OPHTHALMIC TUMORS

1. DR KANHU CHARAN PATRO
RADIATION ONCOLOGIST
M.D,D.N.B[RT],FAROI[USA],MBA[ICFAI],PDCR,CEPC

6. Loved married at first sight

9. Life

11. O
N
O L
Y
O
M
G
C
H
R
I
C
G
R
S
P
E
U
S P E C I
L
T
Y
I
VISAKHAPATNAM,1/7-MVP[AP]
11

13. Statistics
• >9.7 million cases are detected each
year
• 6.7 million people will die from
cancer
• Every day, around 1700 Americans
die of the disease
• 20.4 million people living with
cancer in the world today
• 1 in 3 people will be diagnosed with
cancer in the UK and 1 in 4 will die
from their disease

14. Lung
Breast
Colon/Rectum
Stomach
Liver
Prostate
Cervix uteri
Oesophagus
Bladder
Non-Hodgkin
Lymphoma
Leukaemia
Oral cavity
Pancreas
Kidney
Ovary
1000 800 600 400 200 0 200 400 600 8001000
Men Women
From: D.M. Parkin The Lancet Oncology 2: 533-543 (2001)
(Thousands)
Incidence
Mortality
337
293
105
0370
241
318
446
234
165
166
471
233
133
111
76
33
121
68
113
86
47
97
101
101
34
71
192
114
810
902
558
405
255
499
398
384
204
543
279
260
227
99
93
167
144
109
81
170
116
112
57
119
5.3 million cases
3.5 million deaths
4.7 million cases
2.7 million deaths
The Global Burden of Cancer 2000

15. ? ?
6/1/2018 3:26:21 AM 15

19. Oncologist
Diagnosis
Treatment
Radiologist
Cytopathologist
Surgeon
HistopathologistMolecular
Pathologist
Geneticist
psychiatrist
Nursing
And
Support staff
Audit

20. Role of radiotherapy in various cancers
• Needed for all most head and neck cancer
• Radical-
– Naso-pharynx, laryx, hypopharynx etc.
• post-op-adjuvant
– MOSTLY ALL ORAL CANCERS except T1 lesions
• Palliative
– compression, bleeding, obstruction, pain
6/1/2018 3:26:21 AM 20

23. Radiotherapy procedure
1. Tumor board decision
2. Positioning And immobilization
3. Imaging
4. Target delineation
5. Planning
6/1/2018
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
23

24. IMAGE GUIDED RADIATION THERAPY
EQUIPMENT REQUIRED
CT-SCAN MRI PET-CT
6/1/2018 24
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm

25. Cobalt machine
6/1/2018 3:26:21 AM 25

26. 6/1/2018 3:26:21 AM 26

27. Plaster of Paris Mould-older method
6/1/2018 3:26:21 AM 27

28. Head & Neck
6/1/2018 3:26:21 AM 28

29. PLANNING
6/1/2018 3:26:21 AM 29
CONFORMAL
CLINICAL

30. 6/1/2018 3:26:21 AM 30

31. 6/1/2018 3:26:21 AM 31

32. Evolution of Treatment Techniques
CUSTOMISED BLOCKS
MULTILEAF COLLIMATOR
BASED 3D-CRT
1990s1980s
6/1/2018 3:26:21 AM 32

33. 6/1/2018 3:26:21 AM 33

34. Treating Head & Neck with Sliding Windows
6/1/2018 3:26:21 AM 34

35. IMRT
• Divides each treatment field into
multiple segments
• Modulates beam intensity,
giving discrete dose to each
segment
• Uses multiple, shaped beams
(~9) and thousands of segments
IMRT Initiated in 1995
Reached the clinic in 2000

