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Role of Conformal Radiotherapy in HNC

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Role of Conformal Radiotherapy in HNC

Conformal Radiotherapy in Head and neck cancers is essential in terms of improving quality of life and local control in this era. This presentation aimed at giving an overview of conformal radiotherapy and its role in HNC to a 'general audience'.

Conformal Radiotherapy in Head and neck cancers is essential in terms of improving quality of life and local control in this era. This presentation aimed at giving an overview of conformal radiotherapy and its role in HNC to a 'general audience'.

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Role of Conformal Radiotherapy in HNC

  1. 1. Role of Conformal Radiotherapy in Head and Neck Cancers- An overview DR SASIKUMAR SAMBASIVAM MBBS.,DNB., MNAMS., PDCR., CONSULTANT AND HEAD- RADIATION ONCOLOGY, DR APJ ABDUL KALAM CENTRE FOR ONCOLOGY, MEENAKSHI HOSPITAL TANJORE
  2. 2. Treatment for Cancer Radiation Medical Surgical
  3. 3. Head and Neck Cancers– Radiotherapy  Intent Curative  Radical/ Definitive  Adjuvant Radiotherapy  Recurrent Settings  Re Irraditation  Palliation
  4. 4. What is the Role of Radiotherapy?? Indigenous Essential part of a Multimodality treatment
  5. 5. What is the Rationale behind adding Radiotherapy???  Increases Survival in Combined Modality  Adjuvant– prevents Local Recurrence  Palliation– Pain relief / deters progression  Recurrent--- Increases survival Benefit  and ORGAN PRESERVATION
  6. 6. Organ Preservation??  Why is it important?  Quality of life after therapy– a Major Concern  Started a decade back  Many RCTs and Meta-analysis--- EVIDENCE  Surgery may be mainstay of many malignancies till now.  Chemo--Radiation towards Organ preservation
  7. 7. Evidence for Role of Radiotherapy  Oral Cavity Cancers– Lips, Buccal Mucosa, Oral Tongue, Alveolar, Hard Palate.  Nasopharynx  PNS  Larynx  Hypopharynx  Carcinoma of Unknown Primary  Skin  Thyroid Malignancy LEVEL 1 Evidence Recommendation
  8. 8. Adjuvant Radiotherapy  High Risk features on HPR  pT stage  Margins  PNI  ECE  Depth of Infiltration  Number of Nodes +
  9. 9. Recurrent Cancers  Is there a role??  How do we do it?  Highly Precise treatment
  10. 10. Radiation Oncology  Consultant  Medical Physicist and RSO  Technologists
  11. 11. Side effects : acute and Long term  Skin  Mucosa  Dysphagia  Xerostomia • Seriously affects Outcome and Quality of Life
  12. 12. Older Techniques – Skin Effects – Week 5
  13. 13. On Conformal High Precision– Week 7- On Completion
  14. 14. Older Techniques
  15. 15. Conformity????  Treatment Planning in high Accuracy  Treatment Delivery in high Precision  Treatment Monitoring in high Quality Let us see HOW do we do it.
  16. 16. Dimensions in Physics o Spatial---3 Dimesnions (X, Y , Z /Rotational) o 4th Dimesnion : Temporal (Time) o RELEVANT TO MEDICAL PHYSICS
  17. 17. The Linear Accelerator(LINAC)
  18. 18. Multileaf Collimator in LINAC
  19. 19. Multi Leaf Collimators “Shape the Shape as a Tumour Needs’’
  20. 20. Conformal techniques Vs Conventional Techniques  Better Dosing  High Precision  HighQuality  Lesser Side effects  Overall, Better Tolerance, Lesser treatment Breaks, Better QOL
