Subject: RADIOLOGY

Topic: RAD ONCOLOGY

Date: AUGUST 14, 2012
Lecturer: DR. ALABASTRO
Transcriber: MELODICINE
Editor: JAN ERIC
Pages: 8

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BATCH 2014

HISTORICAL PERSPECTIVE: EARLY OBSERVATIONS OF THE EFFECTS OF IONIZING RADIATION

1895

X-rays discovered by Conrad Roentgen

1896

First skin burns reported

First use of x-ray
ray in the treatment of cancer
Discovery of radioactivity of Becquerel

1897

First case of skin damage reported

1899

First basal cell epithelioma reported cured

1902

First report of x-ray induced cancer

1911

First report of leukemia in human & lung cancer from occupational exposure
94 cases of tumor reported in Germany ( 50 being radiologist)

MODALITIES TRADITIONALLY USED IN THE MANAGEMENT OF PATIENTS WITH CANCER

A. SURGERY

For lesions that can be technically removed completely

LIMITATIONS

1. Inadequate removal of the gross tumor,

tumor leading to A local recurrence
2. Inadequate resection of microextensions in tissues adjacent to gross tumor.
3. Undetected metastasis to regional lymph nodes
4. Systemic micrometastases

B. CHEMOTHERAPY

C. RADIATION
THERAPY

1.
2.

L
I
M
I
T
A
T
I
O
N
S

A. TUMOR
CELL
BURDEN

a.

B. PHYSICAL
& TECHNICAL
FACTORS

a.

To eradicate microscopic metastases or tumor cell

dissemination outside the operative or irradiated volume

NEOADJUVANT

To reduce the initial tumor cell number before definitive

surgery or irradiation or both & potentially to decrease the
viability of micrometastases

DEFINITIVE
THERAPY

In tumors that are chemosensitive & can be controlled with

cytotoxic agents alone

PALLIATIVE

In the treatment of systemic macrometastases or to relieve

symptoms in patients with chemosensitive tumors

For localized lesions in which surgery may cause undesirable sequelae

For more extensive lesions not amenable to a surgical resection

Inadequate depopulation of clonogens in primary tumor which may cause

local recurrence
b. Regional microextensions or metastasis to lymphatics which may not be
included in the irradiated volume may cause A recurrence
c. Clinically UNAPPARENT DISTANT METASTASIS at the time of initial therapy

b.
c.

C. BIOLOGIC
FACTORS

ADJUVANT

Inaccurate tumor localization because of inability to define the target volume

adequately (GEOGRAPHIC
GEOGRAPHIC MISS )
Inadequate treatment planning,
planning which may result in NON-HOMOGENOUS DOSES
of radiation throughout the target volume
Unreliable daily irradiation techniques,
techniques which may result in poor positioning &
immobilization (inaccurate treatment)

a.

HYPOXIC CELL SUBPOPULATION which require higher doses of radiation than well
oxygenated cells for the same level of cell kill
b. Repair of sublethal or potentially lethal damage after irradiation
c. Position of the cell in the proliferative cycle. Cells in the LATE G1 OR S PHASE ARE
MORE RESISTANT TO IRRADIATION than are cells in other portions of the cycle.
Cells in the G0 are also more resistant to irradiation than are rapidly proliferating
cells. CELLS IN M PHASE ARE THE MOST RADIOSENSITIVE TO IRRADIATION.
IRRADIATION
D. TUMOR CELL REPOPULATION during fractionated therapy or after completion of
therapy
E. LIMITED TOLERANCE OF THE SURROUNDING NORMAL TISSUES TO IRRADIATION,
IRRADIATION
thus precluding the delivery of higher doses

1/8

RADIATION ONCOLOGY 1/8

IRRADIATION & SURGERY: COMBINATION OF THERAPEUTIC MODALITIES

p
p

INDICATION
FOR TUMORS
WITH

1. Low cure rates by either surgery or radiation therapy alone

2. Great potential for local or regional recurrence
3. Great potential for residual disease after surgery
4. Great potential for lymphatic invasion
5. For preservation of function & the enhancement of cosmesis

RATIONALE FOR
PREOPERATIVE
RADIATION
THERAPY

1.
2.
3.
4.
5.

