UNDERSTANDING RADIOTHERAPY

UNDERSTANDING RADIOTHERAPY

1. UNDERSTANDING RADIOTHERAPY

2. DR KANHU CHARAN PATRO RADIATION ONCOLOGIST M.D,D.N.B [RT], FAROI [USA], MBA [ICFAI], PDCR , CEPC

3. 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

4. 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

5. 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 0 200 400 600 800 1000 Men Women From: D.M. Parkin The Lancet Oncology 2: 533-543 (2001) (Thousands) Incidence Mortality 337 293 1050 370 241 318 446 234 165 166 471 233 133 111 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

6. Radiotherapy X ray Surgery PET MRI Chemo ? ? 9/27/2019 5:34:30 PM 8

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

8. 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 5:34:32 PM 13

9. 9/27/2019 5:34:33 PM 14 Radiation –Part of life

10. 9/27/2019 5:34:33 PM 15 Wilhelm Conrad Rontgen

11. 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 5:34:36 PM 16

12. GOALS High dose to tumor tissue-Tumor control Normal tissue sparing Minimize long and short term toxicities Better Quality of life 9/27/2019 5:34:37 PM 17

13. 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 5:34:37 PM 18

14. Types of radiotherapy 9/27/2019 5:34:38 PM 19 TELETHERAPY BRACHYTHERAPY

15. Radiotherapy procedure Tumor board decision Positioning And immobilization Imaging Target delineation Planning 9/27/2019 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 20

16. IMAGE GUIDED RADIATION THERAPY EQUIPMENT REQUIRED CT-SCAN MRI PET-CT 9/27/2019 21 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm

17. Cobalt machine 9/27/2019 5:34:40 PM 22

18. 9/27/2019 5:34:41 PM 23

19. Plaster of Paris Mould-older method 9/27/2019 5:34:41 PM 24

20. Head & Neck 9/27/2019 5:34:43 PM 25

21. 9/27/2019 5:34:46 PM 26

22. Abdomen and Pelvis 9/27/2019 5:34:46 PM 27

23. Vacuum Mould 9/27/2019 5:34:47 PM 28

24. 9/27/2019 5:34:48 PM 29

25. Evolution of Treatment Techniques CUSTOMISED BLOCKS MULTILEAF COLLIMATOR BASED 3D-CRT 1990s 1980s 9/27/2019 5:34:48 PM 30

26. 9/27/2019 5:34:50 PM 31

27. Treating Head & Neck with Sliding Windows 9/27/2019 5:34:51 PM 32

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. 9/27/2019 5:34:52 PM 34

30. 9/27/2019 5:34:53 PM 35

31. 9/27/2019 5:34:53 PM 36

32. 9/27/2019 5:34:54 PM 37

33. Mesothelioma 9/27/2019 5:34:54 PM 38

34. Small Volume Adjacent to Critical Structure 9/27/2019 5:34:54 PM 39

35. 3D Dose Shaping - H&N and Brain Brain Stem 9/27/2019 5:34:55 PM 40

36. Target Motion in Radiotherapy Caveman et al Oops! The target moves! IGRT/GATED RT 9/27/2019 5:34:56 PM 41

37. 9/27/2019 5:34:56 PM 42

38. 9/27/2019 5:34:57 PM 43

39. 9/27/2019 5:34:58 PM 44

40. 9/27/2019 5:34:59 PM 45

41. Radiation ECRT 9/27/2019 5:35:00 PM 46

42. RADIOTHERAPY

43. CONVENTIONAL 3DCRT IMRT IGRT VMAT /RAPIDARC SRS/SRT/SBRT PET GUIDED RADIOTHERAPY

44. X-KNIFE TREATMENT BY HIGH ENERGY X RAYS MOSTLY NON INVASIVE EQUALLY EFFECTIVE CHEAPER AVAILABILITY 9/27/2019 50

45. CYBER-KNIFE 9/27/2019 51

46. VARIAN STX 9/27/2019 52

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

48. 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

49. ELEKTA AGILITY 9/27/2019 55

50. ELEKTA AGILITY 9/27/2019 56

51. ELEKTA AGILITY 9/27/2019 57

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

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

54. HEXAPOD 9/27/2019 60

55. SRS SMALL FIELD CONES 9/27/2019 61

56. BRAIN TUMORS MALIGNANT TUMORS BENIGN TUMORS FUNCTIONAL DISORDERS REIRRADIATION 9/27/2019 62

57. INDICATIONS AVM MENINGIOMA PITUITARY ADENOMA ACOUSTIC NEUROMA BRAIN METASTASIS REIRRADIATION FOR RECURRENT GLIOMAS TRIGEMINAL NEURALGIA SKULL BASE TUMORS SPINAL METASTASIS SPINAL HEMANGIOMAS 9/27/2019 63

