radiotherapy in head and neck
TRANSCRIPT
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AFTERNOON
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RADIOTHERAPY
Presenter :Dr. Narla susheel
III yr PG
Dept of OMFS
Sids
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CONTENTS
• PHYSICAL NATURE OF RADIATION
• BIOLOGICAL ACTION
• TUMOR EFFECTS
• NORMAL TISSUE EFFECTS AND
TOLERANCE
• PRINCIPLES OF RADIOTHERAPY
• EXTERNAL BEAM THERAPY• RESULTS & METHODS TO IMPROVE EBT
• BRACHYTHERAPY
•
RADIATION SOURCES•
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• THE TRETMENT !SING IONISING
RDITION THT INTER"TS #ITH
F$!IDS TO PROD!"E FREE IONS• T%PE: E$E"TROMGNETI"• RNGE : &' (e) * +, Me)• SO!R"E: - ray set or $INER
""E$RTOR &' /o0alt fro1 de/ay of
radio isotope
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RDITION DOSGE 2 "ON" OF
RDITION EFFE"T 3!NTIT% OF≠ENERG%
• SI !nit of a0sor0ed dose is GR% 4Gy5• Gy 2 67oule 8 (9• Old unit 2 the rad• 6'' rads 2 6Gy
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BIOLOGICAL ACTION
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• Cells – onsng ra!aton – "reera!cals #ntercellular $ater%
• A!&acent large 'olecules (
!enaturaton• I" DNA Da'age – cell ) 'toss )• I" cell atte'pts to !*!e – cell !eath
ensue – MITOTIC DEATH
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T!MOR EFFE"TS
• Rate o" cell prol"eraton + nter*al,-$
rra!aton
an! cell !eathG*en Dose sterlsng all the tu'orcells !epen!s on . "actors/
01RADIOSENSITI2IT341O)3GENATION 5.1T6MOR SI7E
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• Ra!osenst*t8/ 9ologcal nherentpropert8
•Depen!s on the a,lt8 o" the cell torepar DNA !a'age1
•
O:8genaton/ A't o" O4 conc ; t'eo" ra!aton + Free ra!cal to causecell !eath
• Tu'or S
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NORMA> TISS6E EFFECTSAND TO>ERANCE
• MITOTIC DEATH – nor'al tssue – s!ee?ect
• Acute reactons # Heal co'pletel8%(
Mucosa (04 !a8s@ s=n – 40 !a8s –'an"est ra!aton changes
• 2ascular en!othelal !a'age –
.'onths to se*eral 8ears ( late!a'age an! rre*ers,le1
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PRINCIP>ES OFRADIOTHERAP3
• Fun!a'ental 'etho!s o"ra!otherap8/01 Teletherap8 or E:ternal ,ea'
Ra!aton/e:ternal source through a
'achne1
41 9rach8therap8( source s $thn orn
close
pro:'t8 –
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E)TERNA> 9EAM THERAP3
• Most $!el8 use!• A,sorpton energ8 o" photons an!0- $a*elength1
• Ortho*oltage )( ra8 'achnes – .=* – lo$ penetraton – 'a: !ose tos=n sur"ace – s=n reactons
• A!! !sa!*antage ( 2er8 hgha,sorpton 'aterals $th hgh ato'cnu',ers – eg calcu' (
osteora!onecross
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• Ne$er a!*ances –• TE>ECO9A>T MACHINES ( ra!aton(0 Me2
• >INEAR ACCE>ARATORS – )(Ra8s –Me2
• AD2ANTAGES/ More penetraton !epth
; se*eral 'll'eters ,elo$ s=nsur"ace
• A,sorpton n 'atter s less
!epen!ent on ato'c nu',er so
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Super *oltage ra!aton
• 4 or 'ore ,ea's o" ra!atoncon*ergng on tu'or *olu'e arepro&ecte!
