The document discusses organ preservation using radiation therapy techniques like brachytherapy. It provides examples of various cancers where brachytherapy can be used to preserve organs like penis, breast, bone, soft tissue sarcomas, anal canal, tongue and others. Brachytherapy provides conformal dose distribution allowing dose escalation to tumor and sparing of adjacent normal tissues, thus helping organ preservation and improved quality of life for patients. Expertise is required for brachytherapy planning and procedures to achieve optimal outcomes of local tumor control and organ preservation.

1. ORGAN CONSERVATION
TO CUT OR NOT TO CUT
DR KANHU CHARAN PATRO
RADIATION ONCOLOGY
MAHATMA GANDHI CANCER HOSPITAL
VISAKHAPATNAM

2. ? ?
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6. Oncologist
Diagnosis
Treatment
Radiologist
Cytopathologist
Surgeon
HistopathologistMolecular
Pathologist
Geneticist
psychiatrist
Nursing
And
Support staff
Audit

7. • COSMETIC DEFECT
• FUNCTIONAL DEFECT
• IMPAIRED QUALITY OF LIFE
SURGERY
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8. RADIOTHERAPY

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14. PROCEDURE
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15. IMAGING AND PLANNING
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16. ISODOSE

17. • PENILE CANCER
• HEAD AND NECK CANCERS
• BREAST CANCERS
• SOFT TISSUE SARCOMA
• ANAL CANAL CANCERS
ORGAN PRESERVATION
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18. GLIMPSE
• Squamous carcinoma (SCC) of the penis
affects about 1 in 100,000 men in western
societies.
• Circumcision protects.
• Circumcision to total panectomy is the
common approach.
• Conservation is being less practiced as
minimal referrals from surgeons and even in
less popular in radiation oncologists.

19. A SURGEON’S PROSPECTIVE AND DOMINANCE
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20. RADIOTHERAPY
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TELETHERAPY
BRACHYTHERAPY

23. ALGORITHM FOR PRIMARY

24. To cut or not to cut
Ozsahin M /Int J Radiat Oncol Biol Phys./2006

25. ANALYSIS
• 60 PATIENTS
• SX-45, RT-29,PORT-22
• MED-F UP
62 MONTH
• LOCAL FAILURE RATE
SX vs RT 13 % vs 36%
• PENILE PRESERVATION RATE-52%
• 5 YR & 10 YR SURVIVAL
43 % AND 26%
• OS (SX vs RT)
56 % vs 53%

26. A 10-YEAR RETROSPECTIVE AUDIT OF PENILE
CANCER MANAGEMENT IN THE UK
• RT was given to 18/65 patients as primary radical
treatment,
• Immobilization of the penis using a wax block, with a
field arrangement of two opposing lateral photon
fields.
• Doses used varied from 55 Gy in 16 # to 50 Gy in 20 #
(dose /#-3.4–2.5 Gy).
• The equivalent dose in 2 Gy fractions was 52–62 Gy,
• Complications associated with local RT were necrosis
(two patients) and one each with phimosis, erectile
dysfunction and urethral stricture
Tina Mistry/2007/Bju

29. CASE SELECTION FOR RADIOTHERAPY
• Superficial or exophytic lesions.
• Lesions of <4 cm, and tumour located on the glans or
coronal sulcus.
• Lesions of <4 cm on the glans penis with no tumour
extension onto the shaft may be suitable for BT.
• Circumcision should be performed before radiotherapy
with glans tumor to reduce radiation-induced
complications.
• Radiotherapy may be offered to patients medically
unfit for surgery or as palliative treatment.
• Efficacy depends on careful planning and appreciation
of dosimetry.

30. MRI
• When MRI scans are used to look at penile
tumors, the pictures are better if the penis is
erect.
• The doctor can inject a substance called
prostaglandin into the penis to make it erect.

32. Inguinal evaluation

42. TESTICULAR SHIELD

43. PUT WET GAUGE
PUT WET GAUGE

44. EBRT
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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
44

47. PENIS AND LUNGI BOTH PRESERVED

48. BARCHYTHERAPY IN SITU
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50. Analysis
• 03/2006 to 08/2013-12 patients
• T1-T2 (<4 cm) non-metastatic
• TEMPLATE.
• 36 Gy in 9 fractions over 5 days ADJ.
• 39 Gy in 9 fractions over 5 days RAD
• median follow-up of 27 months
• 5-year relapse-free, cause-specific and overall survival
rates were 83%,100% and 78% respectively.
• pre and post treatment evaluation, no IPSS or IIEF-5 are
same.
• G3 successfully treated with hyperbaric oxygen therapy.
One urethral meatus stenosis G3 required meatotomy

52. TORONTO & OTTAWA EXPERIENCE
• 49 men
• (SQCC) of the penis
• From September 1989 to September 2003
• Mean age, 58 years; brachytherapy for penile SCC.
– 51% were T1,
– 33% T2, and
– 8% T3;
– 4% were in situ
– 4% Tx. Grade
– well differentiated in 31%,
– moderate in 45%, and poor in 2%;
– grade was unspecified for 20%.
• All tumors in Toronto had pulsed dose rate (PDR) brachytherapy (n = 23), whereas those in
Ottawa had either Iridium wire (n = 22) or seeds (n = 4).
• with no correction in total dose, which was 60 Gy in all cases.
• Median follow-up was 33.4 month
• At 5 years, actuarial overall survival was 78.3% and cause-specific survival 90.0%.
Crook JM /Int J Radiat Oncol Biol Phys./2005

