcinoma-in-situ I: Confined to cervix Ia: Microinvasive Ia1: Depth </= 3mm Width </= 7mm Ia2: “ - 3 – 5 mm “ “ Ib: Invasive – Clinically visible Ib1: <4cm dia Ib2: >4cm dia II: Beyond cervix but not to pelvic wall IIa: Upper 2/3 of vagina IIb: Parametrial involvement (not to PSW) III: Extension to PSW / Lower 1/3 rd Vagina / Hydronephrosis IIIa: Lower 1/3 of vagina IIIb: PSW or hydronephrosis IV: Extension beyond true pelvis / bladder / rectum IVa: Bladder or rectal mucosa IVb: Spread outside true pelvis / Distant metastases
  • 6.
    1A 4B </=4cm > 4cm Upper2/3 of vagina Parametrial involvement not to PSW Lower 1/3 of vagina PSW or hydronephrosis Bladder or rectal mucosa Spread outside true pelvis / Distant metasts
  • 7.
    RULES FOR CLASSIFICATION FIGOguidelines: Clinical-Diagnostic staging: Staging based on clinical evaluation(EUA) Clinical Staging must NOT be changed because of subsequent findings If stage doubtful EARLIER stage allocated
  • 8.
  • 9.
    FOLLOWING INVESTIGATIONS OPTIONAL Lymphangiography,Venography Laproscopy USG,CT Scan,MRI(planning therapy) > Not generally available > intepretation variable FNAC : scan detected LN (planning therapy)
  • 10.
    IMPACT OF IMAGINGON TREATMENT DECISION AND PLANNING The choice of treatment depends on – - Tumor size - Parametrial invasion - Invasion to the ureter, bladder & rectum - Lymph node metastases , esp above the level of true pelvis & distant metastasis
  • 11.
    METS TO PARA- AORTICLN Stg IB 8% Stg IIA 18% Stg IIB 20-30% Stg IIIB 33-46% Stg IV 25 -50%
  • 12.
    ROLE OF IMAGING-USG Delineates the location ,size and extent of tumor Hydronephrosis Determine nodal spread Follow up Sensitivity for Parametrial spread – 56 % and specificity is – 67 %
  • 13.
  • 14.
    ROLE OF IMAGING– CT To determine extent of disease to aid in planning treatment Determine nodal and Parametrial spread Sensitivity to determine parametrial spread is 67 % and specificity is 70 % Assessment of patients with a persistent mass after treatment for cervical cancer to differentiate residual or recurrent disease from benign anatomical or post treatment changes Bulky I B / Lower uterine segment involved or Stage II / III B
  • 15.
    ROLE OF IMAGING- MR To determine extent of disease to aid in planning treatment Determine nodal and Parametrial spread Sensitivity to determine parametrial spread is 96 % and specificity is 92 % Recommended for assessment of depth of tumor/ Parametrial spread / tumor volume(> 40 cc worse prognosis) DURING THERAPY: During first 2 weeks provides tumor regression information especially for brachytherapy tailoring FOLLOW UP- Assessment of patients with a persistent mass after treatment for cervical cancer to differentiate residual or recurrent disease from benign anatomical or post treatment changes
  • 16.
    CORELATION OF MRIWITH SURGICAL SPECIMEN
  • 17.
    ROLE OF PETIMAGING Grigsby et al PET vs CT 2 yr PFS based on para-aortic positive nodes : - 64% in CT neg & PET neg - 18% in CT neg & PET + ve - 14% in CT + ve & PET + ve
  • 18.
    ROLE OF PET– CA CERVIX Higher incidence of para – A LN positivity on PET when endometrial invasion present on D&C ( Grigsby et al) Planning for brachytherapy improving overall dose distribution & reduction of dose to sorrounding pelvis During therapy: Reduction in physiologic tumor volume of 50% within 20 days of Rx (Lin et al) Follow up
  • 19.
    CT V/S MRIin cervical cancer
  • 20.
    PROGNOSTIC FACTORS PATIENT: Age <35 yrs have decreased survival European studies have shown the reverse TUMOR: Stage Tumor volume Vascular/ Lymphovascular Invasion
  • 21.
    TREATMENT Choice of Treatmentdepends upon: 1. Stage of disease 2. Age 3. General Condition 4. Desire for fertility
  • 22.
    RADIATION Radiotherapy uses megavoltageradiation Diagnostic Radiology uses kilovoltage radiation Radiation acts by interaction with patients tissues + reactions causing DNA damage
  • 23.
