POSITIONING AND CLINICAL IMPACT

ON
RADIOTHERAPY
- I have no conflicts of interest to disclose
- Some of materials in this presentation already presented on
SEARC Meeting on October 19th 2018

DISCLAIMER
FAST IS FINE, BUT ACCURACY IS
EVERYTHING

Wyatt Earp
 Overview of radiation oncology
 Technical terms in Radiotherapy
 The Importance of set-up in Radiotherapy
 Clinical impact

OUTLINES
Radition Oncology : Discipline of human medicine concerned with the
generation,conservation, and dissemination of knowledge concerning
the causes, prevention, and treatment of cancer

Radiation therapy is a clinical modality dealing with the use of ionizing radiations in the
treatment of patients with malignant neoplasias (and occasionally benign diseases)

DEFINITION
 Deliver a precisely measured dose of irradiation to a defined
tumor volume with as minimal damage as possible to surrounding
healthy tissue, resulting in eradication of the tumor, a high
quality of life, and prolongation of survival at a reasonable cost

AIM
 Methods of Delivery

External beam irradiation :

Using a machine to aim high-energy rays
radiation at the cancer from outside of the
body

Brachytherapy :
Placing radiation source inside or adjacent to
a cancer, or in an area that might contain
microscopic tumor burden.
CANCER TREATMENT

Surgery

Multidisciplinary
Chemotherapy Radiotherapy

daksa_ganapati
Pre-operative RT ROLES OF RADIOTHERAPY
Aims to:
Improve resectability

Definitive RT
Radiotherapy acts as primary treatment 60 – 70 % cancer patients
 QUALITY OF LIFE needs to be irradiated
usually in conjunction with Chemotherapy

Post-operative
(“adjuvant”) RT
Aims to improve local control after surgery
especially in patients with risk factors for local recurrence
 Overview of radiation oncology
 Technical terms in Radiotherapy
 The Importance of set-up in Radiotherapy
 Clinical impact

OUTLINES
TARGET
TARGET
 The uncertainties depend on different types of factors, such as :
 Variations in patient positioning
 Mechanical uncertainties of the equipment
 Dosimetric uncertainties
 Transfer set-up
 Human factors
 etc

UNCERTAINTIES
UNCERTAINTIES
 Overview of radiation oncology
 Technical terms in Radiotherapy
 The Importance of set-up in Radiotherapy
 Clinical impact

OUTLINES
 RADIOTHERAPY :

HIGH COST
HIGH RISK
HIGH VOLUME

DAKSA_GANAPATI
UNCERTAINTIES
SET UP

 Geometrical Accuracy :
 Mechanical errors
 Set up errors

 Set Up errors :
 Random errors
 Systematic Positioning errors Largest Impact
Society M. On target :
ensuring geometric
accuracy in
radiotherapy.
https ://humanhealth.iaea.org/patient setup and immobilisation
https ://humanhealth.iaea.org/patient setup and immobilisation
https ://humanhealth.iaea.org/patient setup and immobilisation
https ://humanhealth.iaea.org/patient setup and immobilisation
Beltran C, Pegram A, Merchant TE. Dosimetric consequences of
rotational errors in radiation therapy of pediatric brain tumor
patients. Radiotherapy and oncology : journal of the European
Society for Therapeutic Radiology and Oncology. 2012;102(2):206-
209. doi:10.1016/j.radonc.2011.06.013.
 Overview of radiation oncology
 Technical terms in Radiotherapy
 The Importance of set-up in Radiotherapy
 Clinical impact

OUTLINES
Source : C. H. Hsieh et al., “Impact of postoperative daily
image-guided intensity-modulated radiotherapy on overall
and local progression-free survival in patients with oral
cavity cancer,” BMC Cancer, vol. 16, no. 1, Feb. 2016, doi:
10.1186/s12885-016-2165- .
Source :

