Basic Principles of

Radiotherapy

Objectives
At the end of this presentation, you
should be able to answer the following
questions:
1) What 3 basic principles need to be
considered when recommending
radiotherapy (RT)
2) What are the 3 basic RT approaches for
cancer treatment (ie. When and why is it
used)

3) What are some of the radiation treatment

modalities (list 5) available
4) How is radiation treatment delivered (be
able to describe a standard approach)
5) What are some site specific side effects
(describe 3 side effects for each of brain,
head&neck, chest, breast, abdomen and
pelvis)

Some general background

Radiation has been available as a treatment for
cancer for over 100 years.
Ionizing radiation (X-rays) is a type of energy
found within the electromagnetic spectrum
(which also includes microwaves, radio waves
and visible light).
The goal of radiation treatment is to deliver a
precisely measured dose of radiation to a target
(tumour) with minimal damage to surrounding
normal tissue.

At the Clinic or Bedside

Consultation with Radiation Oncologist

History & Physical Exam (the patient factors)

Staging (the tumour factors)
Diagnosis
Recommend treatment (the treatment factors)

Pre-Treatment Planning
Should this patient be treated with
radiation?
Patient Factors:

Previous therapy
Relevant past medical history
Performance status and age
Social situation
Wishes / likelihood of compliance

Pre-Treatment Planning
Should this patient be treated with
radiation?
Tumour Factors:

Type
Extent
Natural history
Treatment intent
Treatment options, expected toxicities and
results

Pre-treatment Planning
What are 3 radiotherapeutic treatment
intentions ? (part A of treatment
factors)

What are the 3 basic RT

approaches to cancer treatment
1) Curative requires high doses, typically
above 60 Gy (the exception
is lymphomas)
2) Adjuvant requires intermediate doses,
typically in the range of 30-50
Gy
3) Palliative low doses effective, not
greater than 30 Gy in most
cases

Gray
SI unit for absorbed dose is Gray (Gy)
1 Gy = 1 J/kg
Older term rad is no longer used

Dose fractionation
Curative Usually delivered as 2 Gy once
daily, but there can be smaller fraction
sizes (1.2-1.8 Gy) or slightly larger fraction
sizes (2.2 Gy).
Adjuvant Also usually delivered as 2 Gy
once daily, but there can be the same
variations as for curative.
Palliative Much larger fraction size (3-8
Gy) is standard.

Examples of treatment delivery

Curative most often think of H&N
cancers where RT is the
primary treatment modality
The patient requires an immobilization mask.
The RO outlines the various target volumes
on CT images, and also outlines normal
structures that are in proximity to the tumour
Treatment planning can be very sophisticated
using IMRT to target tumour and minimize
dose to normal tissue.

 Adjuvant Typically think of breast

treatment. In these cases,
the gross tumour has been
removed. The RO outlines
the CTV/PTV and treatment
volume, using standard X-ray
(fluoroscopy) or CT imaging.
Treatment planning can be
2D or 3D.

 Palliative Covers a wide range of sites.

The set-up is kept as simple as possible.
Volume delineation may be done using
surface landmarks (eg. Ribs, clavicle,
brain), fluoroscopic imaging (eg, spine,
hips) or CT (lung, H&N, pelvis)
Planning is kept as simple as possible to
expedite initiation of treatment.

 Questions/comments so far?

What are some RT

modalities for treatment of
cancer?

What are some RT modalities for

treatment of cancer
1) External beam
The commonest external beam utilizes photons
Electrons are another type of external beam.

2) Sealed sources
- These are inserted into the patient and can be
temporary or permanent (eg, gynecologic tumours are
treated with temporary insertions while prostate
tumours are treated with permanent seed implants)

3) Unsealed sources
- These are radionuclides such as iodine which are
ingested or injected.

Pre-Treatment Planning
Patient Education:
Rationale for treatment
Expected toxicities of treatment
Process of treatment planning
Rough time frame for starting treatment

Treatment Planning
Goal:
Evaluate possible treatment approaches, and
choose one that:
Gives the best (or at least an acceptable) dose
distribution
Is reproducible
Is verifiable

Treatment Planning:
Simulation
Mark-up
typically used for planning of RT of
superficial lesions (skin CA, breast boost,
palliative DXR for rib / sternal mets)
also used for planning of palliative brain RT

Conventional Simulation
CT-Simulation

Treatment Planning:
Simulation
Get patient in optimal / acceptable
treatment position
Allows reproducible and verifiable treatment of tumour
Possible additional benefit: allows / increases sparing of
normal tissues
Patient comfort is critical
Pain control
Use support devices and immobilization devices liberally
Can patient maintain desired position for 15 30 minutes
without difficulty?
For a given site, avoid treating same patient in different
positions

Treatment Planning: Simulation

Treatment Planning: Simulation

CT-MRI fusion
used for planning of treatment of brain lesions
fairly routinely, as MRI and CT are
complementary imaging modalities

