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multidisciplinary approach
in the treatment of
malignomas
Dr. Tatiana Hadjieva, MD, PhD, D sc
Professor , Head
University Radiotherapy Clinic
Medical University Sofia
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
In sandwich
Radiotherapy alone
Combined RT- different RT methods
Intracavitary curietherapy
Interstitial curietherapy
Metabolic curietherapy
(+/-)
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
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
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
heart
lungs
CT simulation
doctor
Fussed FDG CT
scans
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
Rotation
Conformal RT
by Multilief collimator
Innovations
28
Application of radiotherapy
Reproducibility and realization of treatment plan
Control of dosimetry
Verification systems -visualization of
RT portals
CT in treat room
Cone beam
CT
CBCT Imaging
Adaptive treatment
Tomotherapy
Tumour shrinkage
Cyber knife
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
Gy
IO boost
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
Consolidation radiotherapy
Positive lymph nodes with primary
tumour
Electron-photon irradiation if
int mammary chain is
involved
Palliative RT
Indications for RT
Staging TNM = FIGO
combined brachy+EBRT
+RT
FIGO 0, I A
Only conisation
no RT
If
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.
Postoperative Radiotherapy
for operated FIGO IB- IIA
3D conformal Irradiation
Preoperative RT
99 cm 3
HDR brachytherapy /
Results
Interstitial curietherapy
Radiotherapy > Surgery
> EBRT
External beam RT
by electrons
Daily Fractions
2-5 Gy ,
6-20 fractions
Total dose
50-60 Gy
RT
RTCH