RADIO 250: ICC in Radiology and Nuclear Medicine

LEC 10: RADIATION ONCOLOGY

Exam 01| Dr. Henri Cartier S. Co| September 2, 2013

2. Repopulation of cells between fractions

OUTLINE
I. Radiation Therapy
II. Radiation Biology
III. Four Rs
IV. Radiation Physics
V. RT Process

VI. Forms of RT
A. External Beam Radiation
Therapy
B. Brachytherapy
VII. High-End RT Machines
VIII. Cancers Treated with RT

I. RADIATION THERAPY
is a clinical modality dealing with the use of ionizing radiation in
the treatment of patients with malignant neoplasms (and
occasionally benign diseases)
the aim of radiotherapy is to deliver a precisely measured dose of
irradiation to a defined tumor volume with as minimal damage as
possible to surrounding healthy tissue, resulting in eradication of
tumor, a high quality of life, and prolongation of survival at
competitive cost
radiation therapy always offer locoregional control of neoplasms,
often provides a disease fee interval and sometimes gives overall
survival

3. Redistribution of cells throughout the cell cycle

II. RADIATION BIOLOGY

4.Reoxygenation occurring during repeated exposures
Damage by Ionizing Radiation
directly by ionization within the DNA molecule or
indirectly by the action of chemical radicals formed as a result of
local ionizations in water
o Direct (1%): directly break DNA
o Indirect (99%): form hydroxyl radicals which interrupt cell
functions
Radiation bumps electrons out of orbit and destabilizes atoms
In cells, it hits the DNA of cancer, hopefully destroying its
replication capability
Bergonie and Tribondeau Law
The effect of radiation on undifferentiated divide cells with high
mitotic activity is much greater than the effect of radiation on
undifferentiated cells
DNA Repair
normal mammalian cells can repair a significant proportion of
radiation-induced DNA damage if radiation is given at a low dose
rate or is fractionated
if the injuries are irreparable or misrepaired, it can lead to long
term biologic consequences
Goal is a double strand break, single strand breaks are prone to
mutation

IV. RADIATION PHYSICS

Physics is used in radiation therapy
Physicists calculate the surface doses of radiation, use
relative depth distributions of photons and electrons as well as
isodose curves for various electron energies
No need to delve into this part (unless you want this to become
your specialty)
V.RT PROCESS

III. FOUR Rs
1. Repair of sublethal and potentially lethal damage

1. Consult
Multidisciplinary team is organized for the patient
Staging and treatment planning (where to focus, how much to
give, the whole management plan) are done before calling in the
patient
for simulation

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RADIO 250

LEC 10: RADIATION ONCOLOGY

2. Simulation
Planning is supposed to be fluoroscopy guided, so anatomic
markers are there
A plan is made based on X-ray (here in PGH) and then a treatment
field is created
Fluoroscopy-based simulation vs. CT scan-based simulation
o Fluoroscopy: 2D images, only bony and soft tissues are visible
o CT scan: 3D images, sees how much normal tissue exists,
used to estimate dose, less toxicity, beams eye view and targets
the desired field only
o CT simulation: cornerstone of modern radiation oncology
3. Contouring + Immobilization
There are masks made to hold patients head in place (especially
if this is a head and neck tumor)
Block making is done to block out harmful radiation from
adjacent structures
o Blocks are previously made of lead, now made out of
cerrobend, which is as effective as lead but easier to handle (can
be melted and remolded)
o A pair costs around 3.5K
Immobilization is extremely important
o If the patient moves during therapy (even a slight turn of their
head), treatment field immediately changes
Immobilizers used in radiotherapy:
o Thermoplastic mask: head and neck cancer
o Alpha cradle: conforms to shape of patient so daily setup of
treatment is reproducible
4. Dosimetry
Involves calculating the required dose for treatment of the cancer
Also involves tracking how much radiation a certain path has
received
Some cancers you would want to overdose immediately, but
some you want to break the treatment into several fractions
o Hyperfractionate doses can be done multiple times a day, but
side effects are of course greater
5. Treatment
Process of actually exposing the patient to radiation
6. Portal
Treatment fields and patient exposures are reviewed to check if
radiotherapy is done correctly

VI. FORMS OF RADIATION THERAPY

External Beam Radiation Therapy
Distributing the Grief
A.k.a. Teletherapy
The patient sits or lies on a couch and an external source
of radiation is pointed at a particular part of the body
EBRT types may differ in radiation source