• >atter s rra!ate! ho'ogenousl8 tothe reure! !ose $hle the
negh,orng tssues through $hch tpasses rece*e lo$er !ose1
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Fractonate! E9T
•TOT$ DOSE is diided in to anu10er of s1aller doses
deliered oer a period of seeral;ee
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• Nor'al cells – regenerat*e capact8to repar !na !a'age
• Tu'or response ,8 reo:8genaton
o" h8po:c cells• Ol!er ra!aton sche'es – 0( "ractons ; 04 $ee=s
• Coutar! – 0ce !al8 ; J to $ee=s
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• Oral an! sal*ar8 glan! oncolog8 (s'all treat'ent *olu'es – . c'.or less ;K $ee=s
• JJ G8 ; 4 "ractons ; $ee=s "orra!cal treat'ents
• To lessen the e?ects l=e 'ucosts@
longer treat'ent t'e $th a!euatenutrton suppl8 to the pt n 'eant'e s calle! altere! or
uncon*entonal ra!aton•
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Metho!s to 'pro*e resultso" E9T
• 4 poss,le e:plotatons ,-$ tu'orcells na! nor'al cells are the / –01 o:8gen e?ect
–41 cell prol"eraton =netcsO)3GEN EFFECT – as "ractonate! therap8contnues the o:8genaton o" tu'or cellsoccur $here aggre*aton o" the tu'or s
relat*e to occur1 To o*erco'e the O4 e?ect H8per,arc O4@neutron therap8 an! h8po:c cell
ra!osenstsng !rugs
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H3PER9ARIC O4 THERAP3
• A' s to suppl8 the ra!o resstanth8po:c tu'or $th 'ore O4 at rase!pressure
• Bth pure O4 at . at' – =lls onl810L o" h8po:c cells1
• E?ect*eness o" h8per,arc O4
therap8 0- s
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H3PO)IC CE>> SENSITISINGAGENTS
• O+ * RDIOSENSITISING "TION *E$"TRON FFINIT%
• NE#ER E$E"TRON FFINIT% "OMP!NDS
SIMI$R TO O+ * RDIO?IO$OGI"$PROPERTIES THT RE NON * TO-I-
ND ESI$% DIFF!S?$E 4I)5 RE
ST!DIED• $$ ?E$ONGED TO NITROIMID@O$E
FMI$% * NE!ROTO-I" A SFE DOSES
RE INS!FFI"IENT FOR THE THERP%• NIMOR@O$E
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NE6TRON THERAP3
• Here the t8pe o" ra!aton s less!epen!ant on O4 presence "or thecell =llng e?ect1
• Intro!ucton o" FAST NE6RONS• Dsa!*antages / ,ross an! necross
• As late respon!ng nor'al tssues aacu'alte'ore ra!aton !a'age n ths t8pe $henco'pare! to Electro'agnetc ra!atonn*ol*ng nor'al tssue co'plcatons1
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A>TERED FRACTIONATION
• Increase n nu',er o" "ractons an!re!ucton n the s
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• Tpot – rate o" cell turno*er – t'eta=en ,8 the tu'our to !ou,le thecell *ol " none $ere she!@ !e! an!
!?erentate!•ESTIMTION * throu9h 0iopsy• In7 * ?ROMODEO-% !RIDINE *
la0els /ell in S phase.• Tpot ( scc – .(J !a8s
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• Rate o" repopulaton o" the tu'orncreases !urng a course o"ra!otherap81
• ACCE>ARATION – shortenng thetreat'ent t'e to o*erco'e thee?ect o" repopulaton1
• To re!uce the FRACTION SI7E ACCE>ARATION Q E>EMENT OFH3PERFRACTIONATION
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CHART
• CONTINO6S H3PERFRACTIONATEDACC>EARATED RADIATION THERAP3
• ( NEB accelarate! h8er"ractonate!
reg'es• Intro!uce! ,8 DISCHE ANDSA6NDERS
• Total !ose o" J G8 – splt to ."ractons o" 01J G8 ; 04 !a8s 1
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9RACH3THERAP3•Source o" ra!aton s place! *er8 close tothe tu'or ,e! ,8 4 'etho!s –01 sur"ace 'oul!s –41 ntersttal 'plants
–Prncple/ Depen!s on the >AB OF IN2ERSES6ARES
– 0
INTENSIT3 OF DOASGE OF RADIATION
(((((((((((((((((
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INTERSTITIA> T3PE
• sol! sources – 'plante! !rectl8nto tu'or – hgh !ose o" ra!aton –rap! "allo? – !el*ers lo$ to
surroun!ng nor'al tssues1• Here ho'ogenous !el*er8 o" $hole*s,le an! palpa,le area o" tu'or
$th atleast 0c' sa"et8 'argn se:pose!
