RADIATION ONCOLOGY

dr. M. Fauzi Siregar, Sp.Onk.Rad

Departemen Radiologi FK USU
Historical Milestone

1895: WC Roentgen
1898 :M – P Curie
Radioisotop
Radiodiagnostik/ Imaging
Diagnostik
Radioterapi/ Radiation
Oncology
Kedokteran Nuklir/
Nuclear Medicine
 Terminology
Radiation oncology is that discipline of human medicine concerned with the
generation, conservation, and dissemination of knowledge concerning the
causes, prevention, and treatment of cancer and other diseases involving special
expertise in the therapeutic applications of ionizing radiation.

Radiation therapy is a clinical modality dealing with the use of ionizing

radiations in the treatment of patients with malignant tumor (and occasionally
benign diseases).

Radiation oncologists use radiation therapy to try to cure cancer, to control

cancer growth or to relieve symptoms, such as pain.

Knowledge • Radiation Oncology

Modality • Radiotherapy

Person • Radiation Oncologist

Halperin EC et al. Principles and Practices of Radiation Oncology Lipincott Williams & Wilkins, 2008
• Radiation
→ The propagation of energy from a radiative
source to another medium
1. Non ionizing Radiation
- have wavelengths ≥ 10-7 m
- have energies < 12 eV
2. Ionizing Radiation
- high energy
- has ability to remove electron from atom
 Non Ionizing Radiation
Radio waves
Microwaves
py
ra
Infrared light
e
Visible light io th
d
Ra
Ultraviolet light
Methods of
Delivery

• External beam irradiation : Using a

machine to aim high-energy rays
radiation at the cancer from outside of
the body
Methods of
Delivery

• Brachytherapy :Placing radiation

source inside or adjacent to a cancer,
or in an area that might contain
microscopic tumor burden.
BRAKHITERAPI PADA KANKER LEHER RAHIM
ALAT BANTU BRAKHITERAPI: APLIKATOR INTRAUTERIN
Brakiterapi Intrakaviter Pada Kanker Leher
Rahim
Aspek lateral
Aspek AP

Kandung kemih

uterus

aplikator

rektum
 Radiotherapy machines
Linear accelerator (linac)
• A device that produces high energy
photons (x-rays) on charged particles
for use in radiation therapy
• Produces photons energy of 4 mv – 25
MV and electron energy of 4 mev – 25
MeV

Diagram of Linear Accelerator

Khan F. The Physics of Radiation Therapy. Lipincott Williams & Wilkins, 2008
 Telecobalt-60

• A devices that use cobalt-60 as the

source of radiation
• Cobalt-60 unit have a cylindrical
source 2 cm in diameter
• Produces gamma rays energy of
1.17 – 1.35 mv
• The half-life of Co-60 is 5,27 years

Diagram of Cobalt-60 treatment head

Beyzadeoglu M et al. Basic Radiation Oncology. Springer, 2008

Alat bantu radioterapi
fiksasi kepala
 RADIOTERAPI
Tujuan Radioterapi:
Mematikan jaringan kanker
sebanyak banyaknya, tetapi
cedera yang timbul pada
jaringan sehat diusahakan
seminimal mungkin
(rasio terapeutik)
THERAPEUTIC-RATIO
RADIOSENSITIVE TUMORS
RADIORESISTANT TUMORS
 Respons Jaringan Kanker Terhadap
Radiasi

1. Radiosensitif:
• Sistem limfatik dan hematologi
• Asal jar. Embrional
• Sistem reproduktif
• Dosis 30 – 40 Gy
2. Radioresponsif
• Berasal dari sel epitel,
• Nasofaring, payudara, serviks
• Dosis > 40 Gy – 70 Gy
3. Radioresisten
• Jaringan sarkoma: tulang, jaringan ikat,
rawan
• Osteosarkoma, fibrosarkoma
• Pigmen kulit: melanoma
• Dosis di atas 70 Gy
Radiosensitive : lymphoma
malignum

