radiation therapy of oral cancers
TRANSCRIPT
Radiation Therapy Radiation Therapy of Oral Cancersof Oral Cancers
Dr. V. Lokesh M.DDr. V. Lokesh M.DProfessor & Head of UnitProfessor & Head of UnitDepartment of Radiation Department of Radiation
Oncology, Kidwai Memorial Oncology, Kidwai Memorial Institute of Oncology, BangaloreInstitute of Oncology, Bangalore
Radiation therapy is the art of using Radiation therapy is the art of using ionising radiation to destroy ionising radiation to destroy malignant tumours while being able malignant tumours while being able to minimise damage to normal to minimise damage to normal tissue.tissue.
IntroductionIntroduction Basics of Radiation TherapyBasics of Radiation Therapy
Ionizing Radiation – X / Ionizing Radiation – X / γγ Rays Rays Interaction of Radiation with matterInteraction of Radiation with matter
Transmission
Attenuation
Scatter Absorption
Rad / Grey / cGy
Cancer Cell & Ionizing Cancer Cell & Ionizing RadiationRadiation DNADNA is primary target is primary target
Double Strand breaks – Primary Double Strand breaks – Primary requisiterequisite
Reproductive Cell DeathReproductive Cell Death
RT is a Double Edge RT is a Double Edge SwordSword
↑ ↑ RT RT DoseDose
↓ ↓ RT DoseRT Dose
↑ ↑ T – ControlT – Control ↓ ↓ T – ControlT – Control
↑ ↑ Normal Normal Tissue Tissue ToxicititesToxicitites
↓ ↓ Normal Normal Tissue Tissue ToxicititesToxicitites
TeletherapyTeletherapy TelecobaltTelecobalt Linear AcceleratorLinear Accelerator
Simple TeletherapySimple Teletherapy SRS/SRTSRS/SRT 3DCRT3DCRT IMRTIMRT IGRTIGRT Rapid ArcRapid Arc True BeamTrue Beam
Gamma KnifeGamma Knife TomotherapyTomotherapy Cyber KnifeCyber Knife
BrachytherapyBrachytherapy IntracavitoryIntracavitory InterstitalInterstital MouldMould
Pre Loaded / Pre Loaded / AfterloadingAfterloading
Manual / RemoteManual / Remote LDR / HDR LDR / HDR
Kilovoltage X-Ray 1920Kilovoltage X-Ray 1920
Telecobalt 1970sTelecobalt 1970s
Linear AcceleratorLinear Accelerator 3DCRT 3DCRT IMRTIMRT
True BeamTrue Beam
BrachytherapyBrachytherapy
RT in Oral CancerRT in Oral Cancer
Management:Management: Treatment OutcomeTreatment Outcome CosmesisCosmesis Organ Preservation & FunctionOrgan Preservation & Function AgeAge Quality of lifeQuality of life
RTRT Radical RTRadical RT
RT:RT: Conventional (7-8 weeks)Conventional (7-8 weeks) Hyperfractionation (5-6 weeks)Hyperfractionation (5-6 weeks) Hypofractionation (1-2 Gap 1-2 weeks)Hypofractionation (1-2 Gap 1-2 weeks)
Pre Operative RT Pre Operative RT (2-5 weeks)(2-5 weeks)
Post Operative RT Post Operative RT (5-7 weeks)(5-7 weeks)
Palliative RTPalliative RT Short Course Short Course (1-2 weeks)(1-2 weeks)
Saturation Technique Saturation Technique (1-2 weeks gap 3-4 weks)(1-2 weeks gap 3-4 weks)
RT CombinationsRT Combinations RT aloneRT alone
Photons alonePhotons alone Photons + ElectronsPhotons + Electrons Recent adv - Photons + Particle Recent adv - Photons + Particle
(Protons/Neutorns/C ions)(Protons/Neutorns/C ions) RT RT ++ Radiation Sensitizers (CT drugs / BRM / Radiation Sensitizers (CT drugs / BRM /
CT+BRM)CT+BRM) RT RT ++ Radiation Protectors (Amifostine) Radiation Protectors (Amifostine)
RT RT ++ Brachytherapy Brachytherapy Brachytherapy aloneBrachytherapy alone
Brachy typeBrachy type Single palne implantSingle palne implant Duble plane implantDuble plane implant Volume implantsVolume implants
