SUM M ARY UM ESH M AHANTSHETTY DANIEL BERGER Message : 1 - - PowerPoint PPT Presentation

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Dec 02, 2023 323 likes •454 views

SUM M ARY UM ESH M AHANTSHETTY DANIEL BERGER Message : 1 TREATMENT DECISION GYN ONCOL EXPERTISE RAD. ONCOL EXCELLENT OUTCOM E & QOL PATIENT PATIENT CHOICE MULTI-DISCIPLINARY TUMOR COST Vs TECHNOLOGY BOARD EFFECTIVE PHYSICIAN

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SUM M ARY

UM ESH M AHANTSHETTY DANIEL BERGER

SLIDE 2

Message : 1 TREATMENT DECISION

EXPERTISE TECHNOLOGY WORKLOAD COST EFFECTIVE

PATIENT PATIENT CHOICE Vs PHYSICIAN BIAS

GYN ONCOL

RAD. ONCOL

LAPROSCOPY / ROBOTIC NEWER RADIATION TECHNOLOGY INCLUDING BRACHYTHERAPY HIGH Vs LOW VOLUM E LOAD ACADEM IC Vs CORPORATE EXCELLENT OUTCOM E & QOL

MULTI-DISCIPLINARY TUMOR BOARD

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w = 7.0 cm h = 5.0 cm t = 5.0 cm X

Dose of EBRT Gy

IVA - Bladder

Vagina: 2.5 cm

7.0cm w

Case V

45 dd/mm/yy

/ /

Signature

At Diagnosis At Brachytherapy

Message : 2

Clinical Examination & Drawings Documentation

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GEC-ESTRO DVH Parameters Dose to Point A, ICRU-B, ICRU-R

Brachy Procedure Applicators Imaging Contouring Applicator Reconstruction Definition of Dose Points Planning Plan Evaluation Dose Delivery

Point A, ICRU pts Fletcher Orthogonal X Rays X Ray M arkers Std loading, M anual Optimisation Target/ OARs HRCTV, D2cc , Point A, ICRU pts CT/ M R Compatible IC+IS CT/ M R. Contrast Applicator Commissioning Std Loading, M anual/ Graphical Opt, IP

2D BT 3D BT

Message : 3 BT processes

TEAM APPROACH

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Vienna Applicator

IR – CTV HR-CTV GTV rectum sigmoid Bladder SBR

w = 7 cm h = 5 cm t = 4 cm

w

“GOLD STANDARD” Clinical drawing & M R Imaging

Benefit of Image Based BT Approach Application – Imaging – Optimization

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Cancer Cervix FIGO IV A (Bladder M ucosa Involved) M RI and Cystoscopy shows bladder invasion at Diagnosis

Cystoscopy positive Focal Invasion <2 cm * Extensive Invasion Radical Chemoradiation Chemotherapy and assess after 3-4 cycles with cystoscopy

* Arbitrary and not based on any evidence-

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Cancer Cervix FIGO IV A (Bladder M ucosa Involved) M RI and Cystoscopy shows bladder invasion at Diagnosis

After 45- 50 Gy EBRT: A Repeat Cystoscopy is performed Negative Positive M RI with BT Applicators No Grey zones in bladder wall High signal intensity in bladder wall To include the involved wall and mucosa as GTV-B* Grey zones in bladder wall To include the involved wall in IR- CTV only but not in HR-CTV To include the involved wall in HR- CTV

* If adjacent bladder wall shows grey zones then include it in HR-CTV

> 85 Gy EQD2* * 60 - 65 Gy EQD2 90 -95 Gy EQD2 to GTV-B* * > 85 Gy EQD2 to HR-CTV

* * Risk of higher bladder toxicities to be anticipated

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CT - BASED CONTOURING Pre - requisites

Experience of M R Based Approach: M andatory
At Diagnosis: Clinical drawings, M R +/ - CT
At Brachytherapy: Standardization of the CT protocol
CT compatible applicators
bladder filling protocol with dilute contrast
Intravenous contrast
Adopt the M R based definitions

w

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0.5 1 1.5 2 2.5 3 3.5 1 2 3 4 5 6 7 8 9 10 11 12 Series1 Series2 0.5 1 1.5 2 2.5 3 1 2 3 4 5 6 7 8 9 10 11 12 Series1 Series2

MR CT MR CT

CT and M RI correlation: Ongoing Research

TM H Study

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Published in J une 2016

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Attended the GYN Teaching Course: Understand the Concepts
Hands on Workshop & Fellowships : Atleast 1 – 2
Standardization of processes & Learning Curve : 15 - 25 pts
Transition to 3D: M R / CT +/ - US
Retrospective Analyses and Introspection
Expert M ission and Audits
Teaching / Hands on Workshops
Prospective Research protocols

TM H J

urney: M R Image Guided Adaptive BT