UNDERSTANDING RADIOTHERAPY

1. 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

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

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

38. Mesothelioma
9/27/2019 12:42:57 PM 38

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

46. Radiation
ECRT
9/27/2019 12:42:57 PM 46

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

51. CYBER-KNIFE
9/27/2019 51

52. VARIAN STX
9/27/2019 52

53. WE HAVE-ELEKTA
9/27/2019 53

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

55. ELEKTA AGILITY
9/27/2019 55

56. ELEKTA AGILITY
9/27/2019 56

57. ELEKTA AGILITY
9/27/2019 57

58. CBCT- CONE BEAM CT
9/27/2019 58

59. CBCT- CONE BEAM CT
9/27/2019 59

60. HEXAPOD
9/27/2019 60

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

88. ORGAN PRESERVATION

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

95. PROCEDURE
9/27/2019 12:42:57 PM 96

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

166. OCULAR MELANOMA
RETINOBLASTOMA
9/27/2019 12:42:57 PM 168

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

172. WHO PRESERVES
HE DESERVES

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

176. Sharp gun-missed target
178

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

182. Spinal metastasis
184

183. 185

184. Brain metastasis
186

185. 187

186. Whole brain radiotherapy
188

187. Choroidal metastasis
189

188. Superscan-extensive bone mets
190

189. Hemibody radiation
191

190. Prophylactic radiation
192

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

218. Prevention-passive smoking

219. Promise-Stop drinking alcohol
10/20/12 01:12 PM 221

220. RELAX

221. Meditation
10/20/12 01:12 PM 223

222. 224
Dietary protective factors

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)

238. TOGETHER
WE TREAT
2409/27/2019

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)

244. DNB CURRICULUM-RADIOTHERAPY
9/27/2019 246

245. PHYSICS TEAM-THEY PLAN THE DOSE
2479/27/2019

246. TECHNOLOGIST TEAM-THEY DELIVER
9/27/2019 248

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

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

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
?