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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)
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)
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.
Questions/comments so far?
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
Beam Choices
Orthovoltage
Photons
Co-60
MV
Electrons
Exotica (you cant do that here)
Neutrons
Protons
dose (%)
75 kVp
225 kVp
250 kVp
0
10
depth (cm)
15
Orthovoltage
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
Co-60 Beam
Megavoltage Beam
100
Co-60
6 MV
18 MV
80
60
40
20
0
0
10
depth (cm)
20
Switching Horses
dose (%)
100
6 MeV e9 MeV e12 MeV e16 MeV e20 MeV e-
80
60
40
20
0
0
10
depth (cm)
15
Exotica
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
Questions?
2D-RT
Conventional simulator used to design
beam portals based on standardized beam
arrangement techniques and bony
landmarks visualized on planar
radiographs
Margins
GTV -> CTV: local sub-clinical
CTV -> PTV: setup variation
- patient movement
- organ movement
- variations in organ shape &
size
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
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
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
No
Satisfied ?
Yes
Accept treatment plan
No
Satisfies constraints ?
Yes
Accept treatment plan
IMRT- 9 Beams
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)
Thank you.
Any questions?