EP 432

RADIOTHERAPY PHYSICS
I n s t r u c t o r : A s s i s t . P r o f . D r. V u r a l E m i r K a f a d a r
E-mail: kafadar@gantep.edu.tr
Web:http://www1. gantep.edu.tr/~kafadar/

Exam contributions to the final grade:

*First mid term: 30% :26/03/2015
*Second mid term: 30% :30/04/2015
*Final exam: 40% :??/05/2015

Reference textbooks:
1 ) T h e p hys i c s o f R a d i a t i o n T h e ra p y, K h a n
2 ) B a s i c R a d i a t i o n O n co l o g y, M u ra t B eyz a d e o ğ l u , G ö k h a n Öz y i ğ i t , C u n ey t E b r u l i
3 ) H a n d b o o k o f R a d i o t h e r a p y P h y s i c s T h e o r y a n d P r a c t i c e , Ta y l o r & F r a n c i s
 COURSE CONTENT
Chapter 1: Intoduction

Chapter 2: Interaction of Radiation with Matter

Chapter 3:Treatment Machines for External Beam Radiotherapy

Chapter4: External Photon Beams: Physical Aspects

Chapter 5: Central Axis Depth Dose Calculations

Chapter 6: Clinical Tretment Planning in External Photon Beam Radiotherapy

Chapter 7: Brachytherapy

Chapter 8: Special Procedures and Techniques in Radiotherapy

Chapter 9: Basic Radiobiology &Radiation Protection and Safety in Radiotherapy

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 Cancer... wow... that sounds scary, doesn't it?
 Cancer is one word that no one wants to hear. It can bring a lot of fear and confusion to
many families who have a member diagnosed of cancer. Usually, it is more seen in
adults, but in recent time, cancer has also been diagnosed in children, and even too. Very
often if it happens in kids, it can be treated and cured.

 Cancer is simply a disease of the cells, where bad cells multiply themselves and grow into
tumors and even affect all other body organs. There are many types and kinds of cancer.
But cancer is a huge issue everywhere in the world today. It is also very technical (which
means it is not easy to understand). Even though there are great advancements in cancer
management, there is still a lot of research going on with cancer to find out more about
it.

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 What Is Cancer? What Causes Cancer?
 Cancer is a class of diseases characterized by out-of-control cell
growth. There are over 100 different types of cancer, and each is
classified by the type of cell that is initially affected.

 Cancer harms the body when damaged cells divide

uncontrollably to form lumps or masses of tissue called tumors
(except in the case of leukemia where cancer prohibits normal
blood function by abnormal cell division in the blood stream).

 Tumors can grow and interfere with the digestive, nervous, and
circulatory systems, and they can release hormones that alter
body function. Tumors that stay in one spot and demonstrate
limited growth are generally considered to be benign.
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 More dangerous, or malignant, tumors form when two things occur:
 A cancerous cell manages to move throughout the body using the blood or
lymph systems, destroying healthy tissue in a process called invasion
 A cancerous cell manages to divide and grow, making new blood vessels to feed
itself in a process called angiogenesis.

 When a tumor successfully spreads to other parts of the body and grows,
invading and destroying other healthy tissues, it is said to have metastasized. This
process itself is called metastasis, and the result is a serious condition that is very
difficult to treat.

What causes cancer?

 Cancer is ultimately the result of cells that uncontrollably grow and do not die.
Normal cells in the body follow an orderly path of growth, division, and death.
Programmed cell death is called apoptosis, and when this process breaks down,
cancer begins to form. Unlike regular cells, cancer cells do not experience
programmatic death and instead continue to grow and divide. This leads to a
mass of abnormal cells that grows out of control.

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 What are the symptoms of cancer?
 Cancer symptoms are quite varied and depend on where the cancer is located,
where it has spread, and how big the tumor is. Some cancers can be felt or seen
through the skin - a lump on the breast or testicle can be an indicator of cancer in
those locations. Skin cancer (melanoma) is often noted by a change in a wart or
mole on the skin. Some oral cancers present white patches inside the mouth or
white spots on the tongue.

 Other cancers have symptoms that are less physically apparent. Some brain tumors
tend to present symptoms early in the disease as they affect important cognitive
functions. Pancreas cancers are usually too small to cause symptoms until they
cause pain by pushing against nearby nerves or interfere with liver function to cause
a yellowing of the skin and eyes called jaundice.

 Symptoms also can be created as a tumor grows and pushes against organs and
blood vessels. For example, colon cancers lead to symptoms such as constipation,
diarrhea, and changes in stool size. Bladder or prostate cancers cause changes in
6 bladder function such as more frequent or infrequent urination.
  As cancer cells use the body's energy and interfere with normal hormone function,
it is possible to present symptoms such as fever, fatigue, excessive sweating,
anemia, and unexplained weight loss. However, these symptoms are common in
several other maladies as well. For example, coughing and hoarseness can point to
lung or throat cancer as well as several other conditions.

 When cancer spreads, or metastasizes, additional symptoms can present

themselves in the newly affected area. Swollen or enlarged lymph nodes are
common and likely to be present early. If cancer spreads to the brain, patients may
experience vertigo, headaches, or seizures. Spreading to the lungs may cause
coughing and shortness of breath. In addition, the liver may become enlarged and
cause jaundice and bones can become painful, brittle, and break easily. Symptoms
of metastasis ultimately depend on the location to which the cancer has spread.
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 Cancer Signs & Symptoms
 When cancer's found at an early stage, treatment is often easier and more likely to be successful. So
finding cancer sooner rather than later can make a real difference.
 Symptoms of cancer vary based on the type of cancer. As cancer progresses to an advanced stage,
common symptoms can include weight loss, fever, and fatigue. Look out for these:

General
An unusual lump or swelling anywhere on your body
Unusual and unexplained heavy sweating at night
Unexplained weight loss

Skin
A change in the size, shape or colour of a patch of skin
A sore that’s not healing for many weeks

Mouth
Tongue or mouth sore that’s lasted for more that 3 weeks

Throat and Neck

An unusual swelling or lump
A croaky, rough voice that is lasting for many weeks
8 Difficulty in swallowing
 Chest
Breathlessness
Unexplained coughing for more that
three weeks
Coughing up blood

 Genitals
Blood in urine
Problems passing urine
(ladies) Bleeding from the vagina after
sex, after menopause or between
periods

 Bottom Area
Blood in your bowel motions
A noticeable change or frequency in
bowel motions
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 How is cancer classified?
 There are five broad groups that are used
to classify cancer.
 Carcinomas are characterized by cells
that cover internal and external parts of
the body such as lung, breast, and colon
cancer.
 Sarcomas are characterized by cells that
are located in bone, cartilage, fat,
connective tissue, muscle, and other
supportive tissues.
 Lymphomas are cancers that begin in the
lymph nodes and immune system tissues.
 Leukemias are cancers that begin in the
bone marrow and often accumulate in
the bloodstream.
 Adenomas are cancers that arise in the
thyroid, the pituitary gland, the adrenal
gland, and other glandular tissues.

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 What causes cancer?
 Good question. There is not a single answer for this, but experts know that cancer is not
contagious, and isn't caused by germs, like colds or the flu. Each cancer type is different
and that means the causes vary. For example, lung cancer may be caused by inhaling
tobacco smoke, or toxic chemicals. Inhaling the same chemicals will not give you
cervical cancer. In the same way, exposing your skin to intense sunlight can cause
melanoma (skin cancer) but can never give you lung cancer. With this in mind, let us see
a few general causes of cancer.
Genetic make up (inheritance):
 Every person inherits some genes from their parents. If you inherit an abnormal gene
(called a mutation), there is a 10% chance that, that abnormal gene will help cancer
formation if the conditions are right. Specialists call this genetic predisposition. Breast
cancer genes are examples of genetic predisposition. Women who carry one of these
abnormal genes have a higher chance of developing breast cancer than women who do
not.

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 Smoking and second hand smoke
 Secondhand smoke is a known human carcinogen. Tobacco smoke contains more than
7,000 chemical compounds. More than 250 of these chemicals are known to be harmful,
and at least 69 are known to cause cancer.

 Age
 No, age does NOT cause cancer!!!!
Sometimes the changes that make a cell become cancerous in the first place take a long time
to develop. There has to be a number of changes to the genes within a cell before it turns
into a cancer cell. These changes can happen by accident when the cell is dividing. Or they
can happen because the cell has been damaged by carcinogens and the damage is then passed
on to future cells when that cell divides. The longer we live, the more time there is for
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genetic mistakes to happen in our cells.
  The immune system
 People who have problems with their immune systems are more likely to get some types of
cancer. Example, people with organ transplant, people living with HIV or AIDS or even people
with rare medical syndromes which affect their immunity. Some cancers such as cervical cancer
and other cancers of the genital or anal area, some lymphomas, liver cancer and stomach cancer.
Lymphomas are caused by viruses. This means that with a low immune system, viruses attacking
your cells are able to divide without control and are more likely to develop genetic faults and
develop into lymphomas.

 Body weight, diet and physical activity

 Many people in the western world eat too much red and processed meat and less fresh fruit and
vegetables. This eating habit is known to increase the risk of cancer. Drinking alcohol can also
increase the risk of developing some types of cancer.

 Bacterial infection
 Recent studies have shown that people who have helicobacter pylori (H pylori) infection of their
stomach develop inflammation of the stomach lining, which increases the risk of stomach cancer.
Infection can be treated with antibiotics, but when left for so long, it can cause damage to many
vital organs and make the cells in that area vulnerable for cancer formation

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 Day to day environment
 There are many things and chemicals all around us
that may in many little ways make us cancer prone.
These include the sun, natural and man made
radiation, work place hazards like chemicals and
smells, asbestos and others. Some of these are
avoidable and some aren't.
 Viruses
 Viruses can help to cause some cancers. But this
does not mean that these cancers can be caught like
an infection. What happens is that the virus can
cause genetic changes in cells that make them more
likely to become cancerous.
 In summary, cancer is a bit complex and no one
thing is known to cause it. Keeping well, eating
healthy, avoiding chemical inhaling, zero smoking,
staying away from sexual activity until you are
married or old enough to do so, and general
personal care can largely minimize your risk of
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cancer.
 How is cancer diagnosed and staged?
 Early detection of cancer can greatly improve the odds of successful treatment and
survival. Physicians use information from symptoms and several other procedures to
diagnose cancer. Imaging techniques such as X-rays, CT scans, MRI scans, PET scans,
and ultrasound scans are used regularly in order to detect where a tumor is located and
what organs may be affected by it. Doctors may also conduct an endoscopy, which is a
procedure that uses a thin tube with a camera and light at one end, to look for
abnormalities inside the body.

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  Extracting cancer cells and looking at them under a microscope is the only absolute way to
diagnose cancer. This procedure is called a biopsy. Other types of molecular diagnostic tests are
frequently employed as well. Physicians will analyze your body's sugars, fats, proteins, and DNA at
the molecular level. For example, cancerous prostate cells release a higher level of a chemical
called PSA (prostate-specific antigen) into the bloodstream that can be detected by a blood test.
Molecular diagnostics, biopsies, and imaging techniques are all used together to diagnose cancer.

 Common types of cancer

 There are more than 200 different types of cancer. Remember we said it is a disease of the cells?
And cells make up tissues, and tissues make up organs? This means cancer can affect all your body
organs: brain, blood, skin, cervix, throat, pancrease, stomach, intestines, liver, bladder, bone,
testes, infact all your body organs can be affected.
 Breast, lung, bowel (colorectal) and prostate - account for over half (54%) of all new
cases. The most common cancer type for men is prostate cancer, whiles breast cancer is the most
common in women. Below is a list of 9 most common cancer types.
 Bladder Cancer
 Bladder cancer develops from the transitional cells which line the inside of the bladder. The
common early symptom is blood in the urine. In most cases, the cancer is confined to the inside
lining of the bladder. Normal bladder cancers is relatively easy to treat. If the cancer has spread
into or through the muscle layer of the bladder wall then treatment is more difficult.
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  Lung Cancer
 This forms in tissues of the lung, usually in the cells lining air passages. Smoking is the
cause of most cases. There are two main types: small cell lung cancer and non-small cell
lung cancer. Non-small cell lung cancer types is more common.
 Breast Cancer
 It forms in tissues of the breast, affecting the ducts (tubes that carry milk to the nipple)
and lobules (glands that make milk). It largely affects women.
 Skin cancer
 There are two main types are: malignant melanoma (less common but more serious; and
non-melanoma skin cancer, which is very common but not so serious). It starts with cells
that make the pigment melanin. Because it forms on the skin, patients are usually the first
to spot the cancers on the skin.
 Pancreatic Cancer
 This type is also called exocrine cancer. The cancer cells form in the tissues of the
pancreas.

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  Prostate Cancer
This type usually occurs in older men, and it is very common. It develops in tissues of the prostate
(a gland in the male reproductive system found below the bladder and in front of the rectum).
 Leukemia
It is commonly known as cancer of the blood. It starts in blood-forming tissue such as the bone
marrow and causes large numbers of blood cells to be produced and enter the bloodstream.
 Thyroid Cancer
Cancer experts have put them into 4 types: papillary, follicular, medullary, and anaplastic thyroid
cancer. This cancer forms in the thyroid gland. The thyroid is located at the base of the throat.
 The rest include Colon and Rectal Cancer, Non-Hodgkin Lymphoma, Endometrial Cancer

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 Treatment of Cancer
 There are four standard methods of treatment for cancer: surgery, chemotherapy,
radiation therapy (also called radiotherapy), and immunotherapy/biologic
therapy. An oncologist will provide the patient with cancer treatment options
after diagnosis of the cancer. They are the experts and can give you good advice,
but ultimately, the patient has to decide what kind of treatment they want. Some
treatment options can be used by itself, with surgery, with
radiotherapy or together with others.

Chemotherapy
Chemotherapy (chemo) is a drug treatment aimed to cure cancer or relieve any
symptoms cancer can cause. Chemotherapy either kills cancer cells or stops them
dividing. Your doctor will discuss the best options with you and your family if you
wish. This is administered in many ways: by injections, infusion (drip),
continuous infusion (usually carried around as you go about your daily business),
as tablets that you swallow, or as ointment to be applied to skin. There are
various types of cancers and so naturally, chemo treatments will vary.

