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

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

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

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

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

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

1930s

1960s

COBALT MACHINE

RADIOTHERAPY SIMULATOR

LINEAR ACCELERATOR

CT SIMULATOR

TELETHERAPY

PORTAL VISION

RT PORTAL MARKED ON PATIENT RT SIMULATION FILM

EXTERNAL RT FOR SOFT TISSUE SARCOMA

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

HDR BRACHYTHERAPY MACHINE

INTEGRATED BRACHYTHERAPY UNIT

MRI BASED PLANNING

RT FOR CARCINOMA OESOPHAGUS

EXT. RT SIMULATION FILM INTRALUMINAL RT

ENDOBRONCHIAL RADIOTHERAPY

INTERSTITIAL BRACHYTHERAPY FOR

CARCINOMA OF TONGUE

3 D DOSE DISTRIBUTION OF TONGUE IMPLANT

MUPIT IMPLANT IN CA CERVIX

INTERSTITIAL

BRACHYTHERAPY

SURFACE MOULD THERAPY FOR

BASAL CELL CARCINOMA

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

TREATMENT PLANNING COMPUTERSTREATMENT PLANNING COMPUTERS

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

CONVENTIONALCONVENTIONAL IMRTIMRTIMRTIMRT

INTENSITY MODULATED RADIATION THERAPY (IMRT)

Stereotactic Conformal Radiotherapy

Pituitary Adenomas

Craniopharyngiomas

Meningiomas

Optic Gliomas

EXTRA CRANIAL STEREOTACTIC RADIOTHERAPY

Hepatic tumors

Gall bladder cancers

Pancreas tumors

Lung cancers

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)

CT-PET Imaging

Newly Diagnosed Cancers

Staging Investigation

Treatment Planning

Response Evaluation

Recurrence

- Local

- Regional (Pelvic / Para-aortic)- Distant Metastasis

Ca Cervix & Para Aortic Nodal Disease

PET-CT GUIDED RADIATION THERAPY

Eg: PNS TUMORS

TOMOTHERAPY

..

Differential Expression of Biological MarkersN = 120 Cx Biopsy Samples: Jan 2006

Markers for angiogenesis, proliferation, hypoxia and radio - resistance

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

Biological Target Volume

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

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

Thank YouThank You