Advanced Radiotherapy for Cervical cancers for physicians

Advanced Radiotherapy for Cervical cancers for physicians

1. PRECISION RADIOTHERAPY IN CANCER CERVIX Dr Kanhu Charan Patro MD,DNB(Radiation Oncology),MBA,FICRO,FAROI(USA),PDCR,CEPC Clinical Director, HOD-Radiation Oncology ISRo - I nstitute of S tereotactic R adiation o ncology Mahatma Gandhi Cancer Hospital & Research Institute, Visakhapatnam [email protected] /M- [phone]/ www.drkanhupatro.com

2. 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] 2

3. Dr. Kanhu Charan Patro Clinical Director and HOD (Radiation Oncology) (Brain Tumor Specialist) Mahatma Gandhi Cancer Hospital & RI, Visakhapatnam MBBS (Gold Medalist) MD, DNB (Radiation Oncology) MBA (HA), FICRO, FAROI [USA], CEPC, PDCR Visiting Fellow Manheim Cancer Center, Germany V isiting trainee in Accuray Genolier, Switzerland Visiting Fellow Well Cornell Medical College, New York Ex. Resident (TMH-Mumbai) Visiting trainee (AIIMS-New Delhi) [email protected] / M-9160470564/drkanhupatro.com   SL SUBJECT INFERENCE 1 Area of interest NEURO AND URO-ONCOLOGY, NON - INVASIVE BRACHYTHERAPY 2 Clinical experience 25+ years 3 Cancer patients handled (RADIOTHERAPY) Nearly 10000 4 Brain tumors handled Nearly 900 5 Brachytherapy cases handled Nearly 4000 6 Interstitial brachytherapy cases handled Nearly 600 7 SRS/SBRT cases handled Nearly 200 8 Article publication Nearly 50 9 Slide share presentations Nearly 300 10 E Books/Chapter/Abstract Nearly 120 11 Awards received 12 12 Faculty invite- conferences More than 100 13 Thesis guided 10 14 Academic teacher experience 8 years 15 Fellowships awarded 4

4. Statistics

5. THE GLOBAL BURDEN

6. Incidence cervical cancer

7. IN INDIA

8. IN INDIA

9. IN INDIA

10. Why? Low screening rates / late diagnosis Poor awareness and knowledge Sociocultural barriers Cost / economic barriers Health system / infrastructure limitations HPV vaccination coverage is low / delayed Risk factors / demographic and reproductive factors High prevalence of HPV infection (persistent infection with high-risk types) is the necessary cause Early marriage, early sexual debut, higher parity (many children), poor sexual hygiene, lack of contraception, etc. These influence exposure risk Lower socioeconomic status is correlated with worse outcome

11. Why?

12. The HPV

13. Type of patient Multiparous . Low socioeconomic class. Poor hygiene. Multiple partners Low incidence in Muslims and Jews.

14. Pathology type Squamous cell carcinoma- 90%. Adeno carcinoma- 10%. TYPES OF GROWTH Exophytic : is like cauliflower filling up the vaginal vualt . Endophytic : it appears as hard mass with a good deal of induration . Ulcerative : an ulcer in the cervix.

15. TREATMENT Surgical. Radiotherapy. Surgery f/b Radiotherapy Radiotherapy and Chemotherapy Palliative treatment.

16. The choice of treatment will depend on Fitness of the patients Age of the patients Stage of disease. Type of lesion Experience and the resources available.

17. Treatment Algorithm 10/15/2025 2:49:09 PM 18

18. Werthemeim’s Hystrectomy Total abdominal hystrectomy including the parametrium . Pelvic lymphadenectomy 3 cm vaginal cuff The original operation conserved the ovaries , since squamouss cell carcinoma does not spread directly to the ovaries. Oophorectomy should be performed in cases of adenocarcinoma as there is 5-10% of ovarian metastasis

19. Surgery offers some advantage It allows preservation of the ovaries There is better chance of preserving sexual function. Vaginal stenosis occur in up 85% of irradiates. Psychological feeling of removing the disease from the body . More acute staging and prognosis Adenocarcinoma are not detectable by screening are associated with skip lesions and require radical surgery.

20. COMPLICATIONS OF SURGERY Haemorrhage : primary or secondary. Injury to the bladder, Ureters. Bladder dysfunction. Fistula. Lymphocele . Shortening of the vagina.

21. Indication for post op radiation 10/15/2025 2:49:09 PM 22

22. Indication for post op radiation 10/15/2025 2:49:09 PM 23

23. Definitive Chemoradiation Medically inoperable Stage II-IV disease 10/15/2025 2:49:09 PM 24

24. CONCURRENT CHEMO 10/15/2025 2:49:09 PM 25

25. Radiotherapy MX 10/15/2025 2:49:10 PM 26 TELETHERAPY BRACHYTHERAPY

26. Radiotherapy X ray Surgery PET MRI Chemo ? ? 10/15/2025 2:49:10 PM 27

27. Oncologist Diagnosis Treatment Radiologist Cytopathologist Surgeon Histopathologist Molecular Pathologist Geneticist psychiatrist Nursing And Support staff Audit