Indications for RT in Indications for RT in Oral CaOral Ca
Radical RTRadical RT T1, T2, T3, T4a T1, T2, T3, T4a
Unresectable (Altered Fractionation HF/CB or RT + Unresectable (Altered Fractionation HF/CB or RT + Radiation Sensitizer)Radiation Sensitizer)
elderly, frail, comorbid conditionselderly, frail, comorbid conditions refusal for surgeryrefusal for surgery prohibitive morbidity due to surgeryprohibitive morbidity due to surgery
Pre OP RT : Pre OP RT : potentially inoperablepotentially inoperable Post OP RT : Post OP RT : (RT + Radiation Sensitizer)(RT + Radiation Sensitizer)
pT3/4pT3/4 Close & +ve marginClose & +ve margin Multiple nodesMultiple nodes Perineural invasionPerineural invasion Lympho vascular space invasionLympho vascular space invasion Extra Capsular extensionExtra Capsular extension Level IV – V nodesLevel IV – V nodes
RADIOTHERAPY DOSERADIOTHERAPY DOSE
1. External :1. External :
a. Alone : 7000 cGy to 7600 cGy /6-8 wks. a. Alone : 7000 cGy to 7600 cGy /6-8 wks.
(microscopic - 4600 - 5000 cGy)(microscopic - 4600 - 5000 cGy)
b. Pre-op. : 46-50 Gy/ 4 1/2 - 5 1/2 wks.b. Pre-op. : 46-50 Gy/ 4 1/2 - 5 1/2 wks.
c. Post-op.: 60-66 Gy/ 6-7 wks.c. Post-op.: 60-66 Gy/ 6-7 wks.
2. Brachytherapy :2. Brachytherapy :
a. Alone : 6000 - 7000 cGy in 6 to 7 days.a. Alone : 6000 - 7000 cGy in 6 to 7 days.
b. External + Brachytherapyb. External + Brachytherapy
Ext : 46-50 Gy in 4 1/2 - 5 1/2 wks. Ext : 46-50 Gy in 4 1/2 - 5 1/2 wks. ++
Brachy : 2000-3000 cGy in 2-3 days Brachy : 2000-3000 cGy in 2-3 days
pre- radiotherapy Dental pre- radiotherapy Dental ProphylaxisProphylaxis
ExtractionExtraction Caries (non-restorable)Caries (non-restorable) Active periapical disease (symptomatic teeth)Active periapical disease (symptomatic teeth) Moderate to severe periodontal diseaseModerate to severe periodontal disease Lack of opposing teeth, compromised hygieneLack of opposing teeth, compromised hygiene Partial impaction or incomplete eruptionPartial impaction or incomplete eruption Extensive periapical lesions (if not chronic or Extensive periapical lesions (if not chronic or
well localized)well localized)
Start RT after 10 – 14 daysStart RT after 10 – 14 days
RT TechniquesRT Techniques
Simple TeleSimple Tele 3DCRT / IMRT3DCRT / IMRT
Mould RoomMould Room
Patient postioning : Patient postioning : SupineSupine Neck – Extension / hyperflexionNeck – Extension / hyperflexion
Immobilzation devisesImmobilzation devises Head restHead rest Bite blockBite block Tongue depressorTongue depressor ThermoplasticsThermoplastics
SimulationSimulation
Simulator X-Ray MachineSimulator X-Ray Machine CT ScannerCT Scanner
An Isocentric Mounted Simulator X An Isocentric Mounted Simulator X _Ray machine is used to simualte_Ray machine is used to simualte
Fields and Position before treatment Fields and Position before treatment fields will be marked on a patientfields will be marked on a patient
Conventional 2D Conventional 2D PlanningPlanning
3D CRT / IMRT3D CRT / IMRT
Laser setupLaser setup
Virtual SimulationVirtual Simulation
CT-based virtual simulation CT-based virtual simulation use a full 3D image datasetuse a full 3D image dataset software toolssoftware tools external laser system for markingexternal laser system for marking
radiation therapy targetsradiation therapy targets
PLANNING : ECLIPSE / PLANNING : ECLIPSE / HELIOSHELIOS
CONTOURINGCONTOURING
FusionFusion
