Understanding Radiotherapy: A Concise Guide

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

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VISAKHAPATNAM,1/7-MVP[AP]
4

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

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

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

Role of radiotherapy in various cancers
• Needed for all most head and neck cancer
• Radical-
– Naso-pharynx, cervix,laryx,hypopharynx etc.
• post-op-adjuvant
– Rectum, cervix early, stomach, head and neck,
other abdominal malignancies
• Palliative
– compression, bleeding,obstruction,pian
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Radiation –Part of life

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Wilhelm Conrad Rontgen

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
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GOALS
 High dose to tumor tissue-Tumor control
 Normal tissue sparing
 Minimize long and short term toxicities
 Better Quality of life
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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
•
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Types of radiotherapy
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TELETHERAPY
BRACHYTHERAPY

Radiotherapy procedure
1. Tumor board decision
2. Positioning And immobilization
3. Imaging
4. Target delineation
5. Planning
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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
20

IMAGE GUIDED RADIATION THERAPY
EQUIPMENT REQUIRED
CT-SCAN MRI PET-CT
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Cobalt machine
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Plaster of Paris Mould-older method
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Head & Neck
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Abdomen and Pelvis
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Vacuum Mould
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Evolution of Treatment Techniques
CUSTOMISED BLOCKS
MULTILEAF COLLIMATOR
BASED 3D-CRT
1990s1980s
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Treating Head & Neck with Sliding Windows
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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

Mesothelioma
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Small Volume Adjacent to Critical Structure
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3D Dose Shaping - H&N and Brain
Brain
Stem
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Target Motion in
Radiotherapy
Caveman et al
Oops! The target
moves!
IGRT/GATED RT
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Radiation
ECRT
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• CONVENTIONAL
• 3DCRT
• IMRT
• IGRT
• VMAT/RAPIDARC
• SRS/SRT/SBRT
• PET GUIDED RADIOTHERAPY

X-KNIFE
• TREATMENT BY HIGH ENERGY X RAYS
• MOSTLY NON INVASIVE
• EQUALLY EFFECTIVE
• CHEAPER
• AVAILABILITY
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WHAT WE HAVE?
• CONES- FOR SUBCENTEMETER TUMORS
• AGILITY HEAD-MORE CONFIRMITY FOR
SMALLER TUMORS
• FRAXION-NON INVASIVE,FRAMELESS
COMFORTABLE MASK
• CONE BEAM CT-ONLINE CT BASED
CORRECTION
• HEXAPOD-EXTRA DEGREE OF ROTATIONAL
CORRECTION
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CBCT- CONE BEAM CT
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CBCT- CONE BEAM CT
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SRS SMALL FIELD CONES
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BRAIN TUMORS
• MALIGNANT TUMORS
• BENIGN TUMORS
• FUNCTIONAL DISORDERS
• REIRRADIATION
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INDICATIONS
1. AVM
2. MENINGIOMA
3. PITUITARY ADENOMA
4. ACOUSTIC NEUROMA
5. BRAIN METASTASIS
6. REIRRADIATION FOR RECURRENT GLIOMAS
7. TRIGEMINAL NEURALGIA
8. SKULL BASE TUMORS
9. SPINAL METASTASIS
10. SPINAL HEMANGIOMAS
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APPLICATION IN OTHER SITES
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Where is the Target?
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Mahatmagandhi cancer hospital and
research institute
SPARE THE ROD AND SPOIL THE CHILD
DO NOT LOOSE SHIGHT OF FOREST [OAR]FOR THE TREE

TRIPLE FUSION
PET
CTMRI
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Concept of triple-fusion
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Mahatmagandhi cancer hospital and
research institute

Pet CT planning
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78

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Tumor Volume
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Nodal Volume
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VN.C., f, 34y; Cancer of Cervix Uteri; Additional Retroperitoneal Metastases
Example: Increased Target Volume
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Moureau et al. IJROBP 2005
Increased Target Volume in Oesophageal
Carcinoma
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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
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Bird’s eye view Eagle’s eye view
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RADIOTHERAPY DELIVERY
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86

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• COSMETIC DEFECT
• FUNCTIONAL DEFECT
• IMPAIRED QUALITY OF LIFE
SURGERY
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BRACHYTHERAPY

PROCEDURE
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• HEAD AND NECK CANCERS
• BREAST CANCERS
• ESOPHAGUS CANCERS
• PENILE CANCER
• SOFT TISSUE SARCOMA
• BLADDER CANCERS
• CANAL CANCERS
ORGAN PRESERVATION
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ORGAN PRESERVATION FOR
BONE TUMORS
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BREAST CANCERS
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Intra- operative Brachytherapy
procedure

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procedure

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procedure

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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

PENILE CANCERS
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Penile conservation
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119

SARCOMAS
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131

CANCER CERVIX [STAGE
0,EARLY 1]
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ICA HDR application
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CANCER ANAL CANAL
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ANAL CANAL BRACHYTHERAPY
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CANCER TONGUE
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TONGUE IMPLANT IN PROGRESS
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TONGUE IMPLANT IN PROGRESS
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ORGAN PRESERVATION FORCANCER LIP

Complete response –towards healing
hypo-pigmentation

KELOIDS
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CANCER ESOPHAGUS
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ESOPHAGEAL BRACHYTHERAPY
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ILRT-dosimetry

PROSTATE CANCER
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166

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167

OCULAR MELANOMA
RETINOBLASTOMA
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• GOOD COSMETIC
• FUNCTIONAL PRESERVATION
• GOOD QUALITY OF LIFE
• ESTABLISHED PROCEDURE
• EXPERTISE REQUIRED
• AVAILABLE LITERATURES
• LESS TOXIC
FACTS
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SMART THINKING
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Stage IV: Metastatic Breast Cancer

180
METASTASIS
-please do not watch crying

METASTASIS- give a smiling death
182

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

Superscan-extensive bone mets
190

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

Change in bowel habits
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Change in bladder habits
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A sore that does not heal
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Unusual bleeding or discharge
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Thickening or lump in the
breast or any part of the body
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Indigestion or difficulty swallowing
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Obvious change in a wart or mole
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Liver cancer-
hepatitis B vaccine

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LOTS OF BLOOD REQUIRE

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All specialities under one roof

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TABLET FORMS

Cervix cancer vaccine
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Nagging cough or hoarseness
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Promise-Stop drinking alcohol
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Meditation
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224
Dietary protective factors

Just “Doing It” is not good enough !
You must know “what” to do and “where” to do it !
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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)

TOGETHER
WE TREAT
2409/27/2019

TEAM OF EXPERTS IN MEDICAL ONCOLOGY
1. Dr. B.Rakesh Reddy
2. Dr Chandrasekhar B
3. Dr Praveena Voonna
4. Dr Rajani Priya

TEAM OF EXPERTS IN CRITICAL CARE AND PAIN

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

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

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

DNB CURRICULUM-RADIOTHERAPY
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PHYSICS TEAM-THEY PLAN THE DOSE
2479/27/2019

TECHNOLOGIST TEAM-THEY DELIVER
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DNB CURRICULUM- SURGICAL ONCOLOGY
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PAIN AND PALLIATIVE CARE FELLOWSHIP
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YOUNG RADIATION ONCOLOGY
CONFERENCE -2014

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

EMPOWER
•EQUIPMENT
•EXPERT
•EXPERIENCE
•EASY ACCESSES

10/20/12 01:12 PM 274
Whenever not
possible,
make friends

Understanding Radiotherapy: A Concise Guide

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