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Σημειώσεις ακτινολογίας. Ραδιολογία. Πυρινική Φυσική. Ραδιοθεραπεία
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Radiotherapy as a part of multidisciplinary approach
in the treatment of malignomas
Dr. Tatiana Hadjieva, MD, PhD, D sc
Professor , Head University Radiotherapy Clinic
Medical University Sofia
Radiotherapy tackles all hallmarks of cancer
Solimini et al. Cell 2007
Multidisciplinary approach = Multimodality treatment of
malignomas Classical treatment methods
Surgery Radiotherapy Chemotherapy = Drug therapy with
Cytostatics
Hormones
Target therapy drugs
Immunomodulators
Vaccines
RT, chemotherapy, target therapy
Prescribing Radiotherapy Management decision
RT combined with surgery
Preoperative RT Postoperative RT Intraoperative RT
RT combine with Chemotherapy Simultaneous Postponed In sandwich
Radiotherapy alone Combined RT- different RT methods
Intracavitary curietherapy Interstitial curietherapy Metabolic curietherapy
(+/-)
Recent development in cancer strategy
6
Prescribing Radiotherapy Define tumour target
Staging umor Node Metastasis System- prognostic factors
Tumour histopathological characteristics - prognostic factors determined tumour biology
Definition of the goal of RT : curative palliative
Patients status (Karnofski index)
Prescribing Radiotherapy
Anatomical and topographical planning of RT Optimal tumour volume
Staging Histological parameters Lymph node involvement Tumour and normal tissue anatomy and topometry
Large volume Small volume boost
Optimal dose probability of tumour control Tumour Radiosensitivity ( RS) Radiocurability -
more then 90% probability of tumour control
High RS tumours : haemoblasoses lymphomas, semonomas, disgerminomas Doses 40 Gy conventional fractionation
Moderately RS tumours : epithelial neoplasmas carcinomas SCC (G1-G3 Ca cutis, colli uteri, ORL; adenocarcinomas Doses 60-70 Gy
Radioresistant tumours: mesenhymomas - bone and soft tissue sarcomas, some epithelial blastomas (adenosquamous or mucoepidermoid type)
Optimal dose probability of tumour control
Doses for different tumour volumes- more then 90%
probability of tumour control
Lymphoma 30-40 Gy Carcinoma Palpable tumour ( T1-T4) 60-80
Gy. Surgical margins -microscopical
disease 10 6 cells 60-65 Gy, Sub-clinical disease in lymph
nodes or arround the tumour less than 106 cells45-50 Gy
Optimal dose probability of tumour control versus
normal tissue tolerance
Tolerance dose TD 5/5 no more than 5% severe complication rate within 5 years of treatment
Normal tissue tolerance dose depends: 1. Inrtnsic radiosensitivity of the tissue Normal tissue with low tolerance limiting dose tissue
haemopoetic tissue, reproductive organs, lens, spinal cord, liver, lung
Normal tissue with high tolerance non limiting dose tissues bones, muscles, nerves
2. Volume of the irradiated tissues 3. Fractionation - 4. Overall treatment time
Normal tissue tolerance Chronologically the manifestation depends on the kinetic property
of the tissue cells (slow or rapid renewal) and the dose given Early effects during and up to 3 months Late effects after 6 months No correlation between severity of acute and late effects- different cell
curves.
--- Early ef; Late ef
Dose volume histograme
heart
target volume
lungs
Immobilization and simulation
Immobilization CT simulation
3-D treatment planning Correlation of multi-serial CT scans for the tumour and the
normal surrounding tissue
doctor
Fussed FDG CT scans
Change in RT goal from radiacak palliative (Cadwell, I J Rad Oncol, Biol Phys, 2001 51, 923)
Dosimetry CT system for treatment planning anatomical and dosimetry moduls
Physisist
-
Dosimetry planing Optimisation of the radiation quality gamma
photons, X-ray photons, electrons
Basic techniques Two opposite fields Four- fields box
Multiple -fields Rotation
Conformal RT by Multilief collimator
28
Innovations
Application of radiotherapy Reproducibility and realization of treatment plan
Patients fixation and imobilisation
Control of dosimetry Verification systems -visualization of
RT portals
CT in treat room
Cone beam CT
Volumetric Modulated Arc Treatment
KV KV verification & matching
CBCT Imaging
Adaptive treatment
Tomotherapy Tumour shrinkage
Cyber knife Combination of low energy Linac with
movable arm moving arround the patient on the PC command\
Navigation recognize tumour and normal tissue image by imaging system
And adapts according the patient small movements
Short course fraction 1-5 The session is long 30 -70 minutes, patient
asleeps with music Wake up session has finished
180
70,000 ? 4; - 1; -
1; 1. -3; 3 ..
