The Diagnostic and Therapeutic Role of Ionizing Radiation in Managing Oncologic Disease

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The Diagnostic and Therapeutic Role of Ionizing
Radiation in Managing Oncologic Disease

• O. Kenneth Macdonald, M.D.
• Senior Associate Consultant
• Assistant Professor of Radiation Oncology
• College of Medicine
• Mayo Clinic

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DISCLOSURES

• I took Physics 121 and 122
• I was not a fan of Physics 121 or 122
• I ate lots of bear claws and drank lots of
  chocolate milk at the Wilk during the assigned
  hours for Physics 121 and 122
• I am not a fan of vectors
• Quantum, on the other hand. . .

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DISCLOSURES

• I am NOT
• Funded by corporate entity
• On a speakers panel
• A consultant or corporate advisor
• A partner/investor in medically-related equities
• I AM
• A Radiation Oncologist

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The Epidemiology of Cancer
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The Epidemiology of Cancer- Estimated increase by
2020
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The Epidemiology of Cancer- 2007 U.S. Estimates
Jemal, 2007
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The Epidemiology of Cancer
Jemal, 2007
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The Epidemiology of Cancer
Jemal, 2007
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The Epidemiology of Cancer
Jemal, 2007
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The Epidemiology of Cancer
Jemal, 2007
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Medicine is a collection of uncertain
prescriptions the results of which, taken
collectively, are more fatal than useful to
mankind. Napoleon Bonaparte (1769 - 1821)
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MAYO CLINIC
1883
Rochester,Minnesota
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MAYO CLINIC- Early Days
Dr. William Worrall Mayo
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Ionizing Radiation- Early Days
Wilhelm Conrad Röntgen 1845-1923 Observe
fluorescence of platino-cyanide salts exposed to
x-rays (invisible rays)
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Ionizing Radiation- Early Days
Antoine Henri Becquerel 1852-1908 In 1896
characterized and reported the phosphorescence
of uranium fogging of photo- graphic plates
through aluminum
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Ionizing Radiation- Early Days
Pierre and Marie Curie Extraction of
Radium Polonium discovered 1898 Radium
discovered 1898 (Dec)
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Ionizing Radiation- Early Days

• ...the rays emitted by radium have been found to
  have a marked curative effect upon external
  cancers...
• ...there is no reason why a tiny fragment of
  radium...should not be inserted into the very
  heart of the cancer...
• Alexander Graham Bell
• American Medicine, p 261, 1903

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Ionizing Radiation- Early Days

• 1903 M. A. Cleaves describes the treatment of a
  gynecologic patient with intracavitary radium in
  New York.
• 1903 H. Streble describes afterloading
  interstitial technique.
• 1904 W. Pusey and E. Caldwell treat uterine
  cancer with a radium capsule inserted in the
  uterus.
• 1910 L. Wickman and P. Degrais published textbook
  and described gynecological applicators.

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Ionizing Radiation- Early Days
Left Infraorbital Carcinoma, treated with
paste-mounted radium
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MAYO CLINIC- Expanding
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MAYO CLINIC- Expanding
Dr. Charlie
Dr. Will
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Ionizing Radiation- Expansion

• Bohr Model of the Atom

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Ionizing Radiation- Expansion
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Ionizing Radiation- Expansion

• Bremsstrahlung
• Braking
• Characteristic x-rays
• Auger electrons
• Positrons

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Ionizing Radiation- Expansion

• X-Ray Race
• First Generation
• Tubes
• Van-de-graff
• Atom Smasher
• Resonant Transformer
• 2nd Generation
• Betatron
• Cobalt
• LinAc

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Ionizing Radiation- Expansion
Cobalt 60
Orthovoltage
Superficial Therapy
Grenz Rays
Contact Therapy
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Ionizing Radiation- Expansion
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Ionizing Radiation- Expansion
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MAYO CLINIC- Defining a Destination
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Therapeutic Radiology-Defining a Destination

• Biology of Radiation Damage
• Indirect Action
• Primary Action
• -OH free radicals
• Direct Action
• Relatively Fewer
• DS breaks

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Therapeutic Radiology-Defining a Destination

• Fractionation
• Tumor kill
• Normal Tissue repair
• 4 Rs
• Repair
• Repopulation
• Reoxygenation
• Reassortment

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Therapeutic Radiology-Defining a Destination

• Therapeutic ratio
• Tumor kill
• Normal Tissue Injury
• Variables
• of clonogens (size)
• Cell cycle
• Oxygenation
• Total dose/ Fraction size
• Quality of Radiation
• SLD repair capacity

