RADIATION ONCOLOGY FOR DENTISTS

1. DR KANHU CHARAN PATRO
RADIATION ONCOLOGIST
M.D,D.N.B[RT],FAROI[USA],MBA[ICFAI],PDCR,CEPC

2. Do not take it
seriously / personally
Sincere request

3. Patient history
• 38 year old spiritual Hindu male named ‘x’
from Visakhapatnam
• presented with 2x1cm [h/p-sq] ulcer on
Right lateral border of tongue with
• HISTORY OF ILL FITTED DENTURE
• no co-morbidity died during MRI
evaluation of lesion due to anaphylactic
reaction because of contrast.

4. Hindu mythology-Yamdut ward

5. INTERVIEW WITH MR. X
•I want to be get rid of
the tongue cancer
without surgery for the
tongue

6. Chitragupta search
ENT SPECIALIST Dentist

7. INTERVIEW WITH ENT SPECIALIST
•E-EAR
•N-NOSE
•T-THROAT
•ORAL CAVITY

8. INTERVIEW WITH DENTIST
Though Yamraj agreed but the patient
denied because he got scared of
tongue trauma caused by denture

9. cancer surgeon

11. O
N
O L
Y
O
M
G
C
H
R
I
C
G
R
S
P
E
U
S P E C I
L
T
Y
I
VISAKHAPATNAM,1/7-MVP[AP]
11

13. Statistics
• >9.7 million cases are detected each
year
• 6.7 million people will die from
cancer
• Every day, around 1700 Americans
die of the disease
• 20.4 million people living with
cancer in the world today
• 1 in 3 people will be diagnosed with
cancer in the UK and 1 in 4 will die
from their disease

14. Lung
Breast
Colon/Rectum
Stomach
Liver
Prostate
Cervix uteri
Oesophagus
Bladder
Non-Hodgkin
Lymphoma
Leukaemia
Oral cavity
Pancreas
Kidney
Ovary
1000 800 600 400 200 0 200 400 600 8001000
Men Women
From: D.M. Parkin The Lancet Oncology 2: 533-543 (2001)
(Thousands)
Incidence
Mortality
337
293
105
0370
241
318
446
234
165
166
471
233
133
111
76
33
121
68
113
86
47
97
101
101
34
71
192
114
810
902
558
405
255
499
398
384
204
543
279
260
227
99
93
167
144
109
81
170
116
112
57
119
5.3 million cases
3.5 million deaths
4.7 million cases
2.7 million deaths
The Global Burden of Cancer 2000

15. ? ?
7/21/2018 8:47:56 AM 15

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

20. Role of radiotherapy in various cancers
• Needed for all most head and neck cancer
• Radical-
– Naso-pharynx, laryx, hypopharynx etc.
• post-op-adjuvant
– MOSTLY ALL ORAL CANCERS except T1 lesions
• Palliative
– compression, bleeding, obstruction, pain
7/21/2018 8:47:56 AM 20

21. Postoperative Radiation for Oral Cavity
Squamous Cell Carcinoma
• Oral Cavity Cancer is a Surgical Disease
• Use Radiation Postoperatively for Appropriate
Patients

22. • RT can be used as primary therapy for small
(T1, T2) tumors of the oral cavity.
• Oral tongue
• Floor of Mouth
• Lip
• Best results are with a combination of external
beam radiation and brachytherapy

28. DOCTOR : WHAT
TRETMENT YOU HAVE
GIVEN , I AM NOT ABLE
TO EAT PANIPURI.
THAT PANIPURI MOMENT
7/21/2018 28

29. 1. TRISMUS
2. DYSGUESIA
3. XEROSTOMIA
4. DYSPHAGIA
7/21/2018 29

30. ZEROING THE
XEROSTOMIA
&
DISCARDING
THE DYSPHAGIA
7/21/2018 30

31. Methods preventing xerostomia
7/21/2018 31

32. 7/21/2018 8:47:56 AM 32
Radiation –Part of life

33. 7/21/2018 8:47:56 AM 33
Wilhelm Conrad Rontgen

34. History - radiation
1896 – Becquerel - Radioactivity
1898 – Madam Curie / Pierre Curie - Radium
1903 – Nobel Prize for Curie’s & Becquerel
1903 – First successful case of malignancy basal
cell carcinoma of face
7/21/2018 8:47:56 AM 34

