Nana Supriana, Henry Kodrat

Radiotherapy Department,
Dr. Cipto Mangunkusumo National General Hospital,
Faculty of Medicine - University of Indonesia
Jakarta

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 CURRICULUM VITAE

Nana Supriana , MD

Born : Purwadadi, July 1947

Education
1. GP : Faculty of Medicine, University of Indonesia, 1972
2. Radiologist : Faculty of Medicine, University of Indonesia, 1984
3. Radiation Oncologist : Faculty of Medicine, University of Indonesia, 1986

Current Positions :
Staff of Radiotherapy Department , Dr. Cipto Mangunkusumo National
General Hospital
Secretary of Indonesian Radiation Oncology Society
Secretary of Indonesian Society of Oncology

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 Definition
Radiation oncology is that discipline of
human medicine concerned with the
generation, conservation, and dissemination
of knowledge concerning the causes,
prevention, and treatment of cancer and
other diseases involving special expertise in
the therapeutic applications of ionizing
radiation.

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Radiotherapy is clinical modality dealing
with the use of ionizing radiations in the
treatment of patients with malignant
neoplasias (and occasionally benign
diseases).
Role in:
• Curative management
• Palliation
• Adjuvant therapy

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The Aim of Radiation Therapy
To 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.
• Prolongation of survival.
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THERAPEUTIC-RATIO

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RADIORESISTANT TUMORS

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RADIOSENSITIVE TUMORS

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THE AIMS OF RADIOTHERAPY/THERAPEUTIC RATIO
CURATIVE MANAGEMENT

TCP: Tumor Control Probability
NTCP: Normal Tissue Complication Probability
ULC : Uncomplicated Local Control 
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The purpose of radiotherapy evolution: RSCM
to reduce the dose to organ at risk, therefore reduce toxicity
 The Five Fundamental Questions of
Radiation Therapy
• What is the indication Would radiotherapy be efficacious for the
for radiation therapy? patient? The gold standard is phase III

• What is the goal of Curative or palliative

radiation therapy?
• What is the planned GTV, CTV, PTV (ICRU 50 and ICRU 62)

treatment volume?
• What is the planned Conventional RT, 3D-CRT, 4D-Adaptive
RT, IMRT, VMAT, IGRT, Brachytherapy
treatment technique?
• What is the planned GTV = 70 Gy
treatment dose? Elective Lymph Node = 50 Gy
Palliative = 40 Gy

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Halperin EC et al. Principles and Practices of Radiation Oncology Lipincott Williams & Wilkins, 2008
ALGORITMA KANKER SERVIKS

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ALGORITMA  RADIOTERAPI KANKER ENDOMETRIUM 

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 Improvement in Radiation Therapy
• Technological innovations that allow delivery of
higher radiation doses to the tumor or lower doses
to normal tissues – IMRT, IGRT, VMAT (Arc
Therapy).
• The implementation of strategies that modulate
the biologic response of tumors or normal tissues
to radiation:
– Altered fractionation scheduling.
– Combined modality treatments using chemical or
biologic agents - Chemotherapy.
– Targeting molecular processes and signaling
pathways – Targeted Therapy.

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 Strategy of Combination Chemotherapy
with Radiotherapy as a Local Treatment

Induction or Chemotherapy
Neo-adjuvant Radiotherapy

During or Chemotherapy
Concomitant Radiotherapy

After or Chemotherapy
Adjuvant Radiotherapy

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 Interaction Between
Chemotherapy and Radiotherapy
• Spatial cooperation – target disease in different
anatomical sites; radiotherapy treats the primary
tumor, chemotherapy deals with systemic spread.
• Independent cell kill and “shared” toxicity – RT &
CT can be given at full dose, total cell kill should be
greater than RT or CT alone; In this mechanism, RT &
CT is given sequentially to avoid side-effects when
given concomitantly.
• Cellular and molecular interaction – RT & CT interact
each other at cellular and molecular level such that the
net effect greater than the simple addition. This
mechanism is likely to play a substantial role in
concomitant chemoradiation.
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Effect of Concurrent  Chemo‐Radiotherapy  on  Tumor Response

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 Molecular Mechanism of Interaction
Between Chemotherapy and
Radiotherapy
• Enhanced DNA/chromosome damage
and repair
• Cell-cycle synchronization
• Enhanced apoptosis
• Re-oxygenation
• Inhibition of cell proliferation during the
radiation interfraction interval – the key
benefit
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 Toxicity Resulting From
Concomitant Use of
Chemotherapy and Radiotherapy
• Early toxicity
– Imbalance between physiological loss of mature
cells and renewal from the stem cells or the
precursor cells.
– Due to inhibition of stem cell or precursor cell
proliferation
• Late toxicity
– Inhibition of DNA repair
– Specific mechanism of drug toxicity in sensitive
tissue (eg. Doxorubicin in the heart, Bleomycin in
the lung)

