Ακτινολογία σημειώσεις!

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 Radiotherapy as a part of multidisciplinary approach in the treatment of malignomas  Dr. Tati ana Hadj i eva , MD, Ph D, D sc Professor , Head University Radiotherapy Clinic Medical University Sofia

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Σημειώσεις ακτινολογίας. Ραδιολογία. Πυρινική Φυσική. Ραδιοθεραπεία

Transcript of Ακτινολογία σημειώσεις!

  • 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