Prinsip Dasar Radioterapi
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Transcript of Prinsip Dasar Radioterapi
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04/13/23 D. ERAWATI
PRINSIP-DASAR ONKOLOGI RADIASI
dr. Dyah Erawati. Sp.Rad.(k) Onk.Rad Instalasi Radioterapi, Lab/SMF Radiologi
RSU Dr.Soetomo/FK. UNAIR Surabaya.
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Terapi keganasan
3 besar pengobatan penyakit keganasan:
Operasi
Radiasi
kemoterapi
Treatment Photon
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Tujuan
Memahami proses interaksi radiasi pengion dengan materi biologik, secara fisik maupun biologik, serta faktor yang mempengaruhinya dalam rangka pemanfaatan radiasi pengion untuk pengobatan kanker .
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Definisi
Radioterapi : pengobatan penyakit kanker dengan sinar pengion .
Sinar pengion gelombang elektromagnetik atau partikel berenergi yang menimbulkan ionisasi
bila melewati berbagai materi termasuk materi
biologi.
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RADIOTERAPI meliputi :
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04/13/23 D. ERAWATI
FISIKA RADIASI
DALAM ONKOLOGI RADIASI
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Peran Fisika Radiasi Dalam Radioterapi:
Menjelaskan mekanisme interaksi radiasi pengion dengan materi, serta faktor yang mempengaruhinya
Menetapkan sistem dosimetri, serta teknik pengukuran dosis in vitro dan in vivo
Mengukur dan memvisualisasikan distribusi dosis radiasi dalam fantom
Menyusun perencanaan radiasi
Quality assurance
Proteksi radiasi
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Ionizing Radiations
Electromagnetic Particulate
x-ray = γ-raysα-particles
electrons
(β-particles)
neutrons
protons
π-meons
heavy ions
Ionizing Radiations
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Macam sinar pengion
I.I. Gel Elektromagnetik (non korpuskuler):
- Panjang gel. Sangat pendek.
- Tidak bermassa dan bermuatan.
- Contoh : Sinar X dan sinar Gamma.
II.II. Kelompok partikel (korpuskuler)
- Bermassa dan bermuatan.
- Daya tembus kecil.
- Contoh : - sinar alpha , bermuatan positif.
- sinar beta, bermuatan negatif Sr90,
Au138
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Tujuan Radiasi:
Dengan energi tinggi, akan menghancurkan dan mensterilkan sel-sel tumor secara langsung (direct) maupun tidak langsung(indirect).
Prinsip :Prinsip :
Mematikan sel-sel kanker >>>, sel normal << (rasio terapeutik)
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Dasar-dasar fisika
MEKANISME INTERAKSI RADIASI PENGION DENGAN MATERI :
tergantung dari besarnya energi
- EFEK FOTO LISTRIK
- EFEK COMPTON
- PRODUKSI PASANGAN POSITRON -
ELEKTRON
Ionisasi
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Dosimetri :
1 . Paparan radiasi diudara, - satuan: R (Rontgen) Sievert
2. Dosis = jumlah energi radiasi yang diserap persatuan berat jaringan, satuan rad (Radiation Absorbed Dose) Gy (Gray) = 1 Joule per 1 Kg jaringan.
1 Gy = 100 Rad = 100 cGy
3. Aktivitas : Currie Becquerel (Bq )
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Berbagai jenis alat ukur disesuaikan dengan :
Jenis radiasi : foton, elektron
Besaran energi : kilovoltase, Megavoltase
Pengukuran diudara, dalam phantom, in vivo, dalam jaringan tubuh
Radiasi eksternal, brachyterapi, radiasi dengan sumber terbuka
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Visualisasi Distribusi Dosis Radiasi
Dalam phantom air atau phantom solid, yang mempunyai kesamaan densitas dengan jaringan lunak
Variasi tergantung dari jenis radiasi, besaran energi radiasi
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Proteksi radiasi
waktu
Jarak
pelindung
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monitoring
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RADIOBIOLOGI
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TUJUAN RADIOBIOLOGI
( THE ART OF RADIOTHERAPY )
A B C
DOSE in Gy
prob
abil
ity
Menjauhkan kurve TCP & NTCP
Sensitiser
Protektor
Dosis fraksinasi
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Time scale of radiation effect.
