Radiotherapy plays an important role in the treatment of lung cancer. It can be used as a primary treatment for early-stage lung cancers, as an adjuvant treatment after surgery, and concurrently with chemotherapy. New techniques like IMRT and SBRT allow for more precise radiation delivery to tumors while minimizing dose to surrounding healthy tissues. Ongoing challenges include improving prevention, early detection, access to innovative treatments, and multidisciplinary coordination of lung cancer care.

1. THE ROLE OF
RADIOTHERAPY IN
THE LUNG CANCER
MANAGEMENT
Virginia Ruiz Martin MD
Radiation Oncology. University Hospital of November 17th 2020

2. HELLO!
I am Virginia Ruiz
I am here because I am a
Radiation Oncologist
Radiation is my “superpower” to
kill cancer
You can find me at @roentgen66
2

3. INTRODUCTION:
INDEX
▹ EPIDEMIOLOGY
▹ LUNG ANATOMY
▹ LUNG PHISIOLOGY/ CARCINOGENESIS
▹ LUNG CANCER SYMPTOMS
▹ DIAGNOSIS
▹ LUNG CANCER PATHOLOGY
▹ STAGING
▹ TREATMENTS
▹ RADIOTHERAPY: WHAT, HOW,WHEN AND WHY
▹ FUTURE CHALLENGES
.
3

4. 1. EPIDEMIOLOGY
4

5. EPIDEMIOLOGY:
▹ Every year around 470.000 new cases of
lung cancer are diagnosed in Europe
and this is increasing (Globocan 2018)
▹ It is the third tumor with the highest
incidence
▹ Affects more men than women
▹ Represents 20% of cancer deaths
▹ Tobacco use is the most important risk
factor
▹ An estimated 15% of smokers will develop
lung cancer
▹ Smokers are 20 times more likely than non-
smokers
5

6. EPIDEMIOLOGY:
▹ The clear tobacco-cancer relationship
has caused great social stigmatization
▹ 1/5 women and 1/10 men with lung
cancer are NON-smokers
▹ It is a silent tumor since it does not
usually show symptoms until advanced
stages
6

7. ETHIOLOGY:
▹ Tobacco
▹ Work occupations: asbestos, mining,
textile, radiation, etc.
▹ Frequency increases with age
▹ It is three times more common in men
▹ Genetic causes: family history
▹ Benign diseases: COPD, pulmonary
fibrosis, scleroderma
7

8. ETHIOLOGY:8

9. 2. LUNG ANATOMY
9

10. LUNG ANATOMY:
▹ The lungs are two organs located in the
thorax and breathing is carried out
through them.
▹ They are separated by an area called
the mediastinum, a space where they
are:
▸ Heart
▸ Trachea
▸ Esophagus
▸ Large blood vessels
10

11. LUNG ANATOMY:
▹ Air reaches the lungs through the
trachea and the main bronchi.
▹ Within the lungs, each main bronchus is
divided into:
▸ Secondary bronchi
▸ Bronchioles
▸ Alveolar ducts
▸ Alveoli
11

12. 3. LUNG PHISIOLOGY
12

13. LUNG PHISIOLOGY:
▹ The alveoli contain capillaries where
gas exchange occurs during respiration
▹ In inspiration, the oxygen that enters
the lungs is absorbed and in expiration,
CO2 is expelled to the outside.
▹ The lungs are covered by a membrane
called pleura that makes it easier for
the lungs to contract and expand.
13

14. LUNG CARCINOGENESIS
▹ The lung is made up of a group of cells that divide
regularly in order to replace those that are already
aged or dead
▹ This process is regulated by a series of mechanisms
that tell the cell when to start dividing and when to
remain stable
▹ If these mechanisms are disrupted in a cell,
uncontrolled division begins that eventually will lead
to a tumor or nodule
▹ When these cells grow uncontrollably, invading
surrounding tissues or organs and move to proliferate
in other parts of the body (metastasis).
14

15. 4. LUNG CANCER SYMPTOMS
15

16. LUNG CANCER SYMPTOMS:16

17. LUNG CANCER SYMPTOMS:17

18. 5. DIAGNOSIS
18

19. DIAGNOSIS:19
▹ Blood test
▹ Chest X-ray
▹ Sputum cytology
▹ Bronchoscopy
▹ CT-scan
▹ Core needle biopsy
▹ Spirometry
▹ PET-CT
▹ EBUS
▹ Mediastinoscopy
▹ Liquid biopsy

20. DIAGNOSIS: CHEST X-RAY20

21. DIAGNOSIS: CT-SCAN21

22. DIAGNOSIS: BRONCHOSCOPY22

23. DIAGNOSIS: PET-CT23

24. DIAGNOSIS: EBUS24

25. 6. PATHOLOGY
25

26. PATHOLOGY:26
Adenocarcinoma
45%
Epidermoid
carcinoma
30%
Small cell
carcinoma
15%
Big cell
carcinoma
10%
Non small cell
carcinoma