DISADVANTAGE

RATIONALE FOR
POSTOPERATIVE
RADIATION

DISADVANTAGE

Ability to eradicate subclinical disease beyond the margins of surgical resection

Diminish tumor implantation by decreasing # of viable cells in operative field
Sterilize lymph node metastases outside the operative field
Decrease dissemination of clonogenic tumor cells (produce distant metastases)
Increase the possibility of resectability

It may interfere with normal healing of tissues affected by the radiation

Interference is minimal if radiation doses are below 4500 cgy to 5000 cgy in 5 weeks
It is possible to treat any residual tumor in the operative field by:
a. Destroying subclinical foci of tumor cells following the surgical procedure
b. Eradicating adjacent subclinical foci of cancer (including lymph node metastases)
c. Delivering higher doses than can be achieved with preoperative irradiation the
greater dose being directed to the volume of high risk or known residual disease.
1. Delay on the initiation of radiation therapy (at least 1 month) until wound
healing is complete
2. Vascular changes produce in tumor bed by surgery may impair radiation effect

IRRADIATION & CHEMOTHERAPY: COMBINATION OF THERAPEUTIC MODALITIES

EFFECT

INDEPENDENT, ADDITIVE OR INTERACTIVE

CHEMO BEFORE RADIATION

THERAPY

Produces some cell kill & reduction in the number of cells to be

eliminated by the irradiation

CHEMO DURING RADIATION

THERAPY (CHEMORADIATION)

It could interact with the local treatment (additive & even supraadditive action)
action & affect subclinical disease early in treatment

CHEMO AFTER RADIATION

THERAPY

As an adjuvant has been used primarily for control of subclinical

disease

INTEGRATED MULTIMODALITY CANCER MANAGEMENT

Combination of two or even all modalities frequently are used to improve tumor control & patient survival
Steel postulated
the BIOLOGIC
BASIS OF CANCER
THERAPY as :

A. SPATIAL COOPERATION

Agent is active against tumor cells spatially missed by

another agent

B. ADDITION OF ANTI-TUMOR
TUMOR EFFECTS BY TWO OR MORE AGENTS
C. NON-OVERLAPPING
OVERLAPPING TOXICITY & PROTECTION OF NORMAL TISSUES

RADIATION ONCOLOGY
A clinical & scientific
endeavor devoted
to:

A. Cancer ( & other disease) by ionizing radiation, alone or combined w/ other modalities
B. Investigation of the biologic & physical basis of radiation therapy
C. Training of professionals in the field

RADIATION
THERAPY

Deals with use of ionizing radiation in treatment of malignant neoplasia ( & some benign)
Often use in combination with chemotherapy & surgery
50-60 % of cancer patients will benefit from radiotherapy
GOAL

MAJOR
INDICATIONS FOR
RADIOTHERAPY

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RATIONALE OF
RADIATION
THERAPY IN
METASTATIC
DISEASE
EFFECTS OF
RADIATION ON
BODY DEPENDS ON:

To deliver with accuracy a precisely measured dose of radiation to a defined tumor

volume with as minimal damage to surrounding healthy tissues resulting in eradication of
the tumor, a high quality of life & prolongation of survival at a reasonable cost
1.
2.
3.
4.

Head & neck cancers: Eg.. Nasopharyngeal

Gynecological cancers : Eg.
Eg Cervix, Uterine
Prostate CA
Other pelvic malignancies : Rectum, bladder

5.
6.
7.
8.

Adjuvant breast treatment

Colon Cancer
Brain cancer
Palliation

1. Relieve severe pain

2. Control hemorrhage
3. Prevent impending pathologic fracture
4. Reverse spinal cord compression before
transection takes place

5. Alleviate SVC syndrome (Lung Ca)

6. Relieve symptoms & disability from brain
metastases
7. Prevent obstruction (Eg. Esophagus)
8. Halt destruction of an organ

1. Volume of tissue irradiated

2. Anatomical site irradiated
3. Radiation dose delivered

4. Rate at which the radiation is delivered

5. Dose fractionation

2/8
RADIATION ONCOLOGY 2/8

TREATMENT APPROACHES IN RADIOTHERAPY

1. CURATIVE
TREATMENT

To obtain complete durable remission

Patients has an expected probability of surviving after adequate therapy even if that chance is
low. RADIOTHERAPY IS:
A. The sole agent with curative intent for anatomically limited tumors of Retina, Optic Nerve,
Brain, Spinal Cord, Nasopharynx,
Nasopharynx Etc.
B. COMBINED W/ SURGERY for more extensive cancers of Head & Neck, Lungs, Breast, Testis.
C. Adjuvant to chemotherapy for patients with Lymphomas, Lung Cancer & Cancer In Children