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SKEMA STRUKTUR SEL
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Mekanisme kerusakan sel akibat radiasi (fisika & biologi)
X Ray
Ionisasi
efek langsung tidak langsung
(DNA) (H2O)radikal bebas
SSB/DSB ect
P53 (G1 blok)
repair genes
Apoptosis proliferasi
Rasio terapeutik
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Rasio terapeutik
Perbandingan antara tingkat kemungkinan eradi kasi tumor dan kemungkinan terjadinya kerusa
kan jaringan sehat pada lapangan radiasi dan
dosis yang sama.
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Rasio terapeutik……..
Rasio terapeutik optimal Radiation physic Physical aspect approach - supporting technique - Computer technology ( radiotherapy) - Imaging facility. Radiobiology
- Biological effect modifiers : - proliferation (G2/M hyperfractionated) - Heat (hyperthermi) - Oxygen (hyperbaric) - apoptosis - Radiosensitizer (chemo irradiation), radio protector.
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Kepekaan sel terhadap radiasi
1. Faktor intrinsik ( faktor dari dalam sel )
a. Siklus sel.
b. Kontrol genetik
2. Faktor ekstrinsik ( faktor dari luar sel)
a. Oksigen.
b. bahan kimia : - radiosensitizer.
- radioprotektor.
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Siklus sel
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Basic Principles cell cycle
Cell cycleG1 - RNA and protein synthesisS - DNA synthesisG2 - RNA and protein synthesisM - mitosis
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Respon jaringan thd radiasi tergantung antara lain :
Radiosensitivitas sel.
Jumlah sel yang aktif dalam proliferasi ( Growth fraction )
Oksigenasi intraseluler.
Cara pemberian radiasi.
- Radiasi tunggal
- Radiasi fraksinasi ( radiasi berulang dg dosis kecil, dan
interval tertentu ).
LET ( Linier Energi Transfer) radiasi pengion.
Hipertermi.
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Respon jaringan kanker terhadap radiasi :
Radiosensitif : contoh : - limfo-hematologi : leukemia, limfoma. - sel benih : seminoma testis, disgerminoma. - embrional : retinoblastoma, tumor wilms ( ginjal ) dosis : 30-40 Gy.
Radioresponsif : dosis 40-66Gy kanker payudara, leher rahim, nasofaring, kulit.
Radioresisten : dosis diatas 70 Gy. Sarkoma kulit, tulang, melanoma.
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• Cara pemberian radiasi
1. Dosis tunggal ( radiasi tunggal) ------ sekali
pemberian.
2. Radiasi fraksinasi ( radiasi berulang dg dosis kecil,
dan interval waktu tertentu)
mis: 1,8-2 Gy/fraksi/hari
Seminggu 5 kali.
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Dampak radiasi fraksinasi
dibandingkan radiasi tunggal, radiasi fraksinasi akan menghasilkan : - kematian sel tumor >>>
- keutuhan jaringan normal lebih dapat dipertahankan
Dampak radiasi tunggal
Jr. tumor mengandung sel yang heterogen
bila diberikan dosis tunggal akan menyebabkan tersisanya sel yang resisten yang mampu berkembang terus
perlu dosis >>> kematian jr. normal >>>
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Rasional dari fraksinasi berdasarkan pada :
Konsep 5 R : 1. Reoksigenasi. 2. Redistribusi. 3. Repair( reparasi) 4. Repopulasi 5. Intrinsik radiosensitivitas
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Rasional…….
Proses reoksigenasi
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Rasional…..
Proses redistribusi :
radiasi pertama kematian sel yg sensitive (fase M/G2), sdng fase yg lain terus berlanjut, shg saat radiasi kedua sel dlm fase G1 dan S tsb sdh ada dalam fase G2/M.
dst..
Proses repair
pada jr. sehat berlangsung lebih cepat dari rata-rata sel kanker.
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Normal cell repair better between Normal cell repair better between radiation treatment radiation treatment
Malignant cell do not repair readily Malignant cell do not repair readily after radiation treatment after radiation treatment
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Rasional……...
Proses repopulasi
- repopulasi jaringan sehat.
- perlu waspada adanya accelerated repopulasi dari
sel tumor selama berlangsungnya radiasi, setelah
minggu ke 3/4 dari radiasi fraksinasi.