36. Conventional vs Conformal vs IMRT
Head and Neck
Conventional
Conformal
IMRT
6/1/2018 3:26:21 AM 36

38. 6/1/2018 3:26:21 AM 38

39. Small Volume Adjacent to Critical Structure
6/1/2018 3:26:21 AM 39

40. 3D Dose Shaping - H&N and Brain
Brain
Stem
6/1/2018 3:26:21 AM 40

41. Target Motion in
Radiotherapy
Caveman et al
Oops! The target
moves!
IGRT/GATED RT
6/1/2018 3:26:21 AM 41

42. 6/1/2018 3:26:21 AM 42

43. 6/1/2018 3:26:21 AM 43

44. 6/1/2018 3:26:21 AM 44

52. RADIOTHERAPY

55. • CONVENTIONAL
• 3DCRT
• IMRT
• IGRT
• VMAT/RAPIDARC
• PET GUIDED RADIOTHERAPY

56. Plaque Brachytherapy
• Chemoreduction failure or recurrence
• Rarely as primary therapy
• Commonly uses Iodine125, Ruthenium106
• 4000-4500 cGy to tumor apex
• 90% success in tumor control

57. Radioactive
Plaques
• Various sizes & shapes
• Round, Single notched, Double notched etc
• 10- 25 mm in diameter

58. Ruthenium 106
Brachytherapy Plaque therapy

59. Tumor assessment
Clinical &
Radiological
assessment
• Location
• Basal diameter
• Height
Courtesy : Dr Vijay Anand P Reddy

60. Plaque placement
• Under GA / LA
• Conjunctiva peritomy
• Tumor location marked on sclera
• Dummy plaque used to confirm
location
• Plaque placed & sutured to
sclera
• Conjunctiva sutured
• Patient is kept in isolation
Courtesy : Dr Vijay Anand P Reddy

65. Courtesy : Dr Vijay Anand P Reddy

68. Dose distribution
Courtesy : Dr Vijay Anand P Reddy

71. 1. Brachytherapy team
2. Plaque surgeon
3. Radiation oncologist
4. Medical physicist

72. • Multidisciplinary
approach.
Ocular
oncologist
Pediatric oncologistRadiation oncologist
Radiologist
Child
Psychologist
Pathologist

74. • Orbital lymphoma
• Eyelid tumors
• Uveal melanoma
• Retinoblastoma

78. 6/1/2018 3:26:21 AM 79

79. 6/1/2018
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
80

81. 6/1/2018
Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
82

89. Plaque Brachytherapy

91. Orbital lymphoma
• Lymphoid tumors -common despite the orbit not containing lymph nodes
or a well defined lymphatic vasculature.
• Incidence 13% of all orbital tumors.
• Primary or associated with systemic disease.
• Represents 8% of all extranodal NHL & 1 % of all NHL
• Approx 35% of patients with lymphoid tumors of orbital tumors will
eventually develop systemic lymphoma
• Presenting age- 15- 70 yrs
• Majority are low grade- 84%

92. • Biopsy
• Worked up for systemic disease
• Including a complete physical exam, a complete blood count,
bone marrow biopsy and CT scans of the thorax, abdomen and
pelvis.
• CSF examination
• CT scan -homogeneous mass with well defined borders that
does not destroy surrounding structures or bone.
• MRI – to assess extent ofdisease
• PET CT

94. T1 axial
Hypointense on T1

95. T1 Axial

96. T1 c
Homogenous Enhancement

97. Radiotherapy
• Stage I, II-RT main t/t
• - Whole orbit is to be
treated
• Energy- 1.25 Mv / 6Mv
• Supine
• Immobilise
• Ant & lat field using 45
wedges
• Looks into beam,
• dose- 25-30Gy@ 1.8- 2
Gy/#
• Bilateral disease- parallel
opposed fields

98. • If there is a forward displacement of eveball
• Involvement of post or anteromedial part of orbit
• Sup & inf oblique fields

99. Results: All patients had a complete response to RT. Intraorbital recurrence
developed in previously uninvolved areas not included in the initial target
volume in 4patients (33%) treated with partial orbit RT. All were salvaged by
repeat RT or surgery. No patient treated with whole orbit RT developed
intraorbital recurrence. The acute and long-term toxicity was similar in both
groups. All but 1 patient retained good vision.
Conclusion: Patients with orbital lymphoma should be treated to the entire
orbit.

