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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

(+/-)

Prescribing Radiotherapy
Define tumour target
Staging umor Node Metastasis Systemprognostic 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 volume
Optimal tumour

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;

Dose volume histograme


target volume

heart

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

Multiple -fields

Four- fields box

Rotation

Conformal RT
by Multilief collimator

Innovations

28

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

Optical nerve benign tumour


Difficult for surgery.
37

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 BCIs this necessary ???
Concept of whole breast IR
Cancer cells spreding in the periphery of major tumour
(lland et al, Cancer, 1985

National standard for breast cancer RT , 2002

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

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


1.05
1.04
1.03
1.02
1.01
1.00
0.99
0.98
0.97
0.96
0.95
0.94
0.93
0.92
0.91
0.90
0.89

n=341

10

12

14

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)

National standard for cervix cancer RT , 2002

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.

3D conformal Irradiation

National standard for cervix cancer RT , 2002

Extended field irradiation for


high -risk patients
(pelvic node positive )

National standard for cervix cancer RT , 2002

Preoperative RT for FIGO IB- IIA-B


Indications
Bulky IB tumour
Primarily Inoperable tumour -II A-B
Total dose 30-40 Gy

Preoperative RT effect on tumour


MRI sagittal T2 image, 3D volume analysis

Preoperative RT
99 cm 3

After 22 Gy22 cm 3 - 78% reduction

National standard for cervix cancer RT , 2002

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

Uterus HDR Brachytherapy

HDR brachytherapy /

National standard for cervix cancer RT , 2002

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.

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
Radiotherapy > Surgery

> EBRT

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