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

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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

  1. SUM M ARY UM ESH M AHANTSHETTY DANIEL BERGER

  2. 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 BIAS LAPROSCOPY / ROBOTIC NEWER RADIATION HIGH Vs LOW VOLUM E LOAD TECHNOLOGY INCLUDING WORKLOAD ACADEM IC Vs CORPORATE BRACHYTHERAPY

  3. Message : 2 At Brachytherapy X At Diagnosis 45 Dose of EBRT Gy w Clinical Examination & Drawings Documentation 7.0cm IVA - Bladder w = 7.0 cm h = 5.0 cm t = 5.0 cm Vagina: 2.5 cm dd/mm/yy / / Case V Signature

  4. Brachy Procedure 3D BT 2D BT CT/ M R Compatible Applicators Fletcher IC+IS Imaging Orthogonal X Rays CT/ M R. Contrast Contouring Target/ OARs Applicator Applicator X Ray M arkers Reconstruction Commissioning TEAM APPROACH Definition of HRCTV, D2cc , Point A, Point A, ICRU pts Dose Points ICRU pts Std loading, M anual Std Loading, M anual/ Planning Optimisation Graphical Opt, IP Plan GEC-ESTRO DVH Dose to Point A, Evaluation Parameters ICRU-B, ICRU-R Message : 3 Dose Delivery BT processes

  5. Vienna Applicator rectum sigmoid Bladder SBR Benefit of Image Based BT Approach IR – CTV Application – Imaging – Optimization HR-CTV GTV w w = 7 cm “GOLD STANDARD” h = 5 cm t = 4 cm Clinical drawing & M R Imaging

  6. Cancer Cervix FIGO IV A (Bladder M ucosa Involved) M RI and Cystoscopy shows bladder invasion at Diagnosis Cystoscopy positive Focal Invasion Extensive Invasion <2 cm * Chemotherapy and assess Radical after 3-4 cycles with Chemoradiation cystoscopy * Arbitrary and not based on any evidence-

  7. 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 High signal intensity No Grey zones in Grey zones in in bladder wall bladder wall bladder wall To include the To include the To include the involved wall and involved wall in IR- involved wall in HR- mucosa as GTV-B* CTV only but not in CTV HR-CTV * If adjacent bladder wall shows grey zones then include it in HR-CTV 90 -95 Gy EQD2 to GTV-B* * 60 - 65 Gy EQD2 > 85 Gy EQD2* * > 85 Gy EQD2 to HR-CTV * * Risk of higher bladder toxicities to be anticipated

  8. w 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

  9. CT and M RI correlation: Ongoing Research 1 3.5 12 2 3 2.5 2 11 3 1.5 1 0.5 MR Series1 10 4 0 CT Series2 9 5 8 6 7 1 3 12 2 2.5 2 11 3 1.5 1 0.5 MR Series1 10 4 0 CT Series2 9 5 8 6 7 TM H Study

  10. Published in J une 2016

  11. TM H J ourney: M R Image Guided Adaptive BT TRANSITION FROM 2D TO 3D SECRET TO A SUCCESSFUL J OURNEY! • 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

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