UNDERSTANDING RADIOTHERAPY
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1) Radiotherapy is a key treatment modality for many cancers and involves using high-energy radiation to kill cancer cells. 2) Techniques have evolved from 2D to 3D conformal to IMRT and VMAT which better sculpt the radiation dose around the tumor and spare nearby organs. 3) Newer techniques like stereotactic radiosurgery deliver very precise high doses of radiation in just a few sessions to treat tumors throughout the body while minimizing damage to surrounding tissue.
![DR KANHU CHARAN PATRO
RADIATION ONCOLOGIST
M.D,D.N.B[RT],FAROI[USA],MBA[ICFAI],PDCR,CEPC](https://image.slidesharecdn.com/finalmgch-190927124248/85/UNDERSTANDING-RADIOTHERAPY-2-320.jpg)
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![Where is the Target?
9/27/2019 75
Mahatmagandhi cancer hospital and
research institute
SPARE THE ROD AND SPOIL THE CHILD
DO NOT LOOSE SHIGHT OF FOREST [OAR]FOR THE TREE](https://image.slidesharecdn.com/finalmgch-190927124248/85/UNDERSTANDING-RADIOTHERAPY-75-320.jpg)
![ORGAN PRESERVATION FOR
CANCER CERVIX [STAGE
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9/27/2019 12:42:57 PM 132](https://image.slidesharecdn.com/finalmgch-190927124248/85/UNDERSTANDING-RADIOTHERAPY-130-320.jpg)
UNDERSTANDING RADIOTHERAPY
- 2. DR KANHU CHARAN PATRO RADIATION ONCOLOGIST M.D,D.N.B[RT],FAROI[USA],MBA[ICFAI],PDCR,CEPC
- 4. 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] 4
- 6. 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
- 7. 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
- 8. ? ? 9/27/2019 12:42:57 PM 8
- 13. 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 9/27/2019 12:42:57 PM 13
- 14. 9/27/2019 12:42:57 PM 14 Radiation –Part of life
- 15. 9/27/2019 12:42:57 PM 15 Wilhelm Conrad Rontgen
- 16. 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 9/27/2019 12:42:57 PM 16
- 17. GOALS High dose to tumor tissue-Tumor control Normal tissue sparing Minimize long and short term toxicities Better Quality of life 9/27/2019 12:42:57 PM 17
- 18. 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 • 9/27/2019 12:42:57 PM 18
- 19. Types of radiotherapy 9/27/2019 12:42:57 PM 19 TELETHERAPY BRACHYTHERAPY
- 20. Radiotherapy procedure 1. Tumor board decision 2. Positioning And immobilization 3. Imaging 4. Target delineation 5. Planning 9/27/2019 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 20
- 21. IMAGE GUIDED RADIATION THERAPY EQUIPMENT REQUIRED CT-SCAN MRI PET-CT 9/27/2019 21 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm
- 22. Cobalt machine 9/27/2019 12:42:57 PM 22
- 23. 9/27/2019 12:42:57 PM 23
- 24. Plaster of Paris Mould-older method 9/27/2019 12:42:57 PM 24
- 25. Head & Neck 9/27/2019 12:42:57 PM 25
- 26. 9/27/2019 12:42:57 PM 26
- 27. Abdomen and Pelvis 9/27/2019 12:42:57 PM 27
- 28. Vacuum Mould 9/27/2019 12:42:57 PM 28
- 29. 9/27/2019 12:42:57 PM 29
- 30. Evolution of Treatment Techniques CUSTOMISED BLOCKS MULTILEAF COLLIMATOR BASED 3D-CRT 1990s1980s 9/27/2019 12:42:57 PM 30
- 31. 9/27/2019 12:42:57 PM 31