35. GOALS
 High dose to tumor tissue-Tumor control
 Normal tissue sparing
 Minimize long and short term toxicities
 Better Quality of life
7/21/2018 8:47:56 AM 35

36. Treatment
• Delivered 5 days per week over 6-8 weeks
• Typical treatment takes around 5 minutes
• Treatment is painless--like having an X-ray taken
• No radioactive substances involved; beam goes
on/off
• Side effects usually temporary; controlled with
medication/diet
• Covered by Medicare and many other insurance
companies
•
7/21/2018 8:47:56 AM 36

37. Types of radiotherapy
7/21/2018 8:47:56 AM 37
TELETHERAPY
BRACHYTHERAPY

38. Radiotherapy procedure
1. Tumor board decision
2. Positioning And immobilization
3. Imaging
4. Target delineation
5. Planning
7/21/2018
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
38

39. IMAGE GUIDED RADIATION THERAPY
EQUIPMENT REQUIRED
CT-SCAN MRI PET-CT
7/21/2018 39
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

40. Cobalt machine
7/21/2018 8:47:56 AM 40

41. 7/21/2018 8:47:56 AM 41

42. Plaster of Paris Mould-older method
7/21/2018 8:47:56 AM 42

43. Head & Neck
7/21/2018 8:47:56 AM 43

44. PLANNING
7/21/2018 8:47:56 AM 44
CONFORMAL
CLINICAL

45. 7/21/2018 8:47:56 AM 45

46. 7/21/2018 8:47:56 AM 46

47. Evolution of Treatment Techniques
CUSTOMISED BLOCKS
MULTILEAF COLLIMATOR
BASED 3D-CRT
1990s1980s
7/21/2018 8:47:56 AM 47

48. 7/21/2018 8:47:56 AM 48

49. Treating Head & Neck with Sliding Windows
7/21/2018 8:47:56 AM 49

50. IMRT
• Divides each treatment field into
multiple segments
• Modulates beam intensity,
giving discrete dose to each
segment
• Uses multiple, shaped beams
(~9) and thousands of segments
IMRT Initiated in 1995
Reached the clinic in 2000

51. Conventional vs Conformal vs IMRT
Head and Neck
Conventional
Conformal
IMRT
7/21/2018 8:47:56 AM 51

52. 7/21/2018 52

53. DISCUSSION :
1) less Incidence of RT induced XEROSTOMIA in IMRT Arm.
2) Early Recovery of Saliva Flow in cases treated with IMRT.
3) Improved QOL in IMRT Arm.
4) Comparable PFS & OS in both Arms.
7/21/2018 53

54. DO-IMRT-[Dysphagia Optimized IMRT]
7/21/2018 54
ST.IMRT
VS
DO-IMRT

55. 7/21/2018 55

67. 7/21/2018 8:47:56 AM 67

68. Small Volume Adjacent to Critical Structure
7/21/2018 8:47:56 AM 68

69. 3D Dose Shaping - H&N and Brain
Brain
Stem
7/21/2018 8:47:56 AM 69

70. Target Motion in
Radiotherapy
Caveman et al
Oops! The target
moves!
IGRT/GATED RT
7/21/2018 8:47:56 AM 70

71. 7/21/2018 8:47:56 AM 71

72. 7/21/2018 8:47:56 AM 72

73. 7/21/2018 8:47:56 AM 73

74. 7/21/2018 8:47:56 AM 74

75. • CONVENTIONAL
• 3DCRT
• IMRT
• IGRT
• VMAT/RAPIDARC
• PET GUIDED RADIOTHERAPY

76. RADIOTHERAPY

79. Where is the Target?
7/21/2018 79
Mahatmagandhi cancer hospital and
research institute
SPARE THE ROD AND SPOIL THE CHILD
DO NOT LOOSE SHIGHT OF FOREST [OAR]FOR THE TREE

