Radiotherapy in the Treatment of Cancer

Darin Gopaul MD FRCPC

Grand River Regional Cancer Centre

Introduction

POISONED! -- as They Chatted Merrily at Their Work

Painting the Luminous Numbers on Watches, the Radium Accumulated in Their Bodies, and Without Warning Began to Bombard and Destroy Teeth, Jaws and Finger Bones. Marking Fifty Young Factory Girls for Painful, Lingering, But Inevitable Death"

Marie Curie (1867 1934)

Born in Poland University of Paris age 24 Discovered Radium 1898 t1/2 = 1602 years

Intracavitary Brachytherapy

Fletcher-Suit applicator

Interstitial Brachytherapy

Radium Needles

Prostate Brachytherapy

Prostate Brachytherapy
Iodine 125
t = 60 days Gamma emitter

Energy 35 kV

Free-hand implant technique

Prostate Brachytherapy

Prostate Brachytherapy
Adverse effects Urinary symptoms common
Dysuria, frequency, urgency, nocturia

Acute urinary retention 1-14% Urinary incontinence 5- 6% Proctitis 1-3% But Sexual potency preserved 86 -96%
At 2 3 years

Prostate Brachytherapy
Results:
Gleason 2-4 Gleason 5-6 PSA < 4 PSA 4 -10
T1c T2a

86% 63% 93-100% 70-86%

90-94% 70-74%

5 year actuarial biochemical freedom from failure

Prostate Brachytherapy
Patient Selection
PSA < 10 Gleason score 2 6 T1c T2a

Prostate Brachytherapy
Advantages over standard EBRT:
Does not require 6 - 7 weeks of daily fractionated treatments Less long-term toxicity due to radiation of adjacent organs Lower incidence of erectile dysfunction Day surgery procedure requiring only a single visit

Disadvantages compared to EBRT:

More susceptible to dosimetry errors in delivery of radiation Requires a general / spinal anesthetic for implant Higher incidence of voiding dysfunction at time and after treatment Requires precautions regarding radiation exposure to family and friends Only proven for low-stage and low-grade disease

External Beam Radiotherapy

1951 First Cobalt machine

Saskatoon, Saskatchewan London, Ontario Co 60
t = 5.26 years Gamma emitter Energy 1.25 MV

Cobalt- 60

Definition
Gray: A unit of absorbed radiation equal to the dose of one joule of energy absorbed per kilogram of matter, or 100 rads.

Typical doses
Palliative therapy 8 Gy in 1 fraction 20 Gy in 5 fractions 42.5 Gy in 16 50 Gy in 25 60 Gy in 30 78 Gy in 39

Adjuvant therapy

Radical Doses

Palliative Radiotherapy

Palliative radiotherapy
Relief of symptoms (bone met) Prevention of symptoms or morbidity
Improve survival duration (brain mets)

Case 1 Palliative Radiotherapy

58 yo female with a history of metastatic breast ca. Has had increasing back pain for 6 months. Bone scan showed uptake (metastasis) at T5. No evidence of visceral mets. Pain not well controlled with narcotics (limited by side effects) Pain reproduced on palpation of T5

Case 1 Palliative Radiotherapy

Treated with palliative radiotherapy from T3 T7 inclusive with 30Gy in 10 fractions over 2 weeks. Possible side effects: - skin dryness - skin erythema - odynophagia (radiation esophagitis)

Case 1 Palliative Radiotherapy

Treated with palliative radiotherapy from T3 T7 inclusive with 30Gy in 10 fractions over 2 weeks. Possible side effects: - skin dryness - skin erythema - odynophagia (radiation esophagitis) Pain relief within 3-4 weeks Prevention of spinal cord compression?

Skin Care Recommendations

Prevention - Wash daily with mild, non-scented pH balanced soap - Use of hand for washing the area, pat dry - No new creams or oils in the treatment area Treatment - Asymptomatic erythema : no treatment - Dry / itchy skin: aqueous cream (glaxal base, biafine) - Red/ burning skin: 1% hydrocotisone cream - Moist desquamation : Flamazine Cream +/- dressing

Case 2 Palliative Radiotherapy

59 yo male smoker presenting with SOB, cough and chest discomfort. No hemoptysis. Anorexia, fatigue and a 30 lb weight loss.