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 Immunotherapy/biologic therapy
 Immunotherapy is also sometimes called biologic therapy or biotherapy. It is treatment
that uses certain parts of the immune system to fight diseases such as cancer. This can be
done in a couple of ways: Stimulating your own immune system to work harder or
smarter to attack cancer cells or Giving your immune system components, such as man-
made immune system proteins, or by training the immune system to attack some part of
cancer cells specifically.
 CARE For Patients
 It is very important that people with cancer are given full respect, love and attention to
help them recover well. You should work closely with the doctor (or nurse), and assist
with the treatment programme. If there is a lot of money involved and you think you
need a bit of help, discuss with your doctor for charity organizations to come in. These
charity organizations may also have special skills in helping people, children and families
with cancer members.

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 Radiotherapy
Radiotherapy is a way of treating or managing cancer using radiation. It works by damaging
cells in the area being treated - over half of cancer patients will receive radiotherapy at some point
in their treatment. Radiotherapy can be given as teletherapy (also known as external beam
radiotherapy), when a beam of radiation is aimed at the area to be treated from a machine located
away from the patient. Radiotherapy is a comprehensive and fast-moving discipline which plays a
major role in cancer care.

Safe and effective radiotherapy requires close collaboration between radiation oncologists,
radiation technologists and medical physicists, and all must have an understanding of each others’
disciplines. Today surgery and radiation therapy are the major treatment modalities for curing of
cancer patients. About 20 - 25 per cent of the diagnosed cancers can be cured by each of these
treatment modalities either alone as sole modalities or together in adjuvant treatments.

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  During the last three decades radiation therapy has gone through a
very dramatic development

 During the 1970s Computed Tomography (CT) also known as

Computer Aided Tomography (CAT) and during the 1980s
Magnetic Resonance Imaging (MRI) have revolutionized the
diagnostic phase of radiation therapy by providing truly three
dimensional (3D) diagnostic tools of sub mm accuracy.

 This phase has matured further during the nineties and has been
amplified by an equally important development of radiation therapy
equipment allowing truly 3D dose delivery to the tumor.

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  In addition, some 5 per cent can be cured by cytostatic drugs and other
chemo-therapeutic agents. Thus, over one half of all cancer patients may
be cured and this is also true for that half of the patients who are
receiving radiation therapy.

 The time between the first introduction of new advanced medical tools
and the full realization of the potential benefits in the clinic is often
quite long specially considering the long follow up periods (5 - 10
years) required for many cancer sites.

 Hopefully, during the first decade of the new millennium we will start
to see the benefits of these developments in improved local cure and
survival as new 3D intensity modulated treatment modalities are taken
into clinical use.

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  Cancer Factsheet
 Over 1M Americans are diagnosed with skin cancer each year.
 In the UK, more than one in three people will develop cancer at some point in their
lives. Every year, around 309,500 people are diagnosed with the disease.
 More than 30% of cancers could be cured if detected early and treated adequately.
 More than 30% of cancer could be prevented, mainly by not using tobacco, having a
healthy diet, being physically active and preventing infections that may cause cancer.
 One fifth of all cancers worldwide are caused by a chronic infection, for example
human papillomavirus (HPV) causes cervical cancer and hepatitis B virus (HBV) causes
liver cancer.
 Worldwide, the 5 most common types of cancer that kill women are (in the order of
frequency): breast, lung, stomach, colorectal and cervical.
 About 70% of all cancer deaths occur in low and middle-income countries.
 In 2008, 7.6 million people died of cancer - 13% of all deaths worldwide.
 There are more than 200 types of cancers; any part of the body can be affected.

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 Overview of the Radiation Therapy
 Dependent on the patient history an increasing arsenal of
diagnostic procedures will be used starting from visual
inspection and palpation often complemented with different
forms of endoscopy, ultrasound and fine needle aspiration biopsy
of suspected nodules. In addition, tumor related host factors
such as Prostate Specific Antigen (PSA) etc are evaluated.

 All modern diagnostic imaging tools may also be useful in the

work-up of the patient for diagnostic and treatment planning
purposes. Both as a first step in the evaluation of the stage of the
disease and for the delineation of the clinical tissues that will be
target and organs at risk during the treatment.
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  Most commonly CT and MRI are used as the base for treatment planning
but also Diagnostic X-ray, Mammography, PET, SPECT, Ultrasound (US)
may generate useful data for defining the clinical target volume (CTV).
The CTV is often the same for the two major treatment modalities:
radiation therapy and surgery.

 Depending on the uncertainty in the diagnostic information gained by all

diagnostic modalities and the motions of the tissues inside the body a
margin has to be added to the CTV to ensure a curative treatment. For
radiation therapy this so called "internal margin" has to be added to the
CTV to get the internal target volume (ITV) accurately defined inside
the body in relation to superficial anatomic landmarks.

 The ITV has to be irradiated to a curative dose of radiation to ensure a

beneficial treatment but at the same time the dose to surrounding
normal tissues should be low enough to avoid severe normal tissue
damage.
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 Aim of Treatment
 Radiation therapy is the modality of choice for about half of the
cancer patients at some stage during their treatment. However, the
aim and intent of the treatment can differ significantly from case to
case.

 For a radical treatment with curative intent, radiation therapy may be

used alone or in combination with other adjuvant modalities such as
surgery or chemotherapy. In the former case all clonogenic tumor
cells should be eradicated by radiation alone, and in the latter case in
combination with other modalities.

 Radiation therapy may also be used with a non-radical or palliative

intent in very advanced tumors. In such cases the target for the
irradiation may not necessarily be all the clonogenic tumor cells but
those tissues that are giving an immediate clinical problem or are
27 responsible for the symptoms at hand.
 The aim of radiotherapy could be either curative or palliative. In Curative
Radiation Therapy the aim is to decrease the number of clonogenic tumor
cells to a level that results in permanent tumor control.

 In Curative Radiation Therapy it is commonly understood that:

 1) radiation therapy is used as the main local treatment modality, 2) it has a
significant probability of tumor eradication, and 3) all tumor cells have a
high probability of being included in the defined target volumes.

 Due to the random nature of cell kill, the clinical uncertainty in

microscopic tumor spread and the individual differences and variations in
radiosensitivity, all patients may not be cured. For a curative treatment the
irradiated volumes have to include all macroscopic tumor tissues (the gross
tumor) and volumes with risk for subclinical spread. To minimize the
adverse effects of the irradiation, the gross tumor and subclinical malignant
28 disease should preferably be irradiated to individually selected dose levels
  Palliative Radiation Therapy is given to maintain local tumor control,
to relieve a symptom, to prevent or delay an impending symptom,
and generally to improve the quality of life but not primarily to
increase the probability to eradicate the tumor or improve
survival.

 The target volume(s) for symptom relief does not necessarily need
to encompass all tumor tissues in the patient. The doses are
generally lower than those used for curative treatments, but they
should be sufficient to relieve the symptoms and/or reduce the
tumor cell burden in the target volume(s) such that the life span or
quality of life is increased.

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 What is radiotherapy and how does it work?
 Radiation is broadly divided into X rays (Photons) and particulate radiation. Diagnostic
radiology uses low energy X rays for imaging while in radiotherapy high energy X rays are
used to treat tumor. Particulate radiation includes radiation by electrons, protons or
neutrons.
 The following details pertain to X ray based radiation since this is the form used most often.
 The photons present in the radiation admenisterd ionizes the water in the cell and induces
formation of free radicals which can damage of genetic material (DNA).
 This damage may be lethal and can cause death of the tumour cell. However, often the
damage is not enough to cause cell death i.e. it is is sublethal. This may be converted to lethal
damage by repeated exposure to radiation; radiation is therefore fractionated and given over
multiple sittings.
 Normal cells are also affected adversely by radiation but have the capacity of repair. Within
their tolerance limits, the cells reapair themselves and the damage is transient and reversible.

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 Radiation therapy uses controlled high-energy rays to treat tumors and other diseases of
the body. Radiation works by damaging the DNA inside cells making them unable to
divide and reproduce. Abnormal cancer cells are more sensitive to radiation because they
divide more quickly than normal cells. Over time, the abnormal cells die and the tumor
shrinks. Normal cells can also be damaged by radiation, but they can repair themselves
more effectively, as when your skin heals itself after sunburn (a mild form of radiation
exposure).

 The goal of radiation therapy is to maximize the dose to abnormal cells while minimizing
exposure to normal cells. The effects of radiation are not immediate; the treatment benefit
occurs over time. Typically, more aggressive tumors, whose cells divide rapidly, respond
more quickly to radiation. Radiation therapy is painless and will not make you radioactive.

 Radiation is often given with the intent of destroying the tumor and curing the disease
(curative treatment). However, not all disease or cancer can be cured with radiation.
Sometimes radiation is used to relieve symptoms, such as pain or seizures (palliative
treatment). Sometimes it is used to prevent tumors from developing or spreading
(prophylactic treatment).
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  Radiation may be used alone or in combination with other treatments such as surgery,
chemotherapy or immunotherapy. If used before surgery, radiation will shrink the
tumor to make it easier to remove. If used after surgery, radiation will destroy tumor
cells that may have been left behind.
 There are two ways to deliver radiation:
 external beam radiation is delivered from outside the body by using a machine to
aim high-energy rays (x-rays, gamma rays or photons) at the tumor.
 internal radiation (brachytherapy) is delivered from inside the body by surgically
placing radioactive material, sealed in catheters or seeds, directly into the tumor.

 Principles of radiation therapy

 All types of radiation therapy follow these general principles:
 Precisely locate the target
 Hold the target still
 Accurately aim the radiation beam
 Shape the radiation beam to the target
 Deliver a radiation dose that damages abnormal cells yet spares normal cells
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  Forms of Radiation Therapy
 Stereotactic Radiosurgery (SRS) delivers a high dose of radiation during a single session.
Because a single radiosurgery dose is more damaging than multiple fractionated doses, the target
area must be precisely located and completely immobilized with a stereotactic head or body
frame.

 Fractionated Stereotactic Radiotherapy (FSR) delivers radiation over many visits and uses
stereotaxis to precisely locate the target and accurately reposition the patient for each treatment
session. Until recently, fractionation was not possible using stereotaxis because there was no way
to keep the rigid frame in place after the first treatment session.

 Conventional Radiotherapy delivers fractionated radiation doses over many visits. The target
area usually includes a margin of normal tissue.

 Who performs radiation therapy?

 Radiation oncologists are doctors with special training in treating cancer and other diseases with
radiation. Their role is to evaluate the patient and determine the treatment plan, also called the
prescription. The radiation oncologist works with a team that includes a surgeon, medical
physicist, dosimetrist, radiation therapist and oncology nurse. The surgeon and radiation
oncologist decide what techniques to use to deliver the prescribed dose. The physicist and the
dosimetrist then make detailed treatment calculations and set up the equipment. The radiation
therapists are specially trained technologists who deliver the daily treatments.

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 What are the side effects?
 Side effects vary depending on the tumor type, total radiation dose, size of the fractions,
length of therapy, and amount of healthy tissue in the target area. Some side effects are
temporary and some are permanent. Ask your doctor about specific side effects you may
experience. General side effects may include:
 Fatigue. Fatigue, or tiredness, is the most common side effect-. Make sure you get
plenty of sleep, take a nap after treatment, and eat a balanced diet during treatment.
Fatigue can continue for weeks or months after treatment stops. Some may notice a lack
of appetite and a loss of taste. Nausea and diarrhea may occur; medications can provide
relief.
 Skin irritation. The skin in the area where the radiation beams pass through may
occasionally become reddened and dry. This will resolve after treatment stops.
 Hair Loss. You may experience hair loss in the treated area about 2 weeks after
treatment begins. This is often temporary; your hair will grow back after treatment stops.
 Swelling. Radiation causes cells to lose their ability to regulate fluids, and swelling may
occur. This does not always happen. If swelling occurs, it can cause headaches, seizures
and confusion. Steroid medication may be given to reduce the fluid within the tumor
cavity.
 Necrosis. On rare occasions, the radiation dose can cause the tumor tissue to become
necrotic several weeks to months after treatment. Dead or necrotic tissue can become
toxic to surrounding normal tissue, and swelling may occur. Treatment for radiation
necrosis may include steroid medication, hyperbaric oxygen treatments or surgical
34 removal.
 Radiotherapy

What Is Radiation Therapy?

Radiation therapy (sometimes called

radiotherapy, x-ray therapy, or irradiation)
is the treatment of disease using
penetrating beams of high energy waves or
streams of particles called radiation.

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The radiation used for cancer treatment
comes from special machines or from
radioactive substances.

Radiation therapy equipment aims specific

amounts of the radiation at tumours or
areas of the body where there is disease.

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 How Does Radiation Therapy Work?
Radiation in high doses kills cells or keeps
them from growing and dividing.

Because cancer cells grow and divide more

rapidly than most of the normal cells around
them, radiation therapy can successfully
treat many kinds of cancer.

Normal cells are also affected by radiation

but, unlike cancer cells, most of them
recover from the effects of radiation.
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 What Are the Goals and Benefits of
Radiation Therapy?

• The goal of radiation therapy is to kill the

cancer cells with as little risk as possible to
normal cells.
• Radiation therapy can be used to treat
many kinds of cancer in almost any part of
the body.
• Radiation treatment affects the cancer
cells only in a specific area of the body.

38
 FAST FACTS ABOUT RADIATION THERAPY

• Radiation treatments are painless.

• External radiation treatment does not
make you radioactive.
• Skin in the treated area may become
sensitive and easily irritated.
• Side effects of radiation treatment are
usually temporary and they vary depending
on the area of the body that is being
treated.
39
40
 END OF CHAPTER 1

ANY QUESTIONS
41
Chapter 2: Interaction of radiation with matter
 Radiation Physics (Introduction)

 The propagation of energy from a radiative source to another

medium is termed radiation.
 This transmission of energy can take the form of particulate
radiation or electromagnetic radiation (i.e., electromagnetic
waves). The various forms of radiation originating from atoms,
which include (among others) visible light, X-rays and g-rays, are
grouped together under the terms “electromagnetic radiation or
“the electromagnetic spectrum”.

