1. The patient presented with a 1.5 x 1.5 cm cancerous growth on their uvula. A biopsy confirmed it was a moderately differentiated squamous cell carcinoma. 2. A mould was prepared using alginate impression material and dental stone to create an intraoral prosthesis for brachytherapy treatment planning and delivery. 3. Brachytherapy treatment was planned using CT imaging and catheter reconstruction to deliver 60Gy in 13/14 fractions twice daily to adequately cover the clinical target volume while sparing nearby organs at risk.

1. ROSE CASE
MOULD BRACHY UVULA
RADIATION ONCOLOGY
SIMULATION TO EXECUTION
DR KANHU CHARAN PATRO

2. HISTORY
• Painful swallowing
• Mass in the upper part of palate

3. DIAGNOSIS BY LOCAL ENT SURGEON
• 1.5 x 1.5 cm uvular growth
• Not extending to soft palate
• Planned biopsy

4. EXICISIONAL BIOPSY
• Outside by ENT surgeon

5. BIOPSY REPORT
• PT-1X0.8X0.8 CM
• Squmaous cell carcinoma
• Moderately differentiated
• Margins not commented

6. NECK NODE EVALUATION
• NON SPECIFIC LYMPHADENOPATHY
– MRI
– USG
– CT

7. FINAL DIAGNOSIS
• CANCER UVULA –POST EXICIONAL BIOPSY
• MARGIN NOT COMENTED
• pT1NOMO

8. TUMOR BOARD PLAN
• BRACHYTHERAPY
• MOULD
• EQD2- 60Gy

9. REQUIREMENTS
FOR MOULD PREPARATION
• ALGINATE IMPRESSION MATERIAL
• Cast
• Dental stone
• Water
• U-CLASP
• COLD CURE ACRYLIC powder and
liquid
• 2ml syringe
• Spatula
FOR BRACHY
• Gention violet
• Ear bud
• 2ml syringe
• Spatula
• Miro pore
• Copper wire
• Quickfix
• Xylocaine spray

10. MOULD PREPARATION

11. SELECTION OF IMPRESSION TRAY

12. MIXING ALGINATE IMPRESSION MATERIAL

13. UPPER IMPRESSION TAKEN WITH
ALGINATE IMPRESSION MATERIAL

14. MIXING DENTAL STONE WITH WATER

15. POURING OF CAST WITH DENTAL STONE

16. DENTAL CAST

17. PREPARATION OF U-CLASP WITH SS WIRE

18. PREPARATION OF U-CLASP WITH SS WIRE

19. POURING OF CAST WITH DENTAL STONE

20. U-CLASP

21. DENTAL CAST WITH FOUR U-CLASPS

22. APPLICATION OF SEPARATING MEDIUM

23. DENTAL CAST, COLD CURE ACRYLIC POWDER AND LIQUID

24. SPRINKLE TECHNIQUE

25. SPRINKLE TECHNIQUE

26. SPRINKLE TECHNIQUE

27. REMOVAL OF PROSTHESIS FROM DENTAL CAST

28. AFTER TRIMMING OF SHARP MARGINS

29. CHECKING THE FIT OF PROSTHESIS IN PATIENTS MOUTH

30. ADDITION OF MODELLING WAX TO PROSTHESIS

31. IOP in patients mouth

32. IOP IN PATIENTS MOUTH

33. Intra oral Prosthesis
INTRA ORAL PROSTHESIS

34. SPACING OF WIRES

35. GROOVING

36. FIXING WITH QUICK FIX

37. GENTION VIOLET

38. EAR BUD

39. EAR BUD –CUT ONE SIDE

40. 2ML SYRINGE

41. FILL THE EAR BUD

42. MARK THE TARGET AREA

43. TAKING IMPRESSION AND
EXTRAPOLATION ON MOULD

44. COPPER WIRE

45. FXING THE COPPER WIRE

46. FINAL MOULD

47. CONTACTING WITH PPW

48. SEPARATING THE PPW BY RYLE’S TUBE

49. PLANNING CT
• 1 MM SLICE
• SUPINE
• WITH MOULD
• WITH IOP
• VERTEX TO CLAVICLE
• MULTIPLANNAR

50. CATHETER NUMBERING

51. CATHETER RECONSTRUCTION

52. TARGET DELINEATION
• Target definition of the Gross Tumor Volume (GTV)
and Clinical Target Volume (CTV) are usually
performed by clinical examination aided by imaging
and intraoperative findings.
• In brachytherapy, typically no additional margin is
required to ensure that theCTV receives the planned
dose and therefore.
• Unlike external beam irradiation, CTV and PTV
(Planning Target Volume) are considered equivalent