Radioresponsive : squamous cell

carcinoma, adenocarcinoma, basal
cell carcinoma

Radioresistant : sarcoma,
melanoma malignum, nerve tumor

Beyzadeoglu M et al. Basic Radiation Oncology. Springer, 2008

 Double strand break DNA

The type od DNA damage:

• Double strand breaks (DSB)
• Single strand breaks (SSB)
• Base damage
• Cross links damage

Beyzadeoglu M et al. Basic Radiation Oncology. Springer, 2008

 The R of Radiation Biology

Repair of cellular
damage

Reoxygenation of the
tumor
Redistribution within
the cell cycle

Repopulation of cells

Radiosensitivity
intrinsic
 t i ve
si
s en
o
di
Ra

Fractionated radiotherapy during reoxygenation

Beyzadeoglu M et al. Basic Radiation Oncology. Springer, 2008

Daur sel (Cell Cycle)
Peran Radioterapi Makin Nyata
dengan
Peningkatan Insidens
Penyakit Kanker
 Insidens Penyakit Kanker
(Globocan 2012)
• Pasien kanker di seluruh dunia: 32,6 juta
• Kasus kanker baru: 14,1 juta
• Kematian karena kanker 8,2 juta per tahun
melebihi kematian karena HIV /AIDS + TBC +
malaria
• 65 % kasus baru terjadi di negara berkembang
 Angka angka pada tahun 2020

• Angka kematian akibat kanker per tahun 10

juta
• Kasus baru per tahun 16 juta
• Sebagian besar ada di negara berkembang
• Radiotherapy → high technology!

• Radiation Oncology = cancer medicine + radiation

sciences + technology

• Radiotherapy evolves with modern science and

technology

(Low, 2006)
 MILESTONES IN RADIOTHERAPY
IMAGING 4D PET 4D CT
Image
CT MRI PET PET CT
Intensifier

1950’s 1970’s 1980’s 1990’s 2000 2003

THERAPY
CT Body TOMO 4DART
Co-60 LINAC MRI Brain IMRT IGRT

1951 1952 1985 1988 2000 2003 2004

sics

ggyy
hy
nce

oolloo
cl eP i e
arti Sc

hhnn
r&
P ter ing

tteecc
le a mpu ag
Nuc

BBiioo
Co Im
 Radioterapi
Konvensional
(2D)
Radioterapi
Conformal
(3D)

Intensity Modulated
Radiotherapy Image Guided
(IMRT) Radiotherapy
 RO RO
RTT T
R
E
A
CT Scan T
M
RO + Medical physics E
N
RO T
RTT Image Import P
BEV L
MLC A
N
Radiotherapy N
I
Immobilization Process N
G

Medical physicist RTT Dose Planning S

Y
S
T
E
M

Quality Assurance Treatment Evaluation

What is IMRT?
 Why IMRT for HN Cancer?
Miles et al. Radiother Oncol. 2005;77(3):421-426.

• Complex anatomical region

– Normal tissues and targets in close proximity

• Optic nerve, chiasm, eyes, lenses

• Spinal cord, brain stem
• Parotid glands
• Oral cavity
• Temporal lobes, internal auditory canals
• Mandible, TMJ
• Multiple target • Larynx
– T – N - OAR
– Intra tumor heterogenity
IMRT
Gamma knife

44
Cyberknife

45
The purpose of radiotherapy evolution:
to reduce the dose to organ at risk, therefore reduce toxicity
 In the multidisciplinary management of cancer,
where’s radiotherapy ………….. ?
Medical Treatments Medical Treatments
Well-established standard Novel & Promising
Evidence-based Still accumulating Evidence

Chemotherapy

Nanoparticles Cryo

Surgery Radiotherapy

Non-medical Radioimmunotherapy
HIFU
treatments
Unclear evidence
Unclear efficacy

TCM, CAM
 Roles of Radiotherapy
As a definitive treatment?
Local Glotic Cancer, Local NPC, Prostate cancer (high risk)

Combination chemo-radiotherapy as a definitive treatment?

