- The doctor who oversees the radiation
Radiation Therapy for therapy treatments.
Head and Neck
Cancers
Teresa T. Sy Ortin, MD
September 27, 2007
Introduction to Radiation Oncology
- Radiation has been an effective tool for
treating cancer for more than 100 years.
- Radiation oncologists to use radiation to
eradicate cancer.
- About two-thirds of all cancer patients will
receive radiation therapy as part of their
treatment.
What Is Radiation Therapy?
- Radiation therapy works by damaging the
DNA within cancer cells and destroying their
ability to reproduce.
- When the damaged cancer cells are
destroyed by radiation, the body naturally
eliminates them.
- Normal cells can be affected by radiation,
but they are able to repair themselves.
- Sometimes radiation therapy is the only
treatment a patient needs.
- Other times, it is combined with other
treatments, like surgery and chemotherapy.
Brief History of Radiation therapy
- The first patient was treated with radiation
in1896, two months after the discovery of
the X-ray
- Back then, both doctors & non-physicians
treated cancer patients with radiation
- Rapid technology advances began in the
early 150s with cobalt units followed by
linear accelerators a few years later
- Recent technology advances have made
radiation more effective and precise
Cobalt 60
- Uses radioactive material
Linear accelerator
- radiation source: high energy x-ray machine
- Very high in energy & very penetrating
Cobalt 60 vs. Linear Accelerator
- In terms of quality of radiation, which is more
effective? SAME
- In terms of energy (energy determines
penetration)
- Cobalt 60 – fixed at 1.24 millivolts
- Linear accelerator – since electrically
generated, you can specify → low and
high energy
- e.g. Patient, obese with AP diameter of more
than 30 → Prefer to use linear accelerator
How Is Radiation Therapy Used?
Radiation therapy is used two different ways.
- To cure cancer:
- Destroy tumors that have not spread to
other body parts.
- Reduce the risk that cancer will return
after surgery or chemotherapy.
- To reduce symptoms:
- Shrink tumors affecting quality of life, like
a lung tumor that is causing shortness of
breath.
- Alleviate pain by reducing the size of a
tumor.
Meet the Radiation Oncology Team
Radiation Oncologist
Medical Radiation Physicist
- Ensures that complex treatment plans are
properly tailored for each patient.
Dosimetrist
- Works with the radiation oncologist and
medical physicist to calculate the proper
dose of radiation given to the tumor.
Radiation Therapist
- Administers the daily radiation under the
doctor’s prescription and supervision.
Radiation Oncology Nurse
- Cares for the patient and family by providing
education, emotional support and tips for
managing side effects.
Types of Radiation Therapy
- Radiation therapy can be delivered two ways
– externally and internally.
- External beam radiation therapy delivers
radiation using a linear accelerator.
- Internal radiation therapy, called
brachytherapy or seed implants,
involves placing radioactive sources
inside the patient.
- The type of treatment used will depend on
the location, size and type of cancer.
HDR Brachytherapy applicator
(high dose radiation)
- Putting tubes in nasopharynx
- Radioactive material
- Emphasize: brachytherapy is a very localized
treatment
- Most often than not, used in combination
with external beam radiation because you
cannot cover surrounding areas
- Effective only where you put the applicator
- Most of the time, when we do radiation
treatment, we want to be very radical,
radiate a bigger area
- In an attempt to deliver more radiation to the
tumor
Mold Brachytherapy
- PALATE
- e.g. Patient’s with cancer of palate
- Make a dental mode
- And put tubes in the region where we think
should receive radiation
- Conduit for radioactive material to go in
- After treatment, just remove dental mode
Interstitial Brachytherapy
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 - FLOOR OF MOUTH
- e.g. We want o radiate tongue → insert
needles submentally into the floor of the
mouth into the tongue
- High dose rad system – after treatment
patient can go home
- In earlier centuries, do interstitial treatment
→ needle have to stay for 3-4 days
- Also have for TONGUE
Intraoral treatment
- These machines have accessories that look
like cones
- For cooperative patients
Fractionation schemes
Hyperfractionation
- EORTC
- 10-15% improvement in local control
- Most radiation treatment are done once a
day
- But it has been shown you get better results
if you do it 2x a day
Accelerated fractionation schedules
- Shortened overall treatment time
- Instead of 6 weeks  3-4 weeks
- Result are good but toxicity  not
acceptable
RTOG 90-03 compared the three regimens
- Recent analysis of 1073 patients enrolled
showed concomittant boost and
hyperfractionation regimens yielded
significantly higher local regional control,
however, did not improve LRC rate over the
standard fractionation.