Radiosensitivitas.
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RADIOTERAPI
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Unit Radioterapi
I. Sumber Daya Manusia A. Dr. ahli radioterapi ( Radiation oncology) di Ind : Dr. ahli radiology + pendidikan subspesialisasi onkologi radiasi. B. Ahli fisika radiasi Sarjana fisika + pendidikan khusus untuk penerapan radiasi pada pengobatan. C. Radiographer khusus radioterapi. D. Ahli tehnik/sarana tehnik. E. perawat. D. administrasi.
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Unit radioterapi…...
II. Pesawat radiasi
1. Radiasi eksterna ( teleterapi )
2. Brakhiterapi
III. Sarana penunjang
1. Simulator.
2. Treatment Planning System (TPS)
3. Kamar cetak ( mould room) & immobilisasi
4. Ruang perawatan sehari.
IV. Gedung
- ketebalan dinding harus dihitung, min 1,5-2 m beton
konkrit.
- arah lobang pemipaan harus ditegaskan proteksi
radiasi
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Modalitas alat radiasi
Ditinjau dari sumbernya:
A. Generator listrik. B. Alamiah hasil dari proses
radioisotop dan menghasilkan
sinar Gamma, sinar beta,
sinar alfa.
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Modalitras…….
GENERATOR LISTRIK : - Sinar X dan sinar Gamma. - Berdasarkan energi : I. Kilovolt : - Grenz ray ( 10-20Kv.) - Contact therapy ( 40-50Kv) - Superficial therapy ( 50-150Kv) - Orthovoltage/deeptherapy(150-500Kv.)
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Modalitas……..
II. Megavoltage Menghasilkan sinar dengan energi minimal 1 megavolt.
Contoh : LINAC Cobalt 60.
Betatron Cyclotron
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SUMBER ALAMIAH
1. Sumber terbuka : I131, Au 198.
2. Sumber tertutup : Cobalt 60, Cs 137, Ir 192
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Radiasi eksterna (teleterapi)
- kilovolt
- megavolt : - cobalt 60, LINAC
Brakhiterapi ( sealed radioactive source)
- Manual.
- After loading : - manual
- remote control.
Radiasi interna (unsealed radioactive source)
Terapi sistemik : Jodium131 ( I131)
RADIASIRADIASI
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RADIASI EKSTERNA (TELETERAPI)Mempunyai jarak tertentuKeutungan : mencakup target yang luas (lokoregional)
Cobalt 60Cobalt 60
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LINAC (Varian Clinac 2100)
Dengan MLC
LINAC EBRT - Electron
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BRAKHITERAPI
RIWAYAT :
1898 Ra 226 ditemukan o/ Currie.
5 tahun kemudian ada laporan keberhasilan RTX dg Ra.
Perkembangan metode Paris, Stockholm, Manchester.
Perkembanagan radioisotop selain radium: Cs 137, Co 60, I125, Ir 192.
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Brakhiterapi…..
Prinsip : mendekatkan sumber radiasi pada/didalam target radiasi.
Keuntungan :
1. Distribusi dosis radiasi lebih terlokalisir.
2. Kerusakan jr. normal sekitarnya <<<
3. Kontrol tumor >>>
4. Waktu tx lebih singkat, bila dibandingkan radiasi
eksterna konvensional m kesempatan
tumor repopulasi selama terapi.
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Brakhiterapi…….
Kontra indikasi : - tumor sangat besar. - tumor telah menginfiltrasi tulang/ batas target tak
jelas.
Digunakan : 1. Modalitas tunggal radikal terapi t.u : - localized tumor. - diameter tu. 5mm/ < - target volume jelas. 2. Booster kombinasi dg : operasi radiasi eksterna.
Dasar radiobiologi brakhiterapi = radiasi eksterna.
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Brakhiterapi……..
Penggolongan Brakhiterapi : A. Letak sumber radioaktif
- interstitiil brakhiterapi didalam tumor.
- contact brakhiterapi didekat tumor.
Intracaviter, intraluminer, surface ( plesiotherapy),
endovasculer.