2. PROPHYLACTIC
TREATMENT

Irradiation of macroscopically uninvolved areas which are thought to be the site of occult
subclinical localizations. RADIOTHERAPY TO:
A. REGIONAL, clinically uninvolved lymphatic chains after surgery and/or radiotherapy to the
primary tumor.
B. LYMPHATIC CHAINS,, spleen & brain in the absence of clinically evident lesions in malignant
lymphomas.
C. AFTER MACROSCOPICALLY RADICAL SURGERY for locally advanced cancers at a high risk of
local relapse.
D. BRAIN when primary cancer has a high risk of spreading to the brain (SMALL
(
CELL LUNG CA )

3. PALLIATIVE
TREATMENT

Limited intent of improving the patients quality of life & prolonging his survival
A. Allow for symptom-free
free period longer than DEBILITATION DUE TO TREATMENT PERIOD
B. PROLONG USEFUL OR COMFORTABLE SURVIVAL so that other factors might lead to death
C. Relieve distressing symptoms although survival may not be prolonged
D. Avert impending symptoms such as hemorrhage, perforation, obstruction etc.

MODALITIES OF RADIOTHERAPY

BRACHYTHERAPY

TELETHERAPY

1. ADMINISTRATION

By applying
pplying a radioactive material INSIDE or in
CLOSE APPROXIMATION to the patient

Delivery from a MACHINE LOCATED

REMOTE from the body

2. Dose OUTSIDE

Can be minimized

Greater than in brachytherapy

3. Dose INSIDE the

treatment volume

Non-uniform
uniform & dose gradients are often high.

Any required degree of dose uniformity

can in principle be achieved.

4. PHYSICAL
LIMITATION

Limited to accessible sites, near the surface of

the body or near natural cavities but any volume
may be treated using complex array of sources

No physical limitations to the size of

volume that can be treated

5. DOSE RATES

Relatively LOW

Relatively HIGH

6. SOURCES
*MEAN ENERGY
PHOTONS(MEV)
*Half life is the time of
radioactive substance
to decay to 1/2 of its
original value.

RADIUM 226
Cesium 137
Iridium 192
Iodine 125
GOLD 198

HALF LIFE
1620YRS
30 yrs
74days
60day
2.7 DAYS

(MEV)
1.2
0.66
0.34
0.027
0.41

UNIT
150-440 Kvp Xray
Cesium 137
Cobalt 60
4 MV Linac
6 MV Linac
20-24 MV Betatron & Linac

(MEV)
0.06-0.14
0.66
1.25
1.3
1.8
6.2-7.0

TYPES OF TELETHERAPY
1. CONVENTIONAL
ROENTGEN
THERAPY

Consist of the use of x-rays

rays produced by equipment functioning with voltages up to 400 kv
A. SHORT DISTANCE ROENTGEN THERAPY

3-5 cm using voltages form 50-60 kv

B. MIDDLE DISTANCE ROENTGEN THERAPY

15-30 cm using voltages greater than 100 kv

C. DEEP ROENTGEN THERAPY

Uses voltages from 250-400 kv

2. EXTERNAL
RADIOTHERAPY WITH
HIGH ENERGY PHOTONS

Most commonly used method for irradiation of deep & semi-deep

semi
seated tumors
A. Cobalt 60 teletherapy unit: HALF- LIFE: 5.26 YEARS ; in 10 years: 25% retained
B. Linear accelerators: Calibrated daily, use in hospitals, high energy xray

3. EXTERNAL RADIOTHERAPY WITH FAST ELECTRONS

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TYPE OF
EQUIPMENTS
& ENERGY
RANGE

1. SUPERFICIAL X-RAY
10 Kv Grenz Ray
40-140 Kv Superficial

AVANTAGES OF TELECOBALT
UNITS & MEGAVOLTAGE
GENERATORS OVER
ORTHOVOLTAGE
ELECTRON BEAMS
CAN BE USED IN
THE PRINCIPAL
TREATMENT OF:

