Principles of Radiation Therapy

Principles of Radiation Therapy

THOMAS J. DEELEY, MB, ChB, FRCR, DMRT

Director, South Wales and Monmouthshire, Radiotherapy Service, South Glamorgan, Area Health Authority (Teaching) and Lecturer in The Welsh National School of Medicine

BUTTERWORTHS

Table of Contents

Cover image

Title page

Inside Front Cover

Copyright

Dedication

Preface

Chapter 1: Introduction

Publisher Summary

Chapter 2: Discoveries

Publisher Summary

THE BACKGROUND

WILHELM KONRAD ROENTGEN

THE CURIES AND RADIUM

Chapter 3: Developments

Publisher Summary

ERA OF DISCOVERY 1890-1900

DEVELOPMENT 1900-1910

TECHNICAL MACHINE DEVELOPMENT 1910-1920

OVERDOSAGE EFFECTS 1920-1930

RATIONALIZATION 1930-1940

MEGAVOLTAGE 1940-1950

DEVELOPMENT OF SUPERVOLTAGE TECHNIQUES 1950-1960

TECHNOLOGICAL ADVANCES 1960-1970

ONCOLOGY 1970-1974

CONCLUSION

Chapter 4: The Treatment of Malignant Disease

Publisher Summary

BENIGN TUMOURS

MALIGNANT TUMOURS

THE CLASSIFICATION OF TUMOURS

DIAGNOSIS

PREPARATION FOR TREATMENT

TREATMENT

PRINCIPLES OF RADIOTHERAPY

CONCLUSION

Chapter 5: Physics

Publisher Summary

ELECTROMAGNETIC RAYS

Chapter 6: The Treatment of Diseases using External Beam Therapy

Publisher Summary

EXTERNAL BEAM THERAPY MACHINES

THE ADVANTAGES OF MEGAVOLTAGE THERAPY

COMPARISON OF TREATMENT GIVEN WITH ORTHOVOLTAGE AND MEGAVOLTAGE

TREATMENT TECHNIQUES

TREATMENT PLANNING

SPECIAL FEATURES

SET-UP AND IMMOBILIZATION OF THE PATIENT

PATIENTS’ RECORDS

AN EXAMPLE OF PLANNING

Chapter 7: Radium

Publisher Summary

INTERSTITIAL

INTRACAVITARY RADIUM

SURFACE THERAPY

RADON SEEDS

REPLACEMENT OF RADIUM BY ARTIFICIAL RADIOACTIVE SOURCES

CONCLUSION

Chapter 8: Radioactive Isotopes

Publisher Summary

DIAGNOSTIC USES

THERAPEUTIC USES

Chapter 9: Radiation Protection

Publisher Summary

Chapter 10: Radiobiology

Publisher Summary

THE OXYGEN STORY

THE MODIFICATION OF RADIATION EFFECTS BY THE USE OF CHEMICALS

Chapter 11: Combined Treatments

Publisher Summary

RADIOTHERAPY AND SURGERY

RADIOTHERAPY AND CHEMOTHERAPY

Chapter 12: Radiation Effects on Normal Tissues

Publisher Summary

ACUTE REACTION

LATE FIBROSIS

RADIATION EFFECTS ON GROWING TISSUES

CARCINOGENESIS

Chapter 13: Aftercare

Publisher Summary

REHABILITATION

Chapter 14: The Organization of Radiotherapy Services

Publisher Summary

PERIPHERAL CLINICS

COMBINED CLINICS

EQUIPMENT

STAFF

ASPECTS OF WORK

Service

Research

Teaching

DISEASES TREATED

Chapter 15: Research in Radiotherapy

Publisher Summary

TREATMENT TECHNIQUES

SELECTION OF PATIENTS FOR TREATMENT

TREATMENT FOR DISSEMINATED DISEASE

NEW MODES OF TREATMENT

AFTERCARE

BASIC RESEARCH

Glossary

Bibliography

Index

Inside Front Cover

Other books on radiotherapy edited by T.J. Deeley

Carcinoma of the Bronchus

Gynaecological Cancer

Central Nervous System Tumours

Malignant Diseases in Children

Computers in Radiotherapy–Clinical Aspects

Modern Trends in Radiotherapy–1 and 2

Copyright

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First published 1976

© Butterworth & Co. (Publishers) Ltd. 1976

ISBN 0 407 00030 5

Library of Congress Cataloging in Publication Data

Deeley, Thomas J.

