Precision radiotherapy techniques

1. RECENT ADVANCES IN
RADIOTHERAPY FOR
SINONASAL MALIGNANCIES
Presenter: Dr. Rituraj Upadhyay
Moderator: Dr. Ahitagni Biswas
09-02-2017
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2. OUTLINE
• Introduction to Sino-nasal tumors
• Clinical presentation and histological types
• Treatment protocols
• Radiotherapy dosage, volumes and techniques
• Precision radiotherapy techniques and its evidence
• Radiotherapy: Acute and Late effects
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3. SINONASAL MALIGNANCIES
• Uncommon neoplasms involving the nasal cavity and paranasal sinuses
• Encompass broad range of anatomical sites and differing histologies
• The overall 5-year survival from sinonasal cancers improved by 20% in
last two decades
• Treatment failures are mostly local, with 81% failures in primary site,
24% nodal and 14% distant
• Management is complicated because of close proximity to multiple
critical structures (the eye, brain, optic nerves and chiasm, brainstem,
and cranial nerves)
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4. SINONASAL MALIGNANCIES
• Surgery and radiotherapy are the mainstay of treatment
• Advances have been made in surgical methods including endoscopic
resections and highly conformal proton and photon techniques enabling
avoidance of adjacent critical structures
• The role of chemotherapy for most of these neoplasms has yet to be
clearly defined
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5. SITES
• Nasal vestibule
• Nasal cavity
PARANASAL SINUSES
• Maxillary sinuses
• Frontal sinuses
• Ethmoid sinuses
• Sphenoid sinus
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6. HISTOLOGICAL CLASSIFICATION*
HISTOLOGY % n = 386
1. Squamous Cell Carcinoma
(squamous cell, transitional, and
32.6
2. Sarcoma (incl RMS) 13.5
3. Esthesioneuroblastoma 10.9
4. Glandular
(adenoid cystic carcinoma and
mucoepidermoid carcinoma)
10.1
(9.1)
5. Lymphomas 9.8
6. Melanoma 8.8
7. Undifferentiated 7.8
8. Adenocarcinoma 6.5
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Dulguerov et al: Nasal and paranasal sinus carcinoma. Cancer 2001.