58. APPLICATION IN OTHER SITES 9/27/2019 67

59. 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

60. TRIPLE FUSION PET CT MRI 9/27/2019 76 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm

61. Concept of triple-fusion 9/27/2019 77 Mahatmagandhi cancer hospital and research institute

62. Pet CT planning 9/27/2019 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 78

63. 9/27/2019 79 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm

64. Tumor Volume 9/27/2019 80 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm

65. Nodal Volume 9/27/2019 81 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm

66. 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

67. Moureau et al. IJROBP 2005 Increased Target Volume in Oesophageal Carcinoma 9/27/2019 83 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm

68. PET-CT -WIN-WIN SITUATION PARAMETER VOLUME CHANNGE T STAGE INCREASE UPSTAGING PREVENTS TUMOR TISSUE MISSING CHANGES TT FROM CURATIVE TO PALLLIATIVE DECREASE DOWN STAGING PREVENTS EXTRA DOSE TO NORMAL TISSUE CHANGES TT. FROM PALLIATIVE TO CURATIVE DOSE ESCALATION IS POSSIBLE N STAGE INCREASE UPSTAGING PREVENTS TUMOR TISSUE MISSING CHANGES TT FROM CURATIVE TO PALLLIATIVE DECREASE DOWN STAGING PREVENTS EXTRA DOSE TO NORMAL TISSUE CHANGES TT. FROM PALLIATIVE TO CURATIVE DOSE ESCALATION IS POSSIBLE M STAGE INCREASE CURATIVE-TO PALLIATIVE DECREASE PALLIATIVE TO CURATIVE 9/27/2019

69. Bird’s eye view Eagle’s eye view 9/27/2019 85 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm

70. RADIOTHERAPY DELIVERY 9/27/2019 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 86

71. 9/27/2019 87 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm

72. ORGAN PRESERVATION

73. 9/27/2019 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 90

74. COSMETIC DEFECT FUNCTIONAL DEFECT IMPAIRED QUALITY OF LIFE SURGERY 9/27/2019 5:30:13 PM 92

75. 9/27/2019 5:30:13 PM 93 BRACHYTHERAPY

76. 9/27/2019 5:30:13 PM 95

77. PROCEDURE 9/27/2019 5:30:13 PM 96

78. 9/27/2019 5:30:13 PM 97

79. HEAD AND NECK CANCERS BREAST CANCERS ESOPHAGUS CANCERS PENILE CANCER SOFT TISSUE SARCOMA BLADDER CANCERS CANAL CANCERS ORGAN PRESERVATION 9/27/2019 5:30:13 PM 98

80. ORGAN PRESERVATION FOR BONE TUMORS 9/27/2019 5:30:13 PM 99

81. 9/27/2019 5:30:13 PM 100

82. 9/27/2019 5:30:13 PM 101

83. ORGAN PRESERVATION FOR BREAST CANCERS 9/27/2019 5:30:13 PM 102

84. 9/27/2019 5:30:13 PM 103 Intra- operative Brachytherapy procedure

85. 9/27/2019 5:30:13 PM 104 Intra- operative Brachytherapy procedure

86. 9/27/2019 5:30:13 PM 105 Intra- operative Brachytherapy procedure

87. 9/27/2019 5:30:13 PM 106 Intra- operative Brachytherapy procedure

88. 9/27/2019 5:30:13 PM 107 3D Brachytherapy Planning CT Loading Dose distribution

89. 9/27/2019 5:30:13 PM 108 Dose prescription and Treatment delivery Dose: 34Gy in 10 fraction bid Dose per fraction: 340cGy