28. Radiation –Part of life 10/15/2025 2:49:10 PM 32

29. 10/15/2025 2:49:10 PM 33 Wilhelm Conrad Rontgen

30. 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 10/15/2025 2:49:10 PM 34

31. GOALS 10/15/2025 2:49:10 PM 35 High dose to tumor tissue-Tumor control Normal tissue sparing Minimize long and short term toxicities Better Quality of life

32. 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 10/15/2025 2:49:10 PM 36

33. Role of radiotherapy in various cancers Needed for all most head and neck cancer Radical- Nasopharynx , cervix , larynx, hypopharynx etc. post-op-adjuvant Rectum, cervix early, stomach, head and neck, other abdominal malignancies Palliative compression, bleeding , obstruction, pian 10/15/2025 2:49:10 PM 37

34. Radiotherapy procedure Tumor board decision Positioning And immobilization Imaging Target delineation Planning 10/15/2025 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 38

35. IMAGE GUIDED RADIATION THERAPY EQUIPMENT REQUIRED CT-SCAN MRI PET-CT 10/15/2025 39 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm

36. Cobalt machine 10/15/2025 2:49:10 PM 40

37. Radiation proctits

38. Radiation cystitis

39. Radiation vaginal stenosis

40. Radiation intestinal stricture

41. Radiation intestinal stricture

42. Radiation vascular necrosis

43. LINEAR ACCELERATOR 10/15/2025 2:49:10 PM 48

44. Abdomen and Pelvis 10/15/2025 2:49:10 PM 49

45. Standard of Care EBRT 45–50.4 Gy with weekly cisplatin (40 mg/m²) Mandatory brachytherapy to reach HR-CTV EQD2 ≥ 85–90 Gy (ICRU 89/GEC‑ESTRO) Overall treatment time (OTT) ≤ 7–8 weeks correlates with outcomes

46. Conventional Radiotherapy 4 Field Box 10/15/2025 2:49:10 PM 51

47. 10/15/2025 2:49:10 PM 52 Conformal Radiotherapy-IMRT

48. EPID- Treatment verification

49. CBCT- Treatment verification

50. Intracavitary brachytherapy 10/15/2025 2:49:11 PM 55

51. 10/15/2025 2:49:11 PM 56 Intracavitary brachytherapy

52. Intracavitary brachytherapy 10/15/2025 2:49:11 PM 57 Uterine Sound Foley’s Bulb Bladder

53. Interstitial brachy 10/15/2025 2:49:13 PM 58

54. Follow-up I. clinical Examination 3monthly for first 2year 6monthly for after 2year Annually there after II. No other investigations in asymptomatic patients for early detection of metastasis, since it is - Not cost-effective Does not prolong survival. Detection and disclosure of spread of disease may be psychologically harmful to an asymptomatic 10/15/2025 2:49:13 PM 59

55. PROGNOSIS Depends on: Age of the patient. Fitness of the patient. Stage of the disease. Type of the tumour. Adequacy of treatment.

56. The survival THE OVERALL 5 YEARS SURVIVAL FOLLOWING THERAPY: Stage I -------80% Stage II-------50-60% Stage III-------30-40% Stage IV-------4%

57. Radiation toxicity Bladder related Rectum related Bowel related Bone related Acute Late 10/15/2025 2:49:13 PM 62

58. Radiation toxicity

59. ADVANCEMENT IN EXTERNAL RT

60. Imaging to Plan Well Pelvic MRI for primary and parametria PET-CT for nodal staging Use MRI/CT for target delineation per GEC‑ESTRO concepts (GTV, HR‑CTV, IR‑CTV)

61. Role of PET CT When things are suspicious PET CT is auspicious Identifying suspicious nodes Boosting the nodes Reirradiation settings

62. Role of PET CT Nodal accuracy and boost

63. Role of PET CT- RT planning

64. Involved Nodes: Boost Strategy Elective nodal coverage (pelvic ± para-aortic per risk) SIB to PET/MRI-positive nodes during EBRT (e.g., 55–60 Gy in 25 fx) Aim for EQD2 ≥ 60–65 Gy to GTVn while respecting OARs

65. When to Treat Para‑aortic Nodes PET‑positive para‑aortic nodes: include in CTV with dose painting/boost Consider sequential or SIB boost based on proximity to bowel/kidney Historical RTOG data support CTRT over EFRT alone in high‑risk patients

66. Role of PET CT- ReRT

67. Why Advanced RT Matters High burden in LMICs; many present with locally advanced disease Concurrent chemoradiation with brachytherapy remains standard of care Advanced RT Improves local control Reduces toxicity vs. 2D plans

68. 2D plan

69. IMRT/VMAT or Tomotherapy Conformal dose to uterus/cervix/parametria Sparing rectum, bladder, bowel; better DVH metrics Facilitates SIB to involved nodes when indicated

70. 2D plan vs VMAT

71. IGRT

72. IGRT

73. IGRT & Adaptive EBRT Daily CBCT for set-up and organ filling variations Re‑planning for tumor regression/bladder/rectum changes Consider offline/online adaptation in weeks 3–4 if significant regression