7. CLINICAL SPECTRUM
• Nasal findings:(50%) obstruction, epistaxis, rhinorrhea, discharge,
extension into nasal cavity
• Oral symptoms:(25-35%) pain, trismus, alveolar ridge fullness, erosion
• Ocular findings:(25%) epiphora, diplopia, proptosis
• Facial signs: paresthesias, facial asymmetry, cheek swelling
• Auditory symptoms: hearing loss
• Neurological: cranial nerve deficits II,III,IV.V1,V2,VI
• Nodal involvement: Seen in about 10%
• Distant mets: rare
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8. RADIOLOGICAL EXAMINATION
• Modern fiberoptic technology, CT scan &/or MRI are needed to
delineate the extent of tumor extracranially and intracranially.
• CT:
• Has 85% accuracy.
• Good for bone erosion in orbital walls, cribiform plate, fovea
ethmoidalis, etc
• Difficult to see periorbital involvement, differentiate tumor,
inflammation and secretions.
• MRI:
• 94% accuracy
• Excellent for determining perineural spread, involvement of the dura,
or intracranial involvement. 09-02-2017
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9. IMAGING
9
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10. STAGING
PRIMARY TUMOR (T) for Maxillary Sinus tumors
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor limited to maxillary sinus mucosa with no erosion or destruction of bone
T2 Tumor causing bone erosion or destruction, including extension into the hard palate and/or
the middle of the nasal meatus, except extension to the posterior wall of maxillary sinus
and pterygoid plates
T3 Tumor invades any of the following: bone of the posterior wall of maxillary sinus,
subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa, ethmoid sinuses
T4a Moderately Advanced Local Disease
Tumor invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal
fossa, cribriform plate, sphenoid or frontal sinuses
T4b Very Advanced Local Disease
Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial
nerves other than maxillary division of trigeminal nerve (V2), nasopharynx, or clivus 09-02-2017
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11. 09-02-2017
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12. AJCC 8th edition
N1, N2a, N2b and N2c unchanged other than
specify without Extranodal extension (ENE)
• N3a: Metastasis in a lymph node more than 6
cm in greatest dimension without ENE
• N3b: Metastasis in a single or multiple lymph
nodes with clinical ENE*
* The presence of skin involvement or soft
tissue invasion with deep fixation/tethering to
underlying muscle or adjacent structures or
clinical signs of nerve involvement is classified
as clinical ENE
N-STAGING: 7TH VS 8TH EDITION
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13. 09-02-2017
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14. SQUAMOUS CELL CARCINOMA
• Most common type(80%)
• Location: Maxillary sinus (70%) and lateral nasal wall(20%)
• 90% have local invasion and present in advanced stages(T3/4)
• Lymph node metastases is more common than most other paranasal sinus
malignancies(10-20%)
• Local recurrence rates are quite high, as high as 30% to 40%
• Complex 3-D anatomy makes clear margins difficult to achieve.
• Surgical resection with postoperative radiation is the treatment of
choice. Some role of chemo, as extrapolated from HNSCC.
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15. ADENOCARCINOMA
• Most often seen in ethmoid sinuses
• Present most often in the superior portions
• Strong association with occupational exposures esp. wood dust workers
• High grade: solid growth pattern with poorly defined margins. 30%
present with metastasis
• Low grade: uniform and glandular with less incidence of perineural
invasion/metastasis.
• Treatment : Surgery followed by PORT
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16. ADENOID CYSTIC CARCINOMA
• 3rd most common site of ACC is the nose/paranasal sinuses
• Perineural spread upto the base of the skull
• It is occurs most frequently in women, and in the fifth and sixth
decades.
• Anterograde and retrograde growth
• Despite aggressive surgical resection and radiotherapy, most grow
insidiously.
• Postoperative XRT is very important.
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17. MUCOEPIDERMOID CARCINOMA
• Extremely rare
• Most patients present with low stage disease (stage I and II), although
invasive growth is common with higher grade disease.
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18. OLFACTORY NEUROBLASTOMA