90. ORGAN PRESERVATION FOR PENILE CANCERS 9/27/2019 5:30:13 PM 117

91. 9/27/2019 5:30:13 PM 118

92. Penile conservation 9/27/2019 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 119

93. 9/27/2019 5:30:13 PM 120

94. 9/27/2019 5:30:13 PM 121

95. 9/27/2019 5:30:13 PM 122

96. 9/27/2019 5:30:13 PM 123

97. ORGAN PRESERVATION FOR SARCOMAS 9/27/2019 5:30:13 PM 124

98. 9/27/2019 5:30:13 PM 125

99. 9/27/2019 5:30:13 PM 126

100. 9/27/2019 5:30:13 PM 127

101. 9/27/2019 5:30:13 PM 128

102. 9/27/2019 5:30:13 PM 129

103. 9/27/2019 5:30:13 PM 130

104. 9/27/2019 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 131

105. ORGAN PRESERVATION FOR CANCER CERVIX [STAGE 0,EARLY 1] 9/27/2019 5:30:13 PM 132

106. 9/27/2019 5:30:13 PM 133

107. 9/27/2019 5:30:13 PM 134

108. ICA HDR application 9/27/2019 5:30:13 PM 135

109. 9/27/2019 5:30:13 PM 136

110. 9/27/2019 5:30:13 PM 137

111. ORGAN PRESERVATION FOR CANCER ANAL CANAL 9/27/2019 5:30:13 PM 138

112. APR 9/27/2019 5:30:13 PM 139

113. ANAL CANAL BRACHYTHERAPY 9/27/2019 5:30:13 PM 140

114. ORGAN PRESERVATION FOR CANCER TONGUE 9/27/2019 5:30:13 PM 141

115. 9/27/2019 5:30:13 PM 142

116. TONGUE IMPLANT IN PROGRESS 9/27/2019 5:30:13 PM 143

117. TONGUE IMPLANT IN PROGRESS 9/27/2019 5:30:13 PM 144

118. 9/27/2019 5:30:13 PM 145 ORGAN PRESERVATION FOR CANCER LIP

119. 9/27/2019 5:30:13 PM 146

120. 9/27/2019 5:30:13 PM 147

121. 9/27/2019 5:30:13 PM 148

122. Applicator in situ with IOP

123. Complete response –towards healing hypo-pigmentation

124. Recent

125. 9/27/2019 5:30:14 PM 157

126. KELOIDS 9/27/2019 5:30:14 PM 158

127. CANCER ESOPHAGUS 9/27/2019 5:30:14 PM 159

128. ESOPHAGEAL BRACHYTHERAPY 9/27/2019 5:30:14 PM 160

129. 9/27/2019 5:30:14 PM 161 ILRT-dosimetry

130. PROSTATE CANCER 9/27/2019 5:30:14 PM 162

131. 9/27/2019 5:30:14 PM 163

132. 9/27/2019 5:30:14 PM 164

133. 9/27/2019 5:30:14 PM 165

134. 9/27/2019 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 166

135. 9/27/2019 Mahatma Gandhi Cancer Hospital & Research Institute,Visakhapatnanm 167

136. OCULAR MELANOMA RETINOBLASTOMA 9/27/2019 5:30:14 PM 168

137. 9/27/2019 5:30:14 PM 169

138. 9/27/2019 5:30:14 PM 170

139. 9/27/2019 5:30:14 PM 171

140. 9/27/2019 5:30:14 PM 172

141. 9/27/2019 5:30:14 PM 173

142. WHO PRESERVES HE DESERVES

143. GOOD COSMETIC FUNCTIONAL PRESERVATION GOOD QUALITY OF LIFE ESTABLISHED PROCEDURE EXPERTISE REQUIRED AVAILABLE LITERATURES LESS TOXIC FACTS 9/27/2019 5:30:14 PM 175

