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    885 views362 pages

    Radiation Therapy Planning - Word

    Uploaded by

    abilene rodrigues

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 362
    Contents Foreword Preface Acknowledgments Abbreviations Chapter 1 Historical Perspective of Radiation Therapy Chapter 2 External Beam Radiation Therapy Equipment Chapter 3 Dose Determination for External Beams Chapter 4 Dose Calculation for External Beams—Part I Chapter 5 Dose Calculation for External Beams—Part II Chapter 6 Isodose Charts and Typical Field Arrangements Chapter 7 The Treatment Preparation Process—I: Target Localization, Treatment Uncertainties, and Patient Immobilization xi xiii w wwii 16 322 59 je 162 Chapter 8 ‘Treatment Preparation—II: Beam-Modifying Devices and Quality Assurance 29 Chapter 9 ‘Treatment Planning—Head and Neck Region 268, Chapter 10 ‘Treatment Planning—Central Nervous System and Pituitary Gland 331 Chapter 11 ‘Treatment Planning—Thorax and Breast 367 Chapter 12 ‘Treatment Planning—Abdomen 20 Chapter 13 ‘Treatment Planning —Pelvis 439 Chapter 14 ‘Treatment Planning—Miscellaneous ‘Treatments 490 Chapter 15 Dose Calculations in Brachytherapy 533, Chapter 16 Practical Applications of Brachytherapy Techniques 562 Answers to the Problems 616 Appendix ay Color Plates appear between pages 532 and 533. Index 27 AAPM. Al avg Au BEV BSF Bq CaCl, CaF, cccr Gy Gy/mi eGyMU G cm Co COPD Cs CSI Cu %DD D, Abbreviations American Association of Physicists in Medicine aluminum area/perimeter average gold beam’s-eye view backscatter factor becquere! central axis calcium chloride calcium fluoride computer-controlled conformal therapy centigray centigray per minute centigray per monitor unit curie centimeter cubic centimeter cobalt chronic obstructive pulmonary disease cesium craniospinal irradiation computed tomography clinical target volume copper percentage depth dose depth maximum dose ‘depth of maximum dose dps DRR DVH EPID eqsq FL fa GIV HBB HVT IcRu It ISF keV kVp LiF LAO mCi mm disintegrations per second digitally reconstructed radiograph dose-volume histogram electronic portal imaging devices equivalent square field length field size roentgen to centigray in tissue gram ‘grOss tumor volume gray hour half-beam block half-value layer half-value thickness iodine International Commission on Radiation Units and Measurements iridium inverse square factor joule Kiloelectron volt peak kilovoltage lithium fluoride left anterior oblique left posterior oblique millicurie millimeter CHAPTER Historical Perspective of Radiation Therapy THE DISCOVERY OF ROENTGEN RAYS AND RADIOACTIVITY THERAPEUTIC USES OF X-RAYS AND RADIOACTIVITY MEASUREMENTS OF QUALITY AND QUANTITY OF RADIATION BEAMS ‘TECHNICAL DEVELOPMENTS: ‘Technical Developments: 1920-1940 Technical Developments: 19401960 ‘Technical Developments: 1960—Present RADIOBIOLOGY RADIATION PROTECTION THE LIFE OF OUR PIONEERS Wilhelm Conrad Réntgen Marie Sklodowska Curie Antoine Béclére SOME IMPORTANT MILESTONES IN THE HISTORY OF RADIATION THERAPY THE DISCOVERY OF ROENTGEN RAYS AND RADIOACTIVITY On Friday, November 8, 1895, while passing an electric current through a Hittorf-Crookes high- vacuum tube, Wilhelm Conrad Rontgen* noticed a light coming from a workbench about a yard away. He identified the shining object as a piece of paper painted with barium platinocyanide, Realizing that this light must have been caused by a new kind of rays, he called them x-rays which later became known as roentgen rays. He continued the investiga- tion of these rays and found that when he replaced the fluorescent screen with a photographic plate, he ‘could obtain pictures. The most dramatic picture, * Usually writen “Roentgen” inthe English-language literature. taken on December 22, only 6 weeks following the discovery of the invisible rays, showed the bones in his wife’s hand, Density variations, depending on the tissues in the path ofthe rays, were observed, and the value of such radiographic images inthe diagnosis of human ailments immediately became evident. ‘On December 28, 1895, Ronigen delivered a writ- ten presentation of his discovery to the Physical- Medical Society of Wiirzburg. Within a few weeks, this preliminary communication entitled On a New Kind of Rays was translated into many languages. On New Year's Day, 1896, he mailed copies ofhis paper along with some radiographs to several European physicists whom he knew. The news ofthe discovery spread very quickly and was soon known all over the world. Only a few weeks after Réntgen’s discovery, 1 2 RADIATION THERAPY PLANNING Henri Becquerel began investigating the possibil- ity of similar rays being produced by known fluores- cent or phosphorescent substances. He observed the darkening of photographic plates (Chap. 3) by ura- nium salts and realized that these rays were emitted spontaneously and continuously from the uranium; thus, radioactivity was discovered, Marie Curie, who at this time was studying miner- als in Paris, became interested in the phenomenon of radioactivity and chose this subject for her doctoral thesis. Pierre Curie eventually joined his wife in her research, and in July 1898 they discovered polon- ium; in December of the same year, they reported the discovery of radium. Both Becquerel and Pierre Curie experienced ery- thema on the skin of the chest from carrying small samples of radium in their vest pockets, Pierre Curie applied radium to his arm and described in detail the various phases of a moist epidermitis and his recov- ety