/ESTHESIONEUROBLASTOMA
• Originate from stem cells of neural crest origin that differentiate into
olfactory sensory cells.
• Aggressive behavior, with
• 50-75% local failure and
• 20-30% distant mets.
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19. STAGING
• Most commonly used is the modified Kadish staging
Stage Group Description
A Confined to nasal cavity
B Extends into the paranasal sinuses
C Extends beyond the nasal cavity and paranasal
sinuses including involvement of the cribriform
plate, skull base, orbit, or intracranial cavity
D Nodal/ Distant Metastasis
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20. ESTHESIONEUROBLASTOMAS
• Kadish A
• Surgery / radiotherapy alone
• Adjuvant RT is indicated in close and positive margins or with residual disease
• No adjuvant chemotherapy
• Kadish B
• Surgery followed by adjuvant RT
• Kadish C
• Craniofacial resection  post op chemoradiation
• NACT -> surgery (craniofacial resection)  post op chemoradiation or
chemoradiation (unresectable cases)
• Kadish D
• Systemic chemotherapy and palliative RT to local and metastatic sites
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21. MELANOMA
• 0.5- 1.5% of melanoma originates from the NC and PNS
• Anterior Septum: most common site
• IHC markers include S-100 protein, HMB-45, melan-A, tyrosinase, etc.
• Treatment is wide local excision with/without postoperative radiation
therapy
• Prophylactic neck nodal dissection at N0 is not recommended, since the
incidence of occult nodal metastases is relatively low.
• Local, regional, and systemic recurrence rates of 20%, 50%, and 80%,
respectively seen with lung involvement most common
• Classically poor prognosis with 5yr survival of about 11%
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22. RHABDOMYOSARCOMA
• Most common paranasal sinus malignancy in children
• Usually: Non-orbital, parameningeal, Alveolar subtype mostly
• Surgical resection is difficult and ChemoRT is the treatment of choice
• Commonly used chemotherapy drugs include Vincristine, Actinomycin D,
Cyclophosphamide, Ifosfamide, and Etoposide
• A radiation dose of 50.4 GY/28#/5.5 wks is recommended.
• Aggressive chemo/XRT has improved survival from 51% to 81% in
patients with cranial nerve deficits/skull/intracranial involvement
• Other sarcomas: Osteogenic Sarcoma is the most common
• Mandible > Maxilla
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23. LYMPHOMA
• Usually Non-Hodgkins type
• DLBCL are the most common followed by NK-T cell lymphomas
• Highly Radio and chemosensitive
• NK-T cell Lymphoma: often EBV positive. More common in NC
• SMILE/GELOX chemo f/b RT 45-60 Gy
• DLBCL: More common in PNS
• R-CHOP f/b IFRT 30-36Gy/15-20#
• Survival: Around 50-65% at 5 years.
• Survival drops to 10% in case of recurrent lesions
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24. HEMANGIOPERICYTOMA
• Originate from pericytes of Zimmerman
• Present as rubbery, pale/gray, well circumscribed lesions resembling
nasal polyps
• Treatment is surgical resection with postoperative XRT for positive
margins
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25. SINONASAL UNDIFFERENTIATED
CARCINOMA
• Presents with aggressive, locally destructive lesion
• Diagnosed on pathological differentiation after ruling out melanoma, lymphoma,
and olfactory neuroblastoma
• IHC can help in diagnosis: CK-8, p16 positive and EBV and HPV-DNA negative.
• Surgery, when feasible, may improve local control (Reiersen et al)
• Resectable or marginally resectable:
• Primary surgery followed by adjuvant chemo-radiotherapy may be preferable
• May consider induction chemotherapy (Cyclophosphamide/Doxorubicin/Vincristine)
followed by reassessment for surgery (Musy et al)
• Unresectable:
• Concurrent chemoradiation
• Induction chemotherapy followed by concurrent chemoradiation (Rischen et al)
• Optimal sequence of modalities and choice of chemotherapy regimen is still unclear09-02-2017
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26. TREATMENT ALGORITHM
• T1-2N0
• Resection → post-op RT for close margin, PNI, adenoid cystic.
• For + margin, re-resect (if possible) → post-op RT
• T3-4N0
• Resectable: Resection → post-op RT or chemo-RT*
• Unresectable: Definitive RT or chemo-RT*
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*Chemotherapy as extrapolated from Head and neck Squamous Cell Ca