80. CT-MRI FUSION
7/21/2018 8:47:56 AM 80

81. TRIPLE FUSION
PET
CTMRI
7/21/2018 81
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

82. Concept of triple-fusion
7/21/2018 82
Mahatmagandhi cancer hospital and
research institute

87. Target volume definition
7/21/2018 87Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

88. Imaging
7/21/2018
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
88

89. IMAGING
7/21/2018 89
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

90. PET vs.MRI
7/21/2018 90
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

91. PET vs.MRI
7/21/2018 91
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

92. Avoid unnecessary toxicity
7/21/2018
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
92

93. Unknown primary
7/21/2018
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
93

94. Impact on radiotherapy
7/21/2018
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
94
1.Elective nodal irradiation
2.Nodal boost

95. G.P., m, 46y; LN-Metastasis of Hypopharynxcarcinoma
Head and Neck Cancer: Example
7/21/2018 95
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

96. Pet CT planning
7/21/2018
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
96

97. PET-CT-WIN-WIN SITUATION
PARAMETER VOLUME
CHANNGE
T STAGE INCREASE
UPSTAGING
1. PREVENTS TUMOR TISSUE MISSING
2. CHANGES TT FROM CURATIVE TO PALLLIATIVE
DECREASE
DOWN STAGING
1. PREVENTS EXTRA DOSE TO NORMAL TISSUE
2. CHANGES TT. FROM PALLIATIVE TO CURATIVE
3. DOSE ESCALATION IS POSSIBLE
N STAGE INCREASE
UPSTAGING
1. PREVENTS TUMOR TISSUE MISSING
2. CHANGES TT FROM CURATIVE TO PALLLIATIVE
DECREASE
DOWN STAGING
1. PREVENTS EXTRA DOSE TO NORMAL TISSUE
2. CHANGES TT. FROM PALLIATIVE TO CURATIVE
3. DOSE ESCALATION IS POSSIBLE
M STAGE INCREASE CURATIVE-TO PALLIATIVE
DECREASE PALLIATIVE TO CURATIVE
7/21/2018

98. Bird’s eye view Eagle’s eye view
7/21/2018 98
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

99. RADIOTHERAPY DELIVERY
7/21/2018
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
99

100. 7/21/2018 100
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

101. ORGAN PRESERVATION

102. Brachytherapy
• Short distance /contact with tumor
• Expertise needed
• Invasive procedure
• Adequetly sparing normal structure
• Well established
7/21/2018 8:47:56 AM 102

103. Brachytherapy in oral cavity cancers
7/21/2018 8:47:56 AM 103

104. • COSMETIC DEFECT
• FUNCTIONAL DEFECT
• IMPAIRED QUALITY OF LIFE
SURGERY
7/21/2018 8:47:56 AM 104

106. 7/21/2018 8:47:56 AM 106

107. PROCEDURE
7/21/2018 8:47:56 AM 107

108. 7/21/2018 8:47:56 AM 108

109. • HEAD AND NECK CANCERS
• BREAST CANCERS
• ESOPHAGUS CANCERS
• PENILE CANCER
• SOFT TISSUE SARCOMA
• BLADDER CANCERS
• CANAL CANCERS
ORGAN PRESERVATION
7/21/2018 8:47:56 AM 109