    RADIATION – CACERVIX EBRT : Whole pelvis + parametria + common iliac nodes + para- aortic LN Brachytherapy: Central disease for cervix , vagina, medail parametria
  • 24.
    EBRT EBRT delivered beforeICRT in patients : . Bulky cervical lesions to improve geometry for ICRT . Exophytic easily bleeding tumors . Tumors with necrosis / infection . Parametrial involvement
  • 25.
    RADIOTHERAPY MODALITIES External Radiation: -Cobalt 60 gamma rays - Megavoltge Radiation with Linear Accelerator - Conventionl Fractionation 40-50Gy/25# to pelvis over 4 to 5 weeks Aim: Divide total dose over time Allows normal tissue to repair damage
  • 26.
  • 27.
    TARGET VOLUME Whole Pelvis -encompassing extent of primary tumor - Lower margins vagina involved / not invov - Cover inguinal nodes if distal vagina involved - pelvic lymph nodes upto LV- 5 - precautions to keep min bowel in field Methods: - 2,3,4 Field 2-D RT - 3-D CRT - IMRT
  • 28.
    TARGET VOLUME Post OperativeRT: - extreme care for EBRT + ICRT . Bladder & rectum very close to sources . Vascular supply compromise by surgery
  • 29.
    CONVENTIONAL TREATMENT Pelvic RT ParaaorticRT Mutic S et al IJROBP 55 (2003) 28 Region 2: 45Gy (para-aortic LN) Region 1: 45Gy + 5.4Gy EBT + brachytherapy boost
  • 30.
    ROLE OF IMAGINGFOR TARGET DEFINITION CT:  Treatment planning  Nodal assessment MRI:  Extra cervical spread  Design of lateral portals PET:  Lymph node involvement US/TRUS Mutic S et al IJROBP 55 (2003) 28
  • 31.
  • 32.
    ROLE OF IMRTIN CERVIX CANCER For pelvic treatment sparing of normal structures (bone marrow, intestines) Potentially replace brachytherapy (80Gy possible with 0.5cm margin) - alternatively applicator based IMRT (Low et al 2002) Simultaneous integrated boost Lujan 2003
  • 33.
    BRACHYTHERAPY – CA CERVIX LDR( Low dose rate) 137 Cs 0.4 to 2 Gy/ hr HDR ( High Dose rate) 192 Ir > 12 Gy/ hr
  • 34.
    BRACHYTHERAPY Intracavitary : Tandemand Ovoids Miniovoids Central Vaginal applicator Interstitial : Needles Ra , Cs Residual tumor, parametrial involvement
  • 35.
    RADIATION THERAPY (BRACHYTHERAPY) ICRT: (Done under GA ) Radical Boost ( Combined with EBRT ) Place applicators Vaginal packing radiopaque Radiographs using dummy sources Actual treatment Good application delivers high dose of RT to cervix, upper vagina, medial parametria without exceeding tolerance dose to bladder & rectum
  • 36.
    HDR VS LDR LDR:20 hrs continous application Admission to hospital Lesser number of applications (2) 30 Gy to pt A - 2nd week EBRT - after completion of EBRT HDR: Day procedure Treatment time 10 min 5 applications recommended 7 Gy to pt A – weekly starting week 2 of EBRT Lower toxicity (GI & GU) Control rates comparable
  • 37.
  • 38.
  • 39.
  • 40.
  • 41.
    RT - COMPLICATIONS Acute– EBRT GI GU ICA Cx of GA Perforation/Laceration Late – Hematuria Hematochesia Fistula
  • 42.
    MANAGEMENT OF CACERVIX Stage 0 ( Carcinoma in situ) Ectocervical Lesions: - Loop Electrosurgical Excision (LEEP) - Laser - Conisation - Cryotherapy Endocervical Canal Lesions: - Laser/Cryo (Fertility preservation) - TAH - Radiation Therapy > Single Intracavitary insertion 80 Gy vaginal surface dose (Grade B recommendation)
  • 43.
    POST SURGICAL TREATMENT– PATHOLOGICAL STAGING Accurate assessment of disease extent Does not change clinical stage Helps decide adjuvant treatment post Sx
  • 44.