36
Exemple Ciber Knife
37
Optical nerve benign tumour Difficult for surgery.
Ciber Knife Lung cancer or metastates
100-180 fileds
38
Breast Cancer Radiotherapy Indications
Postoperative RT after breast preserving surgery in early BC Postoperative RT after mastectomy in advanced BC
RT in non operable BC
Palliative RT for BC
Postoperative RT after breast preserving surgery in early BC-
Is this necessary ??? Concept of whole breast IR
Cancer cells spreding in the periphery of major tumour (lland et al, Cancer, 1985
Radiotherapy in early breast cancer pTis, p1-2
Whole BR IR after lumpectomy
- long recurrence free survival
- good cosmesis
No RT after mastectomy in pT1pNoMo >=3 cm
-
National standard for breast cancer RT , 2002
Planning of RT for early BC
Radiotherapy techniques for early BC
Large volume : remaining breast and chest wall 50 Gy
Small volume boost overdosage 10-20 Gy; total dose 60-70 Gy
method -Marinova , 2000
IO boost
Survival curves in early breast cancer after quadrantectomie
Marinova 2000
.
,
0.890.900.910.920.930.940.950.960.970.980.991.001.011.021.031.041.05
0 2 4 6 8 10 12 14
n=341
COSMETIC RESULTS
Clinical visit Photos Schedules for
aesthetic evaluation: - Hyperpigmentation,
telangiectasias - Hypertrophic scar - Breast edema - Differences in profile - Differences in
consistency
Radiotherapy for advanced cancer Chemotherapy preceded RT
Why? The risk for tumour dissemination is more
dangerous than risk or loco-regional recurrence
Consolidation radiotherapy Positive lymph nodes with primary
tumour
N+ treatment in breast cancer
Electron-photon irradiation if int mammary chain is
involved
Palliative RT
Mono-bone Metastasis quality of life
dose regimes: one fraction of 8 Gy replaced 10 x 3 Gy; 4 5 Gy
Multiple Bone Mets Local analgetic RT Curietherapy 89 Sr, 32 Drug therapy diphosphonates, opiate
analgetics Brain mets palliative RT Lung Mets no RT
radiosensitiveness of the lung tissue
Radiotherapy for uterine
cervix
Indications for RT
Staging TNM = FIGO
combined brachy+EBRT
+RT
Carcinona in situ -TIS, or microinvasive cancer FIGO 0, I A
Only conisation
no RT
If absolute contraindications for surgery exist
RT is the alternative of surgery Intracavitary curietherapy (45-50 Gy in point A
(whole uterus)
FIGO IB - II A Radical hysterectomy + postoperative RT ( after 1964)
16-25% pelvic 2-11% paraaortic lymph metastases
Or Combine RT ( external beam RT and intracavitary curieterapy
Similar survival
Preference depends on the practice of the institution, patients age and tumour parameters.
National standard for cervix cancer RT , 2002
Postoperative Radiotherapy for operated FIGO IB- IIA
Planning volume pelvis and the superior third of the vagina
Doses: daily fraction of 2 Gy ; total dose 50Gy.
National standard for cervix cancer RT , 2002
3D conformal Irradiation
National standard for cervix cancer RT , 2002 Extended field irradiation for
high -risk patients (pelvic node positive )
Preoperative RT for FIGO IB- IIA-B
Indications
Bulky IB tumour
Primarily Inoperable tumour -II A-B
Total dose 30-40 Gy
?
National standard for cervix cancer RT , 2002
Preoperative RT effect on tumour MRI sagittal T2 image, 3D volume analysis
Preoperative RT 99 cm 3
After 22 Gy- 22 cm 3 - 78% reduction
Advanced cervix cancer FIGO IIB, III IV
Combine RT (external beam RT with intracavitary curieterapy )
National standard for cervix cancer RT , 2002
Advanced cervix cancer FIGO IIB, III IV
External beam RT for pelvic area (30-40 Gy),
Intracavitary curieterapy (40-50 Gy in point A to a total dose up to 70-80 Gy)
External beam RT for parametria up to 56-60 Gy.