144. SMART THINKING 9/27/2019 5:30:14 PM 176

145. 9/27/2019 5:30:14 PM 177

146. Sharp gun-missed target 178

147. Stage IV: Metastatic Breast Cancer

148. 180 METASTASIS -please do not watch crying

149. 10/20/12 01:12 PM 181

150. METASTASIS- give a smiling death 182

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

152. Spinal metastasis 184

153. 185

154. Brain metastasis 186

155. 187

156. Whole brain radiotherapy 188

157. Choroidal metastasis 189

158. Superscan-extensive bone mets 190

159. Hemibody radiation 191

160. Prophylactic radiation 192

161. svco 193

162. 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

163. Change in bowel habits 10/20/12 01:12 PM 195

164. Change in bladder habits 10/20/12 01:12 PM 196

165. A sore that does not heal 10/20/12 01:12 PM 197

166. Unusual bleeding or discharge 10/20/12 01:12 PM 198

167. Thickening or lump in the breast or any part of the body 10/20/12 01:12 PM 199

168. Indigestion or difficulty swallowing 10/20/12 01:12 PM 200

169. Obvious change in a wart or mole 10/20/12 01:12 PM 201

170. Liver cancer- hepatitis B vaccine

171. 9/27/2019 5:30:14 PM 203 LOTS OF BLOOD REQUIRE

172. 9/27/2019 5:30:14 PM 204

173. 9/27/2019 5:30:14 PM 205 All specialities under one roof

174. 9/27/2019 5:30:14 PM 206 TABLET FORMS

175. Cervix cancer vaccine 10/20/12 01:12 PM 207

176. Nagging cough or hoarseness 10/20/12 01:12 PM 208

177. 9/27/2019 5:30:14 PM 211

178. 10/20/12 01:12 PM 213

179. REGULAR CHECK-UP

180. 9/27/2019 5:30:14 PM 217

181. 219

182. Prevention-passive smoking

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

184. RELAX

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

186. 224 Dietary protective factors

187. Breast feeding

188. Physical activity

189. 227

190. 228

191. 9/27/2019 5:30:14 PM 229

192. 9/27/2019 5:30:14 PM 230

193. 9/27/2019 5:30:14 PM 232

194. 10/20/12 01:12 PM 233

195. 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

196. 10/20/12 01:12 PM 235

197. 10/20/12 01:12 PM 236

198. 9/27/2019 238

199. 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 )

200. TOGETHER WE TREAT 240 9/27/2019

201. TEAM OF EXPERTS IN MEDICAL ONCOLOGY Dr. B.Rakesh Reddy Dr Chandrasekhar B Dr Praveena Voonna Dr Rajani Priya

202. TEAM OF EXPERTS IN CRITICAL CARE AND PAIN

203. TEAM OF EXPERTS-- Radiology 1. Dr. P.Madhuri D.M.R.D ( AMC ,Visakhapatnam) 2. Dr. B.Revathi D.M.R.D ( RMC ,Kakinada)

204. GYNAEC ONCOLOGY : Dr.Jyoti Doki M.D. ( Gynaec & Obg ) ( AMC,Visakhapatnam )

205. Nuclear Medicine : Dr. K.Raghava Kashyap M.D (Nuclear Medicine) ( PGIMER, Chandigarh )

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

207. PHYSICS TEAM-THEY PLAN THE DOSE 247 9/27/2019

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

209. DNB CURRICULUM- SURGICAL ONCOLOGY 9/27/2019 249

210. PAIN AND PALLIATIVE CARE FELLOWSHIP 9/27/2019 250

211. v

212. YOUNG RADIATION ONCOLOGY CONFERENCE -2014

213. ACCREDITED

214. ACCREDITED

215. MEMBER

216. APPROVED

217. EXPERTS FROM VARIOUS PRESTIGIOUS INSTITUTIONS ADYAR CANCER INSTITUTE, CHENNAI-1 TATA MEMORIAL HOSPITAL, MUMBAI-3 AIIMS,NEWDELHI-2 CMC-VELLORE-1 PGI-CHANDIGARH-2

218. DECISIONS IN TUMOR BOARD

219. EMPOWER EQUIPMENT EXPERT EXPERIENCE EASY ACCESSES

220. 10/20/12 01:12 PM 274 Whenever not possible, make friends

221. 275 10/20/12 01:12 PM

222. 276 10/20/12 01:12 PM

223. 9/27/2019 5:30:14 PM 277

224. 9/27/2019 5:30:14 PM 278

225. 9/27/2019 5:30:14 PM 279

226. 9/27/2019 280

227. 281 ?