A. Betatrons up to 45 mev

2. ORTHOVOLTAGE
250 Kv Deep X-ray;
600 Kv Radioisotope
Teletherapy ( Cs-137)

B. Linac up to 25 mev

3. SUPERVOLTAGE OR MEGAVOLTAGE
2 Mev Radioisotope Teletherapy ( Co-60)
4-6 MV Low Energy Linear Accelerator
18-20 MV High Energy Linear Accelerator
15-25 MV Dual Mode Linear Accelerator

1. Better depth doses more efficient tumor treatment

2. Less side effects less radiation sickness
3. NO DIFFERENTIAL ABSORPTION BY BONE more uniform dosage
4. Skin sparing effects only skin radiation dermatitis

1. Malignant tumors of the skin & lip

2. Chest wall, neck & brain cancers (Elective after radical/conservative surgery /recurrent disease)
3. Upper respiratory or digestive tract lesion from 1cm to 5cm in depth
3/8
4. Lymph nodes, operative scars & residual tumor
RADIATION ONCOLOGY 3/8

TYPES OF BRACHYTHERAPY
1. INTERSTITIAL BRACHYTHERAPY

2. ENDOCAVITARY BRACHYTHERAPY

Introduction of radioactive sources

(NEEDLE, WIRE, SEEDS) into tissue at or
near tumor site.
USED IN: Tumors Of Head & Neck,
Prostate, Cervix, Ovary, Breast, Perianal &
Pelvic Region
PHOTO: Gold seeds in Prostate Cancer
through the use of needle.

Introduction of radioactive sources contained IN APPLICATORS OR

IN MOLDED DEVICES inside natural, pathological or operative cavities
USED IN: UTERINE; Breast, Bronchial, Cervical, Gallbladder, Oral,
Rectal, Tracheal, Uterine & Vaginal Cancers
PHOTO below: Tandem: Cylinder where radioactive material is placed
inside the uterus.
Strength of Radioactive material: Low dose: 2-3
2 days, High dose: hours
3. CONTACT
BRACHYTHERAPY
Application through
DIRECT CONTACT to the
skin surface or other
sites
USED IN: (Cornea,
External Mucous
Membrane) of
radioactive sources
(beta-emitting) for very
superficial site.

IRRADIATION FRACTIONATION REGIMEN

1. CONVENTIONAL
FRACTIONATION

Consist Of Daily Fractions Of 1.8 TO 2.0 GY 5 DAYS A WEEK: TOTAL 28 DAYS

Total Dose Is Determined By The Type Of Tumor & Tolerance Of Critical
Normal Tissues In The Target Volume ( Usually 60 To 75 Gy).

Common Types Of External-beam

Radiation Therapy Are Given In
Once-daily Fractions For 2 Reasons:

1. To Minimize The Damage To Normal Tissue

2. To Increase Exposure of Cancer Cells To Radiation At The Points In The
Cell Cycle When They Are Most Vulnerable To Dna Damage

2. HYPERFRACTIONATION

Uses An Increased Total Dose,

Numbers Of Fractions Is Increased,
Dose Per Fraction Is Reduced
Overall Time Is Unchanged.

3. QUASI HYPERFRACTIONATION

Same As Hyperfractionation Except That Total Dose Is Not Increased.

4. ACCELERATED FRACTIONATION

Overall Time Is Reduced.

# Of Fractions, Total Dose & Dose Per Fractions Are Unchanged Or Reduced.

5. QUASI ACCELERATED
HYPERFRACTIONATION

Same As Accelerated Fractionation Except The Overall Time Is Not Reduced

Because Of Treatment Interruptions

CURATIVE DOSES OF RADIATION FOR DIFFERENT TUMOR TYPES

NICE TO KNOW ;)

2000-3000 Cgy

Seminoma (Most sensitive)

Dysgerminoma
Acute Lymphocytic Leukemia

6000-6500 Cgy

Larynx (< 1cm)

Breast Cancer( T1)

3000-4000 Cgy

Seminoma (Bulky)
Wilms Tumor
Neuroblastoma

7000-7500 Cgy

4000-4500 Cgy

Hodgkins Disease
Lymphosarcoma
Histiocytic Cell Sarcoma
Skin Cancer( Basal Cell)

Oral Cavity ( <2cm, 2-4cm)

Oro-naso-laryngo-pharyngeal CA
Breast CA(T2)
Bladder CA
Cervix CA
Uterine Fundal CA
Ovarian CA
Lymph Nodes, Metastatic (1-3cm)
Lung CA (<3cm)

