Bachtiar Murtala

Dept of Radiology Medical Faculty Hasanuddin University Makassar

General consideration in choosing modalities in the treatment of cancer :

Surgery, for a lesion that can be technically removed
Irradiation, for a localized lesion in which surgery

may cause anatomically or physiologically undesirable sequelae and for a more extensive lesion not amenable to a surgical resection
Chemotherapy, for the treatment of micrometastases,

chemosensitive tumors, disseminated disease

Some limitations of surgery

Inadequate removal of gross tumor Inadequate resection of microextension Undetected metastases to regional lymph node Systemic micrometastases

Some limitations of chemo

Tumor cell burden
Variation of cell sensitivity Chemoresistance Side effects

Definition
Radiation oncology is a clinical specialty dealing with the use of ionizing radiation ( electromagnetic and particle radiations ) in the management of patients with cancer ( and other neoplasms ), alone, or combined with other modalities such as surgery and chemotherapy

The aim of radiation therapy

Is to deliver a precisely measured dose of radiation to a defined tumor volume with minimal damage in surrounding healthy tissue , resulting in eradication of the tumor and high quality of life

Goal :
1.Radical radiation Treatment intended to cure the patient of his or her disease . The dose is so high, involved tumor and any areas where the risk of microscopic extension present.
2.Palliative radiation Treatment intended to relieve the distressing symptoms of advanced disease ( such as ;relief of pain, luminal patency restored, skeletal integrity preserve, organ function reestablish,large mass, ulceration ). The dose given around 2/3 of full dose and in a shorter time, more simple technique, and with minimal side effect.

Technique of delivering dose

1.

External radiation Radiation beams comes from outside of the body in the certain distance

2. Brachytherapy Introducing radioactive sources into body cavities ( intracavitary ) or inplanted into tissue ( interstitial ) 3. Internal radiation Radioactives fluid introduced into the body orally or intravenously

Steps in radiation therapy procedure

1.
2.

3.
4. 5. 6. 7.

Clinical evaluation : pathobiology of tumor, diagnostic workup, staging Therapeutic decision : goals ( cure or palliation ), choice of therapy, modalities Tumor localization : primary tumor, regional, sensitive organs ) Treatment planning ( simulation, computation, etc) Treatment Periodic evaluation Follow up

Radiation dose
Radiation absorbed dose ( rad ) , the old one Gy ( Grey ) equiv. with 100 cGy =100 rad , now used

routinely

Doses must be given in fractination, based on the

four Rs of radiobiology :
1.

Repair

2. Repopulation 3. Redistribution 4. Reoxygenation

Various types of fractination

Conventional dose : 200 cGy, 5 days a week
Hyperfractination : 115 cGy x 2/day, 5 days a week Acceleration hyperfractination : 200 cGyx2/day Split course : > 200 cGy/day

Radiation given in three settings :

Where no other potentially curative treatment exist 2. Where alternative treatment is considered more toxic 3. When it can provide palliation in advanced disease
1.

In some instances radiotherapy is the best approach

External beam sources

1. X-rays : - Superficial ( 80-150 KeV ) - Orthovoltage ( 250-300 KeV) -Linear accelerator ( Linac ) ( 4-20 MeV )
2. Gamma rays : - Cobalt-60 ( 1.17, 1.33 MeV) - Cesium-137 ( 0.66 MeV ) 3. Particle electron : Linac

Linac

Direction of external beam radiations

Plan parallel ( Right/left lateral )
Tangential/oblique ( medial/lateral ) Rotation

Radioisotopes for brachytherapy

Radium-226 ( 1.1 MeV)
Cesium-137 ( 0.66 MeV ) Cobalt-60 ( 1.17 MeV ) Iridium-191 ( 0.33-0.61 MeV ) Gold-198 ( 0.41-1.09 MeV ) Iodine-125 ( 0.025 MeV )

Iridium - 192

How to kill tumor cells by radiation

Direct action

Radiation or photon energy directly damage the helical chain of DNA

Indirect action

Radiation or photon energy react with macromolecules /water---> free-radicals----> damage the DNA

The most common tumors treated by radiation :

Head and neck cancer ( nasopharyngeal, tonsils etc )
Uterine cervix carcinoma Breast cancer Lung cancer Basal cell carcinoma ( Basalioma ) Bone metastases

Combination Therapy
Radiation and surgery
Indications : 1. Tumors with low cure rates by either surgery or radiation 2. Anaplastic tumors with a great potential for vascular invasion 3. Tumors with a great potential for local or regional recurrence 4. Tumors with a great potential for residual disease after surgery 5. To preserve function 6. To preserve cosmesis

Rationale for preoperative radiation

Eradicate subclinical disease beyond the margins of

surgical resection Influence cell viability Sterilize limph node metastases outside operative field Influence resectability Decrease potential for dissemination Example : Colorectal tumor

Rationale for postoperative radiation

Treat known residual disease not resected
Destroy subclinical foci of tumor cells following the

surgery Eradicate new disease in adjacent area ( including limph node ) Deliver higher radiation dosage to high-risk areas

Example : Breast cancer

Combination of radiation with chemo

Neoadjuvant , to reduce initial tumor cell number before definite surgery or radiation or both and potentially to decrease the viability of micrometastases 2. Adjuvant to eradicate micrometastases or tumor cell dissemination outside the operated or irradiated volume 3. Concomittant chemo-irradiation 4. Definitive therapy, in tumor that are chemosensitive and can be controlled with cytotoxic agents alone 5. Palliative therapy, in the treatment of syastemic macrometastases or to relief symptoms in patients with chemosensitive tumors
1.

Some limitations of radiation therapy

Inadequate eradication of primary tumor
Regional microextensions or meta to the lymph nodes

which may not be included Clinically inapparent distant meta at the time of initial therapy Inaccurate tumor localization Inadequate treatment planning Biologic tumor characterization that decrease the effect of radiation

Toxicity of radiotherapy

Skin ( erythema, desquamation ) Mucous membrane ( mucocitis ) Hair ( alopecia ) Cornea ( keratitis ) Brain (tiredness,lethargy,nausea,vomiting, somnolent ,etc ) Lung ( pneumonitis, cough, dyspneu ) GI tract ( nausea, vomoting , diarrhea ) Bladder ( urinary frequency, dysuria ) Spinal cord ( neurologic defisit ) Liver ( hepatts ) Bone marrow ( suppression of WBC and platelets )

Normal tissue tolerance dose

Whole brain ( 50-55 Gy )
Spinal cord ( 44 Gy ) Brachial plexus ( 50 Gy ) Whole lungs ( 20 Gy ) Part lung ( 40-50 Gy ) Pericardium ( 40 Gy ) Whole liver ( 20-30 Gy ) Thyroid gland ( 30 Gy ) Skin ( 55 Gy )

 Parotid gland ( 10 Gy, temporary dryness), 40 Gy

(prolonged dryness ) Both kidney ( 20 Gy ) Ovary ( 2-6 Gy; permanent sterility ) Testis ( 3-4 Gy; permanent sterility ) Lens ( 5-10 Gy cataract formation )