    STAGE IA Stg IA1(not >3mm depth, no wider than 7mm) (Lymph node mets < 1%) - Conisation - Total Abdominal Hysterectomy or - Intracavitary brachytherapy (2# upto 100 Gy VSD) if no LVI, then no EBRT Stg IA2 (Lymph node mets < 5%) - Radical Hysterectomy Type II with pelvic node dissection or - Radiation therapy Radical Intracavitary / EBRT + Intracavitary
  • 45.
    POST OPERATIVE RISK GROUPING HIGHRISK: Lymph node involvement Parametrial invasion Positive surgical margins Management Adjuvant CT + RT Reduces local failure rate & improves PFS vs Surgery alone
  • 46.
    POST OPERATIVE RISK GROUPING INTERMEDIATERISK: Deep Stromal Invasion Lymphovascular space invasion Tumor size > 4 cm Management Adjuvant RT if 2 out of 3 on HPR Reduces local failure rate & improves PFS vs Surgery alone
  • 47.
    POST OPERATIVE SURGICAL RISKGROUPING LOW RISK: All other patients No adjuvant therapy recommended Observation
  • 48.
  • 49.
    STAGEIB/IIA Appropriate Investigations (Lymph nodemets 10-20%) SURGERY: Type III Radical Hysterectomy + Pelvic lymphadenectomy Risk Grouping Low - Observe Intermediate- Pelvic RT High Risk -- Concurrent CT+ RT( weekly cisplatin) OR RADIOTHERAPY IB1: Radical Radiotherapy IB2: CT+ RT Comparable OAS for RT and Sx ( 80 to 90 %)
  • 50.
    STAGE IIB TOIIIB Appropriate Investigations + Imaging (LN inv upto 40%) Radiotherapy is primary local treatment Primary RT OAS – Stage II B – 65 - 75 %(5 Yr survival) Stage III B – 35 - 50 %(5 Yr survival) Stage IV A – 15 -20 %(5 Yr survival) Para-aortic LN negative: - CT+RT - Radical RT Para-aortic LN positive: - Extended field RT+CT - Neoadj CT 2-3 cycles  Extended field RT
  • 51.
    STAGE II BTO III B Radiation dose – II B – 40 Gy EBRT to Pelvis + MLB – 20 Gy HDR – 7 Gy / 5 # or LDR – 30 Gy / 2 # to Pt A III B – 50 Gy EBRT / 25 # HDR 7 Gy / 3# or LDR – 25 Gy / 1 # to Pt A
  • 52.
    STAGE IVA (15-20 % 5 YR SURVIVAL) Pelvic Exenteration Neo adj CT or CT+RT Palliative Radiotherapy(30 Gy / 10 #) - Effective pain relief in symptomatic mets.(Bone/Brain/LN’s) - Control of bleeding
  • 53.
    LOCAL RECURRENCE FOLL SURGERY RT(Grade C Recommendation) CT+RT (Grade B Recommendation) Pelvic Exenteration (Gr C recommendation)
  • 54.
    LOCAL RECURRENCE POST RT CentralRecurrence: Pelvic exenteration Selection of patient - DFS > 6 months - Recurrent tumor < 3 cm - No pelvic sidewall fixation Pelvic Sidewall / Extrapelvic Recurrence Palliative Chemotherapy
  • 55.
    INTERSTITIAL RT INDICATIONS – RECURRENCE VAULTRECURRENCE PARAMETRIAL RECURRENCE
  • 56.
  • 57.
  • 58.
    HDR – LDREQUIVALENTS HDR dose LDR equivalent 6 Gy x 432 Gy 6 Gy x 540 Gy Taiwan (1996) -— "Determination of the appropriate fraction number and size of the HDR brachytherapy for cervical cancer." Liu WS et al. Gynecol Oncol. 1996 Feb;60(2):295-300. Detroit (1991) -— "Comparison of high and low dose rate remote afterloading for cervix cancer and the importance of fractionation." Orton CG et al. Int J Radiat Oncol Biol Phys. 1991 Nov;21(6):1425-34.  Analysis of 17,000 cervix cancer pts in 56 institutions using HDR.  Conversion of dose from LDR to HDR, use dose factor of 0.54.
  • 59.
  • 60.
    BRACHYTHERAPY Manchester system Point Adose definitions:  Allegedly, Point A corresponds to the paracervical triangle in the medial edge of the broad ligament where the uterine vessels cross the ureter  Original definition: draw a line connecting the superior aspects of the vaginal ovoids and measuring 2 cm superior along the tandem and then 2 cm perpendicular to this. (weakness: failure of localization radiographs to show the surface of the ovoids' caps)  Revised definition #1: 2 cm above the external cervical os and 2 cm lateral to midline  Revised definition #2 (1953, Tod & Meredith): 2 cm above the distal end of the lowest source in the tandem and 2 cm lateral to the tandem  Common variation: use flange at cervical os  Point B - 5 cm lateral from the midline at the same level as Point A
  • 61.