53. DOSE SELECTION

54. DOSE SELECTION
• 4GY
• TWICE DAILY
• 13/14 FRACTIONS
• ALPHA/BETA-10

55. TREATMENT GAP

56. PLANNING
• ACCURATELY MEASURED CATHTER LENGTH BEFORE CT
• CATHTER NUMBERING AND MARKED
• CATHTER RECONSTRUCTION
• PLANNED BY IPSA
• OPTIMIZED GRAPHICALLY
• TREATMENT CALCULATION
• VERIFICATION
• EXECUTION

57. TARGET DOSE EVALUATION

58. TARGET DOSE EVALUATION

59. TARGET DOSE EVALUATION
• CTV coverage is adequate (i.e., D90 is at least 90% of
the prescribed dose)
• The prescription dose is usually the minimum dose
received by the CTV or a CTV surrogate (i.e., the D90 >
100, V100 > 90%)
• DNR should be equal or lower than 0.36 and in IMBT
(intensity modulated Brachytherapy) 0.42
• Dose non-uniformity ratio (DNR= V100/V150)
• The optimal spacing between applicators is <15 mm

60. TARGET DOSE EVALUATION
COVERAGE INDEX
 CTV VOLUME 0.32CC DESIRABLE
 DNR INDEX V150 / V100 = 34.04/96.42 =0.35 0.36 T0 0.5
 D90
98.34% >90%-100%
 V100
96.42% >90%
 V150
34.04% ALARA
 V200
8.94% ALARA
 V300
2.67% ALARA

61. ISODOSE IN ALL PLANES
BLUE 85%
RED 100%
ORANGE 150%
WHITE 200%
GREEN 300%

62. DVH STATISTICS

63. DRR

64. OAR EVALUATION

65. SEPARATING THE BOT

66. SEPARATING THE BOT

67. SEPARATING THE BOT

68. XYLOCAINE SPRAY

69. IOP- SPACER

70. TREATMENT POSITIONING

71. INTRATREATMRNT CARE
• ORAL HYGIENE
• SOS ANALGESICS

72. POST TREATMENT CARE
• ORAL HYGIENE
• SOS ANALGESICS
• COUNSEL ABOUT THE UPCOMING REACTIONS

73. FOLLOW UP
1. FOLLOW UP AFTER 3 MONTHS
2. LOCAL EXAMINATION
3. USG NECK FOR NODES

74. REVIEW LITERATURE
• LIP
• HARD PALATE
• SOFT PALATE
• GINGIVA

75. HARD PALATE

76. LIP AND BUCCAL MUCOSA

77. ALL SITES

78. UVULA
• NOT REPORTED YET

79. SUMMARY
• Follow GEC-ESTRO guidelines
• Train your dentist
• Follow steps
• Wires should not touch necked to any surface
• Use lead /IOP
• Reactions usually observed after treatment- do not
get panic , wait
• Counsel

80. ACKNOWLEDGEMENT
DR RAMAYA REDDY –BDS
1. DR P S BHATTACHARYYA
2. DR C R KUNDU
3. DR V K R REDDY
4. DR M MRITYUNJYA
5. DR SRINIVAS REDDY
1. A C PRABU
2. AKETI SRINU
3. PRASAD
4. DR A ANIL KUMAR
1. DR PRIYASHA DAMODARA
2. DR PREMCHAND A
3. DR MOHANPRIYA A
4. DR KEERTHIGA K
1. SISTER SRITHA
2. SISTER VENKATLAXMI