 Radio waves, which have the longest wavelengths and thus the
lowest frequencies and energies of the various types of
electromagnetic radiation, are located at tone end of the
electromagnetic spectrum, whereas X-rays and gamma-rays, which
have the highest frequencies and energies, are situated at the other
end of this spectrum.
43
  Photon
 If the smallest unit of an element is considered to be its atoms, the
photon is the smallest unit of electromagnetic radiation.
 Photons have no mass.
Electromagnetic radiation can also be subdivided into ionizing and
nonionizing radiations.
 Nonionizing radiations have wavelengths of ≥10-7 m. Nonionizing
radiations
 have energies of <12 electron volts (eV); 12 eV is considered to be the
lowest energy that an ionizing radiation can possess .
Types of nonionizing electromagnetic radiation :
 Radio waves
 Microwaves
 Infrared light
 Visible light
 Ultraviolet light

44
  Ionizing Radiation
 Ionizing (high-energy) radiation has the ability to remove
electrons from atoms; i.e., to ionize the atoms. Ionizing
radiation can be electromagnetic or particulate radiation
(Fig.).
 Clinical radiation oncology uses photons (electromagnetic)
and electrons or (rarely) protons or neutrons (all three of
which are particulate) as radiation in the treatment of
malignancies and some benign conditions.

45
 Ionizing Electromagnetic Radiation
 The electromagnetic spectrum comprises all types of
electromagnetic radiation, ranging from radio waves (low energy,
long wavelength, low frequency) to ionizing radiations (high energy,
short wavelength, high frequency).

46
 X-Rays
 X-rays were discovered by the German physicist Wilhelm Conrad Roentgen in
1895.
 The hot cathode Roentgen tube, which was developed by William David
Coolidge in 1913, is a pressured (to 10-3 mmHg) glass tube consisting of
anode and cathode layers between which a high-energy (106 –108V)
potential is applied (Fig.). Electrons produced by thermionic emission in the
cathode are accelerated towards the anode by the potential.

 They thus hit the anode, which is a metal with high melting temperature. X-rays
are produced by the sudden deceleration of these electrons due to Coulomb
interactions with nuclei in the anode (this sudden deceleration of fast-moving
electrons is known as bremsstrahlung; (Fig.). The energy and the wavelength of
the X-rays depend on the atomic number of the target (anode) metal, as well as
the velocity and the kinetic energy of the electrons. This process is used to
produce medical radiation in diagnostic X-ray units, linear accelerators (linacs),
and betatrons.
47
48
 X-rays are produced by extranuclear procedures. Two kinds of X-rays are
created by X-ray tubes . The first type corresponds to the bremsstrahlung
X-rays mentioned above.

 The second type occurs because an electron in an inner atomic orbital is

knocked out by an incoming electron, and the resulting space in the
orbital is filled by other electron that moves from an outer atomic orbital.

 This electron must shed energy to move in this manner, and the energy
released is radiated as characteristic X-rays. They are characteristic due to
the fact that their energy depends on the target metal onto which the
electrons are accelerated.

 X-rays produced by bremsstrahlung have a broad energy spectrum,

heterogeneous), while characteristic X-rays are monoenergetic beams.

49
 Gamma (γ) Rays
 Gamma rays are physically identical to X-rays, but they are emitted from
atomic nuclei (intranuclearly). An unstable atomic nucleus sheds its excess
energy in the form of either an intranuclear electron (e−) (beta particle)
or a helium nucleus (an “alpha particle”) (Fig.). If it still possesses excess
energy after that, gamma rays are emitted in order to reach its steady state
(Fig.).

50
 Gamma rays have well-defined energies. For instance, two monoenergetic
gamma rays with a mean energy of 1.25 MV (1.17 and 1.33 MV) are
emitted after beta rays of 0.31 MV energy have been emitted during the
decay of 60Co (cobalt-60; Co-60).

 Through this process, 60Co transforms into a final, stable decay product,
60Ni (nickel-60; Ni-60). There is actually a stable naturally occurring
form of cobalt: 59Co. 60Co is created through neutron bombardment in
nuclear reactors, and has a half-life of 5.26 years.

 One gram of 60Co has an activity of 50 Ci (1.85 terabecquerels).

 The half-life of a radioisotope is the time required for its activity to half .
 The activity of a radioisotope is the number of decays per second, and is
defined in becquerels or curies.
 Becquerel (Bq): the standard unit of (radio)activity; it is defined as one
disintegration (decay) per second.
 Curie (Ci): an older unit of (radio)activity, corresponding to 3.7 × 1010
disintegrations per second.
51
 The decay of a radioactive nucleus is a spontaneous process. There are three forms of
radioactive decay. Alpha or beta particles are emitted during the alpha and beta
decays of an unstable nucleus in order to reach a stable nucleus. A gamma decay
occurs without any change in the form of the nucleus.
 Alpha Decay
 An alpha particle consisting of two protons and two neutrons is emitted
if a nucleus is unstable because it has an excessive number of both protons and
neutrons (Fig.). After alpha decay, the alpha particle possesses most of the energy,
due to the conservation of momentum and the fact that the alpha particle is much
less massive than the residual nucleus.

 Although the nucleus is very energetic, does not travel very far compared
to most forms of radiation, due to its relatively heavy mass. Alpha decay is usually
observed in nuclei with mass numbers of more than 190. The energy spectrum of
alpha decay is not continuous, and varies between 4 and 10 MeV. Alpha particles
strongly interact with the electrons of the matter through which they pass, since
they are charged particles.

52
 Beta Decay
 There are three types of beta decay. If a radionuclide is unstable
because it has an excess number of neutrons in its nucleus, it transforms
one of the neutrons into a proton and an electron in order to reduce the
amount of energy in its nucleus. The electron is rapidly propelled out of
the nucleus, while the proton remains. This high-speed electron called a
β- particle or negatron, and the process is termed β- decay. The atomic
number of the radionuclide increases by one, and thus it changes into the
next element in the periodic table. Note that the mass number does not
change (it is an “isobaric” decay).

 If a radionuclide is unstable due to an excess amount of protons or a lack

of neutrons, one of the protons transforms into a neutron and a small
positively charged particle called a positron in a process termed β+ decay.
The neutron stays in the nucleus while the positron is propelled out of it.

 The atomic number of the radionuclide that emits the positron decreases
by one, and thus it changes into the preceding element in the periodic
table. Again, note that the mass number does not change.
53
 If the nucleus is unstable due an excess amount of protons, one of the electrons
close to the atomic nucleus, such as an electron in a K and L orbital, is captured
by the nucleus. This electron then combines with a proton, yielding a neutron
and a neutrino. This process is called electron capture.
 Note that no particle is emitted from the nucleus, but the atomic number decreases
by one, as in positron decay. Yet again, the mass number does not change. The
space in the inner orbital is filled by an electron from an outer orbital, resulting
in the emission of characteristic X-rays.

 Gamma Emission
 A nucleus is not always fully stable (i.e., at its basal energy level) just
after it decays; sometimes, the nucleus will be in a semi-stable state instead. The
excess energy carried by the nucleus is then emitted as gamma radiation. There
is no change in the atomic or mass number of the nucleus after this decay, so it is
termed an “isomeric” decay.

 The half-lives of gamma radiation sources are much shorter than sources of
other types of decay, and are generally less than 10−9 s. However, there are
some gamma radiation sources with half-lives of hours or even years. Gamma
energy spectra are not continuous.
54
55
56
  Ionizing Particulate Radiation
 Electrons, protons, alpha particles, neutrons, pi mesons and heavy ions
are all forms of ionizing particulate radiation. Electrons are the particles
that are generally used in routine clinics. Other particles are only used in
specific clinics worldwide. Electrons, due to their negative charge and
low mass, can be accelerated to high energies in linacs or betatrons.

 Electrons are normally bound to a (positively charged) nucleus. The

number of electrons is equal to the number of protons in a neutral atom.
However, an atom can contain more or less electrons than protons, in
which case it is known as a negatively or positively charged ion,
respectively. Electrons that are not bound to an atom are called free
electrons; free electrons can be produced during nuclear decay
processes, in which case they are called beta particles.

 Electrons have much smaller ranges (i.e., they travel smaller distances) in
matter than gamma and X-rays, and can be absorbed by plastics, glass or
metal layers
57
  Neutrons are the neutrally charged particles that enable the
formation of stable large atomic nuclei by decreasing the repulsion
between the protons in the nucleus. However, neutrons, like
protons, actually consist of particles called quarks; a neutron is one
up quark and two down quarks, while a proton is two up quarks
and one down quark.

58
 The Interaction of Radiation with Matter
 Radiation is scattered and absorbed when it passes through tissue. The intensities
of monoenergetic X-rays or gamma rays attenuate exponentially within tissues.
In other words, the intensity of radiation constantly decreases as it propagates
within tissues. This decrease depends on the type of tissue and its thickness. If
the wavelength stays constant, the intensity of the radiation passing through a
tissue can be calculated by the following formula:

 As seen in the above formula, the intensity of the radiation decreases

exponentially with the absorbent thickness, and the intensity of the outgoing
radiation depends on the tissue absorption coefficient and its thickness.
59
  When radiation strikes matter, both the nature of the radiation and the
composition of the matter affect what happens.
 The process begins with the transfer of radiation energy to the atoms and
molecules, heating the matter or even modifying its structure.

 If all the energy of a bombarding particle or photon is transferred, the

radiation will appear to have been stopped within the irradiated matter.

 Conversely, if the energy is not completely deposited in the matter, the

remaining energy will emerge as though the matter were transparent or at
least translucent. This said, we will now introduce some of the physical
phenomena involved as radiation interacts with matter, and in particular we
shall consider, separately at first, the interactions in matter of both photons
(gamma rays and x-rays) and charged particles (alpha and beta particles).

 Interaction of Photons with Matter

 As they pass through matter, photons interact with atoms. The type of
interaction is a function of the energy of the photons and the atomic number
(Z) of elements composing the matter.
60
  Types of Photon Interactions in Matter

 In the practice of nuclear medicine, where gamma rays with energies between 50
keV and 550 keV are used, Compton scattering is the dominant type of
interaction in materials with lower atomic numbers, such as human tissue (Z = 7.5).

 The photoelectric effect is the dominant type of interaction in materials with

higher atomic numbers, such as lead (Z = 82).

 A third type of interaction of photons with matter, pair production, only occurs
with very high photon energies (greater than 1020 keV) and is therefore not
important in clinical nuclear medicine.

 Compton Scattering

 In Compton scattering the incident photon transfers part of its energy to an outer
shell or (essentially) “free” electron, ejecting it from the atom.
 Upon ejection this electron is called a Compton electron. The photon is
scattered at an angle that depends on the amount of energy transferred from the
photon to the electron. The scattering angle can range from nearly 0◦ to 180◦.
61
 Photoelectric Effect
 A gamma ray of low energy, or one that has lost most of its energy through Compton
interactions, may transfer its remaining energy to an orbital (generally inner-shell)
electron. This process is called the photoelectric effect and the ejected electron
is called a photoelectron.
 This electron leaves the atom with an energy equal to the energy of the incident
gamma ray diminished by the binding energy of the electron. An outer-shell electron
then fills the inner-shell vacancy and the excess energy is emitted as an x-ray.
 Ephotoelectron = Ephoton − Ebinding

 Attenuation of Photons in Matter

 As the result of the interactions between photons and matter, the intensity of the
beam (stream of photons), that is, the number of photons remaining in the beam,
decreases as the beam passes through matter. This loss of photons is called
attenuation; the matter through which the beam passes is referred to as the
attenuator.
 Specifically, attenuation is the ratio of intensity at the point the beam exits the
attenuator, Iout, to the intensity it had when it entered, Iin. Attenuation is an exponential
62 function of the thickness, x, of the attenuator in centimeters.
63
 That the function is exponential can be understood to mean that if half of the
beam is lost in traversing the first centimeter of material, half of the
remainder will be lost traversing the next centimeter, and so on.

 This resembles the exponential manner in which radioactivity decays with

time. Expressed symbolically,

 where μ, the linear attenuation coefficient, is a property of the attenuator.

When, as is usually the case, thickness is given in centimeters, the linear
attenuation coefficient is expressed as “per centimeter.”

 As might be expected, the linear attenuation coefficient is greater for dense

tissue such as bone than for soft tissue such as fat. In general, the linear
attenuation coefficient depends on both the energy of the photons and on the
average atomic number (Z) and thickness of the attenuator.

 The lower the energy of the photons or the greater the average atomic
number or thickness of the attenuator, the greater the attenuation.
64
 A separate term, the mass attenuation coefficient (μ/ρ), is the linear attenuation
coefficient divided by the density of the attenuator. When the density of a material is given
in grams/cm3 the units of the mass attenuation coefficient are cm2/gram.
 Absorption of radiation describes another aspect of the process of attenuation.
Attenuation describes the weakening of the beam as it passes through matter. Absorption
describes the transfer of energy from the beam to the matter.

 Half-Value and Tenth-Value Layers

 A material’s effectiveness as a photon attenuator is described by the attenuation
coefficient. An alternative descriptor, one that is more easily visualized, is the “half-
value layer” (HVL), which is simply the thickness of a slab of the attenuator that will
remove exactly one half of the radiation of a beam.
 A second slab of the same thickness will remove half of the remainder, leaving one
quarter of the original beam, and so forth. For a gamma photon of 100 keV, the HVL in
soft tissue is about 4 cm.
 For any attenuator the HVL can be determined experimentally using a photon source
and a suitable detector. For calculations involving attenuation of high-intensity radiation
beams, an entirely similar concept, the tenth-value layer (TVL), is useful. The TVL is
the thickness of the attenuator that will transmit only one-tenth of the photons in
65
the beam.
  The linear attenuation coefficient, μ, introduced above,
can be calculated from the HVL as follows:

 The term penetrating radiation may be used to

describe x-ray and gamma radiation, as they have the
potential to penetrate a considerable thickness of any
material. Although we have just described some of the
many ways photons interact with matter, the
likelihood of any of these interactions occurring over
a short distance is small.

 An individual photon may travel several centimeters

or farther into tissue before it interacts. In contrast,
charged particles (alpha, beta) undergo many closely
spaced interactions. This sharply limits their
penetration
66
  Interaction of Charged Particles with Matter
 Because of the strong electrical force between a charged particle and the atoms of an absorber,
charged particles can be stopped by matter with relative ease. Compared to photons, they
transfer a greater amount of energy in a shorter distance and come to rest more rapidly. For this
reason they are referred to as nonpenetrating radiation (see Fig). In contrast to a photon of
100 keV, an electron of this energy would penetrate less than 0.00014 cm in soft tissue

67
 Excitation
 Charged particles (alphas, betas, and positrons) interact with
the electrons surrounding the atom’s nucleus by transferring
some of their kinetic energy to the electrons. The energy
transferred from a low-energy particle is often only sufficient
to bump an electron from an inner to an outer shell of the
atom. This process is called excitation.