Principles of radiation therapy

Bibliography: p.

Includes index.

1. Radiotherapy. I. Title. [DNLM: 1. Neoplasms–Radiotherapy. 2. Radiotherapy. QZ269 D313r] RM847.D38 616.9′94′0642 75–6710 ISBN 0-407-00030-5

Typeset and Produced by Scribe Design, Medway, Kent

Printed in Great Britain by Chapel River Press, Andover, Hants.

Dedication

To my parent

JAMES and LOIS

Preface

Radiotherapy is a specialized branch of medicine involved with the treatment of malignant disease. It is essentially a postgraduate study and consequently few medical students have experience of its applications, its limitations, the techniques used, the results of treatment and possible complications. Some medical schools have now included a few lectures and demonstrations on the wider applications of this therapy but these provide little more than a cursory introduction. Whilst there are many excellent books written for the established radiotherapist they inevitably assume that the reader already has a working knowledge of the subject. Medicine is becoming increasingly complex and future progress demands understanding and co-operation between members of those disciplines concerned with the treatment of a particular disease; this is particularly true of malignant disease which is rapidly assuming a major role in health care. With this in mind this short elementary book is presented, written to assist the non-radiotherapist to understand a little of the practice of radiotherapy. It has been simplified, I trust not over-simplified, in the hope that it will also be of help to nurses, physiotherapists and other workers who care for the patient with malignant disease and would like to understand something of this speciality. It is concerned mainly with general principles of treatment and details of special techniques used for diseases at certain anatomical sites are not discussed in detail.

I am grateful to many people for their help in the preparation of this Monograph–to Dr. D. K. L. Davies for the radiographs, Mrs. T. C. Edwards for the isodose distributions, Mr. W. H. Sutherland and Mr. C. W. Smith for their help, Mr. R. Toogood for many of the photographs, Miss J. Williams and Miss S. Edwards for secretarial assistance and to the Tenovus Charities who have generously supported with secretarial help.

I am most grateful to the authors and publishers of two excellent books, The Treatment of Malignant Disease by Radium and X-Rays (1948) by Ralston Paterson published by Arnold, London, and A Concise Text-book of Radiotherapy (1972) by Dr. F. A. Barnes and Dr. D. J. Rees published by Faber & Faber, London, who have given permission to reproduce certain diagrams. In addition it is a pleasure to acknowledge the help of three industrial organizations who have given their permission to reproduce photographs of their machines: Siemens Aktiengesellschaft, Sierex Limited and Radiation Dynamics Limited; in particular I would like to thank Dr. R. Radakovic, Mr. W. P. Wilson and Mr. T. Chippendale respectively of these three firms. Reference has been made in the text in the appropriate places.

The preparation of any publication needs considerable time not allowed for in the organization of a busy service department; I am therefore grateful to my wife, Della, and my children, Owen and Rosemary, for their forbearance.

Finally it is a pleasure to thank the staff of Butterworths for their willing assistance. A tremendous effort has been necessary to convert my very rough diagrams into the artistic figures presented here; the editorial staff have had considerable problems but have expertly overcome them as usual.

J. Deeply Thomas

ONE

Introduction

Publisher Summary

This chapter focuses on the treatment of malignant disease. Benign tumors grow slowly and never metastasize or invade the adjacent tissues but may produce symptoms by their expansion. On the other hand, malignant tumors run a more serious course and will inevitably result in death if not removed or controlled. On the whole, they tend to grow more rapidly than benign tumors, and they may contain numerous mitoses, many of which may be abnormal. Malignant tumors may spread out into the adjacent normal tissues by arm-like processes that grow more rapidly in loose tissues and are held up by more solid tissues such as bone or cartilage. Malignant tumors have the power to disseminate and affect the prognosis. The treatment of malignant disease may be surgery, radiotherapy, chemotherapy or a combination of two or all of these. However, if cure and control are not feasible and if there are no distressing symptoms to palliate, no active treatment is given.