Locally advanced NPC, cervical cancer, unresectable lung cancer

In the adjuvant setting?

Breast cancer, colon cancer, lymphoma, endometrial cancer, sarcoma

In palliative care?
Pain, uncontrolled bleeding, VCSS, brain metastases

in benign lesion?
Adenoma pituitary, AVM, vestibular schwabomma by Stereotactic
Radiosurgery
 Roles of Radiotherapy
Palliative RT
Symptomatic? Focuses on alleviating
Incurable? patient's symptoms
 QUALITY OF LIFE
Asymptomatic?

Patient with cancer

Benefits from
Resectable? becoming resectable?
Curable?
Unresectable?

Doesn't benefit from

becoming resectable?
 Roles of Radiotherapy
Symptomatic? Curative RT
Focuses on alleviating
Incurable? patient's symptoms&
Eradication of the tumor
Asymptomatic?

Patient with cancer

Benefits from
Resectable? becoming resectable?
Curable?
Unresectable?

Doesn't benefit from

becoming resectable?
 Roles of Radiotherapy
Symptomatic?
Incurable?
Asymptomatic?

Patient with cancer

Benefits from
Resectable? becoming resectable?
Curable?
Unresectable?
Post-operative
(“adjuvant”) RT Doesn't benefit from
Aims to improve local control after surgery becoming resectable?
especially in patients with risk factors
for local recurrence
Example: Head&Neck Cancer; Breast Cancer, Prostate Cancer, Brain Tumor
 Roles of Radiotherapy
Symptomatic?
Incurable?
Asymptomatic?

Patient with cancer

Benefits from
Resectable? becoming resectable?
Curable?
Unresectable?

Pre-operative RT Doesn't benefit from

Aims to improve local control after surgery becoming resectable?
Example: Rectal cancer
 Roles of Radiotherapy
Symptomatic?
Incurable?
Asymptomatic?

Patient with cancer

Benefits from
Resectable? becoming resectable?
Curable?
Unresectable?

Pre-operative RT Doesn't benefit from

Aims to: becoming resectable?
Improve resectability
Example: Locally advanced breast cancer
 Roles of Radiotherapy
Symptomatic?
Incurable?
60 – 70 % cancer patients
Asymptomatic? needs to be irradiated

Patient with cancer

Benefits from
Resectable? becoming resectable?
Curable?
Unresectable?
Definitive RT
Radiotherapy acts as primary treatment Doesn't benefit from
 usually in conjunction with Chemotherapy becoming resectable?
Example: Locally advanced Head and Neck Cancer,
Nasopharyngeal cancer, Locally advanced Cervical Cancer, Locally advanced Prostate Cancer
 Multidisciplinary Approach

Multidisciplinary approach
requires great team work

• Surgeon
• Radiation Oncologist
• Medical Oncologist
• Diagnostic Radiologist
• Pathologist
• Dietician
• Physiotherapist
• Nursery
 RADIATION EFFECTS
• Acute Effects
→ occurs during or shortly after RT
→ occurs by direct toxicity to rapidly proliferating
normal tissue cells
• Late (long term) effects:
→ caused by the depletion of slowly proliferating
cells
→ related to damage to the vasculature
→ occur a few months to years after RT
ACUTE EFFECTS ON SKIN LATE EFFECTS ON SKIN
• Erythema • Photosensitivity
• Dry desquamation • Hyperpigmentation/Hypopi
• Hyperpigmentation gmentation
• Moist Desquamation • Atrophy
• Fibrosis
• Teleangiectasia
• Ulceration & necrosis
RADIATION THERAPHY ONCOLOGY GROUP
(RTOG) CRITERIA