Radiation therapy in Cancer Oesophagus
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- 1. Dr. Lokesh Viswanath M.D Professor Department of Radiation
Oncology Kidwai Memorial Institute of Oncology 19-07-2015
- 2. Introduction Radiotherapy forms an important component of
management of esophageal cancer both in the curative as well as
palliative intent of treatment
- 3. Indication for RT Resectable cancer: as pre-operative
concurrent chemo-radiotherapy as postoperative radiotherapy - in
positive cut margins, nodal positivity and presence of residual
disease. unresectable cancer: concurrent chemo-radiation is the
current standard of care advanced & metastatic disease:
palliative radiotherapy is offered either by external beam or
brachytherapy.
- 4. RT Settings Radical RT Palliative RT External RT
Brachytherapy : ILBT Ext RT ILBT Key Factors influencing RT
decisions: 1. KPS 2. Magnitude of dysphagia 3. Nutritional status
4. Estimated tolerance to Oncotherapeutics 5. Co-existing 1.
Disease conditions: impending TOF 2. Organ / adj structure
infiltrations 6. medical conditions 1. Pulmonary 2. cardiac Radical
RT : Ext RT Alone Ext RT + Brachy RT + Radiation Sensitizer O2 CDDP
5FU Taxanes others Biological ADJ RT: Pre OP RT +/- Radiation
Sensitizer Post OP RT +/- Radiation sensitizer Others Intra OP
RT
- 5. RT Dose Radical RT Palliative RT Ext RT : AP : PA : 30 Gy /
15-17 Fr, 5fr/wk 3 Field : 30 Gy / 15-17 Fr, 5fr/wk +/- HDR : 6Gy /
2 f, 1f/wk & LDR : 10 -20 Gy Total RT Dose: 60 64 Gy fr CRT :
50 Gy / 25-28 fr, 5Fr/wk Adj RT Pre OP RT : 40 -50 Gy / 15-17 Fr,
5fr/wk Post OP RT : 50 Gy / 15-17 Fr, 5fr/wk +/- Boost 30Gy / 10 fr
20Gy / 4-5fr 8Gy/1 fr Saturation techniques : If CR > continue
RT to radical dose
- 6. RT Planning Process Patient Positioning Simulation Supine
Prone Device: Skin Marks Vac lock Thermoplastic X ray : Barium : AP
/ Lat / Obliques (cervical / U/3) Virtual CT Simulation : Fiducial
(ant / 2 mid lat), oral / IV contrast PET CT : Simulation with flat
couch MRI Fusion Barium X ray Image 4 D CT ITV dfn
- 7. Ext RT Planning Contouring & Field setup Computerized
Planning system Contouring : ICRU 50 62 CTV : 3 cms Sup / Inf,
radial 1 1.5 cms PTV : 1 2cms Field Setup AP : PA 3 Field : AP /
RPO / LPO 5 Field : AP : PA / RPO / LPO Others Non Coplanar fields
Rotational field isodose plans : Manual / computerised 2 D Plans 3
D CRT IMRT IGRT Rotational modulate arcs
- 8. RT Machines Teletherapy Brachytherpay Telecobalt Linear
Accelerator LA LA with MLC (3DCRT/IMRT/Modulated rotational arcs /
WB - SRS/SRT) Tomotherapy Cyber knife Particle beam: Proton Manual
loading : Cs Remote: HDR : Ir / Co
- 9. Teletherapy
- 10. Linear Accelerator 3DCRT > 1998+ IMRT > 2000+
- 11. IGRT - 2005
- 12. True Beam - 2010
- 13. Brachytherapy
- 14. HDR - Brachytherapy
- 15. Others : optional equipments
- 16. Tomotherapy - 2003
- 17. Synchrony camera Treatment couch Linear accelerator
Manipulator Image detectors X-ray sources Targeting System Robotic
Delivery System Cyber Knife 2003+
- 18. Proton Beam therapy 2012
- 19. contouring Primary Regional
- 20. M/3 - Planning
- 21. U/3
- 22. L/3
- 23. 3D Planning - DVH
- 24. Brachytherapy LDR : Cesium Tubes - Manual HDR : Iridium or
Cobalt Remote contorlled
- 25. ILBT
- 26. RT toxicities Acute Late Oesophagitis Skin reactions Adv
Disease: Progressive dysphagia > Bleeding : from T / > with
mucositis in the stent region TOF Dysphagia : narrowing and
stricture Pulmonary Cardiac Spinal cord Bronchus / trachea
- 27. Variation of mean and maximum esophageal motion as a
function of CT slice number. Motion of the Esophagus Due to Cardiac
Motion
- 28. Results
- 29. Over all Survival (%) 2YRS 3YRS 5YRS SURGERY ALONE 15.4
20.8 18 THE 25.3 TTE 19.9 RT ALONE 16 10.5 CRT 30 26 CRT 50 40 CRT
65 31 PRE OP CT > S 37.6 17.6 PRE OP RT > S 22 PRE OP CRT
> Surgery NON RCT 44 41 34 * RCT 34 39 * POST OP RT NO 38 N+ 34
RT+NIMOTUZUMAB 33.3 26.2 egfr+++ 46 38.5 egfr++ 28.6 28.6 RT + CT +
C225 44 RT + CT 42
- 30. CRT v/s RT alone : 64 Gy
- 31. Thank You