27. TREATMENT ALGORITHM
• N+
• Resection + neck dissection → post-op RT or chemo-RT*.
• Alternatively, definitive chemo-RT*
• Elective Nodal Irradiation
• In T3/T4 tumors, Histology: Squamous cell Ca or Undifferentiated
carcinomas
• Level Ib, II and Retropharyngeal LNs are included.
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*Chemotherapy as extrapolated from Head and neck Squamous Cell Ca

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29. RADIOTHERAPY
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30. • Because these cancers are usually diagnosed at a locally advanced stage
and surgery is the primary therapy, most patients receive postoperative
radiation therapy.
• Addition of RT to surgery improves 5-years survival (44%) when
compared to RT alone (23%) or surgery alone.
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Cengiz et al. Sinonasal Tract Malignancies: Prognostic Factors and Surgery Outcomes

31. INDICATIONS
• Definitive:
Medically inoperable or who refuse radical surgery or early lesions
• Adjuvant:
High risk features, close or positive margin, R1/R2 resection
• Palliative
Metastatic disease
• Preoperative:
In Borderline resectable tumors
It may increase the infection rate and the risk of postoperative
wound complications.
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32. TIME DOSE FRACTIONATION
• Pre-op RT
• 50 Gy/25#/5weeks
• Post-op RT:
• 65 Gy/30#/6 wks to post op residuum
• 60 Gy/30#/6wks to tumour bed
• Definitive RT:
• 65 Gy/30#/6wks to primary disease
• 60 Gy/30#/6wks to local microscopic disease
• Elective Nodal Irradiation
• 54 Gy/30#/6wks to Level Ib, II, RPLNs
• Palliative RT
• 30 Gy/10#/2wks or 20 Gy/5#/1wk 09-02-2017
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33. TARGET VOLUMES
• Volumes
• GTV: Gross primary plus nodal disease or Post-op residual disease
• CTV:
• HR-CTV (CTV65) – GTV + 1cm anatomically constrained margin
• IR-CTV (CTV60) – Expansion to include tumour bed & all tissues
which have been surgically handled; entire involved sinus cavity, all
areas at risk of harbouring microscopic disease.
• LR-CTV (CTV54) - Elective nodes: Ipsilateral or B/L Level Ib, II,
RP LN
• PTV: Respective CTVs with 3-5 mm isotropic expansion
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34. ALTERED FRACTIONATION
• Radiobiological advantage in head and neck cancers because of rapidly
proliferating tumors.
• Hyperfractionation
• refers to giving the total radiation dose in a larger number of doses
• Ex: 2 smaller doses per day instead of 1 larger dose
• Less dose per fraction decreases late effects, Total dose can be escalated
• Accelerated fractionation
• radiation treatment is completed faster
• 6 weeks instead of 7 weeks, for instance
• Decreases accelerated repopulation
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35. 2D
Conventional
Techniques
3D
Conformal
RT
IMRT/
Arc
Therapy
Image
guided
IMRT
Proton
therap
y
Brachyther
apy (with
Image
guidance)
RADIATION TECHNIQUES: EVOLUTION
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36. CONVENTIONAL TECHNIQUES
• 2-field or 3-field technique with wedge pairs used
• Patient lies in a supine
cast with the head in
neutral position.
• Tongue bite is used to
depress tongue &
lower alveolus away
from the target volume.
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37. Anterior field:
• Superior: Supraorbital ridge
• Inferior: Angle of mouth
• Medial: Contralateral medial canthus
• Lateral: Falling off the skin.
When there is no gross involvement of
the orbit, the cornea, lens & lacrimal
gland are shielded
If there is disease in the orbit,
cornea is spared by cutting out the
cast and treating with the eyes open
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38. Lateral fields:
• Superior: Floor of anterior
cranial fossa.
• Anterior: Lateral canthus
parallel to the slope of face
• Posterior: covers the pterygoid
plates.
It is angled 5-10 degree
posteriorly so that the exit beam
avoids the opposite eye
Optic chiasma & hypothalamus are
shielded from the lateral field
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39. 2D ISODOSE DISTRIBUTION
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• Anterior beam is
weighed as 2:1 to
that of lateral beam
• Dose prescription:
• 65Gy/30#/6w or
55Gy/20#/4w

40. 3D CONFORMAL RADIOTHERAPY
• Multiple fields (3-5) are used with multi leaf collimators to shape the
radiation portal in accordance to the disease volume, with adequate
margins.
• Mapping and contouring of disease extent based on:
• Pretreatment physical examination,
• Pretreatment imaging,
• Intraoperative findings, and
• Histopathological examination (e.g., positive margin, perineural
invasion)
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41. 09-02-2017
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42. 09-02-2017
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43. INTENSITY MODULATED RADIOTHERAPY(IMRT)
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• An advanced form of 3D CRT in which non-
uniform fluence(beam intensity) is delivered
by coplanar or non-coplanar beams using
computer-aided optimization and beam
shaping to attain desired doses to target
volume with reduced dose to surrounding
critical structures.
• A non-coplanar arrangement of three to five
sagittal midline beams with right and left
lateral beams avoids entry or exit of beams
through the eyes and provides a uniform dose
distribution

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45. 09-02-2017
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46. IMRT: ADVANTAGES
• Irregular tumors in sinonasal region: IMRT is needed to conform
accurately to the tumor volume
• Vital structures: Optical, auditory and neural structures in the
surroundings
• Relatively less organ motion in head and neck, so less daily setup
errors, despite complicated planning
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47. FIXED FIELD IMRT VS VMAT
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48. EVIDENCE
• N = 81
• 40 patients with cancer of the paranasal sinuses (n = 34) or nasal cavity (n = 6)
received postoperative IMRT to a dose of 60 Gy (n = 21) or 66 Gy (n = 19).
• Retrospectively compared with that of a previous patient group (n = 41) who
were also postoperatively treated to the same doses but with three-
dimensional conformal radiotherapy without intensity modulation.
• Median follow-up was 30 months (range, 4–74 months).
• Two-year local control, overall survival, and disease-free survival were 76%,
89%, and 72%, respectively.
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doi:10.1016/j.ijrobp.2009.09.067

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Compared to the three-dimensional conformal radiotherapy treatment, IMRT
resulted in significantly improved disease-free survival (60% vs. 72%; p = 0.02).

