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radiologyTRANSCRIPT
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RADIATION THERAPYRADIATION THERAPY
A Brief OverviewA Brief OverviewAnd And
New TrendsNew Trends
Dr Umesh Mahantshetty, DMRT, MD, DNBConsultant, Radiation Oncologist
Tata Memorial Centre, Mumbai, India
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40
48
63
20
32
18
64
77
37
52
60
52
37
80
68
82
36
23
63
48
0 20 40 60 80 100
LeukaemiaLeukaemia
NonNon--Hodgkin LymphomaHodgkin Lymphoma
BladderBladder
esophagusesophagus
Mouth/PharynxMouth/Pharynx
LiverLiver
Colon/RectumColon/Rectum
ProstateProstate
StomachStomach
LungLung
DevelopedDevelopedcountriescountries
DevelopingDevelopingcountriescountries
PERCENTPERCENT
Global Cancer Burden for Ten Most Common Sites Global Cancer Burden for Ten Most Common Sites Cancer siteCancer site
(No. in thousands)(No. in thousands)
(901)(901)
(558)(558)
(543)(543)
(499)(499)
(398)(398)
(316)(316)
(279)(279)
(260)(260)
(167)(167)
(144)(144)
Source: IARC website wwwSource: IARC website www--dep.iarc.frdep.iarc.fr 20062006
MALESMALES
-
12
24
20
60
47
39
52
65
19
55
88
76
80
40
53
61
48
35
81
45
00 2020 4040 6060 8080 100100
EsophagusEsophagus
Mouth/PharynxMouth/Pharynx
LiverLiver
Corpus uteriCorpus uteri
OvaryOvary
StomachStomach
LungLung
Colon/RectumColon/Rectum
Cervix uteriCervix uteri
BreastBreast
Global Cancer Burden for Ten Most Common SitesGlobal Cancer Burden for Ten Most Common SitesFEMALESFEMALES
PERCENTPERCENT
Cancer siteCancer site(No. in thousands)(No. in thousands)
(1050)(1050)
(471)(471)
(446)(446)
(337)(337)
(318)(318)
(192)(192)
(189)(189)
(166)(166)
(138)(138)
(133)(133)
Source: IARC website wwwSource: IARC website www--dep.iarc.frdep.iarc.fr 20062006
DevelopedDevelopedcountriescountries
DevelopingDevelopingcountriescountries
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0 20 40 60
Oral cavity
Pharynx
Lung
Oeso-phagus
Larynx
49 29
37 27
34 31
28 26
2314
MALES
No. of cases ( X1000)
Cancer site
Cervixuteri
Breast
Oral cavity
Ovary
Oeso-phagus
FEMALES
No. of cases (X1000)
0 50 100
12670
7940
2917
2012
2018
New casesDeaths
Cancer site
FIVE MOST COMMON CANCERS : INDIAESTIMATED NUMBER OF NEW CASES AND DEATHS (IN THOUSANDS) :
Source: IARC website www-dep.iarc.fr 2006Source: IARC website www-dep.iarc.fr 2006
Five most common cancers account for almost half the total cases and deaths due to cancer in Indian men
Five most common cancers account for almost half the total cases and deaths due to cancer in Indian men
Five most common cancers account for almost two-thirds of the total cases) and deaths due to cancer in Indian women
Five most common cancers account for almost two-thirds of the total cases) and deaths due to cancer in Indian women
New casesDeaths
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Radiation Therapy needed in > 75 % of patients as part of
Radical or Definitive radiotherapyAdjuvant Radiotherapy : Pre op / Post-op
Concomitant Chemo-radiation Consolidation radiotherapy
Palliative radiotherapy
Common Modalities of Cancer TherapyCommon Modalities of Cancer Therapy
Radiation Therapy
Radiation Therapy
Chemo Therapy
Chemo TherapySurgerySurgery
Use of ionizing radiation for treatment of malignant & (benign) lesions
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Marie and Pierre CurieMarie and Pierre Curie
Discovered Radium 1898Curies & Becquerel discovered radioactivity in 1903Nobel prize for discovery of radioactivity in 1903
KonradKonrad Von RoentgenVon Roentgen
Discovery of X-Rays: 1895
HISTORY OF RADIATION THERAPYHISTORY OF RADIATION THERAPY
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Basis Basis ionizing particles interact with cellular moleculesionizing particles interact with cellular molecules
Relies on transfer of energy created by secondary charged Relies on transfer of energy created by secondary charged
particles (usually electrons)particles (usually electrons)
Break chemical bondsBreak chemical bonds
TeletherapyTeletherapy and Brachytherapyand Brachytherapy
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1930s
1960s
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COBALT MACHINE
RADIOTHERAPY SIMULATOR
LINEAR ACCELERATOR
CT SIMULATOR
TELETHERAPY
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PORTAL VISION
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RT PORTAL MARKED ON PATIENT RT SIMULATION FILM
EXTERNAL RT FOR SOFT TISSUE SARCOMA
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Radioactive source close / inside the body/cavitiesRadioactive source close / inside the body/cavities
Rapid radiation dose fall offRapid radiation dose fall off
High doses to tumor with maximal normal tissue sparingHigh doses to tumor with maximal normal tissue sparing
Highly Skill OrientedHighly Skill Oriented
IntracavitaryCs-137- LDRIr-192 - HDR
