Advanced Radiotherapy In Ocular tumors for Ophthalmologists

Advanced Radiotherapy In Ocular tumors for Ophthalmologists

1. PRECISION RADIOTHERAPY IN OCULAR MALIGNANCY 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. Introduction Eyelid malignancies can mimic benign lesions. Early biopsy and histopathology are essential. Common tumors: BCC, SCC, Sebaceous carcinoma, Melanoma, Merkel cell carcinoma.

5. Etiology & Risk Factors Chronic UV exposure (UV-A, UV-B) Genetic syndromes: Gorlin-Goltz , Muir-Torre Immunosuppression , HPV, prior radiotherapy Fair skin, male sex, older age

6. Epidemiology BCC: 56–95%, Lower lid, Most common SCC: 3–18%, Lower lid, Locally aggressive Sebaceous Ca : 34–53%, Upper lid, Mimics chalazion Melanoma: 2%, Lower lid, High mortality MCC: <2%, Upper lid, Radiosensitive

7. Pathophysiology UV-induced p53 mutation → AK → SCC/BCC BCC : PTCH1 mutation (Hedgehog pathway) SC : p53/mismatch repair mutations Melanoma : BRAF mutation → proliferation MCC : Polyomavirus -mediated oncogenesis

8. Histopathology Summary BCC: Basaloid nests, BerEP4+ SCC: Keratin pearls, Cytokeratin+ SC: Foamy cytoplasm, Oil Red O+ Melanoma: Atypical melanocytes, S100+ MCC: Small blue cells, CK20+, NSE+

9. Clinical Features Non-healing nodules, ulceration, lash loss Madarosis , telangiectasia, pigmentation Use slit lamp, dermoscopy , double eversion Check lymph nodes and document with photos

10. Evaluation Biopsy : Full-thickness for histopathology MRI : Soft tissue, CT: bone involvement Sentinel Node Biopsy: Melanoma, SC, MCC Differentiate from chalazion , keratoacanthoma

11. Management Overview Surgery : Mohs or wide local excision Radiotherapy : Curative/adjuvant/palliative Immunotherapy or chemotherapy for advanced disease Individualize based on histology, size, and site

12. Role of Radiotherapy Indications: Inoperable/unresectable or residual disease Perineural invasion, positive margins Orbital extension, elderly or comorbid Palliative control in melanoma/MCC Techniques: EBRT (electrons or IMRT/VMAT) Dose : 50–66 Gy (2 Gy / fx ) OAR limits: Lens <10 Gy , Cornea <40 Gy , Optic Nerve <55 Gy

13. Role of Brachytherapy Indications: Superficial lesions <10 mm Recurrent lesions post-surgery or RT Organ preservation in cosmetically sensitive areas Techniques: Surface mould or plaque (Ru-106, Sr-90, Ir-192, I-125) Dose : 45–60 Gy EQD2 Advantages : Steep dose fall-off, excellent cosmesis

14. Lesion-Specific Summary BCC: Surgery → RT if residual/unresectable SCC: Surgery ± RT → Adjuvant RT for high-risk SC: Mohs or wide excision → RT for orbital/ perineural invasion Melanoma: Wide excision → RT for recurrence/palliation MCC: Surgery + RT → RT integral for control

15. Prognosis BCC: >95% control, rare death SCC: High if early, <5% mortality SC: Variable, 4–11% mortality Melanoma: 20–40% mortality MCC: 33–46% mortality

16. Complications & Prevention Complications : Lagophthalmos , ectropion , dry eye, scarring Prevention : Sun protection, avoid smoking, follow-up Educate : Report recurrence early

17. Key Takeaways Biopsy all suspicious lesions Surgery remains primary; RT/brachytherapy preserve organs Multidisciplinary approach improves outcomes and cosmesis

18. EYE LID 10/16/2025 6:31:09 AM 18

19. SEBACEOUS CARCINOMA

20. BASAL CELL CARCINOMA EYELID

21. SQUAMOUS CELL CARCINOMA

22. Meibomian carcinoma eyelid

23. Case-1- Sebaceous carcinoma

24. Case-2- Mould brachy

25. Eye lid brachy

26. Eye lid brachy

27. Case-3- Sebaceous carcinoma

28. EYE LID BRACHY 10/16/2025 6:31:09 AM 38

29. Case-4- Squamous

30. 10/16/2025 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 40

31. 10/16/2025 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 41

32. Case-5- Meiobian carcinoma

33. Case-6- Pterygium

34. Case-7- Orbital pseudotumor

35. Case-8- Choroidal mets

36. 50 Choroidal metastasis

37. Case-9- Conjunctiva carcinoma

38. Case-10- Rhabdomayosarcoma

39. Case-11-Graves Ophthlmopathy

40. Graves Ophthlmopathy

41. Case-12- Plaque therapy

42. Chemoreduction failure or recurrence Rarely as primary therapy Commonly uses Iodine 125, Ruthenium 106 4000-4500 cGy to tumor apex 90% success in tumor control Plaque Brachytherapy

43. Radioactive Plaques Various sizes & shapes Round, Single notched, Double notched etc 10- 25 mm in diameter

44. Tumor assessment Clinical & Radiological assessment Location Basal diameter Height

45. Plaque placement Under GA / LA Conjunctiva peritomy Tumor location marked on sclera Dummy plaque used to confirm location Plaque placed & sutured to sclera Conjunctiva sutured Patient is kept in isolation

