Role of Radiation Therapy in Cancer Oespohagus, current concepts and changing dimensions

1. Dr. Lokesh Viswanath M.D
Professor
Department of Radiation Oncology
Kidwai Memorial Institute of Oncology
19-07-2015

2. Introduction
 Radiotherapy forms an important component of
management of esophageal cancer both in the curative
as well as palliative intent of treatment

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. 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. 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. 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. 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. 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. Teletherapy

10. Linear Accelerator
 3DCRT > 1998+
 IMRT > 2000+

11. IGRT - 2005

12. True Beam - 2010

13. Brachytherapy

14. HDR - Brachytherapy

15. Others : optional equipments

16. Tomotherapy - 2003

17. Synchrony™
camera
Treatment couch
Linear
accelerator
Manipulator
Image
detectors
X-ray sources
Targeting System
Robotic Delivery System
Cyber Knife – 2003+

18. Proton Beam therapy 2012

19. contouring
•Primary
•Regional

20. M/3 - Planning

21.  U/3

22.  L/3

25. 3D Planning - DVH

26. Brachytherapy
 LDR : Cesium Tubes - Manual
 HDR : Iridium or Cobalt – Remote contorlled

28. ILBT

29. 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

30. Variation of mean and maximum esophageal motion as a function of CT slice number.
Motion of the Esophagus Due to Cardiac Motion

31. Results

32. 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

33. CRT v/s RT alone : 64 Gy

36. Thank You