Conformal Radiotherapy in Head and neck cancers is essential in terms of improving quality of life and local control in this era. This presentation aimed at giving an overview of conformal radiotherapy and its role in HNC to a 'general audience'.

1. Role of Conformal
Radiotherapy in Head and
Neck Cancers- An overview
DR SASIKUMAR SAMBASIVAM
MBBS.,DNB., MNAMS., PDCR.,
CONSULTANT AND HEAD- RADIATION ONCOLOGY,
DR APJ ABDUL KALAM CENTRE FOR ONCOLOGY,
MEENAKSHI HOSPITAL
TANJORE

2. Treatment for Cancer
Radiation
Medical
Surgical

3. Head and Neck Cancers–
Radiotherapy
 Intent Curative
 Radical/ Definitive
 Adjuvant Radiotherapy
 Recurrent Settings
 Re Irraditation
 Palliation

4. What is the Role of
Radiotherapy??
Indigenous
Essential part of
a Multimodality
treatment

5. What is the Rationale
behind adding
Radiotherapy???
 Increases Survival in Combined Modality
 Adjuvant– prevents Local Recurrence
 Palliation– Pain relief / deters progression
 Recurrent--- Increases survival Benefit
 and
ORGAN PRESERVATION

6. Organ Preservation??
 Why is it important?
 Quality of life after therapy– a Major Concern
 Started a decade back
 Many RCTs and Meta-analysis--- EVIDENCE
 Surgery may be mainstay of many malignancies till
now.
 Chemo--Radiation towards Organ preservation

7. Evidence for Role of
Radiotherapy
 Oral Cavity Cancers– Lips, Buccal Mucosa, Oral
Tongue, Alveolar, Hard Palate.
 Nasopharynx
 PNS
 Larynx
 Hypopharynx
 Carcinoma of Unknown Primary
 Skin
 Thyroid Malignancy
LEVEL 1 Evidence
Recommendation

8. Adjuvant Radiotherapy
 High Risk features on HPR
 pT stage
 Margins
 PNI
 ECE
 Depth of Infiltration
 Number of Nodes +

9. Recurrent Cancers
 Is there a role??
 How do we do it?
 Highly Precise treatment

10. Radiation Oncology
 Consultant
 Medical Physicist and
RSO
 Technologists

11. Side effects : acute and
Long term
 Skin
 Mucosa
 Dysphagia
 Xerostomia
• Seriously affects
Outcome and
Quality of Life

12. Older Techniques – Skin Effects –
Week 5

13. On Conformal High Precision–
Week 7- On Completion

15. Older Techniques

16. Conformity????
 Treatment Planning in high Accuracy
 Treatment Delivery in high Precision
 Treatment Monitoring in high Quality
Let us see HOW do we do it.

17. Dimensions in Physics
o Spatial---3 Dimesnions (X, Y , Z /Rotational)
o 4th Dimesnion : Temporal (Time)
o RELEVANT TO MEDICAL PHYSICS

18. The Linear Accelerator(LINAC)

19. Multileaf Collimator in
LINAC

20. Multi Leaf
Collimators
“Shape the Shape
as a Tumour
Needs’’

21. Conformal techniques Vs
Conventional Techniques
 Better Dosing
 High Precision
 HighQuality
 Lesser Side effects
 Overall, Better Tolerance, Lesser
treatment Breaks, Better QOL

22. Conformal Techniques
 3D CRT– 3Dimensional Conformal Radiotherapy
 IMRT– Intensity Modulated Radiotherapy
 IGRT- Image Guided Radiotherapy
 VMAT/ Rapid Arc (Volumetric Modulated Arc
Therapy)
 SBRT (Stereotactic Body Radiotherapy)
 SRS (Stereotactic Radio Surgery)
 IMPT (Intensity Modulated Proton Therapy)

23. Conformal Delivery--
Machinery
Linear Accelerators (LINAC)
Brachytherapy
Cyberknife
Tomotherapy
Proton therapy
(** Mostly those are In Clinical Use)

24. The Rationale behind :
 Maximum dose to the target
 Maximally sparing the Organs at Risk

25. Target Volumes
 Basically, three

26. Older Techniques– 2-Dimensions
2 to 4 fields

28. 3 Dimensions and multiple
filed placements

29. 2D vs 3D vs IMRT--- Know the
difference

30. IMRT Fields

31. IMRT - Fluence and Modulation

32. Rapid Arc /
VMAT

33. Chain of Quality

34. Patient Preparation/ Immobilization
Step 1: Making a Thermoplastic Mask

35. Step 2 :CT Simulation

36. Step 3 :Contouring/ Delineation

37. Step 4: Treatment Planning

38. Step 5: Plan Evaluation

39. The LINAC

40. Step 6 : Quality Assurance and
Treatment Delivery

41. Treatment Delivery--Setup

42. Treatment Delivery--Isocentre

43. Treatment Delivery--Isocentre

44. Treatment Delivery

45. On Couch Verification Before
Delivery- EPID/ CBCT

46. Observation on Intrafraction

47. Dosing in External Beam RT
 Usually delivered in a range of 6 to 7 weeks
 60- 64 Gy for Adjuvant and 66 to 70 Gy in Definitive
settings
 5 days a week
 Others-
 Hyperfractionation schedules
 Hypofractionation schedules

48. Brachytherapy

49. Brachytherapy– The Most
Conformal Treatment
 Radical/ Adjuvant
 Recurrent
 Early stage of disease
 Expertise
 Accessible sites
 Not close to the Bone
 Very High Dose in few days unlike External Beam
 Short Patient stay
 Good cosmesis
 Good quality of Life

50. Brachytherapy -Treating tumors with
radiotherapy closer or inside.

51. Oral Cavity Tumours

52. Oral cavity Tumours

53. Carcinoma Lip

54. Nasopharyngeal Cancers

55. Oropharyngeal Cancers

56. Ear tumours
Courtesy: Dr Kanhu Patro

57. Stereotactic RT techniques
 HIGH DOSE External Beam Radiotherapy in shorter
duration with very high PRECISION
 SBRT
 SRT
 SRS

58. X Knife– LINAC based Stereotaxy

59. Cyberknife
Small recurrent or
metastatic diseases

60. Tomotherapy in Head and Neck
Cancers
• Radiation is delivered slice-
by-slice
• Helical Tomotherapy is a form
of computed tomography (CT)
guided intensity modulated
radiation therapy (IMRT)

61. Palliation

62. What would
you
recommend??

63. Adequate Palliation = Good Quality of Life

64. ‘Cancer is Curable at Early
Stage’

65. High Chances of Treatment
failure at Advanced stages

66. Take Home Message
 Conformal Radiotherapy in Head and Neck Cancers in the Standard of
Care in this era.
 Better sparing of Organs at Risk (Brain stem , Spinal Cord, Parotids,
Uninvolved mucosa)
 Improves Tolerance of patients undergoing RT
 Improves Quality of Life in terms of Preventing Xerostomia, swallowing
difficulty, skin toxicity, mucositis,
 Improves accuracy in treatment planning and delivery thereby
enhancing the quality,
 Multiple techniques available- Chosen based on the patient and
tumour needs. CHOOSE 3D/ IMRT/ VMAT based treatment.
 ORGAN PRESERVATION

67. Say NO to Tobacco !!!

69. Thank You.