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Therapeutic Radiology-Defining a Destination

• Therapeutic Ratio
• Tumor Size

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Therapeutic Radiology-Defining a Destination

• Therapeutic Ratio
• Cell cycle
• Sensitive
• G2/ M-
• Resistant
• S-/ G1

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Therapeutic Radiology-Defining a Destination

• Therapeutic Ratio
• Oxygenation

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Therapeutic Radiology-Defining a Destination

• Therapeutic Ratio
• X-Ray Quality
• LET

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Therapeutic Radiology-Defining a Destination

• Therapeutic Ratio
• Sub lethal
• Damage Repair

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Therapeutic Radiology-Defining a Destination

• Therapeutic Ratio
• Normal tissue tolerance

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MAYO CLINIC- Finding its niche
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Therapeutic Radiology-Finding its Niche
Hodgkins Lymphoma
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Therapeutic Radiology-Finding its Niche
Hodgkins Lymphoma
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Therapeutic Radiology-Finding its Niche
Uterine Cervix
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Therapeutic Radiology-Finding its Niche
Lung Cancer
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Therapeutic Radiology-Finding its Niche
Lung Cancer
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Therapeutic Radiology-Finding its Niche
Lung Cancer
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Therapeutic Radiology-Finding its Niche
Anal Cancer
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Therapeutic Radiology-Finding its Niche
Esophageal Cancer
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Therapeutic Radiology-Finding its Niche
Prostate Cancer
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Therapeutic Radiology-Finding its Niche
Head Neck Cancer
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Therapeutic Radiology-Finding its Niche
Pediatric Cancers
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Therapeutic Radiology-Finding its Niche
Gastrointestinal Gastric Pancreas Hepatobilia
ry Rectal Cancer Genitourinary Testicular Bladd
er Gynecologic Uterine Vaginal Vulvar Lymphoma
NHL Leukemia

• Adjuvant Therapy
• Skin
• melanoma
• non-melanoma
• CNS
• benign
• primary
• metastatic
• Head Neck
• benign
• post-operative
• Breast
• Breast conservation
• post-mastectomy

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MAYO CLINIC in the 21st Century
St. Marys Hospital
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MAYO CLINIC in the 21st Century
Mayo and Gonda Buildings
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MAYO CLINIC in the 21st Century
Scottsdale, Arizona
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MAYO CLINIC in the 21st Century
Jacksonville, Florida
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Radiation Oncology in the 21st Century- Radio
Immunotherapy
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Radiation Oncology in the 21st Century-
Intraoperative Electrons

• IORT
• Recurrence
• Colon Rectal
• Sarcoma
• Gynecologic

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Radiation Oncology in the 21st Century- High Dose
Rate BT

• Afterloading
• Uterine
• Cervix
• Sarcoma
• Head Neck
• Prostate
• Breast

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Radiation Oncology in the 21st Century-
Intracranial Stereotactic Radiosurgery

• SRS
• Glioma
• Metastasis
• Recurrence
• Benign
• Meningioma
• Schwannoma
• Trigeminal Neuralgia
• AVM

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Radiation Oncology in the 21st Century-
Extracranial Stereotactic Radiosurgery

• SBRT
• Lung
• Primary
• Metastasis
• Liver
• Spine
• Retroperitoneum
• Prostate

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Radiation Oncology in the 21st Century- Particle
Therapy

• Protons
• Heavy Ions
• Helium
• Carbon

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Radiation Oncology in the 21st Century- Total
Body Irradiation

• Preparative Regimen
• Leukemia
• Lymphoma
• Graft Rejection

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Radiation Oncology in the 21st Century- Unsealed
Sources

• Palliative Intent
• Samarium
• Strontium
• Adjuvant
• Iodine-131

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Radiation Oncology in the 21st Century- Benign
Disease

• Vascular
• Soft Tissue

• Bone
• Nerve

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Radiation Oncology in the 21st Century- Challenges

• Improve Tumor Cell Kill
• Dose
• Sensitization
• Biologic Modulators

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Radiation Oncology in the 21st Century- Challenges

• Reduce Soft Tissue Toxicity
• Radio protectors
• Improved beam shaping/ dose deposition
• Identify tumor vs. normal cell

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Radiation Oncology in the 21st Century- Challenges

• Image Guided Radiotherapy
• Hitting what you aim at

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Thank You
macdonald.orlan_at_mayo.edu