Accelerated repopulation
- Treatment with any cytotoxic agent,
including radiation, can trigger surviving
cells ( clonogens) in a tumor to divide faster
than before. This is known as accelerated
repopulation.
- This starts in head neck cancer in the human
about 4 weeks after the initiation of
fractionated radiotherapy. About 0.6 Gy per
day is needed to compensate for this
repopulation.
- This phenomenon mandates that treatment
should be completed as soon as practical
once it has started; it may be better to delay
the start than to introduce interruptions
during treatment.
Planning Radiation Therapy - Simulation
- Each treatment is mapped out in detail using
treatment planning software.
- Radiation therapy must be aimed at the
same target every time. Doctors use several
devices to do this:
- Skin markings or tattoos.
- Immobilization devices – casts, molds,
headrests.
External Radiation Therapy
- Specialized types of external beam radiation
therapy
- Three-dimensional conformal
radiation therapy (3D-CRT)
- Uses CT or MRI scans to create a
3-D picture of the tumor.
- Beams are precisely directed to avoid
radiating normal tissue.
- Intensity modulated radiation
therapy (IMRT)
- A specialized form of 3D-CRT.
- Radiation is broken into many
“beamlets” and the intensity of each
can be adjusted individually.
H&N 9 beam vs. 5 beam IMRT
- Protection of the salivary gland
- During preparation, when all images are
obtained
- Radiation oncology sit on computer to
contour to target tumor, contour sensitive
organs that have to be protected during
treatment
- In head and neck area, the salivary gland is
very important
- Years ago, prior to advent of this treatment,
it is given that patient will have dry mouth
after treatment
- Nowadays with this 3D conformal
techniques, especially IMRT, we can spare
salivary glands
- Document benefit of this type of radiation for
head and neck area
- UCSF-San Francisco
- Al Sarraf regimen with IMRT for
nasopharynx
- Of 35 patients treated
- Local control was 100% with a median
follow-up of 21.8 months.
- Xerostomia was grade 0 in 50%, and
another 50% grade I. No patients had
grade II xerostomia.
- As the machine rotates, doctor determines
how many beam
- 2 beam
- Can be front and back
- Can distribute beam into 5 separate
beams
- If it is 3D confirmal, as the beam rotates, you
can shape it the way you like it
- By way of CT or MRI
External radiation therapy
Proton beam therapy
- Uses protons rather than x-rays to treat
certain types of cancer
- Allows doctors to better focus the dose on
the tumor with the potential to reduce the
dose to nearby healthy tissue
Neutron beam therapy
- A specialized form of radiation therapy that
can be used to treat certain tumors that are
very difficult to kill using conventional
radiation therapy
- -radio intensive
Sterotactic radiotherapy
- Sometimes called stereotactic radiosurgery,
this technique allows the radiation oncologist
to precisely focus beams of radiation to
destroy certain tumors, sometimes in only
one treatment
Notes:
 No knife – misnomer, this treatment is used in
place of surgery
 Ex. Small tumors in brain
 Instead of requiring surgeons to open up there
are certain qualification criteria ex. <5cm
 Not near critical areas like optic nerve or optic
chiasm
 Gamma knife or x knife radiosurgery
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Internal Radiation Therapy
- Places radioactive material into tumor or
surrounding tissue.
- Also called brachytherapy – brachy Greek for
“short distance.”
- Radiation sources placed close to the tumor
so large doses can hit the cancer cells.
- Allows minimal radiation exposure to normal
tissue.
- Radioactive sources used are thin wires,
ribbons, capsules or seeds.
- These can be either permanently or
temporarily placed in the body.