27. PATHOLOGY: SCLC27
▹ Staging:
▸ Limited to thorax
▸ Extrathoracic
▹ It is not surgical
▹ Has a worse prognosis
▹ The treatment of choice is concomitant
radiochemotherapy
▹ After completing the treatment, the CNS
should be irradiated prophylactically

28. PATHOLOGY: NON-SCLC28
▸ TNM staging
▸ Whenever it is possible surgery is election
treatment
▸ Has a better prognosis
▸ In non-operable tumors, the treatment of
choice is concomitant radiochemotherapy
▸ Targeted therapies are playing an important
role

29. PATHOLOGY: NON-SCLC29

30. 7. TREATMENTS
30

31. TREATMENTS31
▸ SURGERY
▸ CHEMOTHERAPY
▸ RADIOTHERAPY
▸ TARGETED THERAPIES
▸ OTHERS:
⬩ RADIOFREQUENCY
⬩ ENDOBRONCHIAL LASER

32. TREATMENTS: SURGERY32
▹ INDICATED IN:
▸ STAGES I AND II
▸ AFTER CHEMOTHERAPY
IN STAGES III

33. TREATMENTS: CHEMOTHERAPY33
▸ NEOADJUVANT: Before surgery
▸ ADJUVANT: After surgery
▸ CONCOMITANT: Along radiotherapy
▸ PALLIATIVE: To alleviate symptoms

34. TREATMENTS: RADIOTHERAPY34
▸ RADICAL: As unique treatment in
small non-operable tumors
▸ ADJUVANT: After surgery
▸ CONCOMITANT: Along chemotherapy
▸ PALLIATIVE: To relieve symptoms

35. TREATMENTS: TARGETED THERAPIES35

36. TREATMENTS: OTHER THERAPIES36
RADIOFREQUENCY ENDOBRONCHIAL LASER

37. ”
RADIOTHERAPY IN LUNG
CANCER:
WHAT
HOW
WHEN
AND WHY
37

38. WHAT IS IT?
▹RADIATION ONCOLOGY is a MEDICAL-SURGICAL specialty
that use IONIZING RADIATIONS for the treatment of
malignant tumors
▹It is based on RADIOBIOLOGICAL scientific knowledge
▹It is a PILLAR in the cancer treatment like surgery and
chemotherapy
▹It has more than 100 YEARS OF HISTORY and its evolution
has been exponential
38

39. WHAT IS IT?39

40. WHAT IS IT?40
▸ They are an invisible form of ENERGY
▸ It spreads in the form of ELECTROMAGNETIC
WAVES
▸ Radiation exists NATURALLY: Sun, Uranium,
Radon, Cosmic radiation
▸ Radiation can be produced in an ARTIFICIAL way:
⬩ Low energy X-rays: Radiodiagnosis
⬩ High Energy X-Rays: Linear Accelerators
⬩ Particles: Protons

41. HOW IT WORKS ?41
SOME PEOPLE
IMAGINE US LIKE THIS…

42. HOW IT WORKS ?42
RADIOBIOLOGY is the science
that studies the biological
effects that occur in living
beings after exposure to
energy from ionizing
radiation

43. HOW IT WORKS ?43

44. HOW IT WORKS ?44
▹ RADIOSENSITIVITY
▹ REOXYGENATION
▹ REDISTRIBUTION
▹ REPAIR
▹ REPOPULATION
RESPONSE MECHANISMS TO IRRADIATION

45. HOW IT WORKS ?45

46. WHEN ?46
W. ROËNTGEN M.CURIE H.BECQUEREL

47. WHEN ?47
▸ The first patient treated with
radiotherapy was in 1896, two months
after the X-rays discovery
▸ The first technological advances in
radiotherapy began in the 1950s with
cobalt units and the first linear
accelerators.
▸ Advances have led to more effective and
accurate radiation therapy

48. WHEN ?48

49. WHEN ?49
Lung cancer TNM AJCC 8th edition

50. WHEN ?50

51. WHEN ?51

52. WHEN ?52

53. WHEN ?53

54. WHEN ?54

55. WHEN ?55

56. WHEN ?56

57. WHEN ?57

58. WHEN ?58

59. WHEN ?59
▸ Radiationtherapy has a role in every single
stage in SCLC and NSCLC
▸ There are different ways to deliver
radiation:
⬩ External radiotherapy
⬩ Brachytherapy
▸ There ara different sequences:
⬩ Radical and unique
⬩ Neoadjuvant or preoperative
⬩ Adjuvant or PORT
⬩ Concurrent with chemotherapy
⬩ Palliative

60. WHEN ?60
▸ 3D CONFORMED radiation therapy
▸ MODULATED INTENSITY Radiation Therapy (IMRT)
▸ IMAGE GUIDED Radiation Therapy (IGRT)
▸ VOLUMETRIC ARCHOTHERAPY OF MODULATED
INTENSITY (VMAT)
▸ CRANIAL STEREOTAXIC RADIOSURGERY (SRS)
(Single or fractional session)
▸ BODY OR ABLATIVE RADIOSURGERY (SBRT or SART)
TECHNIQUES