- 32. Treating Head & Neck with Sliding Windows 9/27/2019 12:42:57 PM 32
- 33. 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
- 34. 9/27/2019 12:42:57 PM 34
- 35. 9/27/2019 12:42:57 PM 35
- 36. 9/27/2019 12:42:57 PM 36
- 37. 9/27/2019 12:42:57 PM 37
- 39. Small Volume Adjacent to Critical Structure 9/27/2019 12:42:57 PM 39
- 40. 3D Dose Shaping - H&N and Brain Brain Stem 9/27/2019 12:42:57 PM 40
- 41. Target Motion in Radiotherapy Caveman et al Oops! The target moves! IGRT/GATED RT 9/27/2019 12:42:57 PM 41
- 42. 9/27/2019 12:42:57 PM 42
- 43. 9/27/2019 12:42:57 PM 43
- 44. 9/27/2019 12:42:57 PM 44
- 45. 9/27/2019 12:42:57 PM 45
- 47. RADIOTHERAPY
- 49. • CONVENTIONAL • 3DCRT • IMRT • IGRT • VMAT/RAPIDARC • SRS/SRT/SBRT • PET GUIDED RADIOTHERAPY
- 50. X-KNIFE • TREATMENT BY HIGH ENERGY X RAYS • MOSTLY NON INVASIVE • EQUALLY EFFECTIVE • CHEAPER • AVAILABILITY 9/27/2019 50
- 54. 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 9/27/2019 54
- 58. CBCT- CONE BEAM CT 9/27/2019 58
- 59. CBCT- CONE BEAM CT 9/27/2019 59
- 61. SRS SMALL FIELD CONES 9/27/2019 61
- 62. BRAIN TUMORS • MALIGNANT TUMORS • BENIGN TUMORS • FUNCTIONAL DISORDERS • REIRRADIATION 9/27/2019 62
- 63. 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 9/27/2019 63
- 67. APPLICATION IN OTHER SITES 9/27/2019 67
- 75. Where is the Target? 9/27/2019 75 Mahatmagandhi cancer hospital and research institute SPARE THE ROD AND SPOIL THE CHILD DO NOT LOOSE SHIGHT OF FOREST [OAR]FOR THE TREE
- 76. TRIPLE FUSION PET CTMRI 9/27/2019 76 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm
- 77. Concept of triple-fusion 9/27/2019 77 Mahatmagandhi cancer hospital and research institute
- 78. Pet CT planning 9/27/2019 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 78
- 79. 9/27/2019 79 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm
- 80. Tumor Volume 9/27/2019 80 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm
- 81. Nodal Volume 9/27/2019 81 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm
- 82. VN.C., f, 34y; Cancer of Cervix Uteri; Additional Retroperitoneal Metastases Example: Increased Target Volume 9/27/2019 82 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm
- 83. Moureau et al. IJROBP 2005 Increased Target Volume in Oesophageal Carcinoma 9/27/2019 83 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm
- 84. 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 9/27/2019
- 85. Bird’s eye view Eagle’s eye view 9/27/2019 85 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm
- 86. RADIOTHERAPY DELIVERY 9/27/2019 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 86
- 87. 9/27/2019 87 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm
- 91. • COSMETIC DEFECT • FUNCTIONAL DEFECT • IMPAIRED QUALITY OF LIFE SURGERY 9/27/2019 12:42:57 PM 92
- 92. 9/27/2019 12:42:57 PM 93 BRACHYTHERAPY
- 94. 9/27/2019 12:42:57 PM 95
- 96. 9/27/2019 12:42:57 PM 97
- 97. • HEAD AND NECK CANCERS • BREAST CANCERS • ESOPHAGUS CANCERS • PENILE CANCER • SOFT TISSUE SARCOMA • BLADDER CANCERS • CANAL CANCERS ORGAN PRESERVATION 9/27/2019 12:42:57 PM 98