74. IGRT recommendation

75. Outcomes with higher techniques

76. Outcomes with higher techniques

77. Outcomes with higher techniques

78. Outcomes with higher techniques

79. Bone Marrow–Sparing IMRT Pelvic BM constraints associated with less acute hematologic toxicity Typical planning tips: Contour lumbosacral spine + iliac BM; Limit V10–V20–V40 where feasible Supported by randomized and contemporary data

80. Bone marrow sparing

81. NEW BABY IN THE TOWN

82. ADVANTAGE OF TOMO

83. ADVANTAGE OF TOMO

84. Now In Visakhapatnam

85. Advancement in Brachy

86. From 2D to 3D IGABT ICRU 89 & GEC‑ESTRO define HR‑CTV/IR‑CTV and DVH reporting MRI-based planning preferred; CT acceptable if MRI unavailable Goal: HR‑CTV D90 ≥ 85–90 Gy (EQD2), Limited OAR D2cc (rectum, bladder, sigmoid)

87. 10/15/2025 2:49:13 PM 96 Intracavitary brachytherapy_MRI

88. 10/15/2025 2:49:13 PM 97 Intracavitary brachytherapy_MRI

89. Applicators & Techniques Intracavitary (IC) for typical cases Hybrid IC/IS or Interstitial templates for bulky, residual, or asymmetrical disease ABS 2025 hybrid consensus provides practical guidance

90. EMBRACE Program me EBRT (IMRT/IGRT) MRI-guided adaptive brachytherapy

91. RetroEMBRACE (2005–2011) Design: Retrospective analysis of 731 patients from 12 institutions Objective: Validate MRI-guided adaptive brachytherapy outcomes

92. RetroEMBRACE (2005–2011) Endpoint 3-Year (%) 5-Year (%) Local Control (LC) 91.0 89 Pelvic Control (PC) 87.0 84 Cause-Specific Survival (CSS) 79.0 73 Overall Survival (OS) 74.0 65 LC by Stage IB 98.0 98 LC by Stage IIB 93.0 91 LC by Stage IIIB 79.0 75 PC by Stage IB 96.0 96 PC by Stage IIB 89.0 87 PC by Stage IIIB 73.0 67 5-yr Grade 3-5 Morbidity (Bladder) 5 5-yr Grade 3-5 Morbidity (GI Tract) 7 5-yr Grade 3-5 Morbidity (Vaginal) 5

93. Embrace I (2008) Design: International, multicenter, prospective observational study Population: 1416 patients with cervical cancer treated with MRI-guided adaptive brachytherapy Key Findings: Actuarial overall 5-year local control was 92% Improved outcomes compared with historical controls Safety: acceptable late toxicity rates

94. EMBRACE -I-2021

95. Embrace II (Ongoing, since 2016) Design: International prospective study building on Embrace I Aims Optimize image-guided brachytherapy Integrate modern EBRT (IMRT/IGRT) Reduce morbidity while preserving efficacy Endpoints: Local control, progression-free survival, quality of life, toxicity reduction

96. Dose, Fractionation, Timing EBRT 45–50.4 Gy/25–28 fx with weekly cisplatin Brachy: 4–5 fractions HDR; individualize per HR‑CTV volume and OAR D2cc Finish OTT ≤ 56 days; use workflow pathways to avoid delays

97. Re‑irradiation Options (Selected) Interstitial brachytherapy for central/pelvic recurrences SBRT for nodal or oligometastatic relapse with careful cumulative OAR assessment Case selection via MDT; consider intervals, prior doses, and toxicity risk

98. Reduce Toxicity Proactively Strict OAR constraints (ICRU 89): Bladder/Rectum/Sigmoid D2cc Vaginal stenosis prevention: dilators, lubricants, education Bone marrow sparing; nutritional and symptom support during CTRT

99. Workflow, QA, and Documentation Checklists for imaging, contouring, plan review, in‑vivo verification Document EQD2 (EBRT + BT) for HR‑CTV and OARs Use standard templates for reporting per ICRU 89

100. What’s Next MR‑Linac adaptive EBRT – early data and ongoing trials AI‑assisted contouring and online adaptation Proton therapy: niche indications; data evolving Integration with immunotherapy – trial participation encouraged

101. India‑Specific Considerations High case volume: streamline IGABT workflows Access: hybrid planning pathways (CT‑based with MRI fusion when possible)

102. ICMR guideline

103. NCG guideline

104. EQUIPMENT EXPERT EXPERIENCE EASY ACCESSES Empower

105. Endometrial adjuvant treatment calculator

106. Stage IV: Metastatic Cancer

107. 116 METASTASIS -Please do not watch crying

108. 117 METASTASIS- give a smiling death

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

110. 119 Spinal metastasis

111. 120 PARAPLEGIA

112. 121 Brain metastasis

113. HEMIPLEGIA 122

114. 123 Whole brain radiotherapy

115. 124 Choroidal metastasis

116. 125 SUPERSCAN-EXTENSIVE BONE METS

117. 126 Hemibody radiation

118. 127 Prophylactic radiation

119. 128 svco

120. Never give-up 129

121. 130

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