InterstitialIr-wires LDRIr-Pellet HDR
Surface MouldIr-wires LDRIr-Pellet HDR
Brachytherapy
BRACHYTHERAPYBRACHYTHERAPY
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HDR BRACHYTHERAPY MACHINE
INTEGRATED BRACHYTHERAPY UNIT
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MRI BASED PLANNING
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RT FOR CARCINOMA OESOPHAGUS
EXT. RT SIMULATION FILM INTRALUMINAL RT
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ENDOBRONCHIAL RADIOTHERAPY
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INTERSTITIAL BRACHYTHERAPY FOR
CARCINOMA OF TONGUE
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3 D DOSE DISTRIBUTION OF TONGUE IMPLANT
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MUPIT IMPLANT IN CA CERVIX
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INTERSTITIAL
BRACHYTHERAPY
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SURFACE MOULD THERAPY FOR
BASAL CELL CARCINOMA
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Basic Principle of
Newer Radiotherapy Techniques
Conformal RT Beam Uniform Beam Intensity
IMRT Beam
Non-Uniform Beam IntensityConventional RT Beam Uniform Beam Intensity
squares / rectangles
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TREATMENT PLANNING COMPUTERSTREATMENT PLANNING COMPUTERS
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EXTERNAL BEAM RADIATION THERAPY RECOMMENDATIONS
ANTERIOR LATERAL
WHOLE PELVIS WITH AP/PA OR FOUR FIELD BOX TECHNIQUE DOSE DEPENDING ON THE STAGE
BORDERS
CT SCAN BASED RADIOTHERAPY PLANNING
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CONVENTIONALCONVENTIONAL IMRTIMRTIMRTIMRT
INTENSITY MODULATED RADIATION THERAPY (IMRT)
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Stereotactic Conformal Radiotherapy
Pituitary Adenomas
Craniopharyngiomas
Meningiomas
Optic Gliomas
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EXTRA CRANIAL STEREOTACTIC RADIOTHERAPY
Hepatic tumors
Gall bladder cancers
Pancreas tumors
Lung cancers
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TREATMENT TREATMENT TREATMENT TREATMENT TREATMENT TREATMENT TREATMENT TREATMENT
DELIVERYDELIVERYDELIVERYDELIVERYDELIVERYDELIVERYDELIVERYDELIVERY
Linear Accelerator with Linear Accelerator with
Dynamic Dynamic MultileafMultileaf Collimators Collimators
((dMLCdMLC))
Treatment VerificationTreatment VerificationTreatment VerificationTreatment Verification
by Portal Vision (EPID)by Portal Vision (EPID)by Portal Vision (EPID)by Portal Vision (EPID)
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CT-PET Imaging
Newly Diagnosed Cancers
Staging Investigation
Treatment Planning
Response Evaluation
Recurrence
- Local
- Regional (Pelvic / Para-aortic)- Distant Metastasis
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Ca Cervix & Para Aortic Nodal Disease
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PET-CT GUIDED RADIATION THERAPY
Eg: PNS TUMORS
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TOMOTHERAPY
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..
Differential Expression of Biological MarkersN = 120 Cx Biopsy Samples: Jan 2006
Markers for angiogenesis, proliferation, hypoxia and radio - resistance
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Biological Markers and Clinical Outcome : Jan 2006
(14 3 3 as a factor)(SF 3 as a factor)
Metallothionein II as a factor
High SF3 is associated with poor outcome (p=ns) High expression of 14-3-3 Metallothionein II Needs to be tested on a larger patient base and longer follow-up
correlates with the poor survival significantly
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Biological Target Volume
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Growth of RT infrastructure in India over the years
1962-1986 -- 76 Co-60 & Cs-137 units (> 20 years old): Definitely need replacement
1987-1991 -- 35 Co-60 units (> 15 years old): Should be considered for replacement
Pre 1991 LA -- 12 units (>15 years old): Could be considered for replacement
UNITS
Co-60: 260
LA: 69
R-HDR: 73
MIC: 76
Cesium: 8
LDR: 37
7676737337371861868869692602603373370.330.33102700000102700000
00IndiaIndia
MICMICHDRHDRLDRLDRBrach Brach
unitsunitsCsCs--
137137LALACoCo--
6060TeleTele--
unitsunitsTeleTele--den den
/million/millionPopulationPopulation
123/337 teletherapy units need replacement
0
50
100
150
200
250
300
1960 1980 1985 1990 1995 2000 2005
Co-60 LA Cs137R HDR LDR MIC
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Radiation Oncology : Well Established
Organ and Function Preservation
Rapid Technological Advances
Translational Research and Wider Clinical Applications
Newer techniques : Needs Further Evaluation
Up-gradation and Many More Oncology Centers
SummarySummary
Multidisciplinary , Multimodality Evidence Based Approach
Thank You
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Thank YouThank You