from it. He also provided radium to physicians, who tested it on patients. ‘The news of these discoveries spread quickly, and —having leamed that redness of the skin was ob- served by the users of these rays—several phy’ cians began investigating their effect on malignant tumors; thus, the use of ionizing radiation in the treatment of cancer began. THERAPEUTIC USES OF X-RAYS AND RADIOACTIVITY More than any other innovation, the ability to visual- ize the interior of the living human body painlessly has govemed the practice of medicine during the ‘wentieth century. The radiotherapeutic application of these discoveries also had a profound effect on cancer survival rates. This chapter focuses on the therapeutic uses of x-rays and radioactivity. ‘The discovery of x-rays and radioactivity was promptly followed by their therapeutic application. ‘The first therapeutic use of x-rays is reported to have taken place on January 29, 1896, when a patient with carcinoma of the breast was treated; by 1899, the first cancer, a basal cell epithelioma, had been cured by radiation, ‘The initial dramatic responses observed in the treatment of skin and other superficial tumors gener- ated the hope that a cure for cancer had finally been found. This hope was soon followed by a wave of. disillusionment and pessimism when tumor recur- rences and injuries to normal tissues began to appear. ‘The treatments often involved single massive expo- sures aimed at the eradication of tumors, and the patients who survived the immediate postirradiation period often developed major complications. Be- cause of these disappointing results the use of x-rays to treat tumors would soon have been abandoned had it not been for laboratory and clinical work by Claude Regaud and Henri Coutard. They found that by administering fractionated doses of radiation (that is, smaller daily doses rather than a large single dose), they could achieve the same tumor response but without serious injury to the adjacent normal tis- sues, From the early experience, it was evident that the unique advantage of radium lay in intracavitary and imerstital applications. Here, where the radioactiv- ity was placed directly on or inside the tumor, the radiation did not first have to traverse normal tissue; the short distance and rapid fall-off of dose offered an advantage in this setting. Initially, containers were rather bulky and could be used only for intracavitary gynecologic implants. In 1914, methods were devel- ‘oped for collecting radon (a daughter product of ra- dium) in small glass tubes, which were then placed inside hollow metal seeds. Like radium needles, these could be inserted directly into the tumors. Ra- dium needles and radon seeds were very popular for many years but have more recently been replaced by safer, artificially produced isotopes. “Many of the physical facts of radium were discov- cred early. The skin burns suffered by Becquere] and Carie served as a warming to other users. The value of filtration and the importance of distance from the source tothe treated tissue were soon recognized by the many chemists, physicists, and medical special- ists who worked together in the treatment of patients. Initially, the only countries where radium could be obtained were France and Austria. Later, it was also discovered in Colorado, and in 1911 radium was pu- tified from the Colorado ore. To reduce and purify 11g of radium, it was necessary to use 500 tons of (CHAPTER 1 HISTORICAL PERSPECTIVE OF RADIATION THERAPY 3 ore, 10,000 tons of distilled water, 1000 tons of coal, and 500 tons of chemicals. A gram of radium sold for $120,000. ‘The first use of radium (imported from Europe) in the United States was around 1908. The radium tubes were primarily used in the treatment of gyne~ cologic malignancies, whereas radium solutions ‘were used to treat arthritis and gout. The latter use was discontinued afier a few years. ‘The clinical pioneers in radiation therapy, mostly surgeons and dermatologists, used the "erythema dose,” or radiation dose necessary to cause redness of the skin, to estimate the proper length of the treat- ments, It was recognized early that accurate dosimetry ‘was fundamental to success in any type of radiation treatment. In radium therapy, this comprised three parts: the accurate measurement of the radium con- tent ofthe various sources, the determination of the radiation output of each source in terms of an ac ceptable dose unit, and a knowledge of the distribu- tion of radiation within the tissues under treatment. Until 1911, there was no satisfactory method to standardize radium. Madame Curie then began to prepare an accurate standard of carefully weighed quantities of pure radium salt. This standard was de posited with the Intemational Bureau of Weights and Measures, at Sévres near Paris, and continues to serve as the standard for radioactivity. ‘Madame Curie’s standard was used for determin- ing the amount of radioactivity in each source. Out- put measurements in terms of radiation exposure were very complicated, but following tedious work ‘by many investigators, it was determined that a point source of radium, filtered by 0.5 mm of platinum, delivers what later became known as 8.25 roentgen per hour at 1 cm from the source. AAs for the distribution of the sources within the tissues, a dosage system that is still used in many hospitals was begun in 1932 and published in 1939 by Ralston Paterson and Herbert Parker at Christie Hospital in Manchester, England. Their dosage sys- tem was developed on the