Contents
Foreword
Preface
Acknowledgments
Abbreviations
Chapter 1
Historical Perspective of Radiation Therapy
Chapter 2
External Beam Radiation Therapy Equipment
Chapter 3
Dose Determination for External Beams
Chapter 4
Dose Calculation for External Beams—Part I
Chapter 5
Dose Calculation for External Beams—Part II
Chapter 6
Isodose Charts and Typical Field Arrangements
Chapter 7
The Treatment Preparation Process—I: Target Localization,
Treatment Uncertainties, and Patient Immobilization
xi
xiii
w
wwii
16
322
59
je
162Chapter 8
‘Treatment Preparation—II: Beam-Modifying Devices
and Quality Assurance 29
Chapter 9
‘Treatment Planning—Head and Neck Region 268,
Chapter 10
‘Treatment Planning—Central Nervous System
and Pituitary Gland 331
Chapter 11
‘Treatment Planning—Thorax and Breast 367
Chapter 12
‘Treatment Planning—Abdomen 20
Chapter 13
‘Treatment Planning —Pelvis 439
Chapter 14
‘Treatment Planning—Miscellaneous ‘Treatments 490
Chapter 15
Dose Calculations in Brachytherapy 533,
Chapter 16
Practical Applications of Brachytherapy Techniques 562
Answers to the Problems 616
Appendix ay
Color Plates appear between pages 532 and 533.
Index 27AAPM.
Al
avg
Au
BEV
BSF
Bq
CaCl,
CaF,
cccr
Gy
Gy/mi
eGyMU
G
cm
Co
COPD
Cs
CSI
Cu
%DD
D,
Abbreviations
American Association
of Physicists in Medicine
aluminum
area/perimeter
average
gold
beam’s-eye view
backscatter factor
becquere!
central axis
calcium chloride
calcium fluoride
computer-controlled
conformal therapy
centigray
centigray per minute
centigray per monitor unit
curie
centimeter
cubic centimeter
cobalt
chronic obstructive
pulmonary disease
cesium
craniospinal irradiation
computed tomography
clinical target volume
copper
percentage depth dose
depth
maximum dose
‘depth of maximum dose
dps
DRR
DVH
EPID
eqsq
FL
fa
GIV
HBB
HVT
IcRu
It
ISF
keV
kVp
LiF
LAO
mCi
mm
disintegrations per second
digitally reconstructed
radiograph
dose-volume histogram
electronic portal imaging
devices
equivalent square
field length
field size
roentgen to centigray
in tissue
gram
‘grOss tumor volume
gray
hour
half-beam block
half-value layer
half-value thickness
iodine
International Commission
on Radiation Units and
Measurements
iridium
inverse square factor
joule
Kiloelectron volt
peak kilovoltage
lithium fluoride
left anterior oblique
left posterior oblique
millicurie
millimeterCHAPTER
Historical Perspective of Radiation Therapy
THE DISCOVERY OF ROENTGEN RAYS
AND RADIOACTIVITY
THERAPEUTIC USES OF X-RAYS
AND RADIOACTIVITY
MEASUREMENTS OF QUALITY AND QUANTITY
OF RADIATION BEAMS
‘TECHNICAL DEVELOPMENTS:
‘Technical Developments: 1920-1940
Technical Developments: 19401960
‘Technical Developments: 1960—Present
RADIOBIOLOGY
RADIATION PROTECTION
THE LIFE OF OUR PIONEERS
Wilhelm Conrad Réntgen
Marie Sklodowska Curie
Antoine Béclére
SOME IMPORTANT MILESTONES IN THE
HISTORY OF RADIATION THERAPY
THE DISCOVERY OF ROENTGEN RAYS
AND RADIOACTIVITY
On Friday, November 8, 1895, while passing an
electric current through a Hittorf-Crookes high-
vacuum tube, Wilhelm Conrad Rontgen* noticed a
light coming from a workbench about a yard away.
