1. 1. Dr. Lokesh Viswanath M.D Professor Department of Radiation Oncology Kidwai Memorial Institute of Oncology 19-07-2015
2. 2. Introduction Radiotherapy forms an important component of management of esophageal cancer both in the curative as well as palliative intent of treatment
3. 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. 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. 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. 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. 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. 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. 9. Teletherapy
10. 10. Linear Accelerator 3DCRT > 1998+ IMRT > 2000+
11. 11. IGRT - 2005
12. 12. True Beam - 2010
13. 13. Brachytherapy
14. 14. HDR - Brachytherapy
15. 15. Others : optional equipments
16. 16. Tomotherapy - 2003
17. 17. Synchrony camera Treatment couch Linear accelerator Manipulator Image detectors X-ray sources Targeting System Robotic Delivery System Cyber Knife 2003+
18. 18. Proton Beam therapy 2012
19. 19. contouring Primary Regional
20. 20. M/3 - Planning
21. 21. U/3
22. 22. L/3
23. 23. 3D Planning - DVH
24. 24. Brachytherapy LDR : Cesium Tubes - Manual HDR : Iridium or Cobalt Remote contorlled
25. 25. ILBT
26. 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. 27. Variation of mean and maximum esophageal motion as a function of CT slice number. Motion of the Esophagus Due to Cardiac Motion
28. 28. Results
29. 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. 30. CRT v/s RT alone : 64 Gy
31. 31. Thank You