    MANCHESTER SYSTEM The Manchesterapplicators consisted of a rubber tandem and two ellipsoid "ovoids" with diameters 2, 2.5, and 3 cm. No shielding in ovoids, so needed generous packing anteriorly and posteriorly. Used radium. Used 17.5, 20, and 22.5 mg Ra for the small, medium, and large ovoids, respectively. Designed such that: Point A dose rate was approximately 0.53 Gy/hr for all allowed applicator loadings Vaginal contribution to Point A was limited to 40% of the total dose The rectal dose should be 80% or less of the Point A dose Prescribed 80 Gy to point A in two applications, total of 144 hours, in the absence of external beam. Weakness: - Wide variation in Point A in respect to the ovoids. - Point A often occurs in a high-gradient region of the isodose distribution. Therefore, minor differences in position can result in large differences in dose.
  • 62.
    ICRT - APPLICATORS Fletcherapplicator Derives from the Manchester system. Added internal shielding in the colpostats. Afterloading ability. Colpostat has 2 cm diameter that can be increased to 2.5 or 3 cm by the addition of plastic caps. Minicolpostats are 1.6 cm and have a flat inner surface and have no shielding. Used 15, 20, and 25 mg Ra for small, medium, and large colpostats; use 10 for the minis. Tandems are available in three curvatures. Flange on the tandem avoids slippage past the cervical os, and a keel helps keep it from rotating. A yoke attaches the tandem and colpostats to maintain proper position. Loading of the tandem is 20 - 10 - 10 mgRaEq with Cs-137. Plastic Fletcher applicators are available to be compatible with CT simulation or MRI.
  • 63.
    BRACHYTHERAPY PLANNING AP View Tandem midline, unrotated  Tandem midway between colpostats  Keel (flange) in close proximity to gold seed markers  Colpostats high in the fornices along cervix Lateral View  Tandem bisects the colpostat  Sufficient anterior and posterior packing  Foley balloon firmly tugged down
  • 64.
    BRACHYTHERAPY Good Insertion Characteristics AmericanBrachytherapy Society (ABS) Recommend prescribing to Point H - Draw a line connecting the mid-dwell positions of the ovoids and find the point this line intersects the tandem. Follow 2 cm superior (along the tandem) plus the radius of the ovoids, then 2 cm perpendicular to the tandem. Note: This is basically 2 cm above the top of the ovoids.
  • 65.
    BRACHYTHERAPY  Specification ofimage-guided GTV and CTV Osaka (Japan)(1983-1989) -- HDR fractional dose 7.5 Gy/fx vs. 6.0 Gy/fx  Randomized. 165 patients with cervix adenoCA, Stage IA-IV. Treated with 2 separated dose schedules depending on stage. Arm 1) EBRT + BT using 7.5 Gy/fx (either 37.5/5 or 30/4 or 22.5/3) vs. Arm 2) EBRT + BT using 6.0 Gy/fx (either 36/6 or 30/5 or 18/3).  5-years; 1994 -- "A prospective randomized study concerning the point A dose in high-dose rate intracavitary therapy for carcinoma of the uterine cervix. The final results." (Chatani M, Strahlenther Onkol. 1994 Nov;170(11):636-42.)  Outcome: 5-year CSS: Stage I 100% vs. 100%, Stage II 82% vs. 85%, Stage III 62% vs. 52%, Stage IV 22% vs. 31% (all NS). No difference in LRF or DM  Toxicity: No difference  Conclusion: No difference between the two treatment schedules; small number of fractions at 7.5 Gy/fx may be advantageous due to short duration
  • 66.
    DOSE CALCULATIONS - BRACHYTHERAPY ABS, Problem:What dose/fraction of HDR delivered in six fractions will be equivalent in terms of tumor control to 60 Gy delivered to Point A at 0.55 Gy h−1? Solution: Assume α/β (tumor) = 10 Gy, μ (tumor) = 0.46 h−1. Then: BED (LDR) = 60[1 + (2 × 0.55)/(0.46 × 10)] = 74.3 Equating this to the BED for 6 HDR fractions with dose/fraction d gives: 74.3 = 6d(1 + d/10) Solving this quadratic equation for d gives: d = 7.20 Gy. Conclusion: 6 fractions of 7.20 Gy with HDR is equivalent in terms of tumor control to 60 Gy delivered at 0.55 Gy h−1.