CT Chest/abdomen, CT Brain, Bone scan demonstrate 14cm lung mass invading into the mediastinum (unresectable) but no mets.
PFTs demonstrate FEV1 0.8L and DLCO 36%

Palliative Radiotherapy Lung Ca

Stage III : Not a candidate for radical radiotherapy
Poor PS Significant weight loss Large tumor > 7cm Inadequate pulmonary reserve for radical radiotherapy

Stage IV : metastatic

Palliative Radiotherapy Lung Ca

Goals Symptom Control
Cough Hemoptysis Chest Pain

Delay intrathoracic progression

Prevent lung collapse Prevent SVC

Aim is Quality of life not Quantity of life

Case 3 Palliative Radiotherapy

42 yo female T2N1 NSCLCa, treated with surgery. 8 months later presented with a seziure, CT scan demonstrates multiple (4 brain mets) Treated with Whole Brain Radiotherapy with clinical/radiologic response

Case 3 Palliative Radiotherapy

8 months post Whole Brain XRT, presents with clinical/ radiologic progression. Options? - Steroids (no response) - Surgery (not for multiple lesions) - Radiotherapy (already treated) - Radiosurgery

Co 60 Radiosurgery Gamma Knife

Co 60 Radiosurgery Gamma Knife

Invented 1950s 201 Cobalt sources

Precision mounted
4mm 4cm target Rigid Immobilization

Gamma Knife

Linear Accelerator

Linear Accelerator
X-rays Higher energy (4 - 18Mv)
compared to Gamma rays (1.25 Mv)

Higher energy means More penetrating beam Treat deeper tumors Enhanced skin sparing

Linac Radiosurgery X Knife

High energy beam 1 moving source 5mm 4cm target

Linac Radiosurgery X Knife

Advantages Allows multiple fractions More widely available Linac has other uses

Cranial Radiosurgery
Indications Solitary Brain Met on MRI
< 4 cm maximal dimension

1- 3 Recurrent post Whole Brain Rads

Good Performance Status (KPS > 70%) Limited or Controlled Extracranial Disease

Adjuvant Radiotherapy

Definition
Adjuvant Therapy: Post-operative treatment in the absence of demonstrable residual disease, to reduce the possibility of recurrence.

Adjuvant radiotherapy Breast cancer

Breast conservation Post mastectomy (loco-regional)

Breast Conservation

No difference in OS LR uncommon post adjuvant XRT LR can be salvaged with further surgery

BCS + Radiotherapy = Mastectomy

Breast Tangents

Computer assisted radiation planning

Adjuvant radiotherapy Breast cancer

Reducing treatment duration (OCOG study) 42.5 Gy in 16 vs 50 Gy in 25

No difference in LR control No difference in cosmesis

Adjuvant radiotherapy Breast cancer

42.5 Gy in 16 fractions now standard Not for very large Breast volumes 3-5 boost treatments to the tumor bed
Close or focal positive margins Premenopausal status

Postmastectomy Radiotherapy
Standard for High Risk disease Tumor > 5cm (T3) Tumor involves skin or chest wall (T4) 4 or more lymph nodes
LRR 25-30% postmastectomy LRR 5- 10% post Locoregional radiotherapy OS improves 5%

Postmastectomy Radiotherapy
Intermediate Risk disease
T2 tumor with multiple adverse features
High grade, LVI+, ER-

1-3 lymph nodes Age < 45 years LRR 10 -18% postmastectomy LRR 5% post Locoregional radiotherapy

3D Conformal Radiotherapy

3D Conformal Radiotherapy
Acquire 3D spacial data Radiation Planning in 3D
Deliver Radiation in 3D

CT Simulator

Couch

MRI-CT Fusion (Co-Registration)

MRI Excellent soft tissue

contrast allows better differentiation between normal tissues and many tumors Disadvantages:

Susceptible to spatial distortions

Treatment Planning

Beam Placement

Multileaf Collimator (MLC)

No more lead blocks!

Prostate Radiotherapy

Prostate 3D Planning

Shaping the beam with MLC - prostate

AP View

Lateral View

Beams Eye View (BEV)

Verification - EPID images

Increasing Conformality

Advantages
Enhanced Normal Tissue Sparing
Reduces side effects

Dose Escalation Improves Cure Rate

Higher Dose per Fraction
Reduce Number of fractions Reduce Treatment Duration

The Future

Targeting System

X-ray sources

Manipulator Synchrony camera Linear accelerator

Robotic Delivery System

Image detectors

Thank-you!