External beam RT for paraortic nodes
National standard for cervix cancer RT , 2002
Uterus HDR Brachytherapy
HDR brachytherapy /
Definitive RT = Radiotherapy alone
If the patient remains inoperable after preoperative external beam irradiation, or/and there are no conditions for curietherapy the preoperative external beam irradiation continues as definitive RT.
If there is high-risk for paraortic metastases- irradiation of the area.
National standard for cervix cancer RT , 2002
Palliative RT FIGO IVB
Palliative external beam RT - symptoms Decompressive Analgetic Antihemorrhagic Bone mets metabolic curietherapy 32- , 89-Sr
Results
Radiotherapy for skin cancer
Curable disease epethelial tumours - carcinomas
Aggressive tumours malign melanomas
Treatment of carcinomas
Surgery Radiotherapy Radiotherapy- better function and cosmesis
Interstitial curietherapy > EBRT Radiotherapy > Surgery Deep adherent lesions, multiple lesions, lymph node metastases
Radiotherapy for cancer of the lips
Orthovoltage radioterapy - 60 keV Dose 60 Gy in different fractionation Curable disease
pT1-2- 100-90%
Brachytherapy - 50-70 Gy 5-7 days
External beam RT by electrons
Daily Fractions 2-5 Gy ,
6-20 fractions Total dose 50-60 Gy
Other indication for RT ENT region nasopharynx, larynx Abdominal Region rectal cancer,
endometrial cancer, testicular seminoma Hodgkin and Non- Hodgkin malignant
Lymphomas Benign disease main principles Degenerative diseases main principles
RT RTCH
Radiotherapy as a part of multidisciplinary approach in the treatment of malignomasRadiotherapy tackles all hallmarks of cancerMultidisciplinary approach = Multimodality treatment of malignomasRT, chemotherapy, target therapyPrescribing RadiotherapySlide Number 6Prescribing RadiotherapySlide Number 8 Prescribing Radiotherapy Anatomical and topographical planning of RTOptimal dose probability of tumour controlOptimal dose probability of tumour controlOptimal dose probability of tumour control versus normal tissue toleranceNormal tissue toleranceDose volume histogrameImmobilization and simulation 3-D treatment planningCorrelation of multi-serial CT scans for the tumour and the normal surrounding tissueSlide Number 18Slide Number 19Fussed FDG CT scansDosimetry CT system for treatment planning anatomical and dosimetry moduls - Slide Number 24Dosimetry planingBasic techniquesConformal RTby Multilief collimatorSlide Number 28Slide Number 29Application of radiotherapy Reproducibility and realization of treatment planControl of dosimetryVerification systems -visualization of RT portalsVolumetric Modulated Arc TreatmentKV KV verification & matchingCBCT ImagingAdaptive treatment Cyber knife Exemple Ciber KnifeCiber KnifeLung cancer or metastatesBreast Cancer Radiotherapy IndicationsPostoperative RT after breast preserving surgery in early BC- Is this necessary ???Concept of whole breast IRRadiotherapy in early breast cancer pTis, p1-2Planning of RT for early BCSlide Number 43Radiotherapy techniques for early BC Large volume : remaining breast and chest wall 50 GySmall volume boost overdosage 10-20 Gy; total dose 60-70 Gy method -Marinova , 2000IO boostSlide Number 47Survival curves in early breast cancer after quadrantectomie Marinova 2000COSMETIC RESULTSRadiotherapy for advanced cancerChemotherapy preceded RTWhy? The risk for tumour dissemination is more dangerous than risk or loco-regional recurrence N+ treatment in breast cancerElectron-photon irradiation if int mammary chain is involvedPalliative RTSlide Number 54Indications for RTSlide Number 56 Carcinona in situ -TIS, or microinvasive cancer FIGO 0, I A FIGO IB - II A Postoperative Radiotherapy for operated FIGO IB- IIA3D conformal IrradiationNational standard for cervix cancer RT , 2002 Extended field irradiation forhigh -risk patients(pelvic node positive ) Preoperative RT for FIGO IB- IIA-BPreoperative RT effect on tumourMRI sagittal T2 image, 3D volume analysisAdvanced cervix cancer FIGO IIB, III IV Advanced cervix cancer FIGO IIB, III IVSlide Number 66Uterus HDR BrachytherapyHDR brachytherapy /Definitive RT = Radiotherapy alonePalliative RT FIGO IVB ResultsRadiotherapy for skin cancerRadiotherapy for cancer of the lipsSlide Number 74External beam RT by electronsOther indication for RTSlide Number 77Slide Number 78
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