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No grade 3 or 4 toxicity was reported in the IMRT group, either acute or chronic.

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The use of IMRT significantly reduced the incidence of
acute as well as late side effects, especially regarding skin
toxicity, mucositis, xerostomia, and dry-eye syndrome.

53. IMRT:EVIDENCE
S.
No
Series n Period Site Histology Treatment RT
dos
e
Med
ian
f/u
Local
Control
OS Toxicity
1. Duprez,
Madani et
al(Ghent)
130 1998-
2009
Eth:74
Max:24
NC:31
Sph:1
AdCa:82
SqCC:23
ENB:10
SNUC:8
AdjRT:101
Def:20
ReRT:9
Chemo:7
66-
70
Gy
52m 5y:59% 52% G3
Ocular:11
Brain Nec:6
ORN:1
2. Hoppe et
al (MSKCC)
85 1987-
2005
Max:45
NC:24
Eth:14
SqCC:42
ACC:11
END:7
62%IMRT
63
Gy
62% 67% No>G2 in
IMRT,1
blindness
3. Chen et al
(UCSF)
127 1960-
2005
Max:54
NC:35
Eth:26
Sph:8
F:4
SqCC:83
ACC:28
Adeno:16
Conv:46%
3DCRT:36%
IMRT:18%
60-
72
Gy
49 55%
62%
61%
57%
59%
60s:46
70s:56
80s:51
90s:53
00s:49
G>2:53%
45%
39%
28%
16%
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54. 09-02-2017
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Chen et al. IJROBP 2007. RT in PNS:Are we making improvement?

55. IMRT:EVIDENCE
S.
No
Series n Period Site Histology Treatment RT
dose
Media
n f/u
Local
Control
OS Toxicity
4. Claus et al
(Belgium)
32 1999-
2001
Ethm:21
Max:6
NC:5
Adeno:17
SqCC:8
ENB:3
ACC:2
TCC:1
Lepa:1
Sx-
Adj RT:31
ReRT(2)
Definitive
RT (1)
66-
70
Gy
15m - 80% Mucositis
G1–2:28
G3:4
No Ocular
G3/4 tox.
Dry eye:0
5. Daly et al
(UCSF)
36 1998-
2004
Ethm:13
Max:10
NC: 7
Oth:6
SqCC:12
ENB:7
ACC:5
SNUC:5
AdCa:5
Other:2
Sx-RT:32
Def RT:4
70
Gy
51m 2y:62%
5y:58%
5y:45
%
No decrea
vision.Late
:xerophth:
1, lacrimal
stenosis:1
cataract:1
6. Duthoy et
al (Ghent)
39 1998-
2003
-- AdCa:79%
SqCC:21%
Sx+PORT 70
Gy
2.6yrs 4y:68% 59% Decr
vision 6%,
No blinds
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56. IMAGE GUIDED RADIOTHERAPY
• Use of imaging during radiation therapy to improve the precision and accuracy
of treatment delivery to the designated target volume.
• Compares images taken during treatment to the reference images taken during
simulation,
• Appropriate real-time corrections to patient positioning and setup is made
• Imaging technologies used include
• Orthogonal X-rays(2-D kV),
• Cone beam computed tomography (CBCT),
• MV imaging mounted on the treatment head itself
• Eliminates random and systematic treatment errors
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57. 09-02-2017
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58. PARTICLE THERAPY
• Includes Proton therapy and Heavy ions like Carbon Ion therapy (CIT)
• These have high LET, which increases steadily from the point of
incidence with increasing depth to reach a maximum in the peak region.
• Less dose is delivered to tissues proximal to the tumor and rapid dose
fall off at the distal edge of the tumor (Bragg-Peak effect).
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59. 09-02-2017
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60. 09-02-2017
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61. PARTICLE THERAPY
• Dose escalation
• Minimizing exposure of normal tissues and decreasing toxicity
• Useful for deep-seated tumours.
• High biological efficiency (RBE): Effective in relatively radioresistant
cancers (Carbon Ions)
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62. 09-02-2017
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63. EVIDENCE
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S.
No
Series n Period Site Histology Treatme
nt
RT
dose
Median
f/u
Local
Control
OS Toxicity
1. Dagan et al
(Florida)
84 2007-
2013
NC/Eth
:80%
Max:18
%
ENB:23%
SqCC:22%
ACC:17%
Def:13%
Adj:87%
26% R2
resection
Chemo:7
5%
73.8
GyE
2.7y 3y:83%
R0:90%
R1/2:
59%
RT:61%
3y:68
%
Late: 24%
>G3: 2%
2. Fuji et al
(Japan)
20 2006-
2010
NC:12
PNS:8
Mucosal
Melanoma
No Sx
CT:16
70 Gy
/20fr
35m 62% 5y:51
%
G4:3 (ON
involved)
3. Cianchetti
et al
(Germany)
99 1991-
2003
-- -- Sx:67% 70Gy 8.5y 8y:83% 8y:46
%
>G3:
Sx+RT:29%
RT:7%
4. Pommier et
al (MGH)
23 1991-
2002
-- Adenoid
cystic
Sx:39% 75.9
cGyE
5y:93% 5y:77
%
--