- 98. ORGAN PRESERVATION FOR BONE TUMORS 9/27/2019 12:42:57 PM 99
- 99. 9/27/2019 12:42:57 PM 100
- 100. 9/27/2019 12:42:57 PM 101
- 101. ORGAN PRESERVATION FOR BREAST CANCERS 9/27/2019 12:42:57 PM 102
- 102. 9/27/2019 12:42:57 PM 103 Intra- operative Brachytherapy procedure
- 103. 9/27/2019 12:42:57 PM 104 Intra- operative Brachytherapy procedure
- 104. 9/27/2019 12:42:57 PM 105 Intra- operative Brachytherapy procedure
- 105. 9/27/2019 12:42:57 PM 106 Intra- operative Brachytherapy procedure
- 106. 9/27/2019 12:42:57 PM 107 3D Brachytherapy Planning CT Loading Dose distribution
- 107. 9/27/2019 12:42:57 PM 108 Dose prescription and Treatment delivery • Dose: 34Gy in 10 fraction bid • Dose per fraction: 340cGy
- 116. ORGAN PRESERVATION FOR PENILE CANCERS 9/27/2019 12:42:57 PM 117
- 117. 9/27/2019 12:42:57 PM 118
- 118. Penile conservation 9/27/2019 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 119
- 119. 9/27/2019 12:42:57 PM 120
- 120. 9/27/2019 12:42:57 PM 121
- 121. 9/27/2019 12:42:57 PM 122
- 122. 9/27/2019 12:42:57 PM 123
- 123. ORGAN PRESERVATION FOR SARCOMAS 9/27/2019 12:42:57 PM 124
- 124. 9/27/2019 12:42:57 PM 125
- 125. 9/27/2019 12:42:57 PM 127
- 126. 9/27/2019 12:42:57 PM 128
- 127. 9/27/2019 12:42:57 PM 129
- 128. 9/27/2019 12:42:57 PM 130
- 129. 9/27/2019 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 131
- 130. ORGAN PRESERVATION FOR CANCER CERVIX [STAGE 0,EARLY 1] 9/27/2019 12:42:57 PM 132
- 131. 9/27/2019 12:42:57 PM 133
- 132. 9/27/2019 12:42:57 PM 134
- 133. ICA HDR application 9/27/2019 12:42:57 PM 135
- 134. 9/27/2019 12:42:57 PM 136
- 135. 9/27/2019 12:42:57 PM 137
- 136. ORGAN PRESERVATION FOR CANCER ANAL CANAL 9/27/2019 12:42:57 PM 138
- 137. APR 9/27/2019 12:42:57 PM 139
- 138. ANAL CANAL BRACHYTHERAPY 9/27/2019 12:42:57 PM 140
- 139. ORGAN PRESERVATION FOR CANCER TONGUE 9/27/2019 12:42:57 PM 141
- 140. 9/27/2019 12:42:57 PM 142
- 141. TONGUE IMPLANT IN PROGRESS 9/27/2019 12:42:57 PM 143
- 142. TONGUE IMPLANT IN PROGRESS 9/27/2019 12:42:57 PM 144
- 143. 9/27/2019 12:42:57 PM 145 ORGAN PRESERVATION FORCANCER LIP
- 144. 9/27/2019 12:42:57 PM 146
- 145. 9/27/2019 12:42:57 PM 147
- 146. 9/27/2019 12:42:57 PM 148
- 147. Applicator in situ with IOP
- 148. Complete response –towards healing hypo-pigmentation
- 149. Recent
- 155. 9/27/2019 12:42:57 PM 157
- 156. KELOIDS 9/27/2019 12:42:57 PM 158
- 157. CANCER ESOPHAGUS 9/27/2019 12:42:57 PM 159
- 158. ESOPHAGEAL BRACHYTHERAPY 9/27/2019 12:42:57 PM 160
- 159. 9/27/2019 12:42:57 PM 161 ILRT-dosimetry
- 160. PROSTATE CANCER 9/27/2019 12:42:57 PM 162
- 161. 9/27/2019 12:42:57 PM 163
- 162. 9/27/2019 12:42:57 PM 164
- 163. 9/27/2019 12:42:57 PM 165
- 164. 9/27/2019 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 166
- 165. 9/27/2019 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 167
- 167. 9/27/2019 12:42:57 PM 169
- 168. 9/27/2019 12:42:57 PM 170
- 169. 9/27/2019 12:42:57 PM 171
- 170. 9/27/2019 12:42:57 PM 172
- 171. 9/27/2019 12:42:57 PM 173
- 173. • GOOD COSMETIC • FUNCTIONAL PRESERVATION • GOOD QUALITY OF LIFE • ESTABLISHED PROCEDURE • EXPERTISE REQUIRED • AVAILABLE LITERATURES • LESS TOXIC FACTS 9/27/2019 12:42:57 PM 175