  21. 21. Conformal Techniques  3D CRT– 3Dimensional Conformal Radiotherapy  IMRT– Intensity Modulated Radiotherapy  IGRT- Image Guided Radiotherapy  VMAT/ Rapid Arc (Volumetric Modulated Arc Therapy)  SBRT (Stereotactic Body Radiotherapy)  SRS (Stereotactic Radio Surgery)  IMPT (Intensity Modulated Proton Therapy)
  22. 22. Conformal Delivery-- Machinery Linear Accelerators (LINAC) Brachytherapy Cyberknife Tomotherapy Proton therapy (** Mostly those are In Clinical Use)
  23. 23. The Rationale behind :  Maximum dose to the target  Maximally sparing the Organs at Risk
  24. 24. Target Volumes  Basically, three
  25. 25. Older Techniques– 2-Dimensions 2 to 4 fields
  26. 26. 3 Dimensions and multiple filed placements
  27. 27. 2D vs 3D vs IMRT--- Know the difference
  28. 28. IMRT Fields
  29. 29. IMRT - Fluence and Modulation
  30. 30. Rapid Arc / VMAT
  31. 31. Chain of Quality
  32. 32. Patient Preparation/ Immobilization Step 1: Making a Thermoplastic Mask
  33. 33. Step 2 :CT Simulation
  34. 34. Step 3 :Contouring/ Delineation
  35. 35. Step 4: Treatment Planning
  36. 36. Step 5: Plan Evaluation
  37. 37. The LINAC
  38. 38. Step 6 : Quality Assurance and Treatment Delivery
  39. 39. Treatment Delivery--Setup
  40. 40. Treatment Delivery--Isocentre
  41. 41. Treatment Delivery--Isocentre
  42. 42. Treatment Delivery
  43. 43. On Couch Verification Before Delivery- EPID/ CBCT
  44. 44. Observation on Intrafraction
  45. 45. Dosing in External Beam RT  Usually delivered in a range of 6 to 7 weeks  60- 64 Gy for Adjuvant and 66 to 70 Gy in Definitive settings  5 days a week  Others-  Hyperfractionation schedules  Hypofractionation schedules
  46. 46. Brachytherapy
  47. 47. Brachytherapy– The Most Conformal Treatment  Radical/ Adjuvant  Recurrent  Early stage of disease  Expertise  Accessible sites  Not close to the Bone  Very High Dose in few days unlike External Beam  Short Patient stay  Good cosmesis  Good quality of Life
  48. 48. Brachytherapy -Treating tumors with radiotherapy closer or inside.
  49. 49. Oral Cavity Tumours
  50. 50. Oral cavity Tumours
  51. 51. Carcinoma Lip
  52. 52. Nasopharyngeal Cancers
  53. 53. Oropharyngeal Cancers
  54. 54. Ear tumours Courtesy: Dr Kanhu Patro
  55. 55. Stereotactic RT techniques  HIGH DOSE External Beam Radiotherapy in shorter duration with very high PRECISION  SBRT  SRT  SRS
  56. 56. X Knife– LINAC based Stereotaxy
  57. 57. Cyberknife Small recurrent or metastatic diseases
  58. 58. Tomotherapy in Head and Neck Cancers • Radiation is delivered slice- by-slice • Helical Tomotherapy is a form of computed tomography (CT) guided intensity modulated radiation therapy (IMRT)
  59. 59. Palliation
  60. 60. What would you recommend??
  61. 61. Adequate Palliation = Good Quality of Life
  62. 62. ‘Cancer is Curable at Early Stage’
  63. 63. High Chances of Treatment failure at Advanced stages
  64. 64. Take Home Message  Conformal Radiotherapy in Head and Neck Cancers in the Standard of Care in this era.  Better sparing of Organs at Risk (Brain stem , Spinal Cord, Parotids, Uninvolved mucosa)  Improves Tolerance of patients undergoing RT  Improves Quality of Life in terms of Preventing Xerostomia, swallowing difficulty, skin toxicity, mucositis,  Improves accuracy in treatment planning and delivery thereby enhancing the quality,  Multiple techniques available- Chosen based on the patient and tumour needs. CHOOSE 3D/ IMRT/ VMAT based treatment.  ORGAN PRESERVATION
  65. 65. Say NO to Tobacco !!!
  66. 66. Thank You.

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