64. 09-02-2017
64
Dagan et al Outcomes of Sinonasal Cancer Treated With Proton Therapy. IJROBP 2016

65. 65
Fuji et al. High-dose proton beam therapy for sinonasal mucosal malignant melanoma. Radiation Oncology 2014
09-02-2017

66. 09-02-2017
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Fuji et al. High-dose proton beam therapy for sinonasal mucosal malignant melanoma. Radiation Oncology 2014

67. HEAVY-ION THERAPY
• Use of particles more massive than protons or neutrons, such
as carbon ions.
• Higher biological efficiency by a factor 1.5-3: Role in radioresistent tumors
such as adenocarcinoma, adenoid cystic carcinoma, malignant melanoma
and sarcoma
• Due to the higher density of ionization, more DNA damage in cancer cells
• Disadvantage: Beyond the Bragg peak, the dose does not decrease to
zero. since nuclear reactions between the carbon ions and the atoms
of the tissue lead to production of lighter ions which have a higher
range. Therefore, some damage occurs also beyond the Bragg peak.
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68. 09-02-2017
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CIT plans often show a better dose distribution than the PT plans in head and neck
patients due to the superb penumbra, which could lead to less toxicity.

69. 09-02-2017
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S.
No
Series n Period Site Histology Treatmen
t
RT
dose
Media
n f/u
Local
Control
OS Toxicity
1. Koto et al
(Japan)
22 1997-
2010
Eth:11
Max:5
NC:6
Adeno Def: 16
Salv:4
Adj:2
57.6-
64 GyE
in 16fr
43 3y:61% 3y:
59%
Acute
>G3:6
Late-visual
loss:5,
Brain
necrosis:1
2. Jensen et
al(German)
29 2009-
10
Max
sinus
MC
AdCC MC Def:17
Salv:9
ReRT:2
73GyE
(CI
boost)
5.1m 50%
respon
se
- G3:7, G2:6
No vision
impairment
3. Yanagi et
al (Japan)
72 1994-
2004
Malig
melanoma
52.8-
64GyE
49.2 85% 27% G3 or more
none
4. Ohta et al
(Japan)
3 2013 - AdCC:2
SqCC:1
Sx+RT:1
RT:2
64
GyE/1
6fr
39.6m 100% - Visual
loss:1

70. PROTON VS CARBON ION
70
Demizu et al. Particle therapy for mucosal melanoma of the head and neck:A single-institution retrospective
comparison of proton and carbon ion therapy

71. DOSE DISTRIBUTUION
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CONVENTIONAL RT 3D-CRT

72. DOSE DISTRIBUTUION
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IMRT PROTON-BASED

73. 73
Mock et al. Treatment planning comparison of conventional, 3D conformal, IMRT and proton therapy for
paranasal sinus carcinoma.