Treatment Planning: Simulation

CT-PET fusion

XBRT: Beam Choices &

Characteristics

Beam Choices
Orthovoltage
Photons
Co-60
MV

Electrons
Exotica (you cant do that here)
Neutrons
Protons

Basic Beam Characteristics

Orthovoltage Beam:
characteristics (PDD curve):
full dose at surface
rapid attenuation in tissue (~8%/cm with 250 kVp)
slightly slower with higher energy beams

compared to higher energy photons:

increased absorption in bone
increased scatter when bone in way of path to
tumour (i.e. decreased dose to tissue beyond)
shorter SSD (typically 50 cm)
Slow delivery (typically 10-15 minutes/field)

dose (%)

TBCC Orthovoltage PDD Curves

(8 x 10 cm field)
120
100
80
60
40
20
0

75 kVp
225 kVp
250 kVp
0

10

depth (cm)

15

Orthovoltage

Clin RT Phys, 2nd ed, Fig. 15-2

Absorption in Bone
Clin RT Phys, 2nd ed,
Table 14-3:
ratio of mass-energy
absorption coefficients
for bone/muscle shows
impact of photoelectric
effect at low energies
seen with orthovoltage
radiation

Basic Beam Characteristics

Cobalt-60 beam:
characteristics (PDD curve):
~50% surface dose, with dmax at 0.5 cm depth
slower attenuation in tissue than orthovoltage
(~5%/cm)

not a point source geometric penumbra

contributes to total penumbra
Treatment time typically 2-4 minutes

Co-60 Beam

Clin RT Phys, 2nd ed, Fig. 15-3

Basic Beam Characteristics

Megavoltage Photon Beam:
characteristics (PDD curve):
decreased surface dose with gradual build-up to
dmax
surface dose decreases as increase photon energy
depth of dmax increases as increase photon energy

slower attenuation in tissue than Co-60

rate of attenuation decreases as increase photon energy
Treatment delivery time typically 1-2 minutes/field

Megavoltage Beam

Clin RT Phys, 2nd ed, Fig. 15-4

PDD Curves, 10 x 10 cm field

120
% dose

100
Co-60
6 MV
18 MV

80
60
40
20
0
0

10
depth (cm)

Co-60: past dmax (0.5 cm), lose ~ 5%/cm

6 MV: past dmax (1.5 cm), lose ~ 4%/cm
18 MV:past dmax (3 cm), lose ~ 3%/cm

20

Switching Horses

Basic Beam Characteristics

Electron Beam:
characteristics (PDD curve):
relatively high surface dose (75- 95%)
surface dose increases with increased electron
energy

broad region of maximum dose

this region widens with increased electron energy

rapid dose fall-off beyond region of maximum

dose
slower with increased electron energy

low dose tail (x-ray contamination of electron

beam)

TBCC Electron PDD Curves, 10 x 10 cm field

120

dose (%)

100
6 MeV e9 MeV e12 MeV e16 MeV e20 MeV e-

80
60
40
20
0
0

10
depth (cm)

15

Exotica

Available in a few highly specialized centers

only

Protons

Neutrons
Finally have ability to build treatment machines
which would be suitable for clinical use, but
interest in neutrons has waned because:
no additional benefit over traditional photon or
electron radiation for most tumours
depth-dose characteristics are at best like 6 MV
photons (most like DXR 4 MV)
Only rationale for neutrons = radiobiological

late effects often far worse than expected for given

dose neutrons

Questions?

Designing the treatment

2D-RT
Conventional simulator used to design
beam portals based on standardized beam
arrangement techniques and bony
landmarks visualized on planar
radiographs

Volume delineation for external

beam and sealed sources
The gross tumour volume (GTV) is outlined
A margin is included around the GTV to include
areas at risk for microscopic involvement, this is
the clinical target volume (CTV)
A margin is added onto the CTV to allow for
differences in internal organ motion or day-today set up variations, this is the planning target
volume (PTV)
There is a margin added to the PTV to allow for
physical characteristics of the beam (penumbra),
this is the actual treatment volume.

ICRU 50 Volume Definitions

Gross Tumor
Volume
Clinical Target
Volume
Planning Target
Volume
Treated Volume
Irradiated Volume

Margins
GTV -> CTV: local sub-clinical
CTV -> PTV: setup variation
- patient movement
- organ movement
- variations in organ shape &
size

PTV -> IV: penumbra

Organs At Risk
(Part B of treatment factors)
organs at risk := normal tissues whose
radiation sensitivity may significantly
influence treatment planning and / or
prescribed dose
class I organs : radiation lesions are fatal or
result in severe morbidity (spinal cord)
class II organs : radiation lesions result in
mild to moderate morbidity (bowel)
class III organs : radiation lesions are mild,
transient and reversible, or result in no
significant morbidity (muscle)