100. Uveal melanoma
I. 3 Treatment Options:
Plaque vs Proton Beam vs Enucleation
III. 3 Clinical Questions, 3 Major Studies

101. Fluorescein
Angiography
Ultrasound

102. • Work-up: fundus exam, ultrasound and
fluorescein angiography.
• Measurements: diameter by fundus exam,
thickness by ultrasound
• Biopsy: not done until after radiation for risk of
seeding.
Diagnosis

103. 3 Treatment Options
• Enucleation
Last resort
• Proton Beam
Useful when > 5 mm thickness
• Plaque Brachytherapy
Useful when < 5 mm thickness

104. • prior to 1970
• refractory
cases
Enucleation

105. Enucleation and Prosthesis

106. Proton Beam

107. Plaque

108. Plaque

109. Plaque
• Most common form of treatment
• Good for thin tumors, not thick tumors
• Commonly Iodine-
125 T1/2: 59.4 d
Av Energy: 35.5 keV
• Not possible over
optic nerve due to
anatomy

110. 3 Clinical Questions
I. Is radiation effective?
II. Does radiation cause vision loss?
III. Can prophylaxis prevent vision loss?

111. JAMAOphthalmology, Dec
2006
• Question: Is Radiotherapy as effective as
enucleation?
• Design: Randomized multi-center clinical trial of
iodine 125 brachytherapy vs enucleation.
• Conclusion: No difference in survival between
I-125 brachytherapy vs enucleation.
• Impact: Brachytherapy usually first line treatment.

112. JAMAOphthalmology, Sept 2000

113. Jof Ophthalmology Vol 121, Jan2014

114. • Lesion reduced to a 3 mm scar
Before After
2 Year Follow Up

115. Conclusions
I. Wills Eye protocol for work-up of non-metastatic
melanoma differs from other tumors:
- No biopsy, CT or MRI
- Diagnosis via fundus exam
- Thickness measured by ultrasound
II. Isodose patterns of Plaque vs Proton:
- Plaque ➞ Steep gradient ➞ Thin tumors
- Proton Beam ➞ Wide plateau ➞ Thick tumors.
III. Radiotherapy cures ocular tumors, yet causes
maculopathy
IV. Bevacizumab expected minimize maculopathy
- Too early for long term studies

118. EBRT And Brachytherapy
In Retinoblastoma

119. Scientific evidences
and theoretical
discussion
Practical
experience and
real life issues

120. • Leucocoria
– Most common initial sign
– Retinoblastoma remains intraocular and
curable for 3–6 months after the first
sign of leucocoria
• Other signs
– Proptosis
– Swelling
– Strabismus
– Hypopyon
– Poor visual tracking
Clinical
Presentation
heterochromia
strabismus

121. Retinoblastoma
Diagnosis
Ultrasonography
B-scan
Indirect
Ophthalmoscopy
MRI / CT

122. • 90% show calcification
• Dense homogenous
• Extension to choroid,vitreous
& sclera not reliable.
• Detects intracranial disease
• 3D multiplanar capability.
• Hyperintense to vitreous on T1 &
markedly hypointense on T2
• Delineation of ON, IO & EO
spread
• Differentitates between tumor,
RD & subretinal fluid.
CT/MRI

124. Treatment Options
• Surgery:
– Enucleaion
– Exentration
•Focal Therapy
– Cryotherapy
– Laser
PhotoCoagulatio
n
– Thermotherapy
• Radiotherpy
– EBRT
– Brachytherapy:Scleral Plaque Thearpy
• Chemotherapy
– Chemoreduction
– Adjuvant chemotherpay
– Periocular Chemotherapy
– Intra-arterial Chemotherapy
– Intra-vitreal chemotherapy
– Chemothearapy In Locally Advanced
Disease
– HDCT & ASCT

125. Cryotherapy
Good local therapy. Leaves
Big scars
Photocoagulation Good local
therapy. Causes big scaring,
loses vascularization
Thermotherapy : Good
local therapy. Minimal
scaring

