role of radiotherapy in nasopharyngeal carcinoma€¦ · npc differs from other h & n cancer:...
TRANSCRIPT
ROLE OF RADIOTHERAPY
in
Nasopharyngeal carcinoma
Dyah E, Lulus, Ulinta, Yoke
NPC differs from other H & N cancer:
• Epidemiology
• Pathology
3 histological types (W.H.O.)
Type I – Keratinizing SCC
Type II – Nonkeratinizing
Differentiated Carcinoma
Type III – Nonkeratinizing
Undifferentiated
Carcinoma
• proven role of EBV (1966)
• Diagnostic approach
• Treatment & Outcome
Introduction
RT as the mainstay
• Difficult surgical approach
• Sensitive to radiotherapy
Three Major Issues of the NPC
• How to improve the local control especially
for T3 and T4 patients
• How to reduce the post-irradiation late
sequelae
• How to reduce the ratio of distant
metastasis
Pattern of failure
T1-2 N0-1: good outcome
T3-4 N0-1: local failure dominant
T1-2 N2-3: distant failure dominant
T3-4 N2-3: bothEfficacy of RT
• Control rate
T1/T2: 75-90%
T3/T4: 50-75%
N0/N1: 90%
N2/N3: 70%
• Incorporate chemotherapy to RT
GOAL OF RT
• Maximize probality of tumor
eradication.
• Minimize probality of injury
to surrounding normal
tissue
RT FOR HEAD & NECK EXTREMELY
COMPLEX
I. TUMOR
• Very close proximing of tumor
& critical structure
• Total dose delivery limited by
tolerance of N tissue
II. ANATOMY
Varying Contour & TissueHeterogeneities
Air Sinuses
III. PATIENT
Compromised tolerance to Tx
- Poor nutritional status
and weight loss
- Inadequate oral intake
- Treatment induced
mucositis.
DIFFICULTY IN RT FOR H & N CANCER
IV.
TOLERANCE
DOSE
Source : PK Julka. Dept of Radiotherapy and Oncology AIIMS . New Delhi
Highly conformal radiation technique, such as IMRT
offerthe potential to reduce the spectrum side effects
associated with RT by decreasing the volume of
normal tissue receiving RT
3 DCRT utilizes CT-based treatment planning with dosimetric software to create
composite treatment plans. Fusion of planning CT with MRI is extremely helpful in
assisting with target definition
2D High dose surrounding normal tissue
IMRT
Improves precision/accuracy
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RT TECHNIQUE
3DCRT VMAT
Advanced Techniques : SRS and SRT
- Delivery of high dose of radiation in a single fraction
to small and precisely delineated intracranial lession
Stereotactic RadioSurgery (SRS)
- Delivery of high dose of radiation in a multiple
fraction to small and precisely delineated
intracranial lession
Stereotactic RadioTherapy (SRT)
Heavy particle RT ( PROTON, NEUTRON ect)
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RT TECHNIQUE
BRACHYTHERAPY
TOMOTHERAPY
STRATEGY TO IMPROVE RT
BIOLOGICAL APPROACH
DRUG COMBINATION
FRACTIONATION
HIGH LET
Improvement of
radiosensitivity
PHYSICAL APPROACH
CT based RTPS
3 D, IMRT, VMAT
STEREOTACTIC
Improvement of
dose distribution
ADVANCEMENT OF RT
LOCAL CONTROL SURVIVAL
QOL
CHEMO-RADIASI
29 AUGUST 2020
Randomized clinical trials on CRT for NPC
study
INT 0099a)
Chan’sb)
Taiwanc)
Singaporea)
Hongkonga)
no
147
350
284
221
348
CRT arm
78%
70%*
81%
80%
78%
RT arm
47%
59%*
70%
65%
78%
P-VALUE
0,001
0,049
0,002
0,006
NS
3 y OS
a) RT+ Cisp Cisp/5FU
b) RT+Cisp
c) RT+Cisp/5FU(IJROB 2008, Chen Y. et al )
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INTERNATIONAL MULTICENTER CLINICAL TRIAL OF NPC
FORUM for NUCLEAR COOPERATION in ASIA
( FNCA )
Phase II
29 AUGUST 2020
N0 N1 N2 N3
T1
T2
T3
T4
NPC-I
NPC-II
RT+ weekly Cisplatin
Adjuvant (Cis+5FU
N0 N1 N2 N3
T1
T2
T3
T4
NPC-I
NPC-II
RT+ weekly Cisplatin
(without adjuvant chemo)
Protocol : NPC- IIProtocol : NPC - I
(Cispl 30 mg/m2)(Cispl 30 mg/m2 )
(Cispl 80 mg/m2 & 5-FU: 1000
mg/m2/dayx4days )
Weeks 11, 15,19
(6x)(6x)
29 AUGUST 2020
TUMOR RESPONSE
Study Group
INT 0099
Singapore
Hongkong
Chan’s
FNCA (NPC-II)
FNCA (NPC-I )
CT/MRI
Yes
Yes
yes
yes
no
NR
TIMING
Every 2 Mo
6 Mo
6 Mo
6 Mo
6 Mo
6 Mo
CRT
36%
97%
98%
83%
95%
94%
RT
49%
97%
99%
71%
Complete Response
29 AUGUST 2020
TOXICITIES IN CONCURRENT CRT ARM
Study Group
INT 0099
Singapore
Hongkong
40mg/m2/w
FNCA (NPC-II)
FNCA (NPC-I )
Cisplatin
100mg/m2/3w
100mg/m2/3w
100mg/m2/3w
Chan’s
30mg/m2/w
30mg/m2/w
mucositis
37%
48%
62%
49%
13%
35%
N/V
14%
NR
19%
12%
2 %
5%
Leukopenia
29%
NR
32%
13%
4%
4%
TOXICITIES > grade 3
29 AUGUST 2020
TARGETED THERAPY + RT
Phase II trial 0f Recombinant Humanised Anti- human EGFR Monoclonal Antibody Nimotuzumab in Patients with locally advanced NPC
(Xu Guozhen, Gao Lie)
The CR rate in Px treated with combined tx was significantly higher than that in px receiving monotherapy.
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CT SIMULATOR
TPS (Treatment Planning System)
Radiation Treatment
RT PROCEDURE
(EBRT)
OUT PATIENT
(CLINIC)
Depend on :
• Total dose.
• Total duration of treatment
• Dose per fraction.
• Total number of fraction
• Interval between fraction
• Radiation volume.
TOXICITY
29 AUGUST 2020
ORAL COMPLICATION OF RT
Dysphagia 65 – 100 %
Xerostomia 78 – 95%
Dysgeusia ( change taste) 90 %
mucositis/ stomatitis 45 – 93 %
Pain 75 – 85 %
Chewing/ eating difficulties 70 %
( Brizel.DM. et al.J.Clin.Oncol.2000;18:3339-3345. Scully.C.et al. Head &Neck.2004;26:77-84.Berk.LB.et al.
2005;3:191-200 )
Increase acute toxicity with combined RT + CT
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29 AUGUST 2020
SUMMARY
The Radiation management
Side effect : recent technique
Multidisipline approach
individual. Management NPC
Perfect balance
Top skill
Multidisipline Approach :
ENT
Radiologist
Patologist
Radiation Oncologist
Hemato Oncologist
Nutrition
RT TEAM
• RADIATION ONCOLOGIST ( RO )
• MEDICAL PHYCISIST ( MP )
• DOSIMETRIST
• RADIOTHERAPY TECHNOLOGIST ( RTT)
• NURSE ONCOLOGIST
TEAM WORK
31/8/2020 YS,UP,DE 27