5000-6000 Cgy

Lymph Nodes, Metastatic (No,n1)

Squamous Cell CA
Cervix CA
Head & Neck CA
Embryonal CA
Ewing Tumor
Breast CA & (Excised) Breast CA
Ovarian CA
Medulloblastoma
Retinoblatoma

8000 Cgy Or
Above

Head & Neck CA (>4cm)

Breasts CA (>5cm)
Glioblastoma
Osteogenic Sarcoma
Melanomas
Soft Tissue Sarcomas(>5cm)
Thyroid CA
Lymph Nodes
Metastatic (>6cm)

*Higher dose to more radioresistant. Alimentary Tract: Most radiosensitive tissue to radiation.
RADIATION ONCOLOGY 4/8

4 RS OF RADIOBIOLOGY & TIME/DOSE CONSIDERATIONS

1. REPAIR

Repair
Repair mechanism built into all cells both normal & abnormal

Rest periods in standard fractionation schemes allow the normal cells to repair from subsub
lethal radiation injury

Prolonged
Prolonged breaks in treatment are discouraged because tumor cells also have some
capacity for repair and can prolong radiation treatment.
treatment

2. REOXYGENATION

Ability of both normal & abnormal tumor cell population to revascularize as cells die in an

Ability
attempt to continue thriving

The presence of oxygen increases cellular sensitivity to radiation through greater potential
of free radical formation

Revascularization improves the viability of the abnormal growth

Increased
Increased vascular supply is good for the recovery of normal tissues in the area

3. REPOPULATION

Trigger of surviving cells in a tumor to divide faster in an attempt to live

Trigger

This
This phenomenon is justification for repeated radiation injury events as provided by
fractionated doses

Hyperfraction & hypofractionation schemes are designed with this phenomenon in mind,
with the specific growth & dividing pattern of the cells being irradiated

4. REDISTRIBUTION OR
REASSORTMENT

Ability
Ability for the cell population to return to a more even distribution of younger dividing
cells following decreased surviving fraction

This
This phenomenon also justifies repeated dosing as in standard fractionation & establishes
the importance of avoiding breaks in treatment

Chemical
RADIOPROTECTORS

Drugs that protect normal cells from damage caused by radiation therapy

Is
Is founded on the principle of REOXYGENATION & REPAIR

Scavenge
Scavenge free radicals or facilitate chemical repair at sites of dna damage in normal tissue
Amifostine or Ethyol: Only drug approved by FDA. It reduces dryness of mouth.
Given one hour prior to head and neck exposure to radiation.

Chemical
RADIOSENSITIZERS

Drugs that make cancer cells more sensitive to the effects of radiation therapy

Is
Is founded on the principle of REOXYGENATION as well

Eg. 5-FU, Cysplatin

Chemicals
Chemicals developed as oxygen substitutes are used to make hypoxic tumor cells respond
to radiation as though they were well-oxygenated
well

Some
Some drugs may selectively kill hypoxic cells

It
It is important to administer radiation doses within an hour or two following these biologic
modifier

TREATMENT PLANNING
OBJECTIVE

To achieve a dose distribution inside the volume to be treated(target volume)

volume which is
uniform within 5%
5% of the prescribed dose while limiting the dose to adjacent regions to
below tolerance levels.

STAGES

1. Tumor localization & assessment of volume of tissue to be irradiated (Imaging Studies)

2. Choice of radiation quality & selection of treatment machine
3. Selection of radiation dose & dose-time
dose
relationship
4. Selection of radiation field arrangement & any necessary beam shaping devices
5. Calculation of radiation dose distribution & daily treatment time (physicist-dosimetrist)
(physicist
6. Manufacture & use of devices to ensure accurate localization of treatment field &
accurate & easily reproducible set-up
up from day to day (Use
(
of body molds or head mask)
7. Preparation of radiotherapy prescription