- 174. SMART THINKING 9/27/2019 12:42:57 PM 176
- 175. 9/27/2019 12:42:57 PM 177
- 177. Stage IV: Metastatic Breast Cancer
- 178. 180 METASTASIS -please do not watch crying
- 179. 10/20/12 01:12 PM 181
- 180. METASTASIS- give a smiling death 182
- 181. Palliative radiation Skeletal X-Ray Bone scan MRI PET-CT
- 183. 185
- 184. Brain metastasis 186
- 185. 187
- 191. svco 193
- 192. 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
- 193. Change in bowel habits 10/20/12 01:12 PM 195
- 194. Change in bladder habits 10/20/12 01:12 PM 196
- 195. A sore that does not heal 10/20/12 01:12 PM 197
- 196. Unusual bleeding or discharge 10/20/12 01:12 PM 198
- 197. Thickening or lump in the breast or any part of the body 10/20/12 01:12 PM 199
- 198. Indigestion or difficulty swallowing 10/20/12 01:12 PM 200
- 199. Obvious change in a wart or mole 10/20/12 01:12 PM 201
- 200. Liver cancer- hepatitis B vaccine
- 201. 9/27/2019 12:42:57 PM 203 LOTS OF BLOOD REQUIRE
- 202. 9/27/2019 12:42:57 PM 204
- 203. 9/27/2019 12:42:57 PM 205 All specialities under one roof
- 204. 9/27/2019 12:42:57 PM 206 TABLET FORMS
- 205. Cervix cancer vaccine 10/20/12 01:12 PM 207
- 206. Nagging cough or hoarseness 10/20/12 01:12 PM 208
- 209. 9/27/2019 12:42:57 PM 211
- 211. 10/20/12 01:12 PM 213
- 213. REGULAR CHECK-UP
- 215. 9/27/2019 12:42:57 PM 217
- 217. 219
- 219. Promise-Stop drinking alcohol 10/20/12 01:12 PM 221
- 220. RELAX
- 221. Meditation 10/20/12 01:12 PM 223
- 223. Breast feeding
- 224. Physical activity
- 225. 227
- 226. 228
- 227. 9/27/2019 12:42:57 PM 229
- 228. 9/27/2019 12:42:57 PM 230
- 230. 9/27/2019 12:42:57 PM 232
- 231. 10/20/12 01:12 PM 233
- 232. Just “Doing It” is not good enough ! You must know “what” to do and “where” to do it ! 10/20/12 01:12 PM 234
- 233. 10/20/12 01:12 PM 235
- 234. 10/20/12 01:12 PM 236
- 236. 9/27/2019 238
- 237. 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)
- 239. TEAM OF EXPERTS IN MEDICAL ONCOLOGY 1. Dr. B.Rakesh Reddy 2. Dr Chandrasekhar B 3. Dr Praveena Voonna 4. Dr Rajani Priya
- 240. TEAM OF EXPERTS IN CRITICAL CARE AND PAIN
- 241. TEAM OF EXPERTS-- Radiology 1. Dr. P.Madhuri D.M.R.D ( AMC ,Visakhapatnam) 2. Dr. B.Revathi D.M.R.D ( RMC ,Kakinada)
- 242. GYNAEC ONCOLOGY : Dr.Jyoti Doki M.D. (Gynaec & Obg) (AMC,Visakhapatnam)
- 243. Nuclear Medicine : Dr. K.Raghava Kashyap M.D (Nuclear Medicine) (PGIMER, Chandigarh)
- 245. PHYSICS TEAM-THEY PLAN THE DOSE 2479/27/2019
- 247. DNB CURRICULUM- SURGICAL ONCOLOGY 9/27/2019 249
- 248. PAIN AND PALLIATIVE CARE FELLOWSHIP 9/27/2019 250
- 262. v
- 263. YOUNG RADIATION ONCOLOGY CONFERENCE -2014
- 264. ACCREDITED
- 265. ACCREDITED
- 266. MEMBER
- 267. APPROVED
- 269. 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
- 270. DECISIONS IN TUMOR BOARD
- 272. 10/20/12 01:12 PM 274 Whenever not possible, make friends
- 273. 27510/20/12 01:12 PM
- 274. 27610/20/12 01:12 PM
- 275. 9/27/2019 12:42:57 PM 277
- 276. 9/27/2019 12:42:57 PM 278
- 277. 9/27/2019 12:42:57 PM 279
- 278. 9/27/2019 280
- 279. 281 ?