126. EYES PRESERVED
RE I to III RE IV to V
EBRT
ALONE
53% 45%
EBRT+SALV
AGE
96% 66%
CT ALONE 29% 11%
CT
+SALVAGE
94% 66%
CTRT - 75%
Eye Preservation

127. Vijay Anand P Reddy et al.
External Beam
Radiotherapy

128. Contouring
Normal cross sectional
Anatomy

129. Immobilization/Imaging

130. Pre operative cases with intact
globe;

131. Post enucleation orbital
radiotherapy

133. OAR Dose constraints
Organ Dmax Dmean Other
Eye <54Gy <35Gy
Optic nerve <55Gy <50gy
Chiasm <54Gy <50Gy
Lacrimal Gland <40Gy(Parson)
retina <50Gy
lens <5Gy
cornea <60Gy
pituitary <45Gy
brainstem <55Gy
Cochlea <45Gy
C/L eye, optic nerve, lachrymal gland, cornea, lens, chiasm,
brainstem, temporal lobe, bones of face, cochlea and oral
cavity

134. • Retinoblastoma has been historically
treated with lateral beams to encompass
the affected retina(s), and spare the lens
anteriorly, if possible
• .
Radiation Therapy Techniques

135. • ANTERO-LATERAL PORTALS

136. • Superior & Inferior Oblique
Portals

137. Try to spare Conrea ,
lacrimal gland (when not
involved) and lens while
treating intact Eye

138. Avoid Hot
areas (Try to
keep it within
102/103%
only)

139. Post enucleation cases

140. Sculpt the low
dose iso dose
curve as well

141. Proton therapy
• The dosimetric advantage
of the Bragg-Peak, which
eliminates exit dose,
results in less low dose to
normal, uninvolved
tissue. The reduction in
peripheral dose as
compared with the IMRT
plan is highly desirable in
patients of this young
age, many of whom carry
a germline mutation,
predisposing them to the
development ofLee et al; Int J Radiat Oncol Biol Phys 63:362–372

142. • Reduces tumor volume
• Allows more focused, less damaging
therapeutic measures
Chemoreduction

144. SMART THINKING
6/1/2018 3:26:21 AM 259

145. 6/1/2018 3:26:21 AM 260

146. Stage IV: Metastatic Cancer

147. 262
METASTASIS
-please do not watch crying

148. 10/20/12 01:12 PM 263

149. METASTASIS- give a smiling death
264

150. Palliative radiation
Skeletal X-Ray
Bone scan
MRI
PET-CT

151. Spinal metastasis
266

152. 267

153. Brain metastasis
268

154. 269

155. Whole brain radiotherapy
270

156. Choroidal metastasis
271

157. Superscan-extensive bone mets
272

158. Hemibody radiation
273

159. Prophylactic radiation
274

160. svco
275

161. CAUTION
C - Change in bowel or bladder habits
A - A sore that does not heal
U - Unusual bleeding or discharge
T - Thickening or lump in the breast or any part of the body
I - Indigestion or difficulty swallowing
O - Obvious change in a wart or mole
N - Nagging cough or hoarseness