Treatment Planning:
Dose Distribution
Optimal Dose Distribution:
Cover target volume : appropriate dose &
homogeneity
ICRU 50 recommends that dose coverage of PTV
be kept within +7% and -5% of prescribed dose; if
not possible, RO to access if acceptable

Avoid significant dose to sensitive structures :

Conformal Avoidance
Minimize dose to surrounding normal tissues:
Integral Dose

3D - Conformal Radiotherapy
3D-CRT: method of irradiating target volume
(defined in 3D imaging study) using array of
beams individually shaped to conform to 2D
projection of target
Beam orientations selected to minimize
overlap with neighbouring OARs
Beam characteristics and modifiers selected
to produce dose distribution that is uniform
throughout target(s) and as conformal as
possible, consistent with dose constraints to
normal tissue

3D - Conformal Radiotherapy
Iterative changes to weights, beam modifiers,
number and directions of beams until
satisfactorily uniform dose to target is achieved
without exceeding dose tolerance of
neighbouring OARs
Allows safe escalation of dose to targets in a
variety of areas in the body (prostate,
nasopharynx) that is expected to result in
increased local tumour control probability

Conformal
Treatment
vs.
Conformal
Avoidance

Treatment Planning: DVH

Can extract dose stats from this data,

for both targets and normal tissues:
Maximum or minimum point dose
Mean dose, standard deviation
Vx (e.g., V20 for both lungs PTV)

Can compare DVHs generated for

competing plans to try to decide on
best plan
Can look at DVHs for individual plan to
assess if acceptable
Does not provide any spatial
information therefore complementary to
dose distribution information

Perez, 4th ed, Fig 8.20 A

&B

Limitations of 3D-CRT
3D-CRT cannot conform well to 3D shape of
target unless:
Large numbers of beams are used
Target has relatively simple shape

3D-CRT cannot give a satisfactory treatment

plan if:
Concave tumour wrapped around sensitive
structure
Angles required to avoid / minimize dose to
normal tissues are difficult or impossible to
achieve clinically
target surrounded by different OARs:
e.g., nasopharyngeal cancer

What is Intensity Modulated

Radiotherapy (IMRT)?
IMRT: method of irradiating target volume
(defined in 3D imaging study) using array of
beams, where the intensity of the beams
varies across each treatment field
Does this really help?

Whats Backwards About

Inverse Planning?
Traditional forward planning:
Choose treatment parameters
Produce dose distribution
Assess dose distribution

No

Satisfied ?
Yes
Accept treatment plan

Whats Backwards About

Inverse Planning?
Inverse planning:
Choose dose volume constraints
for target & OARs

Set treatment parameters

Create dose distribution

No

Satisfies constraints ?
Yes
Accept treatment plan

IMRT- 9 Beams

Coronal & Sagittal Slices at Iso

Side effects from radiation

Side effects are grouped into acute, delayed and
late; severity is related to overall dose as well as
patient factors.
1) Acute (fatigue is common to all)

Brain: Headache, nausea, alopecia

H&N: Xerostomia, mucositis, dysphagia
Lung and esophagus: Dysphagia, cough, hoarseness
Breast: skin erythema, breast discomfort
Abdomen or pelvis: nausea, diarrhea, dysuria

 2) Delayed
Lung is the classic organ for a delayed response
(pneumonitis) 2-6 months post RT

3) Late
Brain: Necrosis, pituitary dysfunction, hearing loss
H&N: Xerostomia, dental decay, thyroid dysfunction
Lung/esophagus: Esophageal stricture, lung
fibrosis/dyspnea, coronary artery disease
Breast: Altered skin pigmentation, firmness of breast,
arm edema
Abdomen or pelvis: Bowel obstruction, infertility,
proctitis

Objectives
At the end of this presentation, you
should be able to answer the following
questions:
1) What 3 basic principles need to be
considered when recommending
radiotherapy (RT)
2) What are the 3 basic RT approaches for
cancer treatment (ie. When and why is it
used)

What factors need to be considered

when recommending RT
1) Patient factors (age, performance
status, co-morbidities [particularly
connective tissue diseases], surgery)
2) Tumour factors (extent of disease [ie.
stage]
3) Treatment factors (has there been
previous RT, what normal structures are in
proximity to the tumour)

What are the 3 basic RT

approaches to cancer treatment
1) Curative requires high doses, typically
above 60 Gy (the exception
is lymphomas)
2) Adjuvant requires intermediate doses,
typically in the range of 30-50
Gy
3) Palliative low doses effective, not
greater than 30 Gy in most
cases

3) What are some of the radiation treatment

modalities (list 5) available
4) How is radiation treatment delivered (be
able to describe a standard approach)
5) What are some site specific side effects
(describe 3 side effects for each of brain,
head&neck, chest, breast, abdomen and
pelvis)

 Thank you.
Any questions?