 Following excitation, the displaced electron promptly

returns to the lower-energy shell, releasing its recently
acquired energy as an x-ray in a process called de-excitation.

 Because the acquired energy is equal to the difference in

binding energies of the electron shells and the binding
energies of the electron shells are determined by the atomic
structure of the element, the x-ray is referred to as a
characteristic x-ray.

68
 Ionization
 Charged particles of sufficient energy may also transfer enough energy to an
electron (generally one in an outer shell) to eject the electron fromthe atom.

 This process is called ionization. This hole in the outer shell is rapidly filled
with an unbound electron. If an inner shell electron is ionized (a much less
frequent occurrence) an outer shell electron will “drop” into the inner shell
hole and a characteristic x-ray will be emitted. Ionization is not limited to the
interaction of charged particles and matter.

 The photoelectric effect and Compton interactions are examples of photon

interactions with matter that produce ionization.

69
 Linear Energy Transfer
 Linear energy transfer (LET) is the amount of energy transferred in a given distance by a
particle moving through an absorber. Alpha particles are classified as high LET radiation, beta
particles and photons as low LET radiation.

 Range
 Range is the distance radiation travels through the absorber. Particles that are lighter,
have less charge (such as beta particles), and/or have greater energy travel farther than
particles that are heavier, have a greater charge (such as alpha particles), and/or have less
energy.
 In traversing an absorber, an electron loses energy at each interaction with the atoms of the
absorber. The energy loss per interaction is variable. Therefore, the total distance traveled by
electrons of the same energy can vary by as much as 3% to 4%. This variation in range is called
the straggling of the ranges. The heavier alpha particles are not affected to a significant
degree and demonstrate very little straggling of range.

70
  Annihilation
 This interaction in matter most often involves a
positron (positive electron) and an electron
(negatron).
 After a positron has transferred most of its
kinetic energy by ionization and excitation, it
combines with a free or loosely bound negative
electron.

 Recall that electrons and positrons have equal

mass but opposite electric charge. This
interaction is explosive, as the combined mass
of the two particles is instantly converted to
energy in the form of two oppositely directed
photons, each of 511 keV. This is referred to as
an annihilation reaction.

71
 Bremsstrahlung
 Small charged particles such as
electrons or positrons may be
deflected by nuclei as they pass
through matter, which may be
attributed to the positive charge of the
atomic nuclei.
 This type of interaction generates x-
radiation known as bremsstrahlung,
which in German means “braking
radiation.”

72
73
  Radiation Units and Properties
 Accurate measurement of radiation is critical to any industry or profession that
involves regular use of radiation. Several units have been defined to quantify
different types of radiation measurements. These are summarised in the following
table.

74
75
 Radiological Protection

 For practical purposes of assessing and regulating the hazards of ionizing

radiation to workers and the general population, weighting factors
(previously called quality factors, Q) are used.

 A radiation weighting factor is an estimate of the effectiveness per unit dose

of the given radiation relative a to low-LET standard.
 Weighting factors are dimensionless multiplicative factors used to convert
physical dose (Gy) to equivalent dose (Sv) ; i.e., to place biological effects
from exposure to different types of radiation on a common scale.

 A weighting factor is not an RBE.

 Weighting factors represent a conservative judgment of the envelope of
experimental RBEs of practical relevance to low-level human exposure.

76
77
 Radiation Detection & Measurement
 Ionizing radiation is rarely detected directly. Instead, detectors usually measure the secondary
products arising from the interactions of the radiation with the detector material. For
example, as an alpha or beta particle traverses a detector's sensitive volume, electron-ion
pairs or electron-hole pairs are created and the subsequent movement and collection of
charges gives rise to an electrical pulse or current.

Types of detectors:
 Gas-filled detectors consist of a volume of gas between two electrodes

 In scintillation detectors, the interaction of ionizing radiation produces UV and/or visible light

 Semiconductor detectors are especially pure crystals of silicon, germanium, or other materials to
which trace amounts of impurity atoms have been added so that they act as diodes

78
 Quantities and Units
 Exposure
 Exposure is defined for gamma and X rays in terms of the amount of ionization they produce in air.
The unit of exposure is called the roentgen (R) and was introduced at the Radiological Congress in
Stockholm in 1928 .

 It was originally defined as that amount of gamma or X radiation that produces in air 1 esu of charge
of either sign per 0.001293 g of air. (This mass of air occupies 1 cm3 at standard temperature and
pressure.)
 The roentgen is a unit of exposure. The quantity exposure is a measure of ionization produced in air
by photons.

 The ICRU defines exposure (X) as the quotient of dQ by dm where dQ is the absolute value of the
total charge of the ions of one sign produced in air when all the electrons (negatrons and positrons)
liberated by photons in air of mass dm are completely stopped in air.

 The SI unit for exposure is coulomb per kilogram (C/kg), but the special unit is roentgen (R).

79
 The definition of roentgen is
illustrated in figure.

 An x-ray beam in passing through air

sets in motion electrons by
photoelectric effect, Compton effect,
or pair production.

 These high-speed electrons produce

ionization along their tracks.

 Because of the electric field produced

by the voltage applied across the ion-
collection plates, the positive charges
move toward the negative plate and
the negative charges move toward the
positive plate. This constitutes a
current. The collected charge of
either sign can be measured by an
electrometer.
80
 Measurement of Exposure
 Free-Air Ionization Chamber
 Based on its definition, exposure can be measured operationally with the “free-air,” or
“standard,” ionization chamber, sketched in Fig.1.
 X rays emerge from the target T of an X-ray tube and enter the free-air chamber through a
circular aperture of area A, defining a right circular cone TBC of rays. Parallel plates Q and Q in
the chamber collect the ions produced in the volume of air between them with center P .

81
82
83
  Absorbed Dose
 The concept of exposure and the definition of the roentgen provide a practical, measurable
standard for electromagnetic radiation in air. However, additional concepts are needed to
apply to other kinds of radiation and to other materials, particularly tissue.

 The primary physical quantity used in dosimetry is the absorbed dose. It is defined as the
energy absorbed per unit mass from any kind of ionizing radiation in any target. The unit of
absorbed dose, J kg–1, is called the gray (Gy). The older unit, the rad, is defined as 100 erg
g–1. It follows that:

 Dose Equivalent
 It has long been recognized that the absorbed dose needed to achieve a given level of
biological damage (e.g., 50% cell killing) is often different for different kinds of radiation.
Radiation with a high linear energy transfer (LET) is generally more damaging to a
biological system per unit dose than radiation with a low LET

84
 To allow for the different biological effectiveness of different
kinds of radiation, the International Commission on Radiological
Protection (ICRP), National Council on Radiation Protection and
Measurements (NCRP), and ICRU introduced the concept of
dose equivalent for radiation-protection purposes.

 The dose equivalent H is defined as the product of the absorbed dose D

and a dimensionless quality factor Q, which depends on LET:

85
86
87
88
89
 Effective Atomic Number


90
 

91
92
QUESTIONS
 END OF CHAPTER 2

ANY QUESTIONS
93
 Chapter 3
Treatment Machines for External Beam Radiotherapy
  Since the inception of radiotherapy soon after the discovery of x-rays by
Roentgen in 1895, the technology of x-ray production has first been aimed
toward ever higher photon and electron beam energies and intensities, and
more recently toward computerization and intensity-modulated beam delivery.
During the first 50 years of radiotherapy, the techno-logical progress has been
relatively slow and mainly based on x-ray tubes, Van de Graaff generators and
betatrons.

 The invention of the cobalt-60 teletherapy unit by H.E. Johns in Canada in the
early 1950s provided a tremendous boost in the quest for higher photon
energies, and placed the cobalt unit into the forefront of radiotherapy for a
number of years. The concurrently developed medical linear accelerators
(linacs), however, soon eclipsed the cobalt unit, moved through five increasingly
sophisticated generations, and became the most widely used radiation source in
modern radiotherapy.

 With its compact and efficient design, the linac offers excellent versatility for
use in radiotherapy through isocentric mounting and provides either electron or
megavoltage x-ray therapy with a wide range of energies.

95
  In addition to linacs, electron and x-ray radiotherapy is also carried out with other types of
accelerators, such as betatrons and microtrons. More exotic particles, such as protons,
neutrons, heavy ions, and negative π mesons, all produced by special accelerators, are also
sometimes used for radiotherapy; however, most of the contemporary radiotherapy is carried
out with linacs or teletherapy cobalt units.
 X-RAY BEAMS AND X-RAY UNITS
 Clinical x-ray beams typically range in energy between 10 kVp and 50 MV, and are produced
when electrons with kinetic energies between 10 keV and 50 MeV are decelerated in special
metallic targets.
 • In the target, most of the electron's kinetic energy is transformed into heat and a small
fraction of the energy is emitted in the form of x-ray photons which are divided into two
groups: characteristic x-rays and bremsstrahlung x-rays.
 Characteristic x-rays
 Characteristic x-rays result from Coulomb interactions between the incident electrons and
atomic orbital electrons of the target material (collisional loss).
 In a given Coulomb interaction between the incident electron and an orbital electron, the
orbital electron is ejected from its shell and the resulting orbital vacancy is filled by an electron
from a higher level shell. The energy difference between the two shells may be emitted from the
atom either in the form of a characteristic photon (characteristic x-ray) or is transferred to an
orbital electron which is ejected from the atom as an Auger electron.
96

 The photons emitted through electronic shell transitions have discrete energies that are
characteristic of the particular target atom in which the transitions have occurred; hence the term
characteristic radiation.
 Bremsstrahlung (continuous) x-rays
 Bremsstrahlung x-rays result from Coulomb interactions between the incident electron and the
nuclei of the target material.
 During the Coulomb interaction between the incident electron and the nucleus, the incident
electron is decelerated and loses part of its kinetic energy in the form of bremsstrahlung photons
(radiative loss).
 Photons with energies ranging from 0 to the kinetic energy of the incident electron may be
produced, resulting in a continuous bremsstrahlung spectrum.
 The bremsstrahlung spectrum produced in a given x-ray target depends on the kinetic energy of
the incident electron as well as on the thickness and atomic number Z of the target.
 X-ray targets
 In comparison with the range R of electrons of a given kinetic energy KE in the target material,
targets are divided into two main groups: thin and thick.
 A thin target has a thickness much smaller than R, while the thickness of a thick target is on the
order of R.
 For thin target radiation, the energy radiated is proportional to the product (KE)Z, where Z is the
target atomic number. The intensity versus photon energy (photon spectrum) is constant from 0 to
97
KE, and 0 for all energies above KE.
  A thick target may be considered as consisting of a large number of superimposed thin
targets. The intensity I(hν) of a thick target spectrum is expressed as:

 X-rays are used in diagnostic radiology for diagnosis of disease and in radiation oncology
(radiotherapy) for treatment of disease.
 X-rays produced by electrons with kinetic energies between 10 keV and 100 keV are
called superficial x-rays, with electron kinetic energies between 100 keV and 500 keV
orthovoltage x-rays, and with electron kinetic energies above 1 MeV megavoltage x-
rays.
 Superficial and orthovoltage x-rays are produced with x-ray tubes (machines), while
megavoltage x-rays are most commonly produced with linacs and sometimes with
betatrons and microtrons.

98
 Clinical x-ray beams
 A typical spectrum of a clinical x-ray beam consists of line spectra that are
characteristic of the target material and are superimposed onto the
continuous bremsstrahlung spectrum.

 The bremsstrahlung spectrum originates in the x-ray target, while the

characteristic line spectra originate in the target and in any attenuators
placed into the beam.

 The relative proportion of the number of characteristic photons to

bremsstrahlung photons in an x-ray beam spectrum varies with electron
beam kinetic energy and atomic number of the target. For example, x-ray
beams produced in a tungsten target by 100 keV electrons contain about
20% characteristic photons and 80% bremsstrahlung photons, while in the
megavoltage range the contribution of characteristic photons to the total
spectrum is negligible.
99
  X-ray beam quality specifiers
 Various parameters, such as photon spectrum, half-value layer, nominal
accelerating potential, beam penetration into tissue-equivalent media, etc., are
used as x-ray beam quality indices.

 Complete x-ray spectrum is very difficult to measure; however, it gives the most
rigorous description of beam quality.

 Half-value layer (HVL) is practical for beam quality description in the superficial
(HVL in aluminum) and orthovoltage (HVL in copper) x-ray energy range, but
not practical in the megavoltage energy range because in this energy range the
attenuation coefficient is only a slowly varying function of beam energy .

 The effective energy of a heterogeneous x-ray beam is defined as that energy of

a monoenergetic photon beam that yields the same HVL as does the
heterogeneous beam.

 Recent dosimetry protocols recommend the use of tissue-phantom ratios or

percentage depth doses at a depth of 10 cm in a water phantom as an indicator
of megavoltage beam effective energy (beam quality index).
100
  X-ray machines for radiotherapy
 Superficial and orthovoltage x-rays used in radiation therapy are produced with
x-ray machines. The main components of a radiotherapeutic x-ray machine are:
an x-ray tube; ceiling or floor mount for the x-ray tube; target cooling system;
control console; and an x-ray power generator.

 The electrons producing the x-ray beams in the x-ray tube (Coolidge tube)
originate in the heated filament (cathode) and are accelerated in vacuum toward
the target (anode) by an essentially constant-potential electrostatic field
supplied by the x-ray generator.

 The efficiency for x-ray production in the superficial and orthovoltage energy
range is on the order of 1% or less. Most of the electron kinetic energy
deposited in the x-ray target (99%) is transformed into heat and must be
dissipated through an efficient target cooling system.

 To maximize the x-ray yield in the superficial and orthovoltage energy range the
target material should have a high atomic number Z and a high melting point.

101
  With x-ray tubes, the patient dose is delivered using a timer and the
treatment time must incorporate the shutter correction time that
accounts for the time required for the power supply components to attain
the steady state operating conditions.

 The x-ray tube current is controlled by hot filament emission of electrons

which, in turn, is controlled by the filament temperature (thermionic
emission). For a given filament temperature the x-ray tube current
increases with the tube (anode) voltage, first rising linearly with voltage in
the space charge limited region and saturating at higher voltages when all
electrons emitted from the cathode are pulled to the anode.