117. WHO PRESERVES HE DESERVES

118. 7/21/2018 8:47:56 AM 118

119. 7/21/2018 8:47:56 AM 119

120. 7/21/2018 8:47:56 AM 120

121. ORGAN PRESERVATION FOR
CANCER TONGUE
7/21/2018 8:47:56 AM 121

122. 7/21/2018 8:47:56 AM 122

123. TONGUE IMPLANT IN PROGRESS
7/21/2018 8:47:56 AM 123

124. TONGUE IMPLANT IN PROGRESS
7/21/2018 8:47:56 AM 124

125. TONGUE IMPLANT IN PROGRESS
7/21/2018 8:47:56 AM 125

126. BUCCAL MUCOSA
7/21/2018 8:47:56 AM 126

127. 7/21/2018 8:47:56 AM 127

128. 7/21/2018 8:47:56 AM 128

129. 7/21/2018 8:47:56 AM 129

130. 7/21/2018 8:47:56 AM 130

131. Hard palate
7/21/2018 8:47:56 AM 131

132. 7/21/2018 8:47:56 AM 132

133. Lip cancer
7/21/2018 8:47:56 AM 133

134. 7/21/2018 8:47:56 AM 134

135. 7/21/2018 8:47:56 AM 135

136. 7/21/2018 8:47:56 AM 136

137. 7/21/2018 8:47:56 AM 137

138. Floor of mouth
7/21/2018 8:47:56 AM 138

139. 7/21/2018 8:47:56 AM 139

140. 7/21/2018 8:47:56 AM 140

141. 7/21/2018 8:47:56 AM 141

142. 7/21/2018 8:47:56 AM 142

143. 7/21/2018 8:47:56 AM 143

144. 7/21/2018 8:47:56 AM 144

145. 7/21/2018 8:47:56 AM 145

146. 7/21/2018 8:47:56 AM 146
ORGAN PRESERVATION FORCANCER LIP

147. 7/21/2018 8:47:56 AM 147

148. 7/21/2018 8:47:56 AM 148

149. 7/21/2018 8:47:56 AM 149

150. Applicator in situ with IOP

151. Complete response –towards healing
hypo-pigmentation

152. Recent

153. 7/21/2018 8:47:56 AM 153

154. KELOIDS
7/21/2018 8:47:56 AM 154

155. 7/21/2018 8:47:56 AM 155

156. 7/21/2018
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
156

157. 7/21/2018
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
157

158. 7/21/2018 8:47:56 AM 158

159. 7/21/2018 8:47:56 AM 159

160. 7/21/2018 8:47:56 AM 160

161. 7/21/2018 8:47:56 AM 161

162. • HEAD AND NECK CANCERS
• BREAST CANCERS
• ESOPHAGUS CANCERS
• PENILE CANCER
• SOFT TISSUE SARCOMA
• BLADDER CANCERS
• CANAL CANCERS
ORGAN PRESERVATION
7/21/2018 8:47:56 AM 162

163. ORGAN PRESERVATION FOR
BONE TUMORS
7/21/2018 8:47:56 AM 163

164. 7/21/2018 8:47:56 AM 164

165. 7/21/2018 8:47:56 AM 165

166. 7/21/2018 8:47:56 AM 166

167. ORGAN PRESERVATION FOR
BREAST CANCERS
7/21/2018 8:47:56 AM 167

168. 7/21/2018 8:47:56 AM 168
Intra- operative Brachytherapy
procedure

169. 7/21/2018 8:47:56 AM 169
Intra- operative Brachytherapy
procedure

170. 7/21/2018 8:47:56 AM 170
Intra- operative Brachytherapy
procedure

171. 7/21/2018 8:47:56 AM 171
Intra- operative Brachytherapy
procedure

172. 7/21/2018 8:47:56 AM 172
3D Brachytherapy Planning
CT Loading Dose distribution

173. 7/21/2018 8:47:56 AM 173
Dose prescription and Treatment
delivery
• Dose: 34Gy in 10 fraction bid
• Dose per fraction: 340cGy