He identified the shining object as a piece of paper
painted with barium platinocyanide, Realizing that
this light must have been caused by a new kind of
rays, he called them x-rays which later became
known as roentgen rays. He continued the investiga-
tion of these rays and found that when he replaced
the fluorescent screen with a photographic plate, he
‘could obtain pictures. The most dramatic picture,
* Usually writen “Roentgen” inthe English-language literature.
taken on December 22, only 6 weeks following the
discovery of the invisible rays, showed the bones in
his wife’s hand, Density variations, depending on the
tissues in the path ofthe rays, were observed, and the
value of such radiographic images inthe diagnosis of
human ailments immediately became evident.
‘On December 28, 1895, Ronigen delivered a writ-
ten presentation of his discovery to the Physical-
Medical Society of Wiirzburg. Within a few weeks,
this preliminary communication entitled On a New
Kind of Rays was translated into many languages. On
New Year's Day, 1896, he mailed copies ofhis paper
along with some radiographs to several European
physicists whom he knew. The news ofthe discovery
spread very quickly and was soon known all over the
world.
Only a few weeks after Réntgen’s discovery,
12 RADIATION THERAPY PLANNING
Henri Becquerel began investigating the possibil-
ity of similar rays being produced by known fluores-
cent or phosphorescent substances. He observed the
darkening of photographic plates (Chap. 3) by ura-
nium salts and realized that these rays were emitted
spontaneously and continuously from the uranium;
thus, radioactivity was discovered,
Marie Curie, who at this time was studying miner-
als in Paris, became interested in the phenomenon of
radioactivity and chose this subject for her doctoral
thesis. Pierre Curie eventually joined his wife in her
research, and in July 1898 they discovered polon-
ium; in December of the same year, they reported the
discovery of radium.
Both Becquerel and Pierre Curie experienced ery-
thema on the skin of the chest from carrying small
samples of radium in their vest pockets, Pierre Curie
applied radium to his arm and described in detail the
various phases of a moist epidermitis and his recov-
ety from it. He also provided radium to physicians,
who tested it on patients.
‘The news of these discoveries spread quickly, and
—having leamed that redness of the skin was ob-
served by the users of these rays—several phy’
cians began investigating their effect on malignant
tumors; thus, the use of ionizing radiation in the
treatment of cancer began.
THERAPEUTIC USES OF X-RAYS
AND RADIOACTIVITY
More than any other innovation, the ability to visual-
ize the interior of the living human body painlessly
has govemed the practice of medicine during the
‘wentieth century. The radiotherapeutic application
of these discoveries also had a profound effect on
cancer survival rates. This chapter focuses on the
therapeutic uses of x-rays and radioactivity.
‘The discovery of x-rays and radioactivity was
promptly followed by their therapeutic application.
‘The first therapeutic use of x-rays is reported to have
taken place on January 29, 1896, when a patient with
carcinoma of the breast was treated; by 1899, the
first cancer, a basal cell epithelioma, had been cured
by radiation,
‘The initial dramatic responses observed in the
treatment of skin and other superficial tumors gener-
ated the hope that a cure for cancer had finally been
found. This hope was soon followed by a wave of.
disillusionment and pessimism when tumor recur-
rences and injuries to normal tissues began to appear.
‘The treatments often involved single massive expo-
sures aimed at the eradication of tumors, and the
patients who survived the immediate postirradiation
period often developed major complications. Be-
cause of these disappointing results the use of x-rays
to treat tumors would soon have been abandoned had
it not been for laboratory and clinical work by
Claude Regaud and Henri Coutard. They found that
by administering fractionated doses of radiation (that
is, smaller daily doses rather than a large single
dose), they could achieve the same tumor response
but without serious injury to the adjacent normal tis-
sues,
From the early experience, it was evident that the
unique advantage of radium lay in intracavitary and
imerstital applications. Here, where the radioactiv-
ity was placed directly on or inside the tumor, the
radiation did not first have to traverse normal tissue;
the short distance and rapid fall-off of dose offered
an advantage in this setting. Initially, containers were
rather bulky and could be used only for intracavitary
gynecologic implants. In 1914, methods were devel-
‘oped for collecting radon (a daughter product of ra-
dium) in small glass tubes, which were then placed
inside hollow metal seeds. Like radium needles,
these could be inserted directly into the tumors. Ra-
dium needles and radon seeds were very popular for
many years but have more recently been replaced by
safer, artificially produced isotopes.
