Overview of Radiation - Radiation emitted only when you turn
on the machine since it is electrically
Oncology
Teresa T. Sy Orlin
Sept 20, 2007
- Ways in which cancer is treated
- Operation → surgeons
- Med oncologist → chemotherapy
- Radio oncologist → use radiation to treat
cancer
*Treatments are guided by standard of care
practice which many differ based on histology,
based on location and based on stage of disease
So cancer can be treated either with surgery
alone, combination of surgery and chemotherapy,
chemotherapy and radiation, or radiation alone
Introduction to Radiation Oncology
- Radiation has been an effective tool for
treating cancer for more than 100 years.
- Radiation oncologists are doctors trained to
use radiation to eradicate cancer.
- About two-thirds of all cancer patients will
receive radiation therapy as part of their
treatment.
Radiation Oncology
What is cancer?
How does radiation kill cells?
- Radiation kill malignant or abnormal cells by
targeting the DNA
- Pathology: there is abnormal proliferation
- For radiation to be effective, it has to target
the DNA and disable it from causing
replication of abnormal cells
- Radiation can be given for treatment
purposes
- Can be given with the use of x-rays or
gamma rays
- Xrays can also be use to image the body –
regular chest xray, ct scan
- In higher energy, they can be used to destroy
cells
- In nuclear med, radioactive materials are
being used
- Thyroid imaging
- Bone scan
- Sometimes, radioisotopes can also be used
for treatment
e.g. Cobalt 60 for standard radiation therapy
treatments
Radiation for Diagnostic Use
- Ultrasound → radiation non-ionizing therefore
not capable of destroying structure of DNA
→ despite radiation, it can be used in
pregnant women, no danger/
hazardous effect known to fetus
- CT
- MRI
- Nuclear Medicine → radioisotopes not capable
of destroying structure of DNA
External beam radiation
- Examples
- Cobalt 60
- Like alinear accelerator
- Except that in the head of the machine,
contains radioactive material which is
the cobalt source
- Retracted in the same position when
the machine is off
- It is continuously emitting
- Linear accelerator
driven
- emits x-ray
- Capable of handling bigger volumes of tissue
- e.g. Lung tumor → drainage of lymphatic sites
in mediastinum
Brachytherapy
- Wherein radioactive sources are inserted
directly into the tumor
- Very localized and very focused treatment
*If patient receiving external beam radiation
treatment, patient need not be isolated. In
contrast, ingestion of radioactive material (iodine
131) needs to be isolated
Treatment planning system
- Simulation procedure → simulate the actual
treatment
- If radiation beam pass through critical organs
like spinal cord, shift the radiation beam a bit
so it could stay away from critical organs or
normal tissues
- Thermoplastics → to immobilize patients, not
for shielding
- Especially when treating the head and
neck areas, if patient keeps moving → may
hit the eyes
- Treatment port/verification film
- ensures treatment done properly
- shows area that will be radiated
- for treating nasopharynx and neck
- also cervical lymph nodes
- also for documentation of treatment
- if problem arises, can review if there
was a problem in the treatment
- evidence of what was done
Radiation units
- 1 rad = 1cGy
- 1Gy = 100cGy
- We use centigrades to describe
- Centigray is the system international unit for
a radiation therapy
- Old unit is rad (radiation absorbed dose)
Fractionation scheme
How is it given?
- Conventional 180 cGy – 200cGy
- Hyperfractionated treatments
- Accelerated hyperfractionated treatments.
Palliation – improve quality of life, we give very
short courses and lower dose of radiation
Hyperfractionation
- New ways of treatment of fractionation
scheme which is meant to improve and
control
- May give a little higher dose
- And the side effects is similar
- Same 7 week treatment, more fractions
- Twice a day
- The higher dose you give, the better
chances you give
But you are treating tumors close to the normal
tissues  The normal tissues can tolerate
Accelerated hyperfractionated treatments
- 3 x / day
- But shortened : 3-4 weeks instead of 7
weeks
- Difficult to implement, because you have
to ask the patient to go back in the
afternoon, and do it for 7weeks.
