Basics of Planning and Management of Patients during Radiation Therapy

400 Pages·2018·13.076 MB·English

by  Ashutosh Mukherji

Ashutosh Mukherji
Basics of Planning and
Management of Patients
during Radiation Therapy
A Guide for Students
and Practitioners
123
Basics of Planning and Management
of Patients during Radiation Therapy
Ashutosh Mukherji
Basics of Planning and
Management of Patients
during Radiation Therapy
A Guide for Students and Practitioners
Ashutosh Mukherji
Department of Radiotherapy
Regional Cancer Centre, JIPMER
Puducherry
India
ISBN 978-981-10-6658-0 ISBN 978-981-10-6659-7 (eBook)
https://doi.org/10.1007/978-981-10-6659-7
Library of Congress Control Number: 2018933178
© Springer Nature Singapore Pte Ltd. 2018
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I would like to dedicate this work to my parents for
their guidance and love through all my life; my wife
and my daughter for their patience; and my patients
for having placed their belief in me.
Dr. Ashutosh Mukherji
Preface
What This Book Is About
Radiation medicine has now progressed from a volume and anatomical landmark-
guided approach to an image- and function-guided therapy which takes into account
possible routes of tumour spread, biologically active tumour volumes and critical
normal structures lying in or near target volumes with a focus on delivering maxi-
mal tumouricidal doses and sparing of surrounding normal structures. In the last
three decades, the quantum of advancement in the field of radiation oncology has
been immense with the availability of better diagnostic tools, immobilization meth-
ods and treatment machines. No longer are large regional volumes treated, but the
field is fashioned and the dose sculpted depending on the tumour volume, location
and tumour activity. The addition of imaging modalities to therapy machines has
enabled near and real-time tracking of tumour even during the delivery of therapy,
thus enabling the radiation oncologist to “see what volume he is treating and where
he is delivering radiation”.
With fast-changing parameters, the modern radiation oncologist has to keep in
touch with all modalities falling in his domain. This book tries to fill the gap between
standard textbooks of radiation therapy and pocket handbooks on practice guide-
lines. It describes how to approach a cancer patient, what investigations to order and
how to decide upon a treatment schedule. It deals with the various modalities of
delivering radiotherapy and then takes the reader through the steps of a radiation
treatment planning algorithm – on how to image, immobilize, contour, plan, evalu-
ate and deliver radiation therapy.
This book is divided into various sections mainly in the order in which a radia-
tion oncologist sees a cancer patient. It takes the reader from diagnosis to investiga-
tion, treatment decision and planning, evaluating and delivering radiotherapy. It
talks about the latest modalities in radiation therapy as well as other types of radia-
tion as well as combining radiation with biomolecules and chemotherapy in today’s
world of combined modality treatment. This book describes also the use of adjunc-
tive radiosensitizers as practical points. Finally, this book covers aspects of handling
a patient while on radiation, what problems a practitioner can face and how to solve
various accompaniments of radiotherapy. In addition, the last few chapters also
cover post radiation sequelae and follow-up evaluations.
vii
viii Preface
Objective of This Book
• How to approach a cancer patient
• Deciding a treatment modality
• How to use newer modalities of radiotherapy
• Ways of correctly evaluating a radiation schedule and delivering treatment
correctly
• Care of patient during treatment
• Managing complications and sequelae of treatment
• Counselling of patients
The author of this book has tried to explain by the use of charts and diagrams
especially the role of immobilization, target volume contouring, plan evaluation and
sequelae to provide the readers with an appreciation of what issues they are likely to
face during planning and delivering radiotherapy. This book discusses the general
background, radiobiology, radiophysics and clinical applications of radiation ther-
apy in the management of cancer. This handbook is an up-to-date and comprehen-
sive survey on how to use the latest radiotherapy techniques such as stereotactic and
adaptive radiotherapy, particle beam therapy, concurrent and sequential chemother-
apy, etc. The chapters also cover the impact of different treatment techniques and
toxicities on quality of life and the relationship of toxicity prevention, rehabilitation
and supportive care to quality of life after treatment.
Who Should Read This Book
Over the past three decades, cancer has become a major cause of morbidity and mor-
tality cutting across both developed and developing nations. Cancer is therefore a
major component of the cases a medical postgraduate student encounters in surgery,
gynaecology, orthopaedics, neurosurgery, ENT, haematology as well as many other
disciplines of medicine and of primary concern to nurses and allied health workers.
This work is designed as a quick reference volume of the dos and don’ts of managing
a patient receiving radiotherapy for practitioners of the field of radiation oncology as
well as on how to manage common day-to-day situations that one comes across in
radiation oncology practice. This book is not designed as a textbook of oncology, but
merely as a guide for practising radiation oncology. This book has been planned as a
useful reference for young radiotherapists in their daily dealings with cancer patients