 Research is currently carried out on cold field emission cathodes

produced with carbon nanotubes (CNT). The CNT-based cold cathode x-
ray technology may lead to more durable as well as miniature and portable
x-ray sources for industrial and medical applications.
102
 CLINICAL RADIATION GENERATORS
 Up to about 1950, most of the external beam radiotherapy was carried
out with x-rays generated at voltages up to 300 kVp.

 Subsequent development of higher-energy machines and the increasing

popularity of the cobalt-60 units in the 1950s and the l960s resulted in a
gradual demise of the conventional kilovoltage machines.

 However, these machines have not completely disappeared. Even in the

present era of the megavoltage beams, there is still some use for the
lower-energy beams, especially in the treatment of superficial skin
lesions.

103
 Orthovoltage treatment machines
 These machines have similarities with machines used in diagnostic
radiology. X-rays are produced by accelerating electrons into
tungsten. These X-rays are shaped by collimators before they reach
the tumor tissue.

 Essentially all of the dose is directed onto the surface of the skin;
the percentage depth dose (PDD) curve drops sharply. Thus,
deeply seated tumors cannot be treated using these machines.

 Orthovoltage treatment machines are currently only found in a

few centers, and are only used to treat skin cancers or some very
superficial lesions in the head and neck region.
104
 Megavoltage treatment machines
 Megavoltage treatment machines are the foundation of modern
radiotherapy techniques. Photon beams are produced in megavoltage
treatment machines. Their one difference from orthovoltage machines is
the skin-sparing effect (i.e., the maximum energy is delivered in the
subepidermal region).

 The skin-sparing effect is directly proportional to the energy of the

photons. The maximum dose point distance from the skin is 0.5 cm for
Co-60, 1.5 cm for 6 MV photon beams, and 2.5 cm for 10 MV photon
beams. In addition, these machines have more suitable depth doses for
deeply seated tumors and a sharper dose distribution at the field edge
due to reduced side scattering.

 When electrons are used, deeper healthy tissues are well protected in the
treatment of superficially located tumors by controlling the penetration
depth.

105
 A. Grenz-ray Therapy Machines
 On the basis of beam quality and their use, the x-ray therapy in the
kilovoltage range has been divided into subcategories. The following ranges
are more in accordance with the National Council on Radiation Protection.
 The term grenz-ray therapy is used to describe treatment with beams of very
soft (low energy) x-rays produced at potentials below 20 kV.
 Because of the very low depth of penetration, such radiations are no longer
used in radiation therapy.
B. Contact Therapy Machines
 A contact therapy or endocavitary operates at potentials of 40 to 50 kV and
facilitates irradiation of accessible lesions at very short source (focal spot) to
surface distances (SSD).

 The machine operates typically at a tube current of 2 mA. Applicators

available with such machines can provide an SSD of 2.0 cm or less.

 A filter of 0.5- to 1.0-mm thick aluminum is usually interposed in the beam

106
to absorb the very soft component of the energy spectrum.
  Because of very short SSD and low voltage, the contact therapy beam produces
a very rapidly decreasing depth dose' in tissue.
 For that reason, if the beam is incident on a patient, the skin surface is
maximally irradiated but the underlying tissues are spared to an increasing
degree with depth.
 This quality of radiation is useful for tumors not deeper than 1 to 2 mm. The
beam is almost completely absorbed with 2 cm of soft tissue.

C. Superficial Therapy Machines

 The term superficial therapy applies to treatment with x-rays produced at
potentials ranging from 50 to 150 kV. Varying thicknesses of filtration (usually
1- to 6-mm aluminum) are added to harden the beam to a desired degree.
 The degree of hardening or beam quality can he expressed as the half-value
layer (HVL).
 The HVL is defined as the thickness of a specified material that, when
introduced into the path of the beam, reduces the exposure rate by one-half.
107
  Typical HVLs used in the superficial range are
1 .0- to 8.0-mm Al.
 A superficial beam of the quality shown is useful for irradiating tumors
confined to about 5-mm depth (-90% depth dose).
D. Orthovoltage Therapy or Deep Therapy Machines

 The term orthovoltage therapy, or deep

therapy, is used to describe treatment
with x-rays produced at potentials
ranging from 150 to 500 kV.

 Most orthovoltage equipment is

operated at 200 to 300 kV and 10 to 20
mA.

 Various filters have been designed to

achieve half-value layers between 1 and 4
mm Cu. The SSD is usually set at 50 cm.
108
  The maximum dose occurs close to the skin surface, with 90% of that
value occurring at a depth of about 2 cm.
 Thus, in a single field treatment, adequate dose cannot be delivered to a
tumor beyond this depth.
 However, by increasing beam filtration or HVL and combining two or
more beams directed at the tumor from different directions, a higher dose
to deeper tumors is delivered.

E. Supervoltage Therapy Machines

 X-ray therapy in the range of 500 to 1,000 kV has been designated as
high-voltage therapy or supervoltage therapy. In a quest for higher-
energy x-ray beams, considerable progress was made during the postwar
years toward developing higher-voltage machines.
 The major problem at that time was insulating the high-voltage
transformer.
109
 F. Megavoltage Therapy Machines
 X-ray beams of energy 1 MV or greater can be classified as
megavoltage beams. Although the term strictly applies to the x-ray
beams, the y ray beams produced by radionuclides are also commonly
included in this category if their energy is 1 MeV or greater.

 Examples of clinical megavoltage machines are accelerators such as Van

de Graaff generator, linear accelerator, betatron and microtron, and
teletherapy gama ray units such as cobalt-60.

 Radiotherapy Generators (Summary)

 Kilovoltage X-rays are generally used in the treatment of skin cancers
and superficial tumors, whereas megavoltage X-rays are used in the
management of deeply seated tumors.
 Megavoltage electrons, on the other hand, are used in the treatment of
superficial tumors.

110
 A. Kilovoltage Machines (<500 kV)
1.Contact therapy machines
40–50 kV
Filtered with 0.5–1.0 mm aluminum.
SSD = 2 cm
50% depth dose is 5 mm.

2. Superficial therapy machines

50–150 kV
Filtered with 1–4 mm aluminum.
SSD = 20 cm
50% depth dose is 1–2 cm.

111
 3.Orthovoltage therapy machines
150–500 kV
Filtered with 1–4 mm copper
SSD = 50 cm (for a field size of 20 × 20 cm)
50% depth dose is 5–7 cm
Basic therapy machine before 1950

B. Supervoltage therapy machines

500–1,000 kV
Filtered with 4–6 mm copper
50% percent depth dose is 8–10
112
113
114
 C. Megavoltage Therapy Machines (>1 MV)
1.Van de Graaf generator
Also known as an electrostatic generator
Produces energies of up to 25 MV

2.Cobalt-60 teletherapy unit (Co-60)

Manufactured in 1951
Two gamma rays with energies of 1.17 and 1.33 MV
Dose rate >150 cGy/min
SSD = 80–100 cm (for field sizes of 35 × 35 or 40 × 40 cm)
50% depth dose is 10 cm
The half-life of Co-60 is 5.27 years
Source is 2 cm in diameter, and has a large penumbra in comparison
to a 4 MV linac.
115
 3. Betatron
Developed in 1940
Developed for the circular induction acceleration of electrons and
light particles.
The magnetic field guide is increased over time in order to keep the
particles in a constant-diameter circle
Mean energy is 45 MeV (maximum energy ~300 MV)
Not used after the advent of linacs, due to their large dimensions, high
costs, and low dose rates
4. Linear accelerator (linac)
Entered into routine clinical service in 1953
SSD = 100 cm (for a field size of 40 × 40 cm)
Produces several photon and electron energies
116
 5. Microtron
Entered clinics in 1972
Combination of a linac and a cyclotron
A circular particle accelerator for accelerating electrons to energies
of several MeVs
Has a simple structure and it is easy to select the appropriate energy.
Small compared to other linacs. Just one microtron generator can
provide electrons for more than one treatment room
Produces energies of up to 50 MeV
6.Cyclotron
A circular particle accelerator in which charged subatomic particles
generated at a central source are accelerated spirally outward in a plane
perpendicular to a fixed magnetic field by an alternating electrical field.

A cyclotron is capable of generating particle energies of between a few

million and several tens of millions of electron volts
117
 LINEAR ACCELERATOR (LINAC)
 Medical linear accelerators (linacs) are cyclic accelerators which accelerate
electrons to kinetic energies from 4 MeV to 25 MeV using non-conservative
microwave RF fields in the frequency range from 103 MHz (L band) to 104
MHz (X band), with the vast majority running at 2856 MHz (S band).
 There are two types of accelerator that are used for radiation treatment.
Betatron and linac electron accelerators comprise 99% of all current
accelerator machines used in radiation treatment. Cyclotrons, on the other
hand, are heavy particle accelerators that are used for proton or neutron
treatments.
 Free electrons emitted from a metal wire via thermionic emission (as in the
case of the X-ray tube) are accelerated in an electromagnetic field to increase
their kinetic energies.
 These accelerated high-energy electrons can either be used directly for
radiotherapy (generally for superficial therapy), or they are directed into a
target and high-energy X-rays are produced (for deeply seated tumors).
118
  In this way, X-rays with energies of 4–25 MV are produced by electrons
with energies of 4–25 MeV. It is impossible to accelerate the electrons to
more than 400 kV within conventional X-ray tubes. Thus, high-frequency
magnetic wave chambers are used in linac machines, and the negatively
charged electrons are accelerated by the magnetic fields in such machines,
thus gaining kinetic energy.

 Microwave chamber. This consists of cylindrical, conductive

metal chambers (8 cm in diameter), and it produces 3,000 MHz
electromagnetic waves.

 Electron acceleration. High-frequency electromagnetic waves

occurring within the chamber move into the canal in the middle of
cylinder, and electrons are accelerated linearly by passing from one
chamber to other one within this canal. The velocity of an electron exiting
this tube is equal to the sum of the velocities gained by the electron
within each chamber.
119
  In a linear accelerator the electrons are accelerated following straight
trajectories in special evacuated structures called accelerating
waveguides. Electrons follow a linear path through the same, relatively
low, potential difference several times; hence, linacs also fall into the class
of cyclic accelerators just like the other cyclic machines that provide
curved paths for the accelerated particles (e.g., betatron).

 The high power RF fields, used for electron acceleration in the

accelerating waveguides, are produced through the process of
decelerating electrons in retarding potentials in special evacuated devices
called magnetrons and klystrons.

 Various types of linacs are available for clinical use. Some provide x-rays
only in the low megavoltage range (4 MV or 6 MV) others provide both
x-rays and electrons at various megavoltage energies. A typical modern
high energy linac will provide two photon energies (6 MV and 18 MV)
and several electron energies (e.g., 6, 9, 12, 16, 22 MeV)
120
  Figure is a block diagram of a medical linear accelerator showing
major components and auxiliary systems.
 A power supply provides direct current (DC) power to the
modulator, which includes the pulse-forming network and a switch
tube known as hydrogen thyratron.

121
 High-voltage pulses from the modulator section are flat-topped DC pulses
of a few microseconds in duration.

 These pulses are delivered to the magnetron or klystrod and simultaneously

to the electron gun. Pulsed microwaves produced in the magnetron or
klystron are injected into the accelerator tube or structure via a waveguide
system.

 At the proper instant electrons, produced by an electron gun, are also pulse
injected into the accelerator structure.

 The accelerator structure (or accelerator waveguide) consists of a copper

tube with its interior divided by copper discs or diaphragms of varying
aperture and spacing.

 This section is evacuated to a high vacuum. As the electrons are injected

into the accelerator structure with an initial energy of about 50 keV the
electrons interact with the electromagnetic field of the microwaves.
122
  The electrons gain energy from the sinusoidal electric field by an acceleration
process analogous to that of a surf rider.
 As the high-energy electrons emerge from the exit window of the accelerator
structure, they are in the form of a pencil beam of about 3 mm in diameter. In
the low-energy linacs (up to 6 MV) with relatively short accelerator tube, the
electrons are allowed to proceed straight on and strike a target for x-ray
production.

 In the higher-energy linacs, however, the accelerator structure is too long and,
therefore, is placed horizontally or at an angle with respect to the horizontal.

 The electrons are then bent through a suitable angle (usually about 90 or 270
degrees) between the accelerator structure and the target.

 The precision bending of the electron beam is accomplished by the beam transport
system consisting of bending magnets, focusing coils, and other components.
123
  Magnetron
 This is an oscillator that produces hundreds of microwaves per second. The frequency of
the microwaves is 3,000 MHz.
 The exit power of a low-energy linac magnetron (lower than 6 MV) is 2 MW.
 Klystron
 This does not produce microwaves; it is a microwave amplifier.
 Microwaves produced in low-power oscillators are sent to the klystron in order to gain
power (energy).
 The klystrons used in a high-energy linac can boost the energy to 25 MV, leading to an
exit power of 5 MW.
 The dose stabilities of klystrons are much better than those of magnetrons.

124
125
126
 The Electa SL 25 linac treatment head consists of (in order): a tungsten target, a
primary collimator, a flattening filter (main filter) containing a mixture of tungsten
and aluminum that is used to adjust the spatial modulation of the beam intensity, a
scattering foil to spatially spread the electron beams, two ion chambers, a
motorized 60° wedge filter and multileaf collimator

127
  Linac generations
 During the past 40 years, medical linacs have gone through five distinct generations,
making the contemporary machines extremely sophisticated in comparison with the
machines of the 1960s. Each of the five generations introduced the following new
features:
 Low energy photons (4-8 MV):
 straight-through beam; fixed flattening filter; external wedges; symmetric jaws; single
transmission ionisation chamber; isocentric mounting.
 Medium energy photons (10-15 MV) and electrons:
 bent beam; movable target and flattening filter; scattering foils; dual transmission
ionisation chamber; electron cones.
 High energy photons (18-25 MV) and electrons:
 dual photon energy and multiple electron energies; achromatic bending magnet; dual
scattering foils or scanned electron pencil beam; motorized wedge; asymmetric or
independent collimator jaws.
 High energy photons and electrons:
 computer-controlled operation; dynamic wedge; electronic portal imaging device;
multileaf collimator.
 - High energy photons and electrons:
 photon beam intensity modulation with multileaf collimator; full dynamic conformal
dose delivery with intensity modulated beams produced with a multileaf collimator.
128
  Components of modern linacs
 The linacs are usually mounted isocentrically and the operational systems are
distributed over five major and distinct sections of the machine:

(1) gantry;
(2) gantry stand or support;
(3) modulator cabinet;
(4) patient support assembly, i.e., treatment couch;
(5) control console.