• So applca,le to onl8 so"t tssue1
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Ra!aton sources
• 4 t8pes o" ra!oact*e 'aterals areuse!
• 01 re'o*a,le•
41 per'anentl8 'planta,le –short l*e! an! arerea!l8 !eca8e! to a neglg,le act*t8
GO>D – 0 SEEDS
Del*ere! $th a specal G6N
Accuarte an! un"or' !str,utons not poss,le
Rarel8 use!
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• REMO2A9>E RADIATION SO6RCES1• Earl8 !a8s – ra!u' $as onl8 'ateraluse! enclosng n platnu' nee!les o"
41J '' !a'eter an! 01J ( c' nlength
• ) Ra!u' ) – artcal sotopes – sa"er
han!ellng
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• CAESI6M – 0.• Sa'e as the ra!u'
!el*er8 nee!les
Dsa!*antages – operator e:posure Thc= neee!les – trau'natc an!
unco'"orta,le
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Irr!u' ( 04
• Most popularl8 use!to!a8
• Isotope o" choce "or
oral carcno'as• A*al,le – "or' o"thn $re
•Slotte! gu!e nee!lesor plastc tu,ng areuse!
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Plastc tu,ng technue
• Fner rra!u' $re o" 1. ''!a'eter s use! *a plastc tu,ng
• Tu,es – straght hollo$ gu!e nee!les
– s=n to oral ca*t8• True a"ter loa!ng• Due to $hch the ra!aton e:posure
to sta? an! operator s co'pletel8a*o!e!1
• 6se! n areas o" posteror 0-. r! o"
the tongue an! n chee=
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Dosage
• 9rach8therap8 alone – J( G8 splt1. – 1J G8 "ractons - hr ; J1J – !a8s1
• E:ternal ra!otherap8 Q,rach8therap8
0st e:ternal ,ea' – G8 ;
$ee=s IMP>ANT – .J( G8
Total t'e shoul! ne*er e:ten! ,e8ong
$ee=s
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Pallat*e ra!otherap8
• A' / rel*e s8'pto's o" the !sease• No atte'pt to cure s 'a!e• Approprate "or pts $th ncura,le an!
shor l"e e:pectanc8 pts• Rel*es s8'pto's l=e ,lee!ngpressure pan or o,structon
•6se! 'ostl8 n ,one@,ran or s=n – 4G8 ; J !a8s1
• Not a!*sa,le n oral carcno'as
o' ne ra ot erap8 an
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o' ne ra ot erap8 ansurger8
• Bhen ra!cal ra!otherap8 "allslea*ng a res!ual or recuurence thensurgcal cure s poss,le
• Surger8 per"or'e! a"ter "ale! ra!cal'o!e s =no$n as SA>2AGE S6RGER3
• Co'plcatons / !ela8e! $oun!
healng stula "or'aton $oun! ,rea=!o$n an! carot! arter8 rupture
• Co'plcaton rate s lo$ $hen surger8
per"or'e! . 'onths a"ter
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Pre operat*e ra!otherap8
• A' / ncrease the chance o" thesurgcal cure ,8 recee!ng the gro$thalong the ,or!ers an! the perpher8
o" the tu'or1• 9ase! on 4 !?erent concepts• >o$ !ose technue/ Sgncant lo$
!ose s a!'nster! ''e!atel8,e"ore e:cson contnung "or "e$!a8s n "e$ large "racton an!
