Precision Radiation therapy for physicians

Precision Radiation therapy for physicians

1. 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 PRECISION RADIOTHERAPY

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. THE GLOBAL BURDEN

5. 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 pe ople will be diagnosed with cancer in the UK and 1 in 4 will die from their disease

6. Radiotherapy X ray Surgery PET MRI Chemo ? ? 10/14/2025 6:54:05 AM 7

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

8. Radiation –Part of life 10/14/2025 6:54:05 AM 12

9. 10/14/2025 6:54:05 AM 13 Wilhelm Conrad Rontgen

10. 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 10/14/2025 6:54:05 AM 14

11. GOALS 10/14/2025 6:54:05 AM 15 High dose to tumor tissue-Tumor control Normal tissue sparing Minimize long and short term toxicities Better Quality of life

12. 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 10/14/2025 6:54:05 AM 16

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 10/14/2025 6:54:05 AM 17

14. Types of radiotherapy 10/14/2025 6:54:05 AM 18 TELETHERAPY BRACHYTHERAPY

15. Radiotherapy procedure Tumor board decision Positioning And immobilization Imaging Target delineation Planning 10/14/2025 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 19

16. IMAGE GUIDED RADIATION THERAPY EQUIPMENT REQUIRED CT-SCAN MRI PET-CT 10/14/2025 20 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm

17. Cobalt machine 10/14/2025 6:54:05 AM 21

18. LINEAR ACCELERATOR 10/14/2025 6:54:05 AM 22

19. Plaster of Paris Mould-older method 10/14/2025 6:54:05 AM 23

20. Head & Neck 10/14/2025 6:54:05 AM 24

21. 10/14/2025 6:54:05 AM 25

22. Abdomen and Pelvis 10/14/2025 6:54:06 AM 26

23. Vacuum Mould 10/14/2025 6:54:06 AM 27

24. STEREOTACTIC RADIOTHERAPY 10/14/2025 6:54:06 AM 28

25. Evolution of Treatment Techniques CUSTOMISED BLOCKS MULTILEAF COLLIMATOR BASED 3D-CRT 1990s 1980s 10/14/2025 6:54:06 AM 29

26. 10/14/2025 6:54:06 AM 30

27. Treating Head & Neck with Sliding Windows 10/14/2025 6:54:06 AM 31

28. 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

29. 10/14/2025 6:54:06 AM 33

30. 10/14/2025 6:54:06 AM 34

31. 10/14/2025 6:54:06 AM 35

32. 10/14/2025 6:54:06 AM 36

33. CHEST WLL TUMORS 10/14/2025 6:54:06 AM 37

34. Small Volume Adjacent to Critical Structure 10/14/2025 6:54:06 AM 38

35. 3D Dose Shaping - H&N and Brain 10/14/2025 6:54:06 AM 39 Brain Stem

36. Target Motion in Radiotherapy Caveman et al Oops! The target moves! IGRT/GATED RT 10/14/2025 6:54:06 AM 40

37. 10/14/2025 6:54:06 AM 41

38. 10/14/2025 6:54:06 AM 42

39. 10/14/2025 6:54:06 AM 43

40. 10/14/2025 6:54:06 AM 44

41. Radiation ECRT 10/14/2025 6:54:06 AM 45

42. NEW BABY IN THE TOWN

43. ADVANTAGE OF TOMO

44. ADVANTAGE OF TOMO

45. X-KNIFE Treatment by high energy X- rays Mostly non-invasive Equally effective Cheaper Availability 10/14/2025 50

46. WE HAVE-ELEKTA [X-Knife] 10/14/2025 51

47. WHAT WE HAVE? Cones - for subcentemeter tumors Agility head -more conformity for smaller tumors Fraxion -Non-invasive, frameless comfortable mask Cone beam CT -online ct based correction Hexapod -extra degree of rotational correction 10/14/2025 52

48. WHAT are the requirements? Micro MLC/cone Planning system Imaging Immobilization QA accessories CBCT Protocols 53

49. WHAT we have – micro MLC 54

50. WHAT we have – CONE 55

51. WHAT we have – immobilization 56 FRAXION

52. CT PETCT DOTA PSMA FDG MRI IMAGING WE HAVE 57

53. WHAT we have – planning system 58

54. WHAT we have? – Ray Search planning system 59 FIRST IN INDIA-PHOTON

55. WHAT we have – verification system 60

56. CBCT CORRECTIONS Set-up verification-CBCT 61

57. WHAT we have – Hexapod 62

58. Pre SRS 63

59. SRS PALN 64

60. POST SRS 3 MONTHS 65

61. LIVER METASTASIS SBRT 66

62. NAME UMR PRESENTATION 50 YEAR MALE COLON CANCER FOUND LIVER MET DURING SURGERY 2 LESIONS PET 2 LESIONS SEGMENT VIII SUV-13 SEGMENT V FNAC ADENO CP SCORE A SBRT 40Gy/5# WITH DIBH Case details 67