 The length of the accelerating waveguide depends on the final electron kinetic
energy, and ranges from ~30 cm at 4 MeV to ~150 cm at 25 MeV.

129
  GAMMA RAY BEAMS AND GAMMA RAY UNITS
 Basic properties of gamma rays
 For use in external beam radiotherapy, gamma rays are obtained from specially designed
and built sources that contain a suitable, artificially-produced radioactive material.

 The parent source material undergoes a β

 decay resulting in excited daughter nuclei which attain ground state through emission of
gamma rays (gamma decay).
 The important characteristics of radioisotopes in external beam radiotherapy are:

(i) High gamma ray energy;

(ii) High specific activity;
(iii) Relatively long half-life;
(iv) Large specific air-kerma rate constant

 The basic physical properties of the two gamma emitters (cobalt-60 and cesium-137)
currently used for external beam teletherapy and a potential source for teletherapy
units (europium-152) are listed in the Table 5.I. Of the three radioisotopes cobalt-60 is
the most widely used, since it offers the most practical approach to external beam
radiotherapy, considering the energy of emitted photons, half-life, specific activity, and
means of production.
130
131
132
133
134
135
  PARTICLE ACCELERATORS
 Numerous types of accelerators have been built for basic research in nuclear and
high-energy physics, and most of them have been modified for at least some
limited use in radiotherapy. Irrespective of the accelerator type two basic
conditions must be met for particle acceleration:
(1) Particle to be accelerated must be charged
(2) Electric field must be provided in the direction of particle acceleration.

 The various types of accelerators differ in the way they produce the accelerating
electric field and in how the field acts on the particles to be accelerated.
 As far as the accelerating electric field is concerned there are two main classes of
accelerators: electrostatic and cyclic.

 In electrostatic accelerators the particles are accelerated by applying an

electrostatic electric field through a voltage difference, constant in time, whose
value fixes the value of the final kinetic energy of the particle. Since the
electrostatic fields are conservative, the kinetic energy that the particle can gain
depends only on the point of departure and point of arrival and, hence, cannot
be larger than the potential energy corresponding to the maximum voltage drop
existing in the machine.
136
  The electric fields used in cyclic accelerators are variable and non-
conservative, associated with a variable magnetic field and resulting in
some close paths along which the kinetic energy gained by the particle
differs from zero.

 If the particle is made to follow such a closed path many times over, one
obtains a process of gradual acceleration that is not limited to the
maximum voltage drop existing in the accelerator.

 Thus, the final kinetic energy of the particle is obtained by submitting

the charged particle to the same, relatively small, potential difference a
large number of times, each cycle adding a small amount of energy to the
kinetic energy of the particle.

 Examples of electrostatic accelerators used in medicine are: superficial

and orthovoltage x-ray tubes and neutron generators. The most known
example of a cyclic accelerator is the linear accelerator (linac); other
examples are microtrons, betatrons and cyclotrons.
137
  Betatron
 The betatron was developed in 1940 by D.W. Kerst as a cyclic electron
accelerator for basic physics research; however, its potential for use in
radiotherapy was realized soon thereafter.
 • The machine consists of a magnet fed by an alternating current of frequency
between 50 and 200 Hz. The electrons are made to circulate in a toroidal
vacuum chamber (donut) that is placed into the gap between two magnet poles.

 Conceptually, the betatron may be considered an analog of a transformer: the

primary current is the alternating current exciting the magnet and the
secondary current is the electron current circulating in the vacuum chamber
(donut).
 •The electrons are accelerated by the electric field induced in the donut by the
changing magnetic flux in the magnet; they are kept in a circular orbit by the
magnetic field present in the donut.
 In the 1950s betatrons played an important role in megavoltage radiotherapy.
However, the development of linacs pushed them into oblivion because of the
numerous advantages offered by linacs over betatrons, such as: much higher
beam output (up to 10 Gy/min for linacs vs 1 Gy/min for betatrons); larger
field size; full isocentric mounting; more compact design; and quieter
operation.
138
  Cyclotron
 The cyclotron was developed in 1930 by E.O. Lawrence for acceleration
of ions to a kinetic energy of a few MeV. Initially, the cyclotron was used
for basic nuclear physics research but has later on found important
medical uses in production of radioisotopes for nuclear medicine as well
as in production of proton and neutron beams for radiotherapy.

 The recent introduction of the PET/CT machines for use in radiotherapy

has dramatically increased the importance of cyclotrons in medicine. The
PET/CT machines rely on glucose labeled with positron-emitting
fluorine-18 that is produced by proton cyclotrons.

 In a cyclotron the particles are accelerated along a spiral trajectory guided

inside two evacuated half-cylindrical electrodes (referred to as dees
because of their D-shape form) by a uniform magnetic field (1 tesla) that
139 is produced between the pole pieces of a large magnet.
  A radiofrequency voltage with a constant frequency between 10 and
30 MHz is applied between the two electrodes and the charged
particle is accelerated while crossing the gap between the two
electrodes.
 Inside the electrodes there is no electric field and the particle drifts
under the influence of the magnetic field in a semicircular orbit
with a constant speed, until it crosses the gap again.

 If, in the meantime, the electric field has reversed its direction, the
particle will again be accelerated across the gap, gain a small
amount of energy, and drift in the other electrode along a semicircle
of a larger radius than the former one, resulting in a spiral orbit and
a gradual increase in kinetic energy after a large number of gap
crossings.
140
141
 Microtron
 The microtron is an electron accelerator that combines the principles of both the linear
accelerator and the cyclotron.

 In the microtron, the electrons are accelerated by the oscillating electric field ofone or
more microwave cavities.
 A magnetic field forces the electrons to move in a circular orbit and return to the cavity.

 As the electrons receive higher and higher energy by repeated passes through the cavity,
they describe orbits of increasing radius in the magnetic field.

 The cavity voltage, frequency, and magnetic field are so adjusted that the electrons arrive
each time in the correct phase at the cavity. Because the electrons travel with an
approximately constant velocity (almost the speed of light), the above condition can be
maintained if the path length of the orbits increases with one microwave wavelength per
revolution.

 The microwave power source is either a klystron or a magnetron.

142
  The principal advantages of the microtron over a linear accelerator of comparable
energy are in simplicity, easy energy selection, and small beam energy spread as well
as the smaller size of the machine.

 Because of the low energy spread of the accelerated electrons and small beam
emittance (product of beam diameter and divergence), the beam transport system is
greatly simplified. These characteristics have encouraged the use of a single microtron
to supply a beam to several treatment rooms.

143
 END OF CHAPTER 3

ANY QUESTIONS
144
 Chapter 4
External Photon Beams: Physical Aspects
  Radiotherapy procedures fall into two main categories: external beam radiotherapy
and brachytherapy. In external beam radiotherapy the radiation source is at a
certain distance from the patient and the target within the patient is irradiated with
an external radiation beam. In brachytherapy radiation sources are placed directly
into the target volume (intracavitary or interstitial brachytherapy) or onto a target
(surface mold or intraoperative radiotherapy).

 Most of the external beam radiotherapy is carried out with photon beams, some
with electron beams, and a very small fraction with more exotic particles, such as
protons, heavier ions or neutrons.

 QUANTITIES USED IN DESCRIBING A PHOTON BEAM

 Radiation dosimetry deals with two distinctly different entities: one describes the
photon radiation beam itself in terms of the numbers and energies of photons
constituting the photon beam and the other describes the amount of energy the
photon beam may deposit in a given medium, such as air, water or biological
material.
146
  Photon fluence and photon fluence rate

147
  Energy fluence and energy fluence rate

148
  Air-kerma in air

 Photon Beam Sources

 Photon sources are either isotropic or non-isotropic and they emit either
monoenergetic or heterogeneous photon beams. The most common photon sources
used in radiation oncology are: x-ray machines, teletherapy isotope sources, and linear
accelerators (linacs).

 An isotropic photon source produces the same photon fluence rate in all directions,
while the photon fluence rate from a non-isotropic source depends on direction of
measurement.

 A plot of number of photons per energy interval vs. photon energy is referred to as
photon spectrum.
149
  All photons in a monoenergetic photon beam have the same energy hν while photons
in a heterogeneous x-ray beam form a distinct spectrum with photons present in all
energy intervals from 0 to a maximum value hνmax which equals to the kinetic energy
of electrons striking the target.
 Gamma ray sources are usually isotropic and produce monoenergetic photon beams,
while x-ray targets are non-isotropic sources producing heterogeneous photon spectra.

150
  INVERSE SQUARE LAW
 In external beam radiotherapy photon sources are often assumed to be point sources and
the beams they produce are divergent beams, as shown schematically in Fig. Let us
assume that we have a photon point source S and a square field with side a (area A = a2)
at a distance fa from the source. At a distance fb we then get a square field with side b
(area B = b2), and the two fields are geometrically related as follows:

151
152
  PENETRATION OF PHOTON BEAMS INTO A PHANTOM OR PATIENT
 A photon beam propagating through air or vacuum is governed by the inverse-square
law; a photon beam propagating through a phantom or patient, on the other hand, is not
only affected by the inverse-square law but also by the attenuation and scattering of the
photon beam inside the phantom or patient. The three effects make the dose deposition
in a phantom or patient a complicated process and its determination a complex task.

 A direct measurement of the dose distribution inside the patient is essentially

impossible; yet, for a successful outcome of patient radiation treatment, it is imperative
that the dose distribution in the irradiated volume be known precisely and accurately.
This is usually achieved through the use of several functions which link the dose at any
arbitrary point inside the patient to the known dose at the beam calibration (or
reference) point in a phantom.

 The functions are usually measured with suitable radiation detectors in tissue-equivalent
phantoms and the dose or dose rate at the reference point is determined for, or in,
water phantoms for a specific set of reference conditions, such as depth, field size, and
source-surface distance. A typical dose distribution on the central axis of a megavoltage
153 photon beam striking a patient is shown in Fig.
154
  Surface dose
 For megavoltage photon beams the surface dose is generally much lower than
the maximum dose which occurs at a depth zmax beneath the patient surface.
 In megavoltage photon beams the surface dose depends on beam energy and
field size.

 The larger the photon beam energy, the lower is the surface dose, for a 10×10
cm2 field typically amounting to some 30% of the maximum dose for a cobalt
beam, 15% for a 6 MV x-ray beam and 10% for an 18 MV x ray beam. For a
given beam energy the surface dose increases with field size.

 The low surface dose compared to the maximum dose is referred to as the skin
sparing effect and represents an important advantage of megavoltage beams over
orthovoltage and superficial beams in treatment of deep-seated tumours.

 • Orthovoltage and superficial beams do not exhibit the skin sparing effect, since
their dose maximum occurs on skin surface, i.e., the surface dose is equal to the
maximum dose.

155
  The surface dose represents contributions to the dose from:
(1) Photons scattered from the collimators, flattening filter and air;
(2) Photons backscattered from the patient; and
(3) High-energy electrons produced by photon interactions in air and any
shielding structures in the vicinity of the patient.
 Buildup region
 The dose region between the surface (depth z = 0) and depth z = zmax in
megavoltage photon beams is referred to as the dose buildup region and
results from the relatively long range of energetic secondary charged
particles (electrons and positrons) that are first released in the patient by
photon interactions (photoelectric effect, Compton effect, pair
production) and then deposit their kinetic energy in the patient.
 Depth of dose maximum
 The depth of dose maximum zmax beneath the patient surface depends on
beam energy and beam field size. The beam energy dependence is the
main effect; the field size dependence is often ignored because it
156
represents only a minor effect.
  RADIATION TREATMENT PARAMETERS
 External beam radiotherapy with photon beams is carried out with three types of
treatment machines: x-ray units, isotope teletherapy units (mainly cobalt-60 units), and
linear accelerators (linacs). The main parameters in external beam dose delivery with
photon beams are: (i) depth of treatment, (ii) field size, (iii) source-surface distance in
SSD setups or source-axis distance in SAD (isocentric) setups, and (iv) photon beam
energy.
 Radiation beam field size
 Beams used for radiotherapy have various shapes that usually represent a compromise
between the actual target shape and the need for simplicity and efficiency in beam
shaping. Four general groups of field shapes are used: square, rectangular, circular, and
irregular.

 Square and rectangular fields are usually produced with collimators installed in
radiotherapy machines; circular fields with special collimators attached to the treatment
machine; and irregular fields with custom-made shielding blocks or with multileaf
collimators attached to a treatment machine.
157
  For any arbitrary radiation field an equivalent square or equivalent circular
field may be found, meaning that the arbitrary field and the equivalent square
field or equivalent circular field will be characterized with similar beam
parameters and functions that are of importance in radiation dosimetry.
 An arbitrary rectangular field with sides a and b will be approximately
equivalent to a square field with sides aeq when both fields have the same
area/perimeter ratio (Day’s rule), i.e.,

 An arbitrary square field with sides aeq will be equivalent to a circular field with
radius req when both fields have the same area, i.e.,

158
  Collimator factor
 Exposure in air, air-kerma in air, and “dose to small mass of medium in
air” at a given point P in air contain contributions from two components:
primary and scatter.

 Primary is the major component; it comes directly from the source and
does not depend on field size.

 Scatter represents a minor, yet non-negligible component; it consists of

photons scattered into point P mainly from the collimator but also
possibly from the air and the flattening filter of a linac. The scatter
component depends on field size A (collimator setting): the larger the
field size, the larger is the collimator surface available for scattering and
consequently the larger is the scatter component.

159
  Dose Distribution and Scatter Analysis
 It is seldom possible to measure dose distribution directly in patients
treated with radiation. Data on dose distribution are almost entirely
derived from measurements in phantoms—tissue-equivalent materials,
usually large enough in volume to provide full-scatter conditions for the
given beam. These basic data are used in a dose calculation system
devised to predict dose distribution in an actual patient.
Phantoms
 Basic dose distribution data are usually measured in a water phantom,
which closely approximates the radiation absorption and scattering
properties of muscle and other soft tissues. Another reason for the choice
of water as a phantom material is that it is universally available with
reproducible radiation properties.
 Since it is not always possible to put radiation detectors in water, solid
dry phantoms have been developed as substitutes for water.
160
  Ideally, for a given material to be tissue or water equivalent, it must
have:

 the same effective atomic number,

 number of electrons per gram,
 and mass density.