- Not widely implemented
 - The common strategy is still to do once a
day treatment
Notes:
- Accelerated hyperfractionated treatments →
more applicable to patients living far
- But for curative regimens, standard fractionation
scheme is still encouraged
- And important to do it for 7 weeks
4Rs of RADIOBIOLOGY
- Repair of sublethal damage
- Repopulation
- Reassortment
- Reoxygenation
The normal tissues will not be able tot tolerate
very high doses of radiation in single treatment
You allow the normal tissues to repair
Repair of sublethal damage of normal tissue
Relation to Cell Cycle
- The mitotic energy are most sensitive to
radiation
- G1 and S phase cells – not sensitive
- The cells are in the mitotic and G2 indices –
are killed
- That is why the fractionation scheme is
fashioned this way
Reoxygenation
- Cells farthest from vessels are unoxygenated
- Cells which are oxygenated die first → since
oxygen is needed for the killing mechanism of
radiation
- Cells in the periphery not easily killed
- Reoxygenation allows the peripheral cells to
move towards the blood vessels →
oxygenated → readily killed
- Better control and reduce toxicity
Notes:
 Radiation therapy is a local treatment.
 Side Effects dependent on area treated.
 Targeting is very important for radiation therapy
because it is a local treatment
 It is unlike chemotherapy where in it goes
everywhere in the body (systemic)
 Radiation – where you think the tumor is, you
target it
 Geographic miss in fact, is a very important
factor in treatment failure
 And also side effects will be dependent on the
areas treated
 Head and neck – problems in swallowing
 Pelvic area – diarrhea as consequence of
treatment
 When px is having alopecia – impossible if
radiating abdomen…
Intent of treatment
- Palliation
- Bleeding
- Bone metastasis
- Brain metastasis
- Bronchial obstruction
- Cure
 Is the patient curable or only for palliative
purpiose?
 First thing that comes to mind, the 2nd important
point that you have to ask yourself is the STAGE
 Additional examination is needed
Oncologic Emergencies
- Superior Vena Cava syndrome
- Veins are engorged
- Patient has edema
- Face is edematous
- Arms are swollen
- Signs that return of blood to the heart is
obstructed
- And maybe SVC obstruction
- In this kind of situation, a lot of
interventional radiologist wouldn’t even
dare to poke a needle into the tumor,
because vessels are so engorged, patient
may die if vessels are hit
- Until pathology can be established, more
definitive plan of treatment
- Spinal Cord Compression
- Lung cancer, breast cancer, etc
- Complain of weakness or numbness of
lower extremities
- And you see in MRI that there is abnormal,
tumor invading spinal canal and
compressing the spinal cord
- Tumor impinging on cord
- Another situation wherein you have to
initiate treatment as soon as possible
- Because if patient paralyzed more than 24
hours, harder to reverse the problem
Brachytherapy applications
- Radiation is inserted directly to where the
tumor is
- You can do brachytherapy anywhere in the
body
- If there is a lumen then we can insert tubes
which will serve as a conduit for radioactive
material
- If no lumen / cavity, may insert tube into
tumor itself  interstitial brachytherapy
- Radioactive source is Iridium 192 5mm
- If you need to treat 7 mm tumor, this
radioactive source will just travel through the
tumor and deliver
Different applicators depending on what
patient needs
- Fletcher suit
- Ring cylinder
- LDR Fletcher Suit
*Endless types of applicators to choose which is
best for you patient
Joke:
Neurotics build castles in the sky.
Psychotics live in them.
Psychiatrists collect the rent.
Transcribed by: Fred Monteverde
Notes from: Mitzel Mata
Jennifer Nery
Cecile Ong
Emy Onishi
Fred Monteverde
Mitzel Mata
Emy Onishi
Cecile Ong
Regina Luz
Section C 2009