63. 68

64. 69

65. SPINE METASTASIS SBRT 70

66. NAME UMR Diagnosis Ca Lung left lower lobe with D11 bone metastasis Presented with Cough with expectoration, Pain over left chest wall, Upper backache PET Soft tissue enhancing lesion 5.2cm in LLL abutting pleura s/o primary Hypermetabolic lesion in D11 vertebra (SUV max- 8) – s/o metastasis Planned SBRT 25Gy/5# PET POST SBRT 3M Complete metabolic resolution of the D11 vertebral lesion s/o favourable response to treatment COURTESY DR VKR Case details 71

67. 72 Spine metastasis

68. 73 3 month follow up scan

69. PORTAL VEIN THROMBOSIS SBRT 74

70. GTV-PTV

71. Dose distribution-48Gy/4# STARED ON LENVATINIB AFTER 1 MONTH

72. Post SBRT 1 year

73. Seizure video

74. T1 CONT.- HYPO NON ENHANCING

75. OAR DELINEATION OAR delineation Brain stem OPTIC TRACT

76. The wide spectrum Cranial Metastasis De novo After WBRT Arteriovenous malformation Vestibular schwannoma Reirradiation glioma Glomus jugularae Hamartoma Cavernoma Meningioma Trigeminal neuralgia Tremor Epilepsy Extracranial Bone metastasis Prostate Lung primary/ metastasis Pancreas Adrenal metastasis Liver metastasis/HCC Spine metastasis Nodal recurrence Head and neck reirradiation Cardiac SBRT 82

77. 83 Approval-MD Andreson

78. 84

79. 85

80. 86

81. 87

82. Where is the Target? WHERE IS THE TARGET? 10/14/2025 Mahatmagandhi cancer hospital and research institute 88

83. CANCER TONGUE

84. TRIPLE FUSION PET CT MRI 10/14/2025 90 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm

85. Concept of triple-fusion 10/14/2025 91 Mahatmagandhi cancer hospital and research institute

86. Target volume definition 10/14/2025 92 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm

87. PET BASED RADIOTHERAPY PLAN

88. Avoid unnecessary toxicity 10/14/2025 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 94

89. Unknown primary 10/14/2025 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 95

90. Adaptive –decrease toxicity 10/14/2025 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 96

91. Pet CT planning 10/14/2025 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 97

92. Tumor Volume 10/14/2025 98 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm

93. Moureau et al. IJROBP 2005 10/14/2025 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 99 Tumor Volume

94. Bird’s eye view Eagle’s eye view 10/14/2025 100 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm

95. 10/14/2025 101 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm

96. RADIOTHERAPY DELIVERY 10/14/2025 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 102

97. COSMETIC DEFECT FUNCTIONAL DEFECT IMPAIRED QUALITY OF LIFE SURGERY 10/14/2025 6:54:06 AM 103

98. 10/14/2025 6:54:06 AM 104 BRACHYTHERAPY

99. Brachytherapy machine 10/14/2025 6:54:06 AM 105 Low dose rate brachytherapy High dose rate brachytherapy

100. Brachytherapy machine 10/14/2025 6:54:06 AM 106

101. 10/14/2025 6:54:06 AM 107

102. 10/14/2025 6:54:06 AM 108

103. 10/14/2025 6:54:06 AM 109

104. PROCEDURE 10/14/2025 6:54:06 AM 110

105. IMAGING AND PLANNING 10/14/2025 6:54:06 AM 111

106. ISODOSE

107. TREATMENT DELIVERY

108. HEAD AND NECK CANCERS BREAST CANCERS ESOPHAGUS CANCERS PENILE CANCER SOFT TISSUE SARCOMA BLADDER CANCERS ANAL CANAL CANCERS ORGAN PRESERVATION 10/14/2025 6:54:06 AM 114

109. ORGAN PRESERVATION FOR BONE TUMORS 10/14/2025 6:54:06 AM 115

110. 10/14/2025 6:54:06 AM 116

111. 10/14/2025 6:54:06 AM 117

112. 10/14/2025 6:54:06 AM 118

113. ORGAN PRESERVATION FOR BREAST CANCERS 10/14/2025 6:54:06 AM 119

114. 10/14/2025 6:54:06 AM 120 Intra- operative Brachytherapy procedure

115. 10/14/2025 6:54:06 AM 121 Intra- operative Brachytherapy procedure

116. 10/14/2025 6:54:06 AM 122 Intra- operative Brachytherapy procedure

117. 10/14/2025 6:54:06 AM 123 Intra- operative Brachytherapy procedure

118. 10/14/2025 6:54:06 AM 124 3D Brachytherapy Planning CT Loading Dose distribution