B. Waktu radiasi
1. Permanent implant.
2. Temporary implant
C.Dose Rate ( laju dosis ), ICRU 38
- LDR ( 0,4-2 Gy/h)
- MDR ( 2-12 Gy/h)
- HDR ( > 12 Gy/h)
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Brakhiterapi……
Tehnik aplikasi :
- Tehnik manual : hanya untuk LDR
- Tehnik afterloading :
kelebihan : aman untuk petugas.
lebih akurat pemasangan aplikator kosong.dapat untuk HDR, shg penyinaran
pendek tidak perlu MRS.
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Brakhiterapi …….
Radium 226 (Ra 226) tidak direkomendasikan untuk pemakaian dalam radioterapi ditinjau dari segi proteksi
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APLIKATOR SERVIKS
VAGINAL SILINDER
ALAT BRAKHI
CONTAINER SOURCE
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Brakhiterapi Ca Cx
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Brakhiterapi pada Kanker Nasofaring.
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Simulator
Duplikator alat terapi radiasi menggunakan diagnostic X ray - radiografi film
- fluoroscopy
dilengkapi dg Gantry yang dapat berputar 3600, dapat mengindentifikasi secara geometris yang dapat berhubungan dengan treatment beam.
SARANA PENUNJANG
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MACAM
SIMULATOR
1. KONVENSIONAL
2. SIMULATOR - CT
3. CT - SIMULATOR
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TREATMENT PLANNING SYSTEM
Perencanaan dalam radioterapi yang dilakukan dengan system komputer, dalam bentuk 2D /3D
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TREATMENT PLANNING SYSTEM
Tujuan :Tujuan :
1. Melokalisir volume tumor GTV, CTV,
PTV.
2. Mengukur skema pasien/volume target
organ resiko.
3. Kalkulasi distribusi dosis dan
menentukan konfigurasi .
KONVENSIONAL
IMRT
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IMMOBILISASI
Tujuan :Tujuan : supaya posisi pasien tetap sama selama penyinaran berlangsung dan dapat dibuat tanda-tanda marker pada alat immobilisasi tersebut sehingga marker tersebut tidak hilang.
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macam immobilisasi
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POSISI PASIEN WAKTU RADIASI DENGAN LINAC / MLC
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PERAN RADIASI
DEFINITIF Tx. Utama / tx. Tunggal.AJUVAN atau KOMBINASI dengan ;
A. Operasi : - pre opx, IORT, post opx. B. Sitostatika/ Kemoterapi. Tujuan : - mematikan sel kanker yg
mungkin telah tersebar sistemik. - meningkatkan efek radiasi
(radiosensitizer)
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TAHAPAN RADIASI
PRE PLANNING
PLANNING RT TREATMEMT
TREATMENT DELIVERY
FOLLOW UP
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PRE PLANNING
Clinical evaluation and staging e.g. T.N.M.
Treatment intent RADICAL or PALLIATIVE
Choice of treatment : - surgery.
- radiotherapy.
- chemotherapy.
Description of treatment.
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PLANNING RT TREATMENT
Method of patient immobilization.
Image acquisition of tumor and patient data for planning.
Delineation of volumes ( GTV, CTV, PTV)
Choice of technique and beam modification.
Computation of dose distribution
Dose prescription.
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TREATMENT DELIVERY
Implementation of treatment
Verification
Monitoring of treatment
Recording and reporting treatment.
Evaluation of treatment.
Patient evaluation during treatment.
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FOLLOW UP PASIEN
KONTROL TUMOR.
TOLERANSI JARINGAN NORMAL.
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EFEK SAMPING RADIASI
Umum : pada umumnya akut dan berhubungan dengan keadaan umum lelah, lesu, nafsu makan menurun, (radiation sickness syndrome)
Lokal , tgt daerah yag diradiasi. Berlangsung akut dan kronis. Akut : timbul selama berlangsung radiasi sp 3 bl
akhir radiasi. Umumnya reversibel. Kronis : timbul dg periode laten lebih dari 3 bl. Irreversibel
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Faktor-faktor prediksi respon radiasi
A. KLINIS : - lokasi tumor. - stadium/besar tumor. - gambaran histopatologi. - status penampilan - darah lengkap : Hb, lekosit,trombosit.
B. NON KLINIS : - kinetik sel (proliferasi) - ploidy/ sitogenetik - ekspresi gen - sensitivitas intrinsik.
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