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 The Therapeutic Ratio

Schematic dose response curves for tumor and normal tissue damage with radiation.
The offset between the two curves indicates the therapeutic range.
Chemoradiotherapy leads to a shift of both curves to the left, ideally with a stronger
shift of the tumor curve (as indicated by the longer arrow), increasing overall efficacy
of treatment (radiation enhancement).
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Pelvic Radiation with Concurrent Chemotherapy Compared
with Pelvic and Para-Aortic Radiation for High-Risk
Cervical
Morris M. et al., NEJM, 1999

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Pelvic irradiation with concurrent chemotherapy versus
pelvic and para-aortic irradiation for high risk cervical
cancer: an update of radiation therapy oncology group
trial (RTOG 90-01).
Eifel PJ et al, J Clin Oncol 2004

P = 0,004

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Concurrent chemotherapy and pelvic radiation therapy
compared with pelvic radiation therapy alone as adjuvant
therapy after radical surgery in high-risk early-stage
cancer of the cervix.
Peter WA III et al., J Clin Oncol 2000

P = 0,003 P = 0,007

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Phase III Trial Comparing Radical Radiotherapy With
and Without Cisplatin Chemotherapy in Patients With
Advanced Squamous Cell Cancer of the Cervix
Pearcey R., M. J. Clin Oncol , 2002

p = 0,39

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Clinical Outcome in Posthysterectomy Cervical Cancer
Patients Treated with Concurrent Cisplatin and Intensity
Modulated Pelvic Radiotherapy: Comparison with
Conventional Radiotherapy
Miao FC et al., Int. J. Radiation Oncology Biol. Phys, 2007

Conclusion: Our results suggest that IMRT significantly

improved the tolerance to adjuvant chemoradiotherapy with
compatible locoregional control compared with conventional
Box-RT. However, longer follow-up and more patients are
needed to confirm the benefits of IMRT.
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A systematic review of acute and late toxicity of
concomitant chemoradiation for cervical cancer. Review
article
Kirwan JM, et al., Radiotherapy and Oncology, 2003.

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 PALLIATIVE CARE:
World Health Organization Definition

Palliative care is an approach that improves the

quality of life of patients and their families facing
the problem associated with life-threatening
illness, through the prevention and relief of
suffering by means of early identification and
impeccable assessment and treatment of pain
and other problems, physical, psychosocial and
spiritual.

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 Palliative Care
Advanced  stage  cancer  need  a  multimodal  therapy 
based on a interdisciplinary cooperation
•Surgery
•Medical Oncology
•Anesthesiology
•Psychiatry
•Radiation Oncology
•Psychical Medicine & Rehabilitation
•Dietitian
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Indications for Palliative Radiation
• Pain control • Brain Mets
o Bone mets o Whole Brain
o Nerve compression o Stereotactic
o Spinal Cord Compression • Bleeding
• Superior Vena Cava  o Hemoptysis (lung 
Syndrome cancer)
• Obstructive Relief o Rectal
o Airway/Bronchus o Bladder
o Esophagus o Gynecological
• Subcutaneous met
o Breast cancer

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 Bone Metastases
• Bone  metastases  most  common  cause  of  pain  in 
a cancer patient
• Due  to  nerve  ending  stimulation,  periosteal 
stretching,  or  growth  into  nerves  and 
surrounding soft tissues
• Pain may  be intermittant, or constant; related to 
activity; worse at particular times of day
• Plain x‐rays may show a lytic lesion or fracture
• Bone  scan  may  be  +  if  lesions  are  sclerotic  or 
blastic
• MRI may or may not contribute to the diagnosis
• Treatment:  pain  (WHO  ladder),  bisphosphonate,  
brace,  radiotherapy,  internal  fixation, 
vertebroplasty and  radionuclide
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 Radiotherapy Indications

• Painful Bone Metastases
• Preventing Pathologic Fracture
• Neurologic Complication Cause by Nerve Root 
or Spinal Compression
• Inhibit Local Recurrence After Surgery

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Bone metastases imaging

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 Brain Metastases
• Headache  and  impaired  cognitive  are  the 
most common of symptom.
• The  most  common  primary  are  breast  and 
lung
• MRI + gadolinum contrast can detect multipel 
metastases  dan  leptomeningeal  invasion 
more  effectively  than  any  other  imaging 
technique.

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BRAIN METASTASES

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 Management in brain metastases
• Corticosteroid
• Radiation therapy (WBRT)
• WBRT + Stereotactic radiosurgery (SRS)
• WBRT + Surgery (resection)

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Whole Brain Radiation Therapy

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Radiotherapy to stop Bleeding
Vaginal Bleeding

Vaginal tampon and

Tranexamic acid

Un-respond

Palliative RT
For
Stop bleeding
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The Evolution of External Beam
Radiation Therapy

2D Conventional 3D Conformal
Radiation Therapy Radiation Therapy

Volumetric Modulated Intensity Modulated RSCM

Radiation Therapy Radiation Therapy
The Evolution of Brachytherapy
3D – Image Guided
2D – ICRU 38 Brachytherapy

GTV, HR-CTV ~ 85 Gy
7 Gy in point A, 3 Fr IR-CTV ~ 60 Gy

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Radiotherapy Department, Dr. Cipto
Mangunkusumo Hospital, Jakarta

SRS

IMRT

SRS
SRT

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