174. ORGAN PRESERVATION FOR
PENILE CANCERS
7/21/2018 8:47:56 AM 174

175. 7/21/2018 8:47:56 AM 175

176. 7/21/2018 8:47:56 AM 176

177. 7/21/2018 8:47:56 AM 177

178. 7/21/2018 8:47:56 AM 178

179. ORGAN PRESERVATION FOR
SARCOMAS
7/21/2018 8:47:56 AM 179

180. 7/21/2018 8:47:56 AM 180

181. 7/21/2018 8:47:56 AM 181

182. 7/21/2018 8:47:56 AM 182

183. 7/21/2018 8:47:56 AM 183

184. 7/21/2018 8:47:56 AM 184

185. ORGAN PRESERVATION FOR
CANCER CERVIX [STAGE
0,EARLY 1]
7/21/2018 8:47:56 AM 185

186. 7/21/2018 8:47:56 AM 186

187. 7/21/2018 8:47:56 AM 187

188. ICA HDR application
7/21/2018 8:47:56 AM 188

189. 7/21/2018 8:47:56 AM 189

190. 7/21/2018 8:47:56 AM 190

191. ORGAN PRESERVATION FOR
CANCER ANAL CANAL
7/21/2018 8:47:56 AM 191

192. APR
7/21/2018 8:47:56 AM 192

193. ANAL CANAL BRACHYTHERAPY
7/21/2018 8:47:56 AM 193

195. • GOOD COSMETIC
• FUNCTIONAL PRESERVATION
• GOOD QUALITY OF LIFE
• ESTABLISHED PROCEDURE
• EXPERTISE REQUIRED
• AVAILABLE LITERATURES
• LESS TOXIC
FACTS
7/21/2018 8:47:56 AM 195

196. SMART THINKING
7/21/2018 8:47:56 AM 196

197. 7/21/2018 8:47:56 AM 197

198. Sharp gun-missed target
198

199. Stage IV: Metastatic Cancer

200. 200
METASTASIS
-please do not watch crying

201. 10/20/12 01:12 PM 201

202. METASTASIS- give a smiling death
202

203. Palliative radiation
Skeletal X-Ray
Bone scan
MRI
PET-CT

204. Spinal metastasis
204

205. 205

206. Brain metastasis
206

207. 207

208. Whole brain radiotherapy
208

209. Choroidal metastasis
209

210. Superscan-extensive bone mets
210

211. Hemibody radiation
211

212. Prophylactic radiation
212

213. svco
213

214. CAUTION
C - Change in bowel or bladder habits
A - A sore that does not heal
U - Unusual bleeding or discharge
T - Thickening or lump in the breast or any part of the body
I - Indigestion or difficulty swallowing
O - Obvious change in a wart or mole
N - Nagging cough or hoarseness