Dental clearance prior to radiation therapy
- Patients undergoing radiation will be having
problem with oral infection → Dental carries
- Long after treatment, cannot have dental
extraction
- Tissue grow too slowly after radiation
- They may have infection → lead to
osteoradionecrosis
Nutritional support, assessment and
guidance
Patient cannot eat, saliva is so thick, dry
mouth, mucositis
Head and Neck RT
Primary therapy
- e.g. Patient with glottic cancer
- Early cancer of vocal cord
- Instead of treatment radically, like removing
entire larynx → Can have radiation as primary
treatment
- 90% cure rate
Adjuvant therapy
- primary tx already done
- e.g. Tongue malignancy
Preoperative treatment
- decreasing tumor size (radiation before
surgery)
Concurrent w/ chemotherapy
- very popular
- Not a sloppy treatment
- Proven that despite good treatment, you still
get a little benefit when you give a little
chemotherapy together
- drug: CISPLATIN
- Used for doing this chemoradiation
regimen
- Better benefit, however ↑ side effects
- Patients needs more attention
Palliation
- Bleeding, tumors obstructing the airway
Use of RT
Primary therapy
- nasopharyngeal carcinoma
- early glottic carcinoma
- early stage head and neck tumors
Adjuvant
- T3, T4 lesions
- Positive margins
- RT to neck if positive nodes on
histopathology esp. if with extracapsular
extension
Chemoradiation
- Locally advanced NPCA stage 3 and 4
- Al-Sarraf, JCO, 1998
- Organ Preservation in Oropharyngeal
Malignacies
- VALSG
- Calais
- Fonasteire
- Adjuvant for postop. with high risk features
on histopath.
- Meta- analysis of Chemotherapy on Head
and Neck Cancer Collaborative Group.
- 63 randomized trials- 10741 patients.
- In larynx, mainly done for organ preservation
- Results
- Small statistically significant benefit with
the addition of chemotherapy to local-
regional therapy, which consists of a 4%
improvement in survival at 2 and 5
years.
- Due to favorable effect of concurrent
and
- Alternating benefit of radiation and
chemotherapy resulting in an 8% overall
improvement in survival.
Pre-op Radiotherapy
- Rarely used.
- Only for situations where the cancer is
marginally resectable or has a very rapid
growth rate.
- Patients with small radiocurable tumors and
large adenopathy may be treated with
definitive radiation to the primary tumor and
preoperative radiation to the neck with a
planned neck dissection to follow radiation.
- RADIOTHERAPY FOLLOWED BY
CHEMOTHERAPY
- Occasionally yields complete or partial
response of the tumor in 20% and 60%
of patients.
- In spite of these dramatic responses,
overall control rates in randomized trials
have only been a few percentage points
better than those achievable with RT
alone.
- For occasional patients referred after
chemotherapy, we radiation the entire
original volume with adequate margins
to equivalent doses as primary
radiotherapy alone. A small dose
reduction is sometimes made when
acute reactions are excessive.
Side Effects of Radiation Therapy
- Side effects, like skin tenderness, are
generally limited to the area receiving
radiation.
- Unlike chemotherapy, radiation usually
doesn’t cause hair loss or nausea.
- Most side effects begin during the second or
third week of treatment.
- Side effects may last for several weeks after
the final treatment.
HEAD AND NECK RT
Side effects and complications
- Mucositis
- loss of taste
- pharyngitis
- weight loss secondary to malnutrition
- xerostomia
Management of complications
- nutritional support
- use of sialagogues, artificial saliva
- salt irrigation
- radioprotectors (amifostine)
- skin care
Is Radiation Therapy Safe?
- Many advances have been made in the field
to ensure it remains safe and effective.
- Multiple healthcare professionals develop
and review the treatment plan to ensure that
the target area is receiving the dose of
radiation needed.
3
 - The treatment plan and equipment are
constantly checked to ensure proper
treatment is being given.

Transcribed by: Fred Monteverde

Notes from: Mitzel Mata

Fred Monteverde
Mitzel Mata
Emy Onishi
Cecile Ong
Regina Luz
Section C 2009!