PRESCRIPTION OF
RADIATION IS
BASED ON THE
FOLLOWING
PRINCIPLES

1. Evaluation of full extent of the tumor (staging) by whatever means available including
radiographic, radioisotope & other studies
2. Knowledge of the pathologic characteristic of the disease including potential areas of spread
that may influence choice of therapy ( that is the rationale for elective irradiation of the
lymphatics in the neck or the pelvis)
3. Definition of goals of therapy (cure vs palliation)
4. Selection of appropriate treatment modalities which may be irradiation alone or combined
with surgery, chemotherapy or both
5. Determination of the optimal dose of radiation & the volume to be treated which is made
according to the anatomic location, histologic type, stage & other characteristics of the tumor
& the normal structures present in the region
6. Periodic evaluation of the patients general condition, tumor response & status of the normal
tissues treated

5/8

RADIATION ONCOLOGY 5/8

RESPONSE TO TREATMENT
1. COMPLETE REMISSION

No clinically detectable cancer is found following treatment

2. PARTIAL REMISSION

Measurable tumor is decreased by 50% following treatment; no new area of cancer can
be found & no area of tumor shows progression

3. MINIMAL REMISSION

Same as partial remission but not meeting the criteria of 50% reduction

4. PROGRESSION

Increased of tumor mass by more than 25%; appearance of new lesions or tumortumor
induced death

5. STABLE DISEASE

Measurable tumor does not meet the criteria for CR, PR, MR, or progression

CAUSES OF FAILURE IN RADIATION THERAPY

1. ERROR OF JUDGMENT

Eg. Wrong diagnosis wrong treatment

Failure to detect metastasis before exposing patient to radical treatment for the
primary tumor

2. ERROR OF OMISSION

Eg. Failure to give an adequate level of dosage

3. ERROR OF COMMISSION
OR ERROR IN DOSE
CALCULATION

Eg. Habitual use of a poor technique will in time be reflected in a lower cure rate
than might have been expected
Badly positioned xray applicator which can lead to the so called geographic miss
with an inevitable result of failure to control growth

POSSIBLE SPECIFIC SEQUELAE OF THERAPY

NICE TO KNOW ;)

ACCORDING TO DOC:
1. Non-stochastic or Deterministic Effect: Acute sequelae:
sequelae occurs within days or weeks:. Eg. skin erythema
2. Stochastic: Occurs months or years after exposure to radiation. Eg. Breast Ca: Second Malignancy Lung Ca
ACCORDING TO ww.rpop.iaea.org:
DETERMINISTIC
EFFECTS

A deterministic effect is one where the severity depends upon the radiation dose, e.g. skin
burns. There is a threshold for deterministic effect. Deterministic name comes from
determined to occur once threshold is crossed.

STOCHASTIC EFFECTS

A stochastic effect is one where the probability of occurrence increases w/ radiation dose
but severity of result is same e.g. development of cancer. There is no threshold. Stochastic
stands for something that occurs by chance &is random in nature.

ANATOMIC SITE

ACUTE SEQUELAE

LATE SEQUELAE

BRAIN

Earache, Headache, Dizziness, Hair

Loss, Erythema

Hearing Loss, Damage To Middle Or Inner Ear, Pitiutary

Gland Dysfunction, Cataract Formation, Brain Necrosis

HEAD & NECK

Odynophagia, Dysphagia,, Hoarseness,

Xerostomia Dysgeusia (Metallic Taste),
Weight Loss

Subcutaneous Fibrosis, Skin Ulceration, Necrosis,

Thyroid Dysfunction, Persistent Hoarseness, Dysphonia,
Xerostomia, Dysgeusia, Cartilage Necrosis,
Osteoradionecrosis Of Mandible, Delayed Wound
Healing, Fistula, Dental Decay, Damage To Middle
&Inner Ear, Apical Pulmonary Fibrosis Rare:
Myelopathy

LUNGS &
MEDIASTINUM
OR ESOPHAGUS

Odynophagia, Dysphagia,
Hoarseness,cough, Pneumonitis,
Carditis

Progressive Fibrosis Of Lung, Dyspnea, Chronic Cough,

Esophageal Stricture, Rare: Chronic Pericarditis,
Myelopathy

BREAST OR
CHEST WALL

Odynophagia, Dysphagia,, Hoarseness,

Cough, Pneumonitis, Carditis,
Cytopenia

Fibrosis, Retraction Of Breast, Lung Fibrosis, Arm

Edema, Chronic Endocarditis, MI, Rare:osteonecrosis
Of Ribs

ABDOMEN OR
PELVIS

Nausea, Vomiting, Abd. Pain,

Diarrhea, Urinary Frequency, Dysuria,
Dysuria
Nocturia, Cytopenia

Proctitis, Sigmoiditis, Rectal Or Sigmoid Stricture,

Colonic Perforation Or Obstruction, Contracted
Bladder, Urinary Incontinence, Hematuria Due To
Chronic Cystitis, Vesicovaginal Fistula,rectovaginal
Fistula,leg Edema, Scrotal Edema, Sexual
Impotency,vaginal Retraction,or
Scarring,sterilization,damage To Liver Or Kidney