74. STEREOTACTIC BODY RADIOTHERAPY(SBRT)
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• Accurately delivers a high irradiation dose to an extracranial target in one or
few treatment fractions.
• Nearby tissues are affected as little as possible.
• Main advantage over IMRT: Shortened treatment time.
• SRS: Intracranial target, usually gives the whole radiation dose in one session.
• Offers high biological equivalent dose
• Main problem is complex planning

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• Delivery systems:
• Robotic based Cyber Knife
• Gamma Knife
• LINAC Based

76. SBRT: EVIDENCE
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S.
No
Series n Histology Treatment RT dose Median
f/u
Local
Control
OS Toxicity
1. Vargo et al
(Pittsburgh)
34 NonSqCC Reirradiati
on
40Gy/5# 10m 1y:59% 1y:59% G3 Acute:15%
Late:6%
2. Roh et al
(Korea)
36 NPx:8
Max:8
Neck:8
NC:4
Reirradiati
on
18-
40Gy/3-
5#
17.3m 43%CR
37%PR
9%SD
11%PD
-- G3 Acute:13
Late:3
(necrosis)
3. Bourgeois
et al (New
York)
2 Melanoma R2
resection-
SBRT
15Gy/1# - 7yrs
8m
7yrs
1y
Mild Epistaxis
4. Ozyigit et al
(Turkey)
4 Melanoma R2
resection-
SBRT
30Gy/3# 2y 50% 75% Nasal
regurgitation

77. BRACHYTHERAPY
• Useful for:
• Lesions of nasal cavity and external nares (vestibule)
• Lesions on the septum or the mucosa medial to ala nasi
• Preferable for relatively smaller lesions (T1/T2)
• Ir-192 wire implant or intracavitary mold is used
• Yields a 2-year local control of 86% and ultimate LRC of 100%*
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*Mazeron JJ et al the Groupe Europeen de Curietherapie. Radiother Oncol 1988;13:165-173

78. 09-02-2017
78
Ir-192 wire implant
Perez & Brady's Principles and Practice of Radiation Oncology 6th Ed

79. BRACHYTHERAPY
• Recommended dose
• LDR: 60-65 Gy over 5-7 days
• LDR Boost: 20-25 Gy over 2 days [After EBRT 50 Gy]
• HDR : 18 Gy @ 3Gy/# , 2#/d
• Dose prescription:
• 0.5 cm lateral to the tumor for lateral nasal vestibule
• At the center of the tumor for tumors of the septum
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Mould brachy: A custom mold of the nasal vestibule is
made and 2-4 plastic tubes (1.0-cm apart) inserted in
the mold alongside the tumor.

81. TREATMENT ACCOMPANIMENTS
ACUTE MORBIDITY
• Fatigue
• Dermatitis, Skin erythema
• Mucositis – nasal > oral
• Xerostomia
• Conjunctivitis, epiphora, blurring
of vision
• Alopecia
• Raised ICT
LATE MORBIDITY
• Late skin effects – erythema, fibrosis,
telengectasia
• Atrophic mucositis – septal perforation
• Cataract, dry eye syndrome, optic
neuritis, Chronic keratitis
• Xerostomia
• Facial asymmetry
• Osteoradionecrosis
• Second malignancies
• Neuro endocrine
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82. TREATMENT DELIVERY AND PATIENT
CARE
• Nasal cavity synechiae can be prevented by intermittent dilation of the nasal passages
with a petroleum based jelly-coated cotton swab until mucositis has resolved.
• Dry mucosae can be managed symptomatically with saline nasal spray.
• Oro-dental hygiene
• Exercises to reduce trismus
• Prophylactic feeding tubes
• Ophthalmic review and Lubricating eye ointments
• If there is a pre-existing facial nerve palsy, the eyelid should be taped shut at night to
avoid a dry eye.
• Pituitary function tests should be carried out annually during follow-up to evaluate late
radiotherapy effects to the pituitary gland.
• Xerostomia can be an acute as well as late effect and can de decreased by
administering Amifostine.
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83. CONCLUSION
• Sinonasal malignancies are uncommon and heterogenous group of tumors
• They usually present in locally advanced stages and surgery is the mainstay of
treatment
• RT is often used in adjuvant settings and sometimes alone as definitive RT
• RT has advanced a long way from era of conventional RT to 3D conformal RT, IMRT
and IGRT
• Modern techniques like Proton, IMPT and Carbon ion therapy have enabled dose
escalation to tumor tissue and reduced normal organ toxicity
• SBRT/SRS has shown promise in delivering high dose per fraction, thus reducing
the treatment time to a few days
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