 The electron density (ρe) of a material may be calculated from its

mass density (ρm) and its atomic composition according to the
formula:

 Where;

161
  Phantoms are models constructed from tissue-equivalent material and
used to determine the radiation absorption and reflection characteristics
of a human body or a specific organ.

 Phantom materials are equivalent to human tissues in terms of their

characteristics under X-ray and electron irradiation. Soft tissue, bone and
lungs are equivalent of real density. Soft tissues are mimicked by heat-
hardened plastic material. The effective atomic number of soft tissue is
7.30 ± 1.25%, and its density is 0.985 ± 1.25g/cm3

 Although lung has the same atomic number as soft tissue (7.30), its
density is 0.32 ± 0.01 g/cm3. The bones used in a phantom are real
human bones, and the same cavities exist as in the human body. The
phantom is divided into slices of 2.5 cm thickness. There are drilled holes
of 2.5–6 mm diameter for TLD insertion in each slice.
162
  NA is Avogadro's number and ai is the fraction by weight of the ith
element of atomic number Zi and atomic weight Ai.
 Of the commercially available phantom materials, Lucite and
polystyrene are most frequently used as dosimetry phantoms.

water phantom Solid dry phantoms

163
  In addition to the homogeneous phantoms, anthropomorphic phantoms are
frequently used for clinical dosimetry. One such commercially available system,
known as Alderson Rando Phantom, incorporates materials to simulate various
body tissues—muscle, bone, lung, and air cavities. The phantom is shaped into a
human torso and is sectioned transversely into slices for dosimetric
applications.

164
165
 END OF CHAPTER 4

ANY QUESTIONS

166
 Chapter 5
Central Axis Depth Dose Calculations
  Definition of Beam Geometry
 The accurate delivery of a radiation dose to patient depends on the precise
positioning of the patient and radiation source. The geometric parameters
linking the source and target (tumor at treatment) are described below (Fig.)

168
  SSD and SAD are geometric parameters that can be changed, and
the ability to change them leads to two different planning and
treatment set-up modalities:
 Constant SSD technique. Here, the isocenter (the point at which all of the
radiation beams cross) of the treatment machine (or simulator) is on
the patient’s skin (= nonisocentric technique).
 Field and dose are defined according to A0.

169
  Constant SAD technique . Here the isocenter of the treatment machine (or
simulator) is in the patient (in the tumor) (= isocentric technique;
 Field and dose are defined according to Ad.

170
  Build-Up Region
 The region between the skin and the depth at dose maximum (Dmax) is called the build-up
region. This region between the surface and depth d is referred to as the dose build-up
region in megavoltage beams, and it results from the kinetic energy deposited in the
patient by secondary charged particles (which have relatively long ranges) released inside
the patient by photon interactions (photoelectric effect, Compton effect, pair
production).

171
 Percentage Depth Dose (PDD)
 The ratio (in percent) of the dose absorbed at a predefined depth (Dx) to Dmax (the
dose maximum) for a predefined SSD and field size is termed the percentage
depth dose (PDD or DD%).

 DD% is also defined as the dose at a specific depth as a function of distance, field
and energy in a water phantom.
 The percentage depth dose curve provides information on the quality of the
radiation and its energy.

 The depth at dose maximum can be calculated.

 The most probable energy at the surface of the phantom can be found by
calculating the range of the electrons. This can give information on X-ray
contamination.

172
  Dose: Energy transferred per unit mass of target tissue, and
its unit is Gray (Gy).
 The dose in radiotherapy is normalized to the Dmax calculated in the
phantom. PDD curves are created by plotting DD% values at different
depths from the surface of the phantom.

173
 One way of characterizing the central axis dose distribution is to normalize dose at depth
with respect to dose at a reference depth.
 The quantity percentage (or simply percent) depth dose may be defined as the quotient,
expressed as a percentage, of the absorbed dose at any depth d to the absorbed dose at a
fixed reference depth d0, along the central axis of the beam
 Absorbed dose at any depth: d
A collimator is a
 Absorbed dose at a fixed reference depth: d0 device that narrows a
beam of particles or
waves.

collimator

surface
Dd
P 100 d0
D d0
Dd 0 d
Dd

phantom
 Effect of Field Size and Shape
 Field size may be specified either geometrically or dosimetrically.

 The geometric field size is defined as “the projection, on a plane perpendicular to the
beam axis, of the distal end of the collimator as seen from the front center of the source”.

 This definition usually corresponds to the field defined by the light localizer, arranged as
if a point source of light were located at the center of the front surface of the radiation
source.

 The dosimetric, or the physical, field size is the distance intercepted by a given isodose
curve (usually 50% isodose) on a plane perpendicular to the beam axis at a stated
distance from the source.

 Unless stated otherwise, the term field size in this course will denote geometric field
size. In addition, the field size will be defined at a predetermined distance such as the
source to surface distance SSD) or the source to axis distance (SAD). The latter term is
the distance from the source to axis of gantry rotation known as the isocenter.
  Geometrical field size: the projection, on a plane perpendicular to the beam axis, of the distal
end of the collimator as seen from the front center of the source
 Dosimetric ( Physical ) field size: the distance intercepted by a given isodose curve (usually 50%
isodose ) on a plane perpendicular to the beam axis

pertaining to zones
that receive equal SAD
doses of radiation  Geometrical field size

 Dosimetrical or physical
field size
FS
  Isodose Curves
 Isodose curves are prepared by combining the points in the phantom
or target tissue that receive the same dose. They are calculated by
various dosimetric measurements, and the highest dose is considered
100%. The curves are placed in percentage order, and then used to
create the dose distribution graphics for the target tissue and the
energy of interest (Fig. 1.55).
 By the using the isodose curves during treatment planning, the dose
distribution of the radiation delivered to the target tissue and
neighboring structures can be seen from different angles.

 In a plot of isodose curves, the y-axis shows the depth below the surface of
the skin, while the x-axis shows the range of the field.
177
 Dependence on Source to Surface Distance
 Photon fluence emitted by a point source of radiation varies inversely as a
square of the distance from the source.

 Although the clinical source (isotopic source or focal spot) for external
beam therapy has a finite size, the source to surface distance is usually
chosen to be large (≥80 cm) so that the source dimensions become
unimportant in relation to the variation of photon fluence with distance. In
other words, the source can be considered as a point at large source to
surface distances.

 Percent depth dose increases with SSD because of the effects of the inverse
square law. Although the actual dose rate at a point decreases with an
increase in distance from the source, the percent depth dose, which is a
relative dose with respect to a reference point, increases with SSD.
 In clinical radiation therapy, SSD is a very important parameter. Because percent depth
dose determines how much dose can be delivered at depth relative to the surface dose
or Dmax, the SSD needs to be as large as possible.

 However, because dose rate decreases with distance, the SSD, in practice, is set at a
distance that provides a compromise between dose rate and percent depth dose.

 For the treatment of deep-seated lesions with megavoltage beams, the minimum
recommended SSD is 80 cm.

 Let P (d,r,f) be the percent depth dose at depth d for SSD = f and a field size r (e.g., a
square field of dimensions r × r). Since the variation in dose with depth is governed by
three effects—inverse square law, exponential attenuation, and scattering.

 where µ is the linear attenuation coefficient for the primary and Ks is a function that
accounts for the change in scattered dose.
 f1
f2
r
dm r
d
dm
d

2
 f  d m    ( d d m )
P(d , r , f1 )  100   1  .e .K s
 f 1 d  2
 f 2  d m    ( d d m )
P(d , r , f 2 )  100    .e .K s
 f2  d 
2 2
P(d , r , f 2 )  f 2  d m   f1  d 
     
P(d , r , f1 )  f1  d m   f2  d 
 f1
f2
r
dm r
d
dm
d

PDD increases with SSD

the Mayneord F Factor ( without considering changes in scattering )

2 2
 f2  dm   f1  d 
F 
 f d 
 
 f d 
 eqn.9.11
 1 m   2 
183
  Dose Profile
 The characteristics of the delivered radiation can be determined by
performing measurements in ionization chamber within a water phantom.
These characteristics are the flatness, symmetry, and penumbra for that
energy (Fig).

184
185
  General Features of a Water Phantom System
 The system can perform three-dimensional computerized controlled analyses of
the dose, depth dose, dose ratios [TMR, TPR (measurement and calculation)] and
isodose calculations.

 It has an air scanner capable of making measurements in air, along with an ion
chamber, and build-up blocks. There is also a mechanism in these equipments
which can be used to mount to the head of actual treatment machines.
 The system has a specific test apparatus that can be used to test the isocenter
point for the treatment machine (an “isocheck”).

 It has an apparatus that can check the monitor unit controls of a linac teletherapy
unit (a “monicheck”).
 It also has a “linear array” apparatus for dynamic wedge and MLC measurements.

 Penumbra
 The penumbra is defined as the region of steep dose rate decrease at the edge of
radiation beam, noting that the dose rate decreases as a function of the distance
from the central axis
186
  Types of Penumbra
 The physical penumbra is the penumbra measured in the dose profile. It is
the distance between the points at which the 20 and 80% isodose
curves cross the x-axis at Dmax.
 There are several components to the physical penumbra:

 Geometrical penumbra: This occurs due to the size of the

source; large sources have larger geometrical penumbras.

 Transmission penumbra: This occurs due to the beam

emerging from the edges of blocks or collimators. It can be
decreased by making sure that the shapes of the focalized blocks
take into account the beam divergence.
187
188
  Inverse Square Law
 This is the decrease in radiation intensity with the square of distance from the source. In
tissues, the depth into the tissue thickness is another factor that must be considered in
addition to the distance from the source, and the dose decreases exponentially with depth
into the tissue.

 The inverse square law is very important in both radiotherapy and protection from
radiation. Since radiotherapy treatments are applied at a short distance from the source,
the dose drops off rapidly with distance due to the inverse square law. This situation is
observed for both brachytherapy and external radiotherapy.

 Most external radiotherapy is delivered as teletherapy (at a distance of 80–120 cm). Thus,
the dose fall-off due to distance is relatively small.

 Brachytherapy isodose curves show a rapid dose decrease → rapid fall-off

 Here, the isodose curves are narrow, so isodose distances are short
 Teletherapy isodose curves show a slow dose decrease → slow fall-off
 Here, the isodose curves are wide, so isodose distances are long
 Isocentric treatment (constant SAD) is affected more by the inverse square law than the
SSD technique.

189
  Backscatter Factor (BSF)

 In a phantom, the ratio of the dose maximum to the dose in air at the same
depth is called the backscatter factor (BSF).

BSF
 Increases as the energy increases (gets closer to 1)
 Increases as the field size increases (gets closer to 1)
 Is independent of SSD
 Since the energy of the scattering photon increases as the energy increases, BSF
increases.
 At >2 MV, the BSF approaches 1
 The depth at which the BSF is measured depends on the energy
 The BSF measurement depth at energies below that of Co-60 is the surface,
since Dmax is close to the surface

190
  Tissue to Air Ratio (TAR)
 The ratio of the dose at depth d (Dd) in a phantom to the dose at the same depth in air (Dair)
for the distance used in SAD is defined as the tissue to air ratio (TAR).
 The BSF is only defined at Dmax, whereas TAR can be defined at any depth. When d = Dmax,
TAR = BSF

TAR
 Increases as the energy increases
 Increases as the field size increases
 Is independent of SSD at low megavoltage energies
 Is dependent on SSD at high megavoltage energies (due to electron contamination)
 The BSF includes primary radiation and scattered radiation; the TAR only includes
scattered and absorbed radiation
If Dd = Dmax in the TAR formula → peak scatter factor (PSF).

191
  Tissue Maximum Ratio (TMR)
 The ratio of the dose measured at a depth d (Dd) to Dmax in a phantom is defined as
the tissue maximum ratio (TMR) :

 It is defined by performing two measurements in the phantom (i.e., Dd and

Dmax are measured).
 The TMR is normalized to Dmax, in contrast to the TAR.

TMR
1. Increases as energy increases
2. Increases as the field size increases
3. Is independent of SSD at low megavoltage energies
4.Is dependent on SSD at high megavoltage energies (due to electron
contamination)
192
  The Differences Between TAR and TMR
1. TAR uses the dose in air
2. TMR uses the dose at Dmax in phantom.
3. TAR is used in isocentric treatment technique.4. TMR calculation is
done instead of TAR at energies more than 3 MV.
 Scatter Air Ratio (SAR)
 The ratio of dose measured at d depth (Dd-phantom) in phantom to the
dose measured at the same depth in air (Dd-air) is defined as SAR.

 It is used for the calculation of mean scattered dose.

 It is independent on SSD as TAR, but dependent parameter on
energy, depth, and field size.
193
  Collimator Scattering Factor (Sc)
 The ratio of the dose measured in any field at a depth d in air to
Dmax measured in a reference field (10 × 10 cm2) in air is called the
collimator scattering factor (Sc or CSF

194
  The collimator scattering factor is also termed the output factor.
 Sc is measured in an ion chamber with a build-up cap.
 It is:
1. Correlated with field size
2. Correlated with energy (scattering increases as the field size and
energy increase).
Phantom Scattering Factor (Sp)
 The ratio of the dose measured in a definite field size at a depth d to
Dmax measured in a reference field (10 × 10 cm2) is defined as the
phantom scattering factor (Sp).
 The ratio of the BSF calculated in any field at a depth d to the BSF in a
reference field in a phantom is another way of defining Sp.
 Sp is important for determining scattered radiation from a phantom.
195
196
 Relationship between TAR and Percent Depth Dose
 Tissue-air ratio and percent depth dose are interrelated. The relationship can be
derived as follows: Considering Figure 9.9A, let TAR(d,rd) be the tissue-air ratio at
point Q for a field size rd at depth d. Let r be the field size at the surface, f be the SSD,
and dm be the reference depth of maximum dose at point P. Let Dfs (P) and Dfs (Q) be
the doses in free space at points P and Q, respectively (Fig. 9.9B,C). Dfs (P) and Dfs
(Q) are related by inverse square law:
 Conversion of Percent Depth Dose from One SSD to Another—the TAR Method
 To convert percent depth dose from one SSD to another the Mayneord F factor, which
is derived solely from inverse square law considerations, is used. A more accurate
method is based on the interrelationship between percent depth dose and TAR. This TAR
method can be derived from Equation 9.23 as follows.
 Suppose f1 is the SSD for which the percent depth dose is known and f2 is the SSD for
which the percent depth dose is to be determined. Let r be the field size at the surface
and d be the depth, for both cases. Referring to Figure 9.6, let rd,f1 and rd,f2 be the field
sizes projected at depth d in Figure 9.6A and B, respectively:
As mentioned earlier, for high-energy x-rays, that is, above 8 MV, the variation of percent depth dose with field size is small
and the backscatter is negligible. Equations 9.28 and 9.29 then simplify to a use of Mayneord F factor.
Practical Examples
  Monitor Unit (MU) Calculation in a Linear Accelerator
 Monitor units are the units in which the output of a linac is measured.
Linacs are calibrated to give 1 cGy at a SAD distance of 100 cm, for a
field size of 10 × 10 cm, and at the depth corresponding to Dmax, and this
calibration dose is defined as one monitor unit (MU).

