Mayapada Hospital - Medical Personnel - CS Lin

Contemporary
Radiotherapy
2019/02/10
Tri-Service General Hospital,
National Defense Medical Center,
Taipei, Taiwan
Chun-Shu Lin, MD, PhD
at Mayapada Hospital, Indonesia
Tri-Service General Hospital
Chun-Shu Lin M.D. 林群書副教授
Associate Professor and Director, Division of Radiation Oncology, NDMC
國防醫學院醫學系放射腫瘤學科主任
Director, Department of Radiation Oncology, Tri-Service General Hospital
三軍總醫院放射腫瘤部主任
Deputy Director, Cancer Center of Tri-Service General Hospital
三軍總醫院癌症中心副主任
Director, Taiwan Society of Cancer Palliative Medicine
台灣癌症安寧緩和醫學會理事
2
Taiwan Indonesia
Mirna Primasari Me

Outline
1. Evolution of External Beam Radiotherapy
2. Now and Future of RTD in TSGH
3. Basic Knowledge of Radiotherapy
4. Procedure of Radiotherapy Course
5. Case Sharing
4
Outline
5. Case Sharing
5
The Evolution of External Beam Radiotherapy
Particle therapy
Radiotherapy Radiosurgery
MR-Linac
IGRT X-Knife CyberKnife

IMRT
Tomotherapy GammaKinfe
IGRT + BrainLab
6
Radiation methods
Radiotherapy SRS* SABR**/SBRT†
************* Elekta VersaHD *************
Daily dose Standard Highest High
(1.8-2.0Gy) (>14Gy) (8-12 Gy)
Fractions >10 1 shoot 3-6
Target Large Small Median
significance Can treat regional LNs; Need a small target; “Modified SRS”
preventive treatment cannot treat LNs
Example Almost all cancers: Small brain tumor; Early lung cancer;
Nasopharynx; Lung; Small lung tumor; early liver cancer;
breast; uterus…etc Small spine tumor Relative large brain
tumor
*SRS: Stereotactic RadioSurgery
**SABR: Stereotactic ABlative Radiotherapy 7
†SBRT: Stereotactic Body Radiation Therapy Tri-Service General Hospital
Outline
5. Case Sharing
8
2013-2023 Synergy 2009-2019 Synergy 2016-2026 (BOT)
Present
2017-2027 Versa HD
X
2007-2017 CyberKnife
(ROT)
BOT: Build-Operation-Transfer
ROT: Reconstruction-Operation-Transfer
2012-2022
9
2013-2023 Synergy
2019-2029 Versa HD 2022~ MR-Linac (1.5T)
+ C-Rad Under planning
Future
2017-2027 Versa HD 2019-2029 Versa HD

+ BrainLab
2012-2022
10
2016-2026 (BOT) Tri-Service General Hospital
Proton Therapy Center
(construction 2020-2024)
Proton
成
功
路
二
段
民權東路六段
*IBA, Hitachi, Varian, Mevion…etc. Tri-Service General Hospital
After 2024
12
Outline
5. Case Sharing
13
Characteristics of Radiotherapy
• Dose unit of radiotherapy (Gray)
1 Gray (Gy)
= 100 centi-Gray (cGy)
= 100 rad
(1 Gy 1 J/kg) The energy is about 1 sip of hot coffee
• Local treatment – smart beam
14
Fractionation- 4”R”s
• Benefit:
1.Re-oxygenation of cancer cells
2.Re-distribution of cancer cells
3.Repair of normal tissue
• Disadvantage: Re-population of cancer

cells
15
1. Re-oxygenation
 Killing of oxic cells: thus more oxygen

available to hypoxic cells
 tumor shrinkage: smaller distance to

blood vessels
 lower extra-capillary fluid pressure:

