radiotherapy in the treatment of cancer darin gopaul md frcpc grand river regional cancer centre
TRANSCRIPT
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Radiotherapy in the Treatment of Cancer
Darin Gopaul MD FRCPC
Grand River Regional Cancer Centre
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Introduction
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POISONED! -- as They Chatted Merrily at Their Work
Painting the Luminous Numbers on Watches, the Radium Accumulated in Their Bodies, and Without Warning Began to Bombard and Destroy Teeth, Jaws and Finger Bones. Marking Fifty Young Factory Girls for Painful, Lingering, But Inevitable Death"
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Marie Curie (1867 – 1934)
Born in Poland
University of Paris age 24
Discovered Radium 1898
t1/2 = 1602 years
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Fletcher-Suit applicator
Intracavitary
Brachytherapy
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Interstitial Brachytherapy
Radium Needles
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Prostate Brachytherapy
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Prostate Brachytherapy
Iodine 125
t ½ = 60 days
Gamma emitter
Energy 35 kV
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Free-hand implant technique
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Prostate Brachytherapy
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Prostate Brachytherapy
Adverse effects• Urinary symptoms common
• Dysuria, frequency, urgency, nocturia
• Acute urinary retention 1-14%• Urinary incontinence 5- 6%• Proctitis 1-3%
But…• Sexual potency preserved 86 -96%
• At 2 – 3 years
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Prostate Brachytherapy
Results:
Gleason 2-4 86%
Gleason 5-6 63%
PSA < 4 93-100%
PSA 4 -10 70-86%
T1c 90-94%T2a 70-74%
5 year actuarial biochemical freedom from failure
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Prostate Brachytherapy
Patient Selection
• PSA < 10
• Gleason score 2 – 6
• T1c – T2a
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Prostate Brachytherapy
• Advantages over standard EBRT:Advantages over standard EBRT:– Does not require 6 - 7 weeks of daily fractionated treatmentsDoes not require 6 - 7 weeks of daily fractionated treatments– Less long-term toxicity due to radiation of adjacent organsLess long-term toxicity due to radiation of adjacent organs– Lower incidence of erectile dysfunctionLower incidence of erectile dysfunction– Day surgery procedure requiring only a single visitDay surgery procedure requiring only a single visit
• Disadvantages compared to EBRT:Disadvantages compared to EBRT:– More susceptible to dosimetry errors in delivery of radiationMore susceptible to dosimetry errors in delivery of radiation– Requires a general / spinal anesthetic for implantRequires a general / spinal anesthetic for implant– Higher incidence of voiding dysfunction at time and after Higher incidence of voiding dysfunction at time and after
treatmenttreatment– Requires precautions regarding radiation exposure to family Requires precautions regarding radiation exposure to family
and friendsand friends– Only proven for low-stage and low-grade diseaseOnly proven for low-stage and low-grade disease
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External Beam Radiotherapy
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1951 – First Cobalt machine
• Saskatoon, Saskatchewan
• London, Ontario
• Co 60– t ½ = 5.26 years– Gamma emitter – Energy 1.25 MV
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Cobalt- 60
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Definition
Gray:
A unit of absorbed radiation equal to the dose of one joule of energy absorbed per kilogram of matter, or 100 rads.
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Typical doses
Palliative therapy 8 Gy in 1 fraction
20 Gy in 5 fractions
Adjuvant therapy 42.5 Gy in 16
50 Gy in 25
Radical Doses 60 Gy in 30
78 Gy in 39
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Palliative Radiotherapy
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Palliative radiotherapy
• Relief of symptoms (bone met)
• Prevention of symptoms or morbidity
• Improve survival duration (brain mets)
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Case 1 – Palliative Radiotherapy
58 yo female with a history of metastatic breast ca. Has had increasing back pain for 6 months. Bone scan showed uptake (metastasis) at T5. No evidence of visceral mets. Pain not well controlled with narcotics (limited by side effects)
Pain reproduced on palpation of T5
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Case 1 – Palliative Radiotherapy
Treated with palliative radiotherapy from T3 – T7 inclusive with 30Gy in 10 fractions over 2 weeks.
Possible side effects:
- skin dryness
- skin erythema
- odynophagia (radiation esophagitis)
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Case 1 – Palliative Radiotherapy
Treated with palliative radiotherapy from T3 – T7 inclusive with 30Gy in 10 fractions over 2 weeks.
Possible side effects:
- skin dryness
- skin erythema
- odynophagia (radiation esophagitis)
Pain relief within 3-4 weeks
Prevention of spinal cord compression?
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Skin Care Recommendations
Prevention- Wash daily with mild, non-scented pH balanced soap- Use of hand for washing the area, pat dry- No new creams or oils in the treatment area
Treatment - Asymptomatic erythema : no treatment- Dry / itchy skin: aqueous cream (glaxal base, biafine)- Red/ burning skin: 1% hydrocotisone cream - Moist desquamation : Flamazine Cream +/- dressing
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Case 2 – Palliative Radiotherapy
59 yo male smoker presenting with SOB, cough and chest discomfort. No hemoptysis. Anorexia, fatigue and a 30 lb weight loss.