While the general public are normally aware of most hospital specialities, some confusion often exists about the work of the diagnostic radiologist, the radiotherapist and the radiographer. A diagnostic radiologist uses ionizing radiation, usually x-rays, to help in the diagnosis of certain diseases, by providing photographic records of parts of the body or of certain functions carried out by the body; certain contrast media may help to define certain structures and he is an expert in inserting such substances in the most inaccessible parts of the body. A radiotherapist uses ionizing radiation, mainly x-rays and gamma-rays to treat certain diseases, the majority being malignant. He is a clinician responsible for the full care of the patients in his wards or those having treatment in the department. A radiographer can work either in a diagnostic department or a therapeutic department and is responsible for taking films or for giving treatment under medical direction.

The study of radiology is not yet 80 years old and is still in a state of development. At one time it was possible to specialize in both diagnosis and therapy, but the increasing complexities of both branches now make it impossible for one man to have an overall experience of both. In this country the two have been separate for many years and sub-specialities have grown up within each branch-for example, neuroradiology, gastrointestinal diseases, paediatric radiology in diagnosis; therapists may specialize in the treatment of certain tumours, reticuloses, central nervous system, bronchus and so on.

The radiotherapist, according to Professor Franz Buschke of the Tumor Institute, Swedish Hospital, Seattle, Washington, U.S.A., should have a fundamental knowledge in gross and microscopic pathology and of diagnostic techniques for cancer in all locations; judgement as to the indication for and knowledge of the pharmacology and techniques of application of chemotherapeutic agents; a comprehensive understanding of physics, the clinical indication for and the application of techniques of treatment by x-rays, radium and radioactive isotopes plus a knowledge of the general care and psychological management of the patient with malignant disease.

To these requirements must be added a wide knowledge of malignant disease at all sites, its incidence, aetiological factors, symptomatology, methods of diagnosis, other treatment techniques, aftercare and palliation. In recent years we have adopted the term ‘oncology’ to cover the study of all aspects of malignant disease. The radiotherapist must of necessity be an oncologist; in fact, he has practised as such for many years. Oncology is not a medical speciality but a concept; no one person is able to cover with expert knowledge the whole field of this study. He may be concerned with a specific aspect, as an epidemiologist, a surgeon, a pathologist and so on but whatever his particular interests are he will benefit from at least an elementary knowledge or familiarity with the other specialities. A radiotherapist perhaps covers more of the whole oncological concept than any other clinician. He needs to know of the surgical possibilities in a particular disease even though he does not carry out surgical procedures; if the results are better with surgery than with radiotherapy then that is the treatment of choice; if radiotherapy is unsuccessful the possibility of further treatment by surgical or other methods must be considered. The radiotherapist needs to know the pathological characteristics of a tumour because these frequently have bearing on the treatment, the search for possible metastases and the frequency of follow-up examinations. Thus we can go on detailing the experience needed by the radiotherapist so that he can function fully as a clinical oncologist. While consultants in other specialities are concerned with aspects of the study of malignant disease within their speciality few limit their activities to cancer as does the radiotherapist. In addition to his own clinical responsibilities the radiotherapist must seek co-operation with many other workers, in such specialities as surgery, gynaecology, haematology, ear, nose and throat diseases, holding joint consultative clinics whenever possible.

It would be wrong to give the impression that the radiotherapist is a scientist dealing with complex high-powered machines; that he is solely concerned with complicated mathematical calculations of dosimetry requiring a slide rule, calculating machine or computer; or involved in radiobiology so that he can assess the effects of radiation on animal and vegetable organisms. He is not a scientist but a clinician concerned with the treatment aspects of malignant disease in patients and continually striving to improve the