hence increased blood flow
 active movement of tumor cells 16

2. Re-distribution
17
3. Repair
18
4. Re-population
19
Concept of radiotherapy
≠
Commonly used dose：
• Daily dose：1.8-2.0 Gy D1 D2 D3 D4 D5
[biological effect 2Gy x 5 ≠ 5 Gy x 2 ≠ 10 Gy x 1] In 1 Day
• Total dose：
Gross tumor ≈ 60-70 Gy
High risk area ≈ 60-65 Gy
Low risk area ≈ 45-55 cGy
Special consideration:
1. lymphoma: highly sensitive to radiotherapy; can reduce daily dose to 1.5-1.8 Gy
for large field.
2. Melanoma: radio-resistance; can elevated daily dose to 2.5-3 Gy
3. Normal tissue tolerance
20
4. Others: age, comorbidity…etc Tri-Service General Hospital
Outline
5. Case Sharing
21
Procedure of radiotherapy
Consultation of RTD to confirm Tx location
 1-2 workdays
 simulation
 3-5 workdays (Treatment planning)
 Port film
 Daily RT
Emergent Tx in TSGH:
SVC syndrome、Spinal cord tumor compression、tumor bleeding
22
Simulation
Thermoplastic mesh
23
CT-simulation (4D-CT)
24
CT simulation
25
CT-CT-MR-PET fusion image
26
A schematic representation of tumor volume
and target volume

Definition of Volumes
Example (H&N cancer)

Primary tumor + gross LNs
Lymphatic drainage region
Organ motion

29
Stereo Nasopharynx
Digitally GTVRadiograph
Reconstructive and 95%(DRR)
Envelope
30
IMRT or VMAT
with/without IGRT(CBCT)
• Image guide
• Multi-field or Arc therapy
• Multi-level dose accumulation
in one field
• Dose distribution: good
IMRT: intensity modulated radiation therapy

VMAT: volumetric modulated radiation therapy
IGRT: image-guided radiotherapy
CBCT: cone-beam CT
31
Beam arrangement; Isodose curve;
Dose-Volume histogram (DVH)
32
Image-guided radiotherapy (IGRT)
37
Future !!!
(science fiction film ?)
39
Clinical role of radiotherapy
• Definitive RT/CCRT: NPC; glottis; prostate; anal cancer;
cervical cancer; NSCLC; SCLC; early stage HCC…
• Preop (neo-adjuvant) CCRT: rectal cancer; esophagus…
• Postop (adjuvant) RT/CCRT: breast cancer; sarcoma;
head neck cancer; lymphoma (consolidative)…
• Palliative RT: HCC, metastases…
• Other combination therapy:
RT + ADT (prostate);
RT + targeted therapy (Cetuximab…)
RT + IO
42
Outline
5. Case Sharing-
NPC; lung cancer; breast cancer
44
45
Cancer Mortality Profile in 2014
Taiwan
Lung Lung
Liver & biliary tract Liver & biliary tract

Colon-rectum-anus Colon-rectum-anus
Breast Oral cavity
46
H&N
Case sharing-
NPC
Definitive CCRT
7043708 吳 X 鴻, Male/31

H&N
2011/12/29 MRI: T4 N3 M0
48
H&N
NP scope & pathology

NPscope: archived
Nasopharynx, biopsy --- Non-keratinizing carcinoma, undifferentiated subtype.

########################################
Immunohistochemical stains:
CK: positive for tumor cells.
EMA: positive for tumor cells.
P16: negative result.
LMP-1: negative result.
Ki-67: increase of proliferative index.
########################################
Dx: Non-keratinizing carcinoma of the NP, cT4 N3 M0, stage IVB

49
50
H&N
Treatment Plan
• Plan: Definitive CCRT + adjuvant chemotherapy.
• 2012/1/12 – 2012/3/8 Deliver 70 Gy in 37 fx to the gross
tumor, 60 Gy to the high-risk nodal area and 50 Gy to
low risk nodal area.
• Med Oncol 張平穎 Weekly Cisplatin (2012/01/12 -
2012/03/03), cisplatin+5-FU (2012/04/14, 2012/04/27,
2012/05/24, 2012/06/09, 2012/07/06)
51
H&N
IMRT plan
52
H&N
2012/4/11 [1m after CCRT + C/T]
MRI: 1. marked tumor regression 2. A residual enhancing node
(0.9 cm) over the retropharyngeal space  Oral Ufur 2# bid
53
H&N
2014/3/21 [2yr after CCRT + C/T]
MRI: 1. No tumor recurrence of the nasopharynx. 2. Similar residual
poor-enhancing node (1.0 cm) over the retropharyngeal space
 Stop Ufur [this node is not mentioned after this MRI thereafter]
54
2019/1/14 MRI: cCR