  • 67.
    HDR dose LDRequivalent 6 Gy x 4 = 32 Gy 6 Gy x 5 = 40 Gy
  • 68.
    Bladder point -on the surface of a Foley balloon filled with 7 cc of contrast; located at center of balloon on AP film, posterior surface of the balloon on a line through midballoon on lateral film Rectum point - 0.5 cm posterior to the posterior vaginal wall at the level of the bisection of the T&O. May also use barium + air contrast in rectum Vaginal mucosa - at surface of ovoids Pelvic sidewall, and external, common, and para-aortic LN points should be reported according to ICRU defintions Keep dose to rectum and bladder points below 80% of dose to Point H (ABS recommendation). Or, maximum dose to rectum, 75 Gy (avg dose 68 Gy); bladder, 80 Gy (avg 70 Gy); vagina, 120-140 (avg 125 Gy).
  • 69.
    BRACHYTHERAPY - COMPLICATIONS Acute complications (1960-1992)- "Perioperative and postoperative complications of intracavitary radiation for FIGO stage I- III carcinoma of the cervix." Jhingran A et al. Int J Radiat Oncol Biol Phys. 2000; 46 (5):1177-83  Retrospective. 7662 intracavitary procedures in 4043 patients for FIGO I-III cervical CA  2.8% uterine perforation rate, 14% have fever >101 C during at least 1 admission, 0.1% fatal thromboembolism rate. Perforation did not affect DSS in stage I, II, but did lead to worse prognosis in stage III.
  • 70.
    Late complications 1995 (1960-89)— "Time course and incidence of late complications in patients treated with radiation therapy for FIGO stage IB carcinoma of the uterine cervix." Eifel PJ et al. Int J Radiat Oncol Biol Phys. 1995 Jul 30;32(5):1289-300.  Retrospective. 1784 pts, FIGO stage IB. Grade 3 or higher complications occurred in 7.7% at 3 yrs and 9.3% at 10 yrs. After 10 yrs, 0.34% per year, so at 20 yrs, 14.4% risk.  Risk of rectal complications was the greatest, more than urinary complications.  Conclusion: low risk of major complications using brachytherapy.
  • 71.
    BRACHYTHERAPY Guidelines Keep total duration(of EBRT + implants) to < 8 weeks. For HDR, this necessitates beginning brachytherapy while EBRT is ongoing. Usually give an HDR treatment once per week, not giving EBRT on that day. ABS recommendations LDR (2002) — "The American Brachytherapy Society recommendations for low-dose-rate brachytherapy for carcinoma of the cervix." Nag S et al. Int J Radiat Oncol Biol Phys. 2002 Jan 1;52(1):33-48. HDR (2000) — "The American Brachytherapy Society recommendations for high-dose-rate brachytherapy for carcinoma of the cervix." Nag S et al. Int J Radiat Oncol Biol Phys. 2000 Aug 1;48(1):201-11.
  • 72.
    SCREENING FOR CANCER CERVIX NCCP– Priority for early detection & treatment No current screening programme- technical, financial, manpower constraints Aim: Reduce morbidity & mortality Detection of precancerous lesions HPV Vaccine – Primary prevention . It is a bivalent virus like particle against subtypes 16 & 18.Three doses at 0 , 1 & 6 mths. Efficacy – 100 % in preventing new and persistent infection of genital tract. Duration of protection – Not known
  • 73.
    UNITS OF RADIATION Roentgen: Unit of exposure Absorbed Dose: Energy deposited by radiation as it passes thru tissue to create biological effects RAD: Represents absorption of 0.01J/Kg of absorbing material GRAY: Dose associated with absorption of 1J of energy / kg of absorbing material 1 RAD = 10 mGY
  • 74.
    RADIATION UNITS Equivalent Dose(E):Diff types of radiation produce diff degree of biological damage SIEVERT = Measures dose equivalent Absorbed Dose (Gy) X Radiation weighting factor For this procedure: Your effective radiation dose is: Comparable to natural background radiation for: (CT)- Abdomen 10 mSv 3 years (IVP) 1.6 mSv 6 months (CT)-Head 2 mSv 8 months (CT)-Chest 8 mSv 3 years Radiography- Chest 0.1 mSv 10 days