1. Conventional Radiotherapy (RT)

Cobalt 60
o Uses radioactive isotope (Cobalt 60) as a source
o Cobalt 60 only has one level of energy (what is inherent to it)
o Radium was used previously but it degrades into Radon gas
which can be inhaled
o There is CONSTANT emission from the isotope, whether or not
the machine is in use
o There is a strong need for protective gear or proper safety
precautions for those who enter the room
o Room is usually large and maze-like, to allow the radiation to
dissipate before it reaches end of the room (in theory,
acceptable level of radiation will go out; still, pregnant
women should stay away)
o Trivia: We medical students are counted as general public
and should have little to no exposure to this radiation.
Linear Accelerator (LINAC)
o Uses electricity-generated radiation, hence when turned off,
NO radiation is emitted

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o Can emit many types of energies electrons alone, photons

alone, etc.
o Different level of energies allow better penetration control
o For instance, using LINAC for breast CA prevents radiation to hit
the lungs
o Around PhP 1,200 2,000 / day x 25 days
2. 3D Conformal RT
A technique where the beams of radiation used in treatment are
shaped to match the tumor
Around Php 5,000/day
3. Intensity Modulated RT
Advanced radiotherapy technique used to minimize the amount
of normal tissue being irradiated in the treatment field
Head part: 100% dose
Body part: 30% dose
A tumor has differential amounts of cancer cells; it may have a
core
Around Php 250,000-350,000
4. Image Guided RT
Augments radiotherapy with imaging to increase the accuracy
and precision of target localization, thereby reducing the amount
of healthy tissue in the treatment field
Treatment follows tumor as it moves normally; e.g. with lung
movement in inspiration
Less side effects
Around Php 400,000
Table 1. Class I organs: radiation Damage is morbid and/or highly
fatal.
Organ
Damage
TD
TD
Irradiated field
5/5Gy 50/5Gy size/volume
Bone
Aplasia,
25
4.5
Total
marrow
pancytopenia
35
40
Segmental
Liver
Acte
and 25
40
Total
chronic
15
20
Total thin band
hepatitis
2
Stomach
Perforation,
45
55
100cm
bleeding
2
Small
Perforation,
45
55
400cm
2
intestine
bleeding
50
65
100cm
Brain
Infection,
45
55
10cm
necrosis
Spinal
Infarction,
60
70
Total
cord
necrosis
70
80
25%
2
Heart
Pericarditis,
45
55
100cm
pancarditis
Lung
Acute
and 30
35
60%
chronic
15
25
Total
pneumonia
Kidney
Acute
and 15
20
Total
chronic
20
25
Whole
thin
nephrosclerosis
band
Fetus
Death
2
4
Total

Brachytherapy
Radiation source is placed inside or next to the area requiring
treatment
Commonly used as effective treatment for cervical, prostate,
breat and skin cancer, and other organs
1. Intracavitary
Consists of positioning applicators (bearing the radioactive
sources) into a body cavity in close proximity to the target tissue
Used most widely for treatment of localized gynecologic
malignancies
All intracavitary implants are temporary implants

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LEC 10: RADIATION ONCOLOGY

2. Interstitial
Consists of surgically implanting small radioactive sources
directly into the target tissues
A permanent interstitial implant remains in place indefinitely and
is not removable (ex: prostate CA)
3. Mold/Plesiocurie/Surface-dose Application
Consists of an applicator containing an array of radioactive
sources usually designed to deliver a uniform dose distribution
to a skin or mucosal surface (ex: parotid tumors)
4. Transluminal
Consists of inserting a single line source into a body lumen to
treat its surface and adjacent tissues
VII. EXAMPLES OF HIGH-END RT MACHINES
Truebeam
o a linear accelerator, manufactured by Varian
o dynamically synchronizes imaging, patient positioning, motion
management, and treatment delivery
o available at Medical City
Tomotherapy
o radiation is delivered slice-by-slice
o available at Makati Med
Gamma Knife, Elekta
o delivery of a single, high dose of irradiation to a small and
critically located intra-cranial volume through the intact skull
o available at Cardinal Santos; cost $10,000
Cyberknife
o a frameless robotic radiosurgery system
o available at a government hospitals in Thailand
VIII. CANCERS TREATED WITH RT
Nasopharyngeal CA cant be treated with surgery, radiotherapy
is the best treatment
Oral Cavity and Oropharyngeal CA
Glottic and Supraglottic CA
Non-Small Cell Lung CA
Breast CA > 1 or 10 mm margins / 10 lymph nodes
Gastric CA
Rectal CA
Cervical and Uterine CA
Soft Tissue Sarcoma
Prostate CA
Brain and Bone Metastasis
SVC Syndrome
Visit www.philradonc.com for details on Radiation Oncology in the
Philippines.

END
Ano ang favorite song ng mga rad onco?
Edi, "Burn Baby Burn".
And while searching kung yan ba talaga yung title ng kanta,apparently may
balisang tao na nagtatanong kung ano yung meaning ng burn baby burn.
Ang best answer sa yahoo: Just to be above and at the top of the
"foodchain". Like "uhm who even cares what you think"
Random. hahaha

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