53. TORONTO & OTTAWA EXPERIENCE
• COMPLICATION
• The soft tissue necrosis rate was 16%
• the urethral stenosis rate 12%.
• 8 men with regional failure, 5 were salvaged by lymph node dissection
with or without external radiation.
• 4 men with distant failure died of disease.
• Of 49 men, 42 had an intact and tumor-free penis at last follow-up or
death.
• The actuarial penile preservation rate at 5 years was 86.5%.
• CONCLUSIONS:
• Brachytherapy is an effective treatment for T1, T2, and selected T3 SCC of
the penis. Close follow-up is mandatory because local failures and many
regional failures can be salvaged by surgery.
Crook JM /Int J Radiat Oncol Biol Phys./2005

54. LITERATURE REVIEW

56. IS IT EFFECT SEXUAL FUNCTION?

57. MODERATE IMPACT ON SEXUAL
FUNCTION

59. SEXUAL SCORES ARE NOT INFERIOR

62. TEMPLATE BASED BRACHY

69. BOLUS & EXTERIOR PLANE

70. POST EXPLANT MANAGEMENT
• Moist desquamation throughout the treated area is expected and usually starts
within 10 TO 15 days
• Loose tubular non-stick dressing will prevent the healing skin from adhering to
underclothes
• Tightly bandaged with an occlusive dressing as this maneuver promotes
infection and delays healing
• Multiagent antibiotic cream or ointment Can be applied for the first 2 TO 4
weeks, and
• Some authors recommend that vitamin E ointment be applied later on as re-
epithelialization progresses
• Smoking is discouraged as it is believed to delay wound healing.
• Complete healing usually occurs within 2 months but in some cases may take 3
to 4 months or longer, especially in patients with diabetes or vascular disease.
• Intercourse can be resumed when the patient is comfortable, although the
healing Epithelium is fragile, and extra water-based lubrication is recommended

71. BRACHYTHERAPY DOSE
• 3.2 Gy bid
• 38.4 Gy in 6 days for volume implants is well
tolerated.
• The interval between fractions should be at
least 6 hour
• IGBT-CT based plan should be

72. DOSE DISTRIBUTION

73. MOIST DESQUAMATION

74. PENILE ULCERATION

75. HYPERBAERIC OXYGEN THERAPY

76. MEATAL STENOSIS- 9 to 45%

77. TELANGIECTASIA

78. BEFORE AND AFTER
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79. ADVANTAGES OF BRACHYTHERAPY
• Shorter duration
• Good homogenous dose distribution
• Sparing the shaft from radiation effect
• BT offers good success rates particularly for
low-stage disease and in general is more
successful than EBRT.
• The 5-year rate of penile preservation after BT
ranges from 70% to 88%, which is higher than
the corresponding 36–66% rates for EBRT.

80. TAKE HOME MESSAGE
• After treatment, most patients reported that PB has
little or no effect on their sexuality.
• More than half of patients remained sexually active
after treatment .
• Almost all Continued to have erections even if they
were of lower quality. There was little damage to
body image and sense of manliness.
• This information may play a key role in the choice of
cancer treatment leading to the maintenance of a
good sexual life.

81. NODAL MANAGEMENT
 Lymph node observation is appropriate for small (T1)
well-differentiated tumors .
 Radiographic assessment and directed biopsies are
warranted in moderate or poorly differentiated or
larger tumors more than 4 cm or >T2 tumors.
 Surgical management of positive or suspicious lymph
nodes is preferred
 EBRT is an option if the patient is not a surgical
candidate
 Suitable primary brachytherapy can be combined with
surgical management of the lymph nodes in a
multidisciplinary approach.

82. ORGAN PRESERVATION FOR
BREAST CANCERS
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Intra- operative Brachytherapy
procedure

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Intra- operative Brachytherapy
procedure

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Intra- operative Brachytherapy
procedure

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Intra- operative Brachytherapy
procedure

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3D Brachytherapy Planning
CT Loading Dose distribution

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Dose prescription and Treatment
delivery
• Dose: 34Gy in 10 fraction bid
• Dose per fraction: 340cGy

89. SINGLE FRACTION APBI -SIFEBI STUDY
(SIFEBI) SINGLE-FRACTION ELDERLY BREAST IRRADIATION
Jean-Michel Hannoun-Levi/BRACHYTHERAPY/2017
After lumpectomy, intra-operative catheter
implant was performed for post-operative
APBI (single fraction 16 Gy). Surveillance was
achieved at 1, 3 and 6 months after APBI,
then twice a year.

90. ORGAN PRESERVATION FOR
BONE TUMORS
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94. ORGAN PRESERVATION FOR
SARCOMAS
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100. ORGAN PRESERVATION FOR
CANCER ANAL CANAL
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101. APR
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102. ANAL CANAL BRACHYTHERAPY
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103. ORGAN PRESERVATION FOR
CANCER TONGUE
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105. TONGUE IMPLANT IN PROGRESS
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106. TONGUE IMPLANT IN PROGRESS
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ORGAN PRESERVATION FORCANCER LIP

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111. Applicator in situ with IOP

112. Complete response –towards healing
hypo-pigmentation

113. Recent

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116. KELOIDS
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117. BASE OF TONGUE
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118. PROSTATE CANCER
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122. OCULAR MELANOMA
RETINOBLASTOMA
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124. • GOOD COSMETIC
• FUNCTIONAL PRESERVATION
• GOOD QUALITY OF LIFE
• ESTABLISHED PROCEDURE
• EXPERTISE REQUIRED
• AVAILABLE LITERATURES
• LESS TOXIC
FACTS
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125. SMART THINKING
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131. 131
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132. NO AMPUTATION PLEASE
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