theory that nonuniform spacing of the radioactivity within the tissue could result in a relatively uniform dose distribution. In 1941, Edith Quimby, first at Memorial Hospital and later at the College of Physicians and Surgeons in New York, published a dosage system in which the sources were arranged in a uniform pattern and the resulting dose distribution was nonuniform. Several other systems for radium distribution (Chap. 15) were worked out both inthe United States and in Europe, The Manchester (Paterson and Parker), Paris, and Stockholm techniques are the ‘most notable and are more or less followed by other institutions MEASUREMENTS OF QUALITY AND QUANTITY OF RADIATION BEAMS During the early years of radiology, the methods of ‘measuring the quality (or penetrating power) and ‘quantity of x-ray beams were unsatisfactory. Direct ‘measurements of radiation quality were made by ‘means of a “penetrometer,” which was introduced by Benoist in 1901. This instrument consisted of a thin silver disk surrounded by a ring of aluminum ‘wedges arranged like a stair, with 12 steps of in- creasing thickness. The aluminum step that matched the silver disk in absorption was fluoroscopically or photographically determined and used to represent the radiation quality in designated units. ‘Also at the beginning of the century, Holzknecht described a “‘chromoradiometer,” an instrument to ‘measure quantity of dose. It consisted of small disks cof a fused mixture of potassium chloride and sodium carbonate. These compounds became discolored ‘when irradiated with x-rays. Holzknecht called the dose producing a minimal degree of discoloration “HL” Doses high enough to produce a skin ery- thema would be of the order of sH." ‘Another device, a radiometer, was developed in 1904 to measure quantity of dose. This device was used for many years, primarily by dermatologists. A ‘method of measuring dose in calories was also used at the beginning of the century. These methods were ‘unsatisfactory, and during the subsequent 50 years, ‘many efforts were made to develop accurate and re- liable methods of determining the amount of dose. From 1914 to 1925, a number of physicists worked ‘on the determination of a unit of dose and built ‘various types of instruments, most notably a primary 4) RADIATION THERAPY PLANNING standard ionization chamber for the determination of the dose unit and a secondary instrument to measure dose on the patient. In 1928, H. Geiger and W. Mueller constructed an improved detector tube based on a counter built as early as 1906. In various modified forms, both of these instruments were used well into the 1960s." ‘Antoine Béclére in Paris, Gosta Forssll in Stock- holm, J.J. Thomson in Liverpool, and George Pfahler in Boston were among the pioneers who laid the groundwork of radiation therapy. They and many ‘other dedicated scientists soon recognized the need for an internationally accepted unit of dose and a ‘method by which to define the quality of the rays. In 1913, the term half-value layer, or HVL (aterm now replaced, as in this text, by half-value thickness, or HVT), was suggested as a measure of quality. It was not until 1928 that the roentgen asa unit of measure- ‘ment for x-rays and gamma rays was internationally accepted, and in 1953, the Intemational Commission ‘on Radiological Units and Measurements (ICRU) recommended the rad as the unit of absorbed dose. ‘The rad has more recently been replaced by the cen- tigray (cGy). TECHNICAL DEVELOPMENTS ‘TECHNICAL DEVELOPMENTS: 1920-1940 ‘The equipment used in the treatment of malignant disease during the first yeas of radiation therapy was, to be treeted primitive and temperamental; it also had very low penetrating power. The use of x-rays was limited by the low kilovoltage available. But as the applicability of roentgen rays expanded, the demand for better equipment increased. During the 1920s, Coolidge invented a vacuum x-ray tube capable of operating at peak kilovoltages (kVp) of 200 to 250. With such machines, more deep-seated tumors could be treated without excessive injury to the overlying skin Figure 1.1, copied from Albert Bachem’s textbook Principles of x-ray and Radium Dosage, depicts the use of water bags as compensators, indicating an un- derstanding of isodose distributions and the compo- sition of tissue-equivalent materials prior to 19202 Improved treatment techniques where multiple beams were aimed at the tumor from different direc- tions (Fig. 1.2), the so-called crossfire techniques, ‘were also used. Other advances during this era were improved design and relisblity of treatment ma- chines. Much had been learned about the need for filtra- tion of the radiation produced by these machines. ‘The concept of the inverse-square law, scattering, ‘and the effect of treatment distance on the percentage depth dose (%DD) were also understood. The treat- ‘ment times for external beam treatment were ex- pressed in erythema time factors, whereas the stan- dard measure of erythema dose in radium treatment consisted of 100 milligram hours (mgh)? The ery- thema dose as a measure of how much dose to de- Figure 1.1. The use of water bags as issue-equivalent ‘material in this ilustratin, fst published in 1923, in cates an carly understanding of isodose distributions and the need for compensators, (CHAPTER 1 HISTORICAL PERSPECTIVE OF RADIATION THERAPY 5 Figure 1.2 4 mulile-beam arrangement inthe treatment of breast cancer was used in the erly days of radiation therapy, as

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