215. Change in bowel habits
10/20/12 01:12 PM 215

216. Change in bladder habits
10/20/12 01:12 PM 216

217. A sore that does not heal
10/20/12 01:12 PM 217

218. Unusual bleeding or discharge
10/20/12 01:12 PM 218

219. Thickening or lump in the
breast or any part of the body
10/20/12 01:12 PM 219

220. Indigestion or difficulty swallowing
10/20/12 01:12 PM 220

221. Obvious change in a wart or mole
10/20/12 01:12 PM 221

222. Liver cancer-
hepatitis B vaccine

223. 7/21/2018 8:47:56 AM 223
LOTS OF BLOOD REQUIRE

224. 7/21/2018 8:47:56 AM 224

225. 7/21/2018 8:47:56 AM 225
All specialities under one roof

226. 7/21/2018 8:47:56 AM 226
TABLET FORMS

227. Cervix cancer vaccine
10/20/12 01:12 PM 227

228. Nagging cough or hoarseness
10/20/12 01:12 PM 228

231. 7/21/2018 8:47:56 AM 231

233. 10/20/12 01:12 PM 233

235. REGULAR CHECK-UP

236. 7/21/2018 8:47:56 AM 236

238. 238

239. Prevention-passive smoking

240. Promise-Stop drinking alcohol
10/20/12 01:12 PM 240

241. RELAX

242. Meditation
10/20/12 01:12 PM 242

243. 243
Dietary protective factors

244. Breast feeding

245. Physical activity

246. 246

247. 247

248. 7/21/2018 8:47:56 AM 248

249. 7/21/2018 8:47:56 AM 249

252. 7/21/2018 8:47:56 AM 252

253. 10/20/12 01:12 PM 253

254. Just “Doing It” is not good enough !
You must know “what” to do and “where” to do it !
10/20/12 01:12 PM 254

255. 10/20/12 01:12 PM 255

256. 10/20/12 01:12 PM 256

257. TEAM OF EXPERTS IN SURGICAL ONCOLOGY
1. Dr.Murali Krishna Voonna M.S.,M.Ch.,
(Adyar Cancer Institute ,Chennai)
2. Dr.Karthik Chandra Vallam M.S., M.Ch,DNB.,
(TATA Memorial ,Mumbai)
3. Dr.M.P.S.Chandra Kalyan M.S,, M.Ch.,
(TATA Memorial ,Mumbai)

258. TEAM OF EXPERTS IN RADIATION ONCOLOGY
Dr. Kanhu Charan Patro M.D(RT).DNB(RT)
(ex. TATA Memorial ,Mumbai)
Dr. Partha Sarathi Bhattacharyya M.D (RT)
(ex. AIIMS,NEW DELHI)
Dr. Chittaranjan Kundhu M.D(RT)
(S.C.B.M.C ,Cuttack)
Dr. Venkata Krishna Reddy M.D (RT)
(ex.Christian Medical College ,Vellore)

259. TEAM OF EXPERTS IN MEDICAL ONCOLOGY
1. Dr. B.Rakesh Reddy M.D(Paed).,DM
(Medical Oncology) (AIIMS ,New Delhi)

260. TEAM OF EXPERTS IN CRITICAL CARE AND PAIN
1. Dr. K.V.D. Praveen M.D(Anesthesiology)
(PGIMER, Chandigarh)
2. Dr. A.Shirisha M.D (Anesthesiology)
(AMC ,Visakhapatnam)
3. Dr. Surendra Nadh D.A, DNB(Anesthesiology)
(ISPAT General Hospital, Odisha)

261. TEAM OF EXPERTS-- Radiology
1. Dr. P.Madhuri D.M.R.D
( AMC ,Visakhapatnam)
2. Dr. B.Revathi D.M.R.D
( RMC ,Kakinada)

262. GYNAEC ONCOLOGY :
Dr.Jyoti Doki M.D. (Gynaec & Obg)
(AMC,Visakhapatnam)

263. Nuclear Medicine :
Dr. K.Raghava Kashyap M.D (Nuclear Medicine)
(PGIMER, Chandigarh)

265. EXPERTS FROM VARIOUS PRESTIGIOUS
INSTITUTIONS
1. ADYAR CANCER INSTITUTE, CHENNAI-1
2. TATA MEMORIAL HOSPITAL, MUMBAI-3
3. AIIMS,NEWDELHI-2
4. CMC-VELLORE-1
5. PGI-CHANDIGARH-2

266. ACCREDITED

267. ACCREDITED

268. MEMBER

269. APPROVED

273. Young radiation oncology conference

275. Radiation tumor board

276. DECISIONS IN TUMOR BOARD

277. EMPOWER
•EQUIPMENT
•EXPERT
•EXPERIENCE
•EASY ACCESSES

278. 10/20/12 01:12 PM 278
Whenever not
possible,
make friends

279. 27910/20/12 01:12 PM

280. 28010/20/12 01:12 PM

281. 7/21/2018 8:47:56 AM 281

282. 7/21/2018 8:47:56 AM 282

283. 7/21/2018 8:47:56 AM 283

284. THANKS

285. 285
?