162. Change in bowel habits
10/20/12 01:12 PM 277

163. Change in bladder habits
10/20/12 01:12 PM 278

164. A sore that does not heal
10/20/12 01:12 PM 279

165. Unusual bleeding or discharge
10/20/12 01:12 PM 280

166. Thickening or lump in the
breast or any part of the body
10/20/12 01:12 PM 281

167. Indigestion or difficulty swallowing
10/20/12 01:12 PM 282

168. Obvious change in a wart or mole
10/20/12 01:12 PM 283

169. Liver cancer-
hepatitis B vaccine

170. 6/1/2018 3:26:21 AM 285
LOTS OF BLOOD REQUIRE

171. 6/1/2018 3:26:21 AM 286

172. 6/1/2018 3:26:21 AM 287
All specialities under one roof

173. 6/1/2018 3:26:21 AM 288
TABLET FORMS

174. Cervix cancer vaccine
10/20/12 01:12 PM 289

175. Nagging cough or hoarseness
10/20/12 01:12 PM 290

178. 6/1/2018 3:26:21 AM 293

180. 10/20/12 01:12 PM 295

182. REGULAR CHECK-UP

184. 6/1/2018 3:26:21 AM 299

186. 301

187. Prevention-passive smoking

188. Promise-Stop drinking alcohol
10/20/12 01:12 PM 303

189. RELAX

190. Meditation
10/20/12 01:12 PM 305

191. 306
Dietary protective factors

192. Breast feeding

193. Physical activity

194. 309

195. 310

196. 6/1/2018 3:26:21 AM 311

197. 6/1/2018 3:26:21 AM 312

200. 6/1/2018 3:26:21 AM 315

201. 10/20/12 01:12 PM 316

202. Just “Doing It” is not good enough !
You must know “what” to do and “where” to do it !
10/20/12 01:12 PM 317

203. 10/20/12 01:12 PM 318

204. 10/20/12 01:12 PM 319

205. TEAM OF EXPERTS IN SURGICAL ONCOLOGY
1. Dr.Murali Krishna Voonna M.S.,M.Ch.,
(Adyar Cancer Institute ,Chennai)
2. Dr.Karthik Chandra Vallam M.S., M.Ch,DNB.,
(TATA Memorial ,Mumbai)
3. Dr.M.P.S.Chandra Kalyan M.S,, M.Ch.,
(TATA Memorial ,Mumbai)

206. TEAM OF EXPERTS IN RADIATION ONCOLOGY
Dr. Kanhu Charan Patro M.D(RT).DNB(RT)
(ex. TATA Memorial ,Mumbai)
Dr. Partha Sarathi Bhattacharyya M.D (RT)
(ex. AIIMS,NEW DELHI)
Dr. Chittaranjan Kundhu M.D(RT)
(S.C.B.M.C ,Cuttack)
Dr. Venkata Krishna Reddy M.D (RT)
(ex.Christian Medical College ,Vellore)

207. TEAM OF EXPERTS IN MEDICAL ONCOLOGY
1. Dr. B.Rakesh Reddy M.D(Paed).,DM
(Medical Oncology) (AIIMS ,New Delhi)

208. TEAM OF EXPERTS IN CRITICAL CARE AND PAIN
1. Dr. K.V.D. Praveen M.D(Anesthesiology)
(PGIMER, Chandigarh)
2. Dr. A.Shirisha M.D (Anesthesiology)
(AMC ,Visakhapatnam)
3. Dr. Surendra Nadh D.A, DNB(Anesthesiology)
(ISPAT General Hospital, Odisha)

209. TEAM OF EXPERTS-- Radiology
1. Dr. P.Madhuri D.M.R.D
( AMC ,Visakhapatnam)
2. Dr. B.Revathi D.M.R.D
( RMC ,Kakinada)

210. GYNAEC ONCOLOGY :
Dr.Jyoti Doki M.D. (Gynaec & Obg)
(AMC,Visakhapatnam)

211. Nuclear Medicine :
Dr. K.Raghava Kashyap M.D (Nuclear Medicine)
(PGIMER, Chandigarh)

213. EXPERTS FROM VARIOUS PRESTIGIOUS
INSTITUTIONS
1. ADYAR CANCER INSTITUTE, CHENNAI-1
2. TATA MEMORIAL HOSPITAL, MUMBAI-3
3. AIIMS,NEWDELHI-2
4. CMC-VELLORE-1
5. PGI-CHANDIGARH-2

214. ACCREDITED

215. ACCREDITED

216. MEMBER

217. APPROVED

223. Young radiation oncology conference

225. Radiation tumor board

226. DECISIONS IN TUMOR BOARD

227. EMPOWER
•EQUIPMENT
•EXPERT
•EXPERIENCE
•EASY ACCESSES

228. 10/20/12 01:12 PM 343
Whenever not
possible,
make friends

229. 34410/20/12 01:12 PM

230. 34510/20/12 01:12 PM

231. 6/1/2018 3:26:21 AM 346

232. 6/1/2018 3:26:21 AM 347

233. 6/1/2018 3:26:21 AM 348

235. 350
?