61. WHY ?61
“Cure
sometimes,
treat often,
comfort always”
Hippocrates

62. WHY ?62
First visit
Simulation
Planification
Verification
Treatment
Follow up
Radiotherapy
ASSISTANCE PROCESS

63. WHY ?63
FIRST VISIT

64. WHY ?64
SIMULATION

65. WHY ?65
PLANIFICATION

66. WHY ?66
VERIFICATION

67. WHY ?67
TREATMENT

68. WHY ?68
FOLLOW UP
RESULTS SIDE
EFFECTS

69. WHY ?69
Radiation
Oncologist
Phisicist
Radiotherapist
Nurse
Administrative
Assistant

70. 8. FUTURE CHALLENGES
70

71. PREVENTION CHALLENGES71
▸ Smoking restrictions
▸ Information and education strategies from
childhood to prevent young people from starting
the smoking habit
▸ The increase in the current incidence of lung
cancer among women should be supported by the
implementation of information and smoking
cessation programs

72. DIAGNOSIS CHALLENGES72
▸ Development of a specific early detection
program for lung cancer, so that they can be
identified in early stages
▸ Awareness programs about the symptoms of the
disease, especially in the case of smokers, who
should know the warning signs and go to the
doctor immediately.

73. INNOVATION CHALLENGES73
▸ Collaborate to achieve new advances that help
the level of survival and cure increase
▸ There have been gradual improvements in recent
years, but patients can only benefit from them if
they are guaranteed access to such treatments
and diagnostic methods
▸ Defend equity in access to advances in diagnosis
and treatment for all patients, regardless of where
they reside

74. RESOURCE PLANNING CHALLENGES74
▸ Commitments to allocate more resources:
⬩ Prevention and awareness campaigns
⬩ Research in early detection, diagnosis and
treatment programs
▸ More flexible budgets including healthcare
technology and its replacement
▸ Definition of clinical, radiological and molecular
criteria that allow identifying individuals with a
higher risk of developing lung cancer, together
with the development of screening programs.

75. CANCER CARE CHALLENGES75
▸ Incorporate multidisciplinary teams in a
generalized way in all hospital centers
⬩ Coordination between:
⬩ Pneumologists
⬩ Medical Oncologists
⬩ Radiation Oncologists
⬩ Thoracic surgeons
⬩ Pathologists
⬩ Psychologists, social workers
▸ Real shared decision WITH the patient

76. EXCELLENCE CHALLENGES76
▸ With the current advance of ICT and EMH we
could:
⬩ Unique story
⬩ Create the health navigator figure
⬩ Access to platforms with structured and
quality information
▸ We need studies with Big data, Small data, Real
Data and Artificial Intelligence
▸ Offer more psychological and emotional support,
not only to patients but also to their families and
even healthcare professionals

77. SUPPORT AND HUMANIZATION CHALLENGES77
▸ Patients, their families and friends are the
central axis of the daily work of associations and
support groups for patients like LUCE
▸ HONCOR: Platform to respond to human needs in
OncoHematology and Radiotherapy always
focused on the person www.proyectohoncor.com

78. 9. TAKE HOME MESSAGES
78

79. TAKE HOME MESSAGES79
▸ Radiation Oncology is a medical-surgical specialty with more than a HUNDRED YEARS of history
▸ The evolution of this medical specialty has had EXPONENTIAL GROWTH in the last 20 years
thanks to improvements in the field of Engineering and Informatics.
▸ It represents one of the most important PILLARS in cancer treatment with surgery and
chemotherapy.
▸ Radiation therapy is a LOCOREGIONAL TREATMENT, but its role is increasingly relevant in
metastatic disease

80. TAKE HOME MESSAGES80
▸ Radiation therapy is one of the SAFEST cancer treatments available
▸ Radiation therapy allows you to PRESERVE organs and avoid mutilations
▸ Radiation therapy is a PERSONALIZED AND COMFORTABLE TREATMENT
▸ Radiation therapy is a treatment that requires a high level of TECHNICAL COMPETENCE due
to rapid technological advances

81. TAKE HOME MESSAGES81
▸ Radiation therapy is a CURATIVE treatment
▸ The curative potential of radiotherapy increases SYNERGICALLY with other treatments:
Surgery, Chemotherapy, Immunotherapy, etc.
▸ Radiation therapy is based on RADIOBIOLOGICAL KNOWLEDGE
▸ Radiation therapy is highly COST-EFFECTIVE
▸ The side effects of radiation therapy are KNOWN and TREATABLE

83. 83
THANKS!
Any questions?
You can find me at
▹ Twitter: @roentgen66
▹ radioncologa@gmail.com
▹ www.radioncologa.com