2019/1/14 MRI: cCR

H&N
Case summary
7043708 吳 X 鴻, M/31
• Non-keratinizing carcinoma of the
nasopharynx, cT4 N3 M0, stage IVB s/p
CCRT, adjuvant chemotherapy and oral
UFUR (2 yr) with NED ( 6yr 10m).
• 2018/11/15 EBV viral load: not detectable
57
Chest
Case sharing-
Lung Cancer
Definitive CCRT
1976995 童陳o嬌 Female/84
Incidental finding of a lung tumor
by CXR at 金門H in 2012

Chest
2012/9/11 CT: 1. A tumor, 2.3 cm, RUL. 2. LNs,

right hilar and PTRC spaces. 3. Favor brochogenic
carcinoma; T:1b N:2 M:x
59
Chest
Other studies
• 2012/9/11 [pathology] Lung, R't, CT-
guided biopsy --- Small cell carcinoma.
• 2012/9/12 MRI, brain: Senile brain without
apparent mets are seen.
• 2012/9/13 Bone scan: neg.
• 2012/9/26 PET/CT: cT1bN2M0 [archived]
• Dx: Small cell carcinoma of the lung,
cT1bN2M0, stage IIIA, limited stage.
60
61
Chest
Treatment plan
• 2012/10/17 – 2012/11/30 definitive thoracic
CCRT (60 Gy in 33 fx)
 2012/12/5 – 2012/12/27 PCI (30 Gy in 15fx)
• Chemo at Chest Dr. 蔡: Carboplatin + Etoposide
(20121005, 20121030, 20121121, 20121217)
PCI: Prophylactic Cranial Irradiation

62
Chest
IMRT- thoracic RT 60 Gy
63
64
Chest
Conventional PCI 30 Gy
65
Chest
2014/8/4 [1yr 9 m s/p CCRT]

CT: CR ; radiation pneumonitis
66
Chest
2015/5/29 [2yr 6 m s/p CCRT]

CT: CR ; radiation pneumonitis
Irregular FU after this image

67
Chest
2017/9/12 [4yr 10 m s/p CCRT]

CT: Newly developed 2.5 cm tumor, RUL
2018/9/26 [pathology] Lung, RUL, CT-guide biopsy --- Squamous cell

carcinoma, moderately differentiated. 68
Chest
Treatment plan- 2nd

• Dx: Squamous cell carcinoma, moderately
differentiated, RUL, cT1b N3 M0, stage IIIB,
ALK(-)
• 2017/11/6 – 2017/12/19 definitive CCRT (60 Gy
in 30 fx)
• Chemo at Chest Dr. 蔡: Cisplatin/Docetaxel
(2017/10/17)  Taxotere (2017/11/6,
2017/11/13, 2017/11/27, 2017/12/4, 2017/12/18)
PCI: Prophylactic Cranial Irradiation

69
Chest
Definitive IMRT (Tomotherapy)
60 Gy in 30 fx to
PET-enhanced
lesions
70
Chest
2018/3/20 & 2018/7/18

[7m after 2nd CCRT] CT: PR (1.6 cm)
71
Chest
2018/10/11 [10m after 2nd CCRT]

CT: progression (3.2cm)
72
Chest
Case summary
1976995 童陳o嬌 F/84
• Small cell carcinoma of the lung, cT1bN2M0,
stage IIIA, limited stage s/p definitive CCRT +
PCI with NED (?) (5y 10m).
• Squamous cell carcinoma, moderately
differentiated, RUL, cT1b N3 M0, stage IIIB,
ALK(-) s/p definitive CCRT with disease
progression, during oral Navelbine (since
2018/10/22).
73
Breast
Case sharing-
Breast Cancer
1912406 朱O屏女/57