“Many of the physical facts of radium were discov-
cred early. The skin burns suffered by Becquere] and
Carie served as a warming to other users. The value
of filtration and the importance of distance from the
source tothe treated tissue were soon recognized by
the many chemists, physicists, and medical special-
ists who worked together in the treatment of patients.
Initially, the only countries where radium could be
obtained were France and Austria. Later, it was also
discovered in Colorado, and in 1911 radium was pu-
tified from the Colorado ore. To reduce and purify
11g of radium, it was necessary to use 500 tons of(CHAPTER 1 HISTORICAL PERSPECTIVE OF RADIATION THERAPY 3
ore, 10,000 tons of distilled water, 1000 tons of coal,
and 500 tons of chemicals. A gram of radium sold for
$120,000.
‘The first use of radium (imported from Europe) in
the United States was around 1908. The radium
tubes were primarily used in the treatment of gyne~
cologic malignancies, whereas radium solutions
‘were used to treat arthritis and gout. The latter use
was discontinued afier a few years.
‘The clinical pioneers in radiation therapy, mostly
surgeons and dermatologists, used the "erythema
dose,” or radiation dose necessary to cause redness
of the skin, to estimate the proper length of the treat-
ments,
It was recognized early that accurate dosimetry
‘was fundamental to success in any type of radiation
treatment. In radium therapy, this comprised three
parts: the accurate measurement of the radium con-
tent ofthe various sources, the determination of the
radiation output of each source in terms of an ac
ceptable dose unit, and a knowledge of the distribu-
tion of radiation within the tissues under treatment.
Until 1911, there was no satisfactory method to
standardize radium. Madame Curie then began to
prepare an accurate standard of carefully weighed
quantities of pure radium salt. This standard was de
posited with the Intemational Bureau of Weights and
Measures, at Sévres near Paris, and continues to
serve as the standard for radioactivity.
‘Madame Curie’s standard was used for determin-
ing the amount of radioactivity in each source. Out-
put measurements in terms of radiation exposure
were very complicated, but following tedious work
‘by many investigators, it was determined that a point
source of radium, filtered by 0.5 mm of platinum,
delivers what later became known as 8.25 roentgen
per hour at 1 cm from the source.
AAs for the distribution of the sources within the
tissues, a dosage system that is still used in many
hospitals was begun in 1932 and published in 1939
by Ralston Paterson and Herbert Parker at Christie
Hospital in Manchester, England. Their dosage sys-
tem was developed on the theory that nonuniform
spacing of the radioactivity within the tissue could
result in a relatively uniform dose distribution. In
1941, Edith Quimby, first at Memorial Hospital and
later at the College of Physicians and Surgeons in
New York, published a dosage system in which the
sources were arranged in a uniform pattern and the
resulting dose distribution was nonuniform.
Several other systems for radium distribution
(Chap. 15) were worked out both inthe United States
and in Europe, The Manchester (Paterson and
Parker), Paris, and Stockholm techniques are the
‘most notable and are more or less followed by other
institutions
MEASUREMENTS OF QUALITY AND
QUANTITY OF RADIATION BEAMS
During the early years of radiology, the methods of
‘measuring the quality (or penetrating power) and
‘quantity of x-ray beams were unsatisfactory. Direct
‘measurements of radiation quality were made by
‘means of a “penetrometer,” which was introduced
by Benoist in 1901. This instrument consisted of a
thin silver disk surrounded by a ring of aluminum
‘wedges arranged like a stair, with 12 steps of in-
creasing thickness. The aluminum step that matched
the silver disk in absorption was fluoroscopically or
photographically determined and used to represent
the radiation quality in designated units.