operatng ''e!atel8 ,e"ore an8
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• Hgh !ose technue/• Con*entonal !al8 "ractons o*er (J$ee=s ; – J G8
• Results n nor'al tssue reactons an!h8pere'a an! surger8 s !ela8e! "or"urther . – $ee=s1
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Post operat*e ra!o therap8
• >ess e?ect*e than pre operat*e• A"ter surger8 cells are poorl8*ascularse! an! relat*el8
ra!oresstant1• Post op ra!otherap8 – $thn $ee=s; J G8 – 4J "ractons are !el*ere!1
•
A"ter $ee=s – !ose o" G8 – ."ractons
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S!e e?ects
• Classe! as acute an! late e?ects
• AC6TE EFFECTS –M6COSITIS/ Occurs !ue to 'totc cell
!eath n epthelal lnng –Cell c8cle t'e s !8as an! ,asla la8er s
4( cells thc= –Ra!aton changes are seen a"ter 04 !a8s –Intal8 erthe's@ pathc8 ,rnous e:u!ate –Hgh !ose ( ulceraton $th thc= ,rous
'e',rane o*er the !enu!e! sur"ace1 –
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• SUIN REACTION/ –Cell turno*er s lo$ –.r! $ee= – er8the'a !e*elops 5 prgress
to !r8 an! 'ost !esua'aton –No$ super*oltage ,ea's are use! "or
sur"ace sparng e?ect1
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• alopeca s seen• >oss o" taste sensaton/ 'echans'un=no$n
G8 pro!uces loss o" 0L o" tastecells1 Reco*er8 s "or 'onths1
)EROSTOMIA/ loss o" secretor8 cellsoccurs
Acn are ncapa,le o" reco*erng an!
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• 4 G8 – In a!ults can causeper'anent cessaton to sal*ar8 o$– !'nshes ; J !a8s 5 a"ter J
$ee=s o$ – L an! ne*er reco*ers1• Nasoph8ar8n: ra!otherap8 –!estro8s ,-l parot!s an! – per'anent
:erosto'a1• Salogogues l=e prlocarpne areuse!
•
Artcal sal*as are no$ a*ala,le1
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• In"ecton/ ncrease! 'ucostts an!:erosto'a 'a8 lea! tosupern"ecton $th can!!a1
• Increase! pan an! er8 er8the'a• Dscrete $hte plaues o" thrush• Chlorhe:!ne 14L !lute! to 10L s
reco''en!e! or 'cona
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>ate e?ects
• Ische'a an! ,ross• So"t tssue necross – *arng !egreeso" atroph8@ telangctesa@ !r8ness an!
"raglt8 o" the 'ucosa• 9one necross – osteora!onecross
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MAR) – H8po:c h8po cellular an!
h o *ascular theor
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rotoco or pts $ o reu re
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rotoco or pts $ o reu re!ental e:tractons a"ter
ra!otherap8
Dental care o" patents
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Dental care o" patentsrece*ng ra!otherap8
• Teeth not n rrar!ate! *olu'e• Mouth $ashes – !lute! sol o" chlorhe:!ne
gluconate Oral rnse "or 0 'n $th J'l o" sol n 0 'l o"
$ater
• Topcal our!e applcatons / custo' ,ultcarrers are 'a!e
pt s g*en $th *scose gel o" 0L so!u' our!en a
suee
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• Acr8lc splnts/ coVn a!*ocate!co*erng the teeth $th splnts !urngan! post op "or 4 8rs
• Sal*a su,sttute/ the8 help n =eepngthe 'outh 'ost@ rase the PH1 –Shannon "oun! that the rra!ate pts
sal*a $oul! pro!uce re'neralsaton o"ena'el n e:tracte! teeth n*tro pro*!ecalcu' phosphate an! our!e
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• Teeth $th n the rra!ate! *olu'e• Teeth to ,e e:tracte! are – non( *taltooth nee! o" RCt or ela,rat*e
restorat*e technues or assocate!$th act*e pero!ontal !sease
• E:tractons shoul! ,e per"or'e!
atrau'atcall8 an! gu's suture! topro'ote rap! healng
• I" e:tarcton s necessar8 n hgh !oserra!ate! *olu'e then atru'atc
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HAN 6