119. 10/14/2025 6:54:06 AM 125 Dose prescription and Treatment delivery Dose: 34Gy in 10 fraction bid Dose per fraction: 340cGy

120. ORGAN PRESERVATION FOR PENILE CANCERS 10/14/2025 6:54:06 AM 126

121. THE SURGICAL PROCEDURE 10/14/2025 6:54:06 AM 127

122. 10/14/2025 6:54:06 AM 128

123. THE OUTCOME 10/14/2025 6:54:06 AM 129

124. 10/14/2025 6:54:06 AM 130

125. ORGAN PRESERVATION FOR SARCOMAS 10/14/2025 6:54:06 AM 131

126. THE SURGICAL PROCEDURE 10/14/2025 6:54:06 AM 132

127. 10/14/2025 6:54:06 AM 133 THE BRACHY PROCEDURE

128. ABDOMINAL SARCOMA 10/14/2025 6:54:06 AM 134

129. 10/14/2025 6:54:06 AM 135 BRACHY FOR CANCER CERVIX

130. 10/14/2025 6:54:06 AM 136 BRACHY FOR CANCER CERVIX

131. 10/14/2025 6:54:06 AM 137 BRACHY FOR CANCER CERVIX

132. ANAL CANAL BRACHYTHERAPY 10/14/2025 6:54:06 AM 138

133. ORGAN PRESERVATION FOR CANCER TONGUE 10/14/2025 6:54:06 AM 139

134. LIP BRACHYTHERAPY 10/14/2025 6:54:06 AM 140

135. 10/14/2025 6:54:06 AM 141 LIP BRACHYTHERAPY

136. Applicator in situ with IOP

137. Complete response –towards healing hypo-pigmentation

138. Completed 10 Years

139. 10/14/2025 6:54:06 AM 145 KELOID

140. 10/14/2025 6:54:06 AM 146 KELOID BRACHYTHERAPY

141. CANCER ESOPHAGUS 10/14/2025 6:54:06 AM 147

142. ESOPHAGEAL BRACHYTHERAPY 10/14/2025 6:54:06 AM 148

143. PROSTATE CANCER BRACHY 10/14/2025 6:54:06 AM 149

144. 10/14/2025 6:54:06 AM 150

145. 10/14/2025 6:54:06 AM 151

146. EYE LID BRACHY 10/14/2025 6:54:06 AM 152

147. 10/14/2025 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 153

148. 10/14/2025 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 154

149. 10/14/2025 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 155

150. OCULAR MELANOMA -RETINOBLASTOMA 10/14/2025 6:54:06 AM 156

151. OCULAR BRACHY 10/14/2025 6:54:06 AM 157

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158. 10/14/2025 6:54:06 AM 164

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160. 10/14/2025 6:54:06 AM 166

161. EAR BUD BRACHY

162. EAR BUD BRACHY

163. Eye lid brachy

164. Eye lid brachy

165. GOOD COSMETIC FUNCTIONAL PRESERVATION GOOD QUALITY OF LIFE ESTABLISHED PROCEDURE EXPERTISE REQUIRED AVAILABLE LITERATURES LESS TOXIC FACTS 10/14/2025 6:54:06 AM 171

166. SMART THINKING 10/14/2025 6:54:06 AM 172

167. 10/14/2025 6:54:06 AM 173

168. Sharp gun-missed target 174

169. Stage IV: Metastatic Cancer

170. 176 METASTASIS -Please do not watch crying

171. 177 METASTASIS- give a smiling death

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

173. 179 Spinal metastasis

174. 180 PARAPLEGIA

175. 181 Brain metastasis

176. HEMIPLEGIA 182

177. 183 Whole brain radiotherapy

178. 184 Choroidal metastasis

179. 185 SUPERSCAN-EXTENSIVE BONE METS

180. 186 Hemibody radiation

181. 187 Prophylactic radiation

182. 188 svco

183. Never give-up 189

184. 190

185. 191

186. 10/20/12 01:12 PM 192

187. 10/20/12 01:12 PM 193

188. 194 10/20/12 01:12 PM

189. 195 10/20/12 01:12 PM

190. 10/14/2025 6:54:06 AM 196

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192. 10/14/2025 6:54:06 AM 198

193. THANKS

194. 200 ?

195. ACKNOWLEDGMENTS- TECHNOLOGISTS 201