‘Also at the beginning of the century, Holzknecht
described a “‘chromoradiometer,” an instrument to
‘measure quantity of dose. It consisted of small disks
cof a fused mixture of potassium chloride and sodium
carbonate. These compounds became discolored
‘when irradiated with x-rays. Holzknecht called the
dose producing a minimal degree of discoloration
“HL” Doses high enough to produce a skin ery-
thema would be of the order of sH."
‘Another device, a radiometer, was developed in
1904 to measure quantity of dose. This device was
used for many years, primarily by dermatologists. A
‘method of measuring dose in calories was also used
at the beginning of the century. These methods were
‘unsatisfactory, and during the subsequent 50 years,
‘many efforts were made to develop accurate and re-
liable methods of determining the amount of dose.
From 1914 to 1925, a number of physicists worked
‘on the determination of a unit of dose and built
‘various types of instruments, most notably a primary4) RADIATION THERAPY PLANNING
standard ionization chamber for the determination of
the dose unit and a secondary instrument to measure
dose on the patient.
In 1928, H. Geiger and W. Mueller constructed an
improved detector tube based on a counter built as
early as 1906. In various modified forms, both of
these instruments were used well into the 1960s."
‘Antoine Béclére in Paris, Gosta Forssll in Stock-
holm, J.J. Thomson in Liverpool, and George
Pfahler in Boston were among the pioneers who laid
the groundwork of radiation therapy. They and many
‘other dedicated scientists soon recognized the need
for an internationally accepted unit of dose and a
‘method by which to define the quality of the rays. In
1913, the term half-value layer, or HVL (aterm now
replaced, as in this text, by half-value thickness, or
HVT), was suggested as a measure of quality. It was
not until 1928 that the roentgen asa unit of measure-
‘ment for x-rays and gamma rays was internationally
accepted, and in 1953, the Intemational Commission
‘on Radiological Units and Measurements (ICRU)
recommended the rad as the unit of absorbed dose.
‘The rad has more recently been replaced by the cen-
tigray (cGy).
TECHNICAL DEVELOPMENTS
‘TECHNICAL DEVELOPMENTS: 1920-1940
‘The equipment used in the treatment of malignant
disease during the first yeas of radiation therapy was,
to be
treeted
primitive and temperamental; it also had very low
penetrating power. The use of x-rays was limited by
the low kilovoltage available. But as the applicability
of roentgen rays expanded, the demand for better
equipment increased. During the 1920s, Coolidge
invented a vacuum x-ray tube capable of operating at
peak kilovoltages (kVp) of 200 to 250. With such
machines, more deep-seated tumors could be treated
without excessive injury to the overlying skin
Figure 1.1, copied from Albert Bachem’s textbook
Principles of x-ray and Radium Dosage, depicts the
use of water bags as compensators, indicating an un-
derstanding of isodose distributions and the compo-
sition of tissue-equivalent materials prior to 19202
Improved treatment techniques where multiple
beams were aimed at the tumor from different direc-
tions (Fig. 1.2), the so-called crossfire techniques,
‘were also used. Other advances during this era were
improved design and relisblity of treatment ma-
chines.
Much had been learned about the need for filtra-
tion of the radiation produced by these machines.
‘The concept of the inverse-square law, scattering,
‘and the effect of treatment distance on the percentage
depth dose (%DD) were also understood. The treat-
‘ment times for external beam treatment were ex-
pressed in erythema time factors, whereas the stan-
dard measure of erythema dose in radium treatment
consisted of 100 milligram hours (mgh)? The ery-
thema dose as a measure of how much dose to de-
Figure 1.1. The use of water bags as issue-equivalent
‘material in this ilustratin, fst published in 1923, in
cates an carly understanding of isodose distributions and
the need for compensators,(CHAPTER 1 HISTORICAL PERSPECTIVE OF RADIATION THERAPY 5
Figure 1.2 4 mulile-beam arrangement inthe treatment of
breast cancer was used in the erly days of radiation therapy, as