Contesini, M. et al. Setup errors in patients with head-neck cancer (HNC), treated using the
Intensity Modulated Radiation Therapy (IMRT) technique: How it influences the customised
immobilisation systems, patient’s pain and anxiety. Radiation Oncology 12, (2017).
Source : Hong TS, Tome WA,
Chappell RJ, Chinnaiyan P, Mehta
MP, Harari PM. The impact of daily
setup variations on head-and-neck
intensity-modulated radiation
therapy. Int J Radiat Oncol Biol Phys
2005;61(3):779–88.
Source : Hong TS, Tome WA,
Chappell RJ, Chinnaiyan P, Mehta
MP, Harari PM. The impact of daily
setup variations on head-and-neck
intensity-modulated radiation
therapy. Int J Radiat Oncol Biol Phys
2005;61(3):779–88.
Source : Hong TS, Tome WA,
Chappell RJ, Chinnaiyan P, Mehta
MP, Harari PM. The impact of daily
setup variations on head-and-neck
intensity-modulated radiation
therapy. Int J Radiat Oncol Biol Phys
2005;61(3):779–88.
Source : Kaur I, Rawat S, Ahlawat P, et al.
Dosimetric impact of setup errors in head
and neck cancer patients treated by
image-guided radiotherapy. Journal of
Medical Physics / Association of Medical
Physicists of India. 2016;41(2):144-148.
doi:10.4103/0971-6203.181640.
Source : Kaur I, Rawat S, Ahlawat P, et al. Dosimetric impact of setup errors in head and neck cancer
patients treated by image-guided radiotherapy. Journal of Medical Physics / Association of Medical
Physicists of India. 2016;41(2):144-148. doi:10.4103/0971-6203.181640.
Source : Tome WA,
Fowler JF. On cold spots
in tumor subvolumes.
Med Phys
2002;29(7):1590–8.
Source : J. Su et al., “Different setup errors assessed by
weekly cone-beam computed tomography on different
registration in nasopharyngeal carcinoma treated with
intensity-modulated radiation therapy,” OncoTargets and
Therapy, vol. 8, pp. 2545–2553, 2015, doi:
10.2147/OTT.S87159.
 OAR

Source : Fu W, Ph D, Yang Y, et al. Medical

Dosimetry Dosimetric influences of rotational
setup errors on head and neck carcinoma
intensity-modulated radiation therapy
treatments. Med Dosim [Internet]
2013;38(2):125–32. Available from:
http://dx.doi.org/10.1016/j.meddos.2012.09.0
03
Source : K. Bell, N. Licht, C. Rübe, and Y. Dzierma, “Image
guidance and positioning accuracy in clinical practice:
Influence of positioning errors and imaging dose on the real
dose distribution for head and neck cancer treatment 02
Physical Sciences 0299 Other Physical Sciences 11 Medical and
Health Sciences 1112 Oncology and Carcinogenesis,”
Radiation Oncology, vol. 13, no. 1, Oct. 2018, doi:
10.1186/s13014-018-1141-8.
OAR

Source : Frøseth, T. C., Strickert, T., Solli, K. S.,

SalvesenØyvind, Frykholm, G., & Reidunsdatter, R.
J. (2015). A randomized study of the effect of
patient positioning on setup reproducibility and
dose distribution to organs at risk in radiotherapy
of rectal cancer patients. Radiation Oncology,
10(1). https://doi.org/10.1186/s13014-015-0524-3
Source : D. L. Schwartz and L. Dong,
“Adaptive radiation therapy for head and
neck cancer-can an old goal evolve into
a new standard?,” Journal of Oncology.
2011. doi: 10.1155/2011/690595.
 SUMMARY

 Radiotherapy  HIGH RISK

 Deviation of delivered dose influence the tumor control
probability and also OAR’s
 Systematic errors have the largest impact on the margin needed
to adequately dose the target. The greatest benefit is gained
from strategies to reduce systematic errors.
ACKNOWLEDGEMENT

 Prof.Dr.dr.Soehartati G, Sp.Rad (K.) Onk.Rad

 IROS
 PARI
 SEARC
 Radiotherapy Inst, Sanglah Hospital

correspondence : putudaksa@gmail.com
 MATUR SUKSMA
DAKSA_GANAPATI