MRIMRI PET CTPET CT AngioAngio othersothers
IMRT: FIELDIMRT: FIELD
IMRT : PLANIMRT : PLAN
Neck node CoverageNeck node Coverage
Acute side effectsAcute side effects
Skin – Hyper pigmentation, Dry and Skin – Hyper pigmentation, Dry and moist desqumationmoist desqumation
Mucosa- Mucositis G2/3Mucosa- Mucositis G2/3 Pharynx – Odynophagia / dysphagiaPharynx – Odynophagia / dysphagia Larynx – hoarseness of voiceLarynx – hoarseness of voice Salivary - XerostomiaSalivary - Xerostomia
5 YR SURVIVAL5 YR SURVIVALSTAGE 1STAGE 1 STAGE STAGE
IIIISTAGEIIISTAGEIII STAGEIVSTAGEIV T 3/4T 3/4
LipLip 90%90% <60-30%<60-30% 30%30%
Anterior TongueAnterior Tongue 69%69% 41%41% 25%25%
S+R - 35%S+R - 35%15%15% 33-60%33-60%
Buccal MucosaBuccal Mucosa 77%77% 65%65% 27%27% 18%18% 33-67%33-67%
Floor of the Floor of the MouthMouth
97%97% 72%72% 51%51% 20%20% 33-67%33-67%
Lower GingivaLower Gingiva
Retromolar Retromolar TrigoneTrigone
70%70% 50-30%50-30% 30%30% 30-50%30-50%
Upper GingivaUpper Gingiva
Hard PalateHard Palate 75%75% 46%46% 36%36% 115115
During radiotherapyDuring radiotherapy
Maintenance of good oral hygiene Maintenance of good oral hygiene Brushing 2 to 4 times daily with soft-Brushing 2 to 4 times daily with soft-bristled brush; flossing dailybristled brush; flossing daily
Daily topical fluoride Custom trays, Daily topical fluoride Custom trays, brush-on prescription-strength fluoridebrush-on prescription-strength fluoride
Frequent saline rinsesFrequent saline rinses Lip moisturizer (non-petroleum based)Lip moisturizer (non-petroleum based) Passive jaw-opening exercises to Passive jaw-opening exercises to
reduce trismusreduce trismus
After radiotherapyAfter radiotherapy
Complete dental work that was Complete dental work that was deferred during radiotherapydeferred during radiotherapy
Maintain integrity of teeth Especially Maintain integrity of teeth Especially those in radiation fieldsthose in radiation fields
Frequent follow-upFrequent follow-up
Follow-upFollow-up
Clinical examination of head and neck mucosa Clinical examination of head and neck mucosa (including fiberoptic ) and neck palpation / (including fiberoptic ) and neck palpation / performance status / nutritional assessmentperformance status / nutritional assessment
every 2 months (first 2 years),every 2 months (first 2 years), every 6 months (years 3-5),every 6 months (years 3-5), once a year (> 5 year)once a year (> 5 year) Dental examination and orthopantomogram every 6 Dental examination and orthopantomogram every 6
monthsmonths Chest X-ray every yearChest X-ray every year Chest spiral CT every yearChest spiral CT every year Laboratory tests: TSH every year (if Laboratory tests: TSH every year (if
Radiotherapydelivered)Radiotherapydelivered) Evolution of late toxicity (EORTC/RTOG) scaleEvolution of late toxicity (EORTC/RTOG) scale
Salvage treatment for Salvage treatment for recurrent diseaserecurrent disease
Lip, mobile tongue, floor of mouth:Lip, mobile tongue, floor of mouth: T1 N0 :T1 N0 :
BrachytherapyBrachytherapy SurgerySurgery
Any other T, any other NAny other T, any other N Surgery + radical ND ± post-operative RxTh if not Surgery + radical ND ± post-operative RxTh if not
previously deliveredpreviously delivered RxThRxTh
Palliative carePalliative care Metastasis :Metastasis :
Chemotherapy + best supportive careChemotherapy + best supportive care
Thanking youThanking you