Breast
History
• Left breast cancer, stage I s/p BCS (2004 外院) (no
adjuvant therapy)
• local recurrence  salvage nipple preserving
masectomy, L‘t (2012/08/07 TSGH)
• IDC, gr 2, rpT1b(0.6cm) N0(0/2) M0, ER 90% 3+, PR 1%
2+, Her2/neu DAKO 2+ 30%, FISH (-), Ki-67 (30%)
[refuse adjuvant therapy]
• 2016/2/2 skin recurrences: IDC, gr 3, ER 90% 3+, PR
70% 2+, Her2/neu DAKO 2+ 30%, FISH (-), Ki-67 (30%)
 rcT4 N0 M0
• Refuse surgery; for RT.
75
Breast
2016/1/22 Breast sono:
A 10.1 x 4.4 mm lobular mass with poorly defined margin,
in the LOQ of the left breast, might be skin lesion or
recurrence, suggest surgical evaluation. ACR BIRADS
Category 4a
76
Breast
2016/2/26 PET/CT: are least three

FDG avidities localised to the left
retroareolar region (SUVmax.:4.8)
and left breast skin (esp. lower
quadrant, SUVmax.:4.6) .
77
Breast
Other studies
• 2015/6/29 Mammography: BIRADS
Category 2
• 2016/2/25 MRI, breast: The MRI study
shows no specific abnormal finding.
• 2016/2/26 Abdominal sono: neg for mets
• 2016/3/1 Bone scan: no bone metastasis
78
79
Breast
Treatment plan
• Encourage surgery + chemotherapy + RT
+ AI again and again.
 Patient still refuses surgery and
chemotherapy again and again.
• Salvage radiotherapy + AI (Femara).
2016/3/8 – 2016/4/29 Deliver 50 Gy in 28 fx
to the left whole chest wall (photon) +
tumor bed boost 20 Gy in 10 fx (electron).
Not standard therapy
80
Breast

IMRT
81
Breast
2018/8/20 [2y 6m] Breast sono:

No visible tumors ; BI-RADS category 3

82
Breast

Case summary
1912406 朱O屏女/57
• Left breast cancer, stage I s/p BCS (2004)
with local recurrence s/p salvage nipple
preserving masectomy, L't (2012/08/07
TSGH) with repeated skin recurrences, rc
T4 N0 M0, ER 90% 3+, PR 70% 2+,
Her2/neu DAKO 2+ 30%, FISH (-), Ki-67
(30%) s/p salvage RT, during Femara,
with NED (2yr 6m).
83
Taiwan Indonesia
Thank You!!!

Mayapada Hospital - Medical Personnel - CS Lin

Transféré par

Informations du document

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Mayapada Hospital - Medical Personnel - CS Lin

Transféré par

Droits d'auteur :

Formats disponibles

Contemporary

Tri-Service General Hospital

IGRT X-Knife CyberKnife

Fractions >10 1 shoot 3-6

Target Large Small Median

2017-2027 Versa HD 2019-2029 Versa HD

• Local treatment – smart beam

• Disadvantage: Re-population of cancer

 Killing of oxic cells: thus more oxygen

 tumor shrinkage: smaller distance to

 lower extra-capillary fluid pressure:

 active movement of tumor cells 16

Tri-Service General Hospital

Example (H&N cancer)

Tri-Service General Hospital

IMRT: intensity modulated radiation therapy

Liver & biliary tract Liver & biliary tract

Tri-Service General Hospital

NP scope & pathology

Nasopharynx, biopsy --- Non-keratinizing carcinoma, undifferentiated subtype.

Dx: Non-keratinizing carcinoma of the NP, cT4 N3 M0, stage IVB

Tri-Service General Hospital

Tri-Service General Hospital

Tri-Service General Hospital

2012/9/11 CT: 1. A tumor, 2.3 cm, RUL. 2. LNs,

PCI: Prophylactic Cranial Irradiation

2014/8/4 [1yr 9 m s/p CCRT]

2015/5/29 [2yr 6 m s/p CCRT]

Irregular FU after this image

2017/9/12 [4yr 10 m s/p CCRT]

2018/9/26 [pathology] Lung, RUL, CT-guide biopsy --- Squamous cell

Treatment plan- 2nd

PCI: Prophylactic Cranial Irradiation

Definitive IMRT (Tomotherapy)

2018/3/20 & 2018/7/18

2018/10/11 [10m after 2nd CCRT]

Tri-Service General Hospital

2016/2/26 PET/CT: are least three

Not standard therapy

2018/8/20 [2y 6m] Breast sono:

Not standard therapy

Not standard therapy

Vous aimerez peut-être aussi