46. Courtesy : Dr Vijay Anand P Reddy

47. Dose distribution Courtesy : Dr Vijay Anand P Reddy

48. Case-13- Orbital Lymphoma

49. Imaging

50. If there is a forward displacement of eveball Involvement of post or anteromedial part of orbit Sup & inf oblique fields

51. Specialized radiotherapy

52. Case-14- Melanoma

53. Specialized radiotherapy

54. Fluorescein Angiography Ultrasound

55. Plaque

56. Plaque

57. Case-15- Retinoblastoma

58. heterochromia strabismus

59. Ultrasonography B-scan Indirect Ophthalmoscopy MRI / CT RETINOBLASTOMA DIAGNOSIS

60. 90% show calcification Dense homogenous Extension to choroid,vitreous & sclera not reliable. Detects intracranial disease 3D multiplanar capability. Hyperintense to vitreous on T1 & markedly hypointense on T2 Delineation of ON, IO & EO spread Differentitates between tumor, RD & subretinal fluid.

61. Immobilization/Imaging

62. Pre operative cases with intact globe;

63. Radiation Therapy Techniques

64. Radiation Therapy Techniques Corneal sparing

65. Post enucleation orbital radiotherapy

66. Case-16- OPTIC NERVE GLIOMA

67. Case-17- OPTIC NERVE Meningioma

68. Case-17- Pituitary adenoma

69. Older

70. Newer technique

71. Case-18- Craniophrayngioma

72. Brachytherapy team Plaque surgeon Radiation oncologist Medical physicist Multidisciplinary approach

73. Life

74. 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] 111

75. Statistics

76. THE GLOBAL BURDEN

77. Radiotherapy MX 10/16/2025 6:38:51 AM 115 TELETHERAPY BRACHYTHERAPY

78. Radiotherapy X ray Surgery PET MRI Chemo ? ? 10/16/2025 6:38:51 AM 116

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

80. Radiation –Part of life 10/16/2025 6:38:51 AM 121

81. 10/16/2025 6:38:51 AM 122 Wilhelm Conrad Rontgen

82. 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 10/16/2025 6:38:51 AM 123

83. GOALS 10/16/2025 6:38:51 AM 124 High dose to tumor tissue-Tumor control Normal tissue sparing Minimize long and short term toxicities Better Quality of life

84. 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 10/16/2025 6:38:51 AM 125

85. 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 10/16/2025 6:38:51 AM 126

86. Radiotherapy procedure Tumor board decision Positioning And immobilization Imaging Target delineation Planning 10/16/2025 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 127

87. IMAGE GUIDED RADIATION THERAPY EQUIPMENT REQUIRED CT-SCAN MRI PET-CT 10/16/2025 128 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm

88. Cobalt machine 10/16/2025 6:38:51 AM 129

89. RADIOTHERAPY

90. 10/16/2025 6:31:10 AM 132

91. 10/16/2025 6:31:10 AM 133

92. Evolution of Treatment Techniques CUSTOMISED BLOCKS MULTILEAF COLLIMATOR BASED 3D-CRT 1990s 1980s 10/16/2025 6:31:10 AM 134

93. 10/16/2025 6:31:10 AM 135

94. CONVENTIONAL 3DCRT IMRT IGRT VMAT / RAPIDARC PET GUIDED RADIOTHERAPY

95. If there is a forward displacement of eveball Involvement of post or anteromedial part of orbit Sup & inf oblique fields

96. Specialized radiotherapy

97. Radiation Therapy Techniques

98. Radiation Therapy Techniques Corneal sparing

99. Small Volume Adjacent to Critical Structure 10/16/2025 6:31:10 AM 141

100. NEW BABY IN THE TOWN

101. Now In Visakhapatnam

102. 10/16/2025 6:31:10 AM 145

103. 10/16/2025 6:31:10 AM 146

104. 10/16/2025 6:31:10 AM 147

105. 10/16/2025 6:31:10 AM 148

106. 10/16/2025 6:31:10 AM 149

107. 10/16/2025 6:31:10 AM 150

108. 10/16/2025 6:31:10 AM 151

109. 10/16/2025 6:31:10 AM 152

110. 10/16/2025 6:31:10 AM 153

111. Stage IV: Metastatic Cancer

112. 155 METASTASIS Please do not watch crying

113. 156 METASTASIS- give a smiling death

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

115. 158 Spinal metastasis

116. 159 PARAPLEGIA

117. 160 Brain metastasis

118. HEMIPLEGIA 161

119. 162 Whole brain radiotherapy

120. 163 SUPERSCAN-EXTENSIVE BONE METS

121. 164 Hemibody radiation

122. 165 Prophylactic radiation

123. 166 svco

124. Never give-up 167

125. 168

126. 169

127. 10/20/12 01:12 PM 170

128. 10/20/12 01:12 PM 171

129. 172 10/20/12 01:12 PM

130. 173 10/20/12 01:12 PM

131. 10/16/2025 6:59:07 AM 174

132. 10/16/2025 6:59:07 AM 175

133. 10/16/2025 6:59:07 AM 176