and also as a useful guide for practical exams. This book is primarily meant as a ready
guide to clinical use for practising radiation oncologists as well as those in allied fields
such as medical physicists, radiation technologists, medical oncologists and even sur-
geons primarily dealing with cancer patients. It is intended to serve as a basic how and
why of the irradiation treatment planning process especially for young oncologists and
also hoped to help them ask more questions on the processes involved.
Puducherry, India Ashutosh Mukherji
January 2018
Acknowledgements
Working in oncology can be a very satisfying career, though one must be prepared
to take on and internalize a lot of challenges both intellectually and emotionally.
It is particularly satisfying to be able to help people with this most distressing and
worrying disease, and the sense of satisfaction one feels when one declares a patient
to be in remission is beyond expression. But there is also the frequent acknowledge-
ment of defeat and the emotionally draining experience of delivering bad news to
hopeful ears. At such times we have to remember that in oncology while many
patients are cured, all can be helped.
This book has been my first attempt and I am grateful to all my teachers, who
have fashioned my beliefs and knowledge and have always been there to help and
guide me: Dr. Bhowmik of Safdarjung Hospital, Delhi, and Drs. Rathi and Kishore
Singh of MAMC, Delhi, as well as Dr. Manoj Sharma of MAMC, Delhi; Dr. Veena
Gupta of Safdarjung Hospital, Delhi; Dr. Vinod Nimbran, Mohali; and Dr. KS
Reddy and Dr. S Vivekanandam of JIPMER Puducherry, to name a few. I would like
to acknowledge their presence in my life and thank them deeply for their blessings.
I thank the present director of our institute, Dr. SC Parija, and the previous director
Dr. TS Ravikumar for having constantly given direction and motivation to all facul-
ties. I would also like to thank my colleagues and friends across the country for
providing valuable inputs during our many discussions. Like all teachers, we are
inspired by our students as we not only pass on knowledge to them but also learn
from them. To have interested and enthusiastic students is a real stimulus and privi-
lege, and their doubts and questions were one of the guiding factors when I decided
to first pen down my ideas and frame them for this book. I would also like to thank
the untiring efforts of Dr. Naren and Dr. Eti from Springer Nature for giving shape
to my ideas and guiding my vision towards the final manuscript. They have been
constantly with me, checking my work and offering their inputs which I feel have
added to this work. Also my acknowledgements would not be complete without
thanking my patients who have through their experiences provided me valuable
insight and humility in my short years in clinical practice.
Finally, both clinical practice and academic activities are demanding of time and
energy in our lives. This is the time and energy for which our wives, families and
friends have so often had to make allowances for our absence. Without the love,
support and acceptance of the conditions of my work from my family, this work
would have been severely affected and may not have seen the light of the day.
ix
x Acknowledgements
My family has stood up both for and with me during the preparation of this manu-
script. I especially owe my family a debt of thanks and gratitude for this work and
would like to dedicate this work to my parents, my wife Meetu and my daughter
Arnavi for their patient tolerance of my frequent absence from their lives.
Dr. Ashutosh Mukherji
Puducherry, India
January 2018
Contents
Part I Approaching a Cancer Patient
1 Taking a Decision and Ordering Investigations . . . . . . . . . . . . . . . . . . 3
1.1 Staging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.2 Histopathological Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.3 Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.4 Tumour Markers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.5 Blood Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.6 Genotyping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.7 Deciding on the Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2 Role of Surgery in Cancer Management . . . . . . . . . . . . . . . . . . . . . . . 17
2.1 Future of Surgery in Cancer Management . . . . . . . . . . . . . . . . . . . . . 20
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3 Radiotherapy in Cancer Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
4 Role of Chemotherapy in Management of Cancers . . . . . . . . . . . . . . . 29
4.1 General Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
4.2 Novel Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
5 Principles of Management of Cancers in Paediatric Patients . . . . . . . 35
5.1 General Principles of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
5.2 Principles of Radiotherapy in Paediatric Patients . . . . . . . . . . . . . . . 37
5.3 Principles of Chemotherapy in Paediatric Patients . . . . . . . . . . . . . . 37
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
6 Palliative and Supportive Care of Cancers . . . . . . . . . . . . . . . . . . . . . . 39
6.1 Need for Supportive and Palliative Care Services . . . . . . . . . . . . . . . 40
6.2 Measuring Supportive and Palliative Care . . . . . . . . . . . . . . . . . . . . . 40
6.3 Benefits of Palliative and Supportive Care . . . . . . . . . . . . . . . . . . . . 41
6.4 Globally Available Supportive and Palliative Care Services . . . . . . . 42
6.5 Dealing with Difficult Situations and Breaking Bad News . . . . . . . . 42
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
xi