EXTREMITIES

Erythema,, Dry/Moist Desquamation

Subcutaneous Fibrosis, Ankylosis, Edema, Bone/Soft

Tissue Necrosis

6/8

RADIATION ONCOLOGY 6/8

OTHER METHODS OF TREATMENT

I.
INTRAOPERATIVE
RADIATION
THERAPY

A
A form of external radiation that is given during surgery

It is used to treat localized cancers that cannot be completely removed or that have a high risk
of recurring in nearby tissues

One large high energy dose of radiation is aimed directly at the tumor site during surgery(nearby
healthy tissue is protected with special shield)

It is costly, time consuming procedure because of the necessity of combining the operating
rooms sterile technique with the high energy equipment in a shielded room.

USED IN: thyroid & colorectal cancers, gynecological, small intestinal & pancreatic cancers

USED
USED in clinical trials to treat some types of brain tumor & pelvic sarcomas in adults

II. STEREOTACTIC
RADIOSURGERY

Uses
Uses a stereotactic frame, a radiation delivery system computer hardware & treatment planning
hardware
The patient head is placed in a special frame, which is attached to the patients skull. The frame is
used to aim high-dose radiation beams directly at the tumor inside the brain
Performed
Performed on outpatient basis & time consuming process involving placement of stereotactic
frame determination of target size & location & treatment planning & treatment delivery

THIS CAN BE
DONE IN 3 WAYS:

1. LINAC BASED STEREOTACTIC

RADIOSURGERY

Uses a linear accelarator to administer high-energy

photon radiation to the tumor

2. GAMMA KNIFE

Uses cobalt 60 to deliver radiation

3. HEAVY CHARGED PARTICLE BEAM

THERAPY

Uses protons & helium ions to deliver radiation

Indications:

INDICATIONS:

1.
2.
3.
4.
5.
6.

STEREOTACTIC
RADIOTHERAPY

III. TOTAL BODY

IRRADIATION
Indications:

HEMIBODY
IRRADIATION
(HBI)

The presence of a suitable size( generally < 4 cm) radiographically distinct lesion that has
potential to respond to a single large dose of radiation
The largest worldwide experience has been in treatment of arteriovenous malformations
Low grade & high grade gliomas
2nd most common indication is primary or secondary treatment of brain metastasis ( up to 3
brain metastases)
Middle fossa meningiomas
Acoustic neurinomas

Uses
Uses same approach as stereotactic radiosurgery to deliver radiation to the target tissue
However,
However, it uses multiple small fractions of radiation as opposed to one large dose
Giving
Giving multiple smaller doses may improve outcome & minimizes side effects
Is
Is used to treat tumors in the brain as well as other parts of the body
Has been used as a form of systemic therapy for various disease
1A. PATIENTS WITH AUTOIMMUNE DISEASE

<2 Gy Given As Single Fraction

1B. ALLOGENIC BONE MARROW

TRANSPLANTATION

>9.5 Gy If Used Alone To Prevent Graft

Rejection

1C. PATIENT WITH APLASTIC ANEMIA FOR BONE

MARROW TRANSPLANTATION

Single Dose Of 3 Gy In Conjunction With

Cyclosphosphamide To Reduce The
Probability Of Graft Rejection

2. LOW-DOSE
DOSE SYSTEMIC THERAPY FOR CHRONIC LYMPHOCYTIC
LEUKEMIA & NON-HODGKINS
HODGKINS LYMPHOMA

0.05 To 0.15 Gy 2x To 5x A
Week For Leukocystosis

3. HIGH-DOSE
DOSE CYTOREDUCTIVE THERAPY BEFORE BONE
MARROW OR PERIPHERAL BLOOD STEM CELL
TRANSPLANTATION

1.2 Gy 3x/Day With Partial

Lung Blocks

Used in disseminated tumors involving multiple sites

LINE PASSING ACROSS THE BOTTOM OF L4 IS COMMONLY
USED TO SEPARATE UPPER & LOWER HBI
Most effective dose were: 6 gy for upper hbi, 8 gy for lower &
middle hbi with 80% pain improvement in 1 week
Comparing HBI added to local irradiation with local radiation
therapy alone. Studies showed that adjuvant single dose HBI:
a.
Delayed the progression of existing disease
b.
Reduced the frequency of new disease
c.
Delayed as well as reduced the need for retreatment
RADIATION ONCOLOGY 7/8