CT Chest/abdomen, CT Brain, Bone scan demonstrate 14cm lung mass invading into the mediastinum (unresectable) but no mets.
PFTs demonstrate FEV1 0.8L and DLCO 36%
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Palliative Radiotherapy – Lung Ca
• Stage III : Not a candidate for radical radiotherapy
– Poor PS– Significant weight loss– Large tumor > 7cm– Inadequate pulmonary reserve for radical
radiotherapy
• Stage IV : metastatic
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Palliative Radiotherapy – Lung Ca
Goals
• Symptom Control– Cough– Hemoptysis– Chest Pain
• Delay intrathoracic progression– Prevent lung collapse– Prevent SVC
Aim is Quality of life not Quantity of life
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Case 3 – Palliative Radiotherapy
• 42 yo female T2N1 NSCLCa, treated with surgery. 8 months later presented with a seziure, CT scan demonstrates multiple (4 brain mets)
• Treated with Whole Brain Radiotherapy with clinical/radiologic response
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Case 3 – Palliative Radiotherapy
• 8 months post Whole Brain XRT, presents with clinical/ radiologic progression.
Options?- Steroids (no response)- Surgery (not for multiple lesions)- Radiotherapy (already treated)- Radiosurgery
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Co 60 Radiosurgery – “Gamma Knife”
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“Co 60 Radiosurgery – “Gamma Knife”
• Invented 1950’s
• 201 Cobalt sources
• Precision mounted
• 4mm – 4cm target
• Rigid Immobilization
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Gamma Knife
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Linear Accelerator
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Linear Accelerator
• X-rays• Higher energy (4 - 18Mv)
– compared to Gamma rays (1.25 Mv)
• Higher energy means– More penetrating beam– Treat deeper tumors– Enhanced skin sparing
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Linac Radiosurgery – “X Knife”
• High energy beam
• 1 moving source
• 5mm – 4cm target
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Linac Radiosurgery – “X Knife”
Advantages
• Allows multiple fractions
• More widely available
• Linac has other uses
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Cranial Radiosurgery
Indications
• Solitary Brain Met on MRI • < 4 cm maximal dimension
• 1- 3 Recurrent post Whole Brain Rads
• Good Performance Status (KPS > 70%)
• Limited or Controlled Extracranial Disease
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Adjuvant Radiotherapy
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Definition
Adjuvant Therapy:
Post-operative treatment in the absence of demonstrable residual disease, to reduce the possibility of recurrence.
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Adjuvant radiotherapy – Breast cancer
• Breast conservation
• Post mastectomy (loco-regional)
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Breast Conservation
• No difference in OS
• LR uncommon post adjuvant XRT
• LR can be salvaged with further surgery
BCS + Radiotherapy = Mastectomy
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Breast Tangents
Computer assisted radiation planning
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Adjuvant radiotherapy – Breast cancer
Reducing treatment duration (OCOG study)
• 42.5 Gy in 16 vs 50 Gy in 25
• No difference in LR control
• No difference in cosmesis
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Adjuvant radiotherapy – Breast cancer
42.5 Gy in 16 fractions now standard
• Not for very large Breast volumes
• 3-5 “boost” treatments to the tumor bed • Close or focal positive margins• Premenopausal status
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Postmastectomy Radiotherapy
Standard for High Risk disease
• Tumor > 5cm (T3)
• Tumor involves skin or chest wall (T4)
• 4 or more lymph nodes
– LRR 25-30% postmastectomy– LRR 5- 10% post Locoregional radiotherapy– OS improves 5%
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Postmastectomy Radiotherapy
Intermediate Risk disease– T2 tumor with multiple adverse features
– High grade, LVI+, ER-
– 1-3 lymph nodes– Age < 45 years
– LRR 10 -18% postmastectomy– LRR 5% post Locoregional radiotherapy
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3D Conformal Radiotherapy
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3D Conformal Radiotherapy
• Acquire 3D spacial data
• Radiation Planning in 3D
• Deliver Radiation in 3D
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Couch
CT Simulator
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MRI-CT Fusion (Co-Registration)
MRIExcellent soft tissue
contrast allows better differentiation between normal tissues and many tumors
Disadvantages: Susceptible to spatial
distortions
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Treatment Planning
Beam Placement
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Multileaf Collimator (MLC)
No more lead blocks!
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Prostate Radiotherapy
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Prostate 3D Planning
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Shaping the beam with MLC - prostate
Beam’s Eye View (BEV)Beam’s Eye View (BEV)
AP View Lateral View
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Verification - EPID images
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Increasing Conformality
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Advantages
• Enhanced Normal Tissue Sparing • Reduces side effects
• Dose Escalation Improves Cure Rate
• Higher Dose per Fraction • Reduce Number of fractions• Reduce Treatment Duration
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The Future
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Synchrony™
camera Linearaccelerator
Manipulator
Imagedetectors
X-ray sourcesTargeting System
Robotic Delivery System
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Thank-you!