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OTHER METHODS TO IMPROVE EXTERNAL RADIATION THERAPY

I. THREE
DIMENSIONAL
CONFORMAL
RADIATION
THERAPY

Uses
Uses computer technology to allow doctors to more precisely target a tumor with radiation
beams (using width, height & depth)
3-d
d image of a tumor can be obtained using ct scan, mri etc.
Special
Special computer programs design radiation beams that conforms

to the shape of the

tumor. Because the healthy tissue surrounding the tumor is largely spared by this technique,
higher doses of radiation can be used to treat the tumor
Improved
Improved outcomes have been reported for nasopharyngeal, prostate, lung, liver & brain
cancers

II. INTENSITY
MODULATED
RADIATION
THERAPY (
IMRT)

D conformal radiation therapy that uses radiation beams (x-rays) of varying

A new type of 3-D
intensities to deliver different doses of radiation to small areas of tissue at the same time
Allows
Allows delivery of higher doses within tumor & lower doses to nearby healthy tissue
The
The radiation is delivered by a linear accelarator that is equipped with a multileaf collimator
(a collimator that helps to shape or sculpt the beams of radiation)
The
The collimators can be stationary or can move during treatment allowing the intensity of the
radiation beams to change during treatment sessions.
Allows different areas of a tumor or nearby tissues to receive different doses of radiation
Uses inverse treatment planning wherein oncologist choses the radiation dose to different
areas of tumor & surrounding tissue, then the computer calculates the required number of
beams & cycles of the radiation treatment.
Used
Used to treat tumors in Brain, Head & Neck, Nasopharynx, Breast, Liver, Prostate & Uterus

TOMOTHERAPY

Machine is hybrid
ybrid between a CT imaging scanner & external-beam
external
radiation therapy machine
Can capture CT images of the patients tumor immediately before treatment sessions, to
allow very precise tumor targeting & sparing of normal tissues
Like
Like IMRT, may be better than 3D-CRT
3D
in sparing normal tissues from high radiation dose

III. IMAGEGUIDED
RADIATION
THERAPY (IGRT)

Repeated imaging scans (CT, MRI & PET) are performed during treatment. These imaging
scans are processed by computers to identify changes in a tumors size & location due to
treatment & to allow the position of the patient or the planned radiation dose to be adjusted
during treatment as needed.
Increase the accuracy of radiation treatment & may allow reductions in the planned volume
of tissues to be treated, thereby decreasing the total radiation dose to normal tissue

FLOW CHART OF FUNCTIONS IN RADIATION THERAPY

3 STEPS IN
PREPLANNING

1.
2.
3.

Clinical evaluation & staging, e.g. TNM

Treatment intent: radical or palliative
Choice of treatment: surgery, radiotherapy, chemotherapy

6 STEPS IN
PLANNING
RT
TREATMENT

1.
2.
3.
4.
5.
6.

Description of treatment
Method of patient immobilization
Image acquisition of tumor & patient data for planning
Delineation of volumes (GTV, CTV, PTV)
Choice of technique & beam modification
Computation of dose distribution

6 STEPS IN
TREATMENT
DELIVERY

1.
2.
3.
4.
5.
6.

Dose prescription
Implementation of treatment
Verification
Monitoring treatment
Recording & reporting treatment
Evaluation of outcome
TUMOR VOLUME
Thick Broken line: GROSS TARGET
VOLUME

A. Gross tumor Volume (GTV) -all gross

disease (lymph nodes)

Thin Broken line: CLINICAL TARGET

VOLUME

B. Microextensions- margin around the

tumor that potentially harbours
microscopic disease

Thin line: PLANNING TARGET VOLUME

C. Biological Margin

Thick line: TREATMENT PORTAL VOLUME

D. Geometrical port Margin

END OF TRANSCRIPTION

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RADIATION ONCOLOGY 8/8