 Percent depth dose is a suitable quantity for calculations involving

SSD techniques. Machines are usually calibrated to deliver 1 rad
(10-2 Gy) per monitor unit (MU) at the reference depth t0, for a
reference field size 10 × 10 cm and a source to calibration point
distance of SCD.

203
204
205
206
207
  TMR is the quantity of choice for dosimetric calculations involving isocentric techniques. Since the unit is
calibrated to give 1 rad (10-2 Gy)/MU at the reference depth t0 and calibration distance SCD and for the
reference field (10 × 10 cm), then the monitor units necessary to deliver isocenter dose (ID) at depth d are
given by:

208
209
 Beam Modifiers
 Bolus
 Bolus is used for tissue compensation, and is put on the skin at right angles to
the beam axis. It is made from a tissue-equivalent density material (Fig.). Bolus
use leads to increased effects of radiation scattered into the skin.
 Thus, the entrance dose to the skin increases. Secondary electrons produced by
the bolus also increase the skin dose, since the bolus is in contact with skin (→
the depth corresponding to Dmax gets close to the surface).

 Compensating Filters
 The dose distribution is not homogeneous if the surface of the patient is not flat.
Therefore, a compensating filter is positioned between the beam source and the
skin to reduce the dose delivered to the area with thinner tissue in order to
achieve a homogeneous dose distribution in the irradiated volume (Fig.).

 Compensating filters are made of aluminum–tin or copper–tin mixtures, and

are individually designed to compensate for tissue irregularities.
210
211
212
 Wedge Filters
 Metal wedge filters can be used to even out the isodose surfaces for
photon beams delivered onto flat patient surfaces at oblique beam
angles (Fig.).
 These wedges can be static, dynamic or motorized. They are most
commonly used in tangential irradiation (e.g., the breast, head and
neck regions), and they prevent hot spots in vital organs and cold
spots in the radiation field. They provide a more homogeneous dose
distribution.

213
  Shielding Blocks
 These are manufactured in order to shield the normal critical
structures in radiotherapy portals. There are two types of shielding
block. Standard blocks come with the teletherapy unit, and have
various sizes and shapes.
 They are designed according to the area that needs to be protected.
On the other hand, focalized blocks are individually made in mold
rooms to shield the areas of the field that need protecting
(according to the simulation procedure).
 Standard blocks are only used in emergencies.

214
 Multileaf Collimator (MLC)
 Irregular fields cannot be shaped without focalized blocks in conventional radiotherapy
machines. The collimator systems in Co-60 and old linac machines provide only a
rectangular field. Multileaf collimators, on the other hand, are composed of many leaves,
and each leaf can move independently (Fig.).
 By arranging these leaves appropriately, irregular fields that a required by the treatment
plan can easily obtained without using blocks (Table 1).

215
216
217
218
219
220
221
222
223
224
225
226
 END OF CHAPTER 5
ANY QUESTIONS
227
 Chapter 6

CLINICAL TREATMENT PLANNING IN EXTERNAL PHOTON BEAM

RADIOTHERAPY
  External photon beam radiotherapy is usually carried out with more than
one radiation beam in order to achieve a uniform dose distribution inside
the target volume and as low as possible a dose in healthy tissues
surrounding the target.

 The ICRU report 50 recommends a target dose uniformity within +7%

and –5% of the dose delivered to a well defined prescription point
within the target. Modern photon beam radiotherapy is carried out with
a variety of beam energies and field sizes under one of two setup
conventions: constant source-surface distance (SSD) for all beams or
isocentric setup with a constant source-axis distance (SAD).

 In an SSD setup, the distance from the source to the surface of the
patient is kept constant for all beams, while for an SAD setup the center
of the target volume is placed at the machine isocenter.
229
  Clinical photon beam energies range from superficial (30 kVp to 80 kVp)
through orthovoltage (100 kVp to 300 kVp) to megavoltage energies (Co-60
to 25 MV).

 Field sizes range from small circular fields used in radiosurgery through
standard rectangular and irregular fields to very large fields used for total body
irradiations.

 VOLUME DEFINITION
 Volume definition is a prerequisite for meaningful 3D treatment planning and
for accurate dose reporting. The ICRU 50 and 62 reports define and describe
several target and critical structure volumes that aid in the treatment planning
process and that provide a basis for comparison of treatment outcomes. The
following volumes have been defined as principal volumes related to 3D
treatment planning: gross tumour volume, clinical target volume, internal
target volume, and planning target volume. Figure shows how the different
volumes are related to each other.
230
  Graphical representation of the volumes-of-interest, as defined by the ICRU 50 and 62 reports.
 Gross Tumour Volume (GTV)
 “The Gross Tumour Volume (GTV) is the gross palpable or
visible/demonstrable extent and location of malignant growth” (ICRU
50).
 The GTV is usually based on information obtained from a combination
of imaging modalities (CT, MRI, ultrasound, etc.), diagnostic modalities
(pathology and histological reports, etc.) and clinical examination.
231
  Clinical Target Volume (CTV)
 “The clinical target volume (CTV) is the tissue volume that
contains a demonstrable GTV and/or sub-clinical microscopic
malignant disease, which has to be eliminated. This volume thus has
to be treated adequately in order to achieve the aim of therapy, cure
or palliation” (ICRU 50).

 The CTV often includes the area directly surrounding the GTV
that may contain microscopic disease and other areas considered to
be at risk and require treatment (e.g., positive lymph nodes).

 The CTV is an anatomical-clinical volume and is usually

determined by the radiation oncologist, often after other relevant
specialists such as pathologists or radiologists have been consulted.
232
  The CTV is usually stated as a fixed or variable margin around the GTV (e.g.,
CTV = GTV + 1 cm margin), but in some cases it is the same as GTV (e.g.,
prostate boost to the gland only).
 There can be several non-contiguous CTVs that may require different total doses
to achieve treatment goals.

 Internal Target Volume (ITV)

 Consists of the CTV plus an internal margin.
 The internal margin is designed to take into account the variations in the size and
position of the CTV relative to the patient’s reference frame (usually defined by
the bony anatomy), i.e., variations due to organ motions such as breathing,
bladder or rectal contents, etc. (ICRU 62).

 Planning Target Volume (PTV)

 The planning target volume is a geometrical concept, and it is defined to select
appropriate beam arrangements, taking into consideration the net effect of all
possible geometrical variations, in order to ensure that the prescribed dose is
actually absorbed in the CTV” (ICRU 50).
 Includes the internal target margin (ICRU 62) and an additional margin for set-
up uncertainties, machine tolerances and intra-treatment variations.
233
 The PTV is linked to the reference frame of the treatment machine.
 It is often described as the CTV plus a fixed or variable margin (e.g., PTV = CTV + 1
cm).

 Usually a single PTV is used to encompass one or several CTVs to be targeted by a group
of fields.

 The PTV depends on the precision of such tools as immobilization devices and lasers, but
does NOT include a margin for dosimetric characteristics of the radiation beam (i.e.,
penumbral areas and build-up region) as these will require an additional margin during
treatment planning and shielding design.

 Organ at Risk (OAR)

 Organ at risk is an organ whose sensitivity to radiation is such that the dose received from
a treatment plan may be significant compared to its tolerance, possibly requiring a change
in the beam arrangement or a change in the dose.

 Specific attention should be paid to organs that, although not immediately adjacent to the
CTV, have a very low tolerance dose (e.g., eye lens during naso-pharyngeal or brain
tumour treatments).

234
  Organs with a radiation tolerance that depends on the fractionation
scheme should be outlined completely to prevent biasing during treatment
plan evaluation.

 DOSE SPECIFICATION
 A clearly defined prescription or reporting point along with detailed
information regarding total dose, fractional dose and total elapsed
treatment days allows for proper comparison of outcome results. Several
dosimetric end-points have been defined in the ICRU 23 and 50 reports
for this purpose:

 Minimum target dose – from a distribution or a dose-volume histogram

(DVH).
 Maximum target dose – from a distribution or a DVH.
 Mean target dose – the mean dose of all calculated target points (difficult
to obtain without computerized planning).
 The ICRU reference point dose is located at a point chosen to represent
the delivered dose using the following criteria:
235
  PATIENT DATA ACQUISITION AND SIMULATION
 Need for patient data
 Patient data acquisition is an important part of the simulation
process, since reliable data is required for treatment planning
purposes and allows for a treatment plan to be properly carried out.
The type of gathered data varies greatly depending on the type of
treatment plan to be generated (e.g., manual calculation of parallel-
opposed beams versus a complex 3D treatment plan with image
fusion). General considerations include:

 Patient dimensions are almost always required for treatment time or monitor
unit calculations, whether read with a caliper, from CT slices or by other
means.
 Type of dose evaluation dictates the amount of patient data required (e.g.,
DVHs require more patient information than point dose calculation of organ
dose).
 Landmarks such as bony or fiducial marks are required to match positions in
the treatment plan with positions on the patient.
236
  2D treatment planning

 A single patient contour, acquired using lead wire or plaster strips, is transcribed onto a

sheet of graph paper, with reference points identified.

 Simulation radiographs are taken for comparison with port films during treatment.

 For irregular field calculations, points of interest can be identified on a simulation

radiograph, and SSDs and depths of interest can be determined at simulation.

 Organs at risk can be identified and their depths determined on simulator radiographs.

 3D treatment planning

 CT dataset of the region to be treated is required with a suitable slice spacing (typically

0.5 - 1 cm for thorax, 0.5 cm for pelvis, 0.3 cm for head and neck).

 An external contour (representative of the skin or immobilization mask) must be drawn

on every CT slice used for treatment planning.

237
 Organs at risk and other structures should
be drawn in their entirety, if DVHs are to
be calculated.
 Fig. shows the typical outlining of target
volume and organs at risk for a prostate
treatment plan on one CT slice.
 MRI or other studies are required for
image fusion.
 With many contemporary treatment
planning systems, the user can choose to
ignore inhomogeneities (often referred to
as heterogeneities), perform bulk
corrections on outlined organs, or use the
CT data itself (with an appropriate
conversion to electron density) for point-
to-point correction.
 Simulator radiographs or digitally
reconstructed radiographs (DRRs) are
used for comparison with portal films.
238
 Treatment simulation
 Patient simulation was initially developed to ensure that the
beams used for treatment were correctly chosen and properly
aimed at the intended target.
 Presently, treatment simulation has a more expanded role in the
treatment of patients consisting of:

1)Determination of patient treatment position.

2)Identification of the target volumes and organs at risk.
3) Determination and verification of treatment field geometry.
4)Generation of simulation radiographs for each treatment beam for comparison
with treatment port films.
5)Acquisition of patient data for treatment planning.
239
 The simplest form of simulation involves the use of port films obtained on
the treatment machines prior to treatment in order to establish the
treatment beam geometry. However, it is neither efficient nor practical to
perform simulations on treatment units.

 Firstly, these machines operate in the megavoltage range of energies and

therefore do not provide adequate quality radiographs for a proper
treatment simulation, and secondly, there is a heavy demand for the use of
these machines for actual patient treatment, so using them for simulation
is often considered an inefficient use of resources.

 There are several reasons for the poor quality of port films obtained on
treatment machines, such as:
1) Most photon interactions with biological material in the megavoltage
energy range are Compton interactions that are independent of atomic
number and that produce scattered photons that reduce contrast and blur
the image.
240
 2) The large size of the radiation source (either focal spot for a linear
accelerator or the diameter of radioactive source in an isotope unit)
increases the detrimental effects of beam penumbra on the image quality.
3) Patient motion during the relatively long exposures required and the
limitations on radiographic technique also contribute to poor image
quality.

 For the above reasons, dedicated equipment for radiotherapy simulation

has been developed. Conventional simulation systems are based on
treatment unit geometry in conjunction with diagnostic radiography and
fluoroscopy systems. Modern simulation systems are based on computed
tomography (CT) or magnetic resonance (MR) imagers and are referred
to as CT-simulators or MR-simulators.
 The clinical aspects of treatment simulation, be it with a conventional or
CT-simulator rely on the positioning and immobilization of the patient as
well as on the data acquisition and beam geometry determination.

241
 Patient treatment position and immobilization devices
 Depending on the patient treatment position or the precision
required for beam delivery, patients may or may not require an
external immobilisation device for their treatment.

 Immobilisation devices have two fundamental roles:

− To immobilise the patient during treatment.
− To provide a reliable means of reproducing the patient position from
simulation to treatment, and from one treatment to another.

 The simplest immobilisation means include masking tape, velcro

belts, or elastic bands.
 The basic immobilisation device used in radiotherapy is the head
rest, shaped to fit snugly under the patient’s head and neck area,
allowing the patient to lie comfortably on the treatment couch.
 Figure shows common headrests used for patient comfort and
immobilization during treatment.
242
243
 Modern radiotherapy generally requires additional immobilisation
accessories during the treatment of patients.

 Patients to be treated in the head and neck or brain areas are usually
immobilised with a plastic mask which, when heated, can be moulded to
the patient’s contour. The mask is affixed directly onto the treatment couch
or to a plastic plate that lies under the patient thereby preventing
movement. A custom immobilization mask is shown in Fig.

 For treatments to the thoracic or pelvic area, a variety of immobilisation

devices are available. Vacuum-based devices are popular because of their
reusablility. Basically, a pillow filled with tiny styrofoam balls is placed
around the treatment area, a vacuum pump evacuates the pillow leaving the
patient’s form as an imprint in the pillow.

 The result is that the patient can be positioned snugly and precisely in the
pillow prior to every treatment. Another system, similar in concept, uses a
chemical reaction between reagents in the pillow to form a rigid mould of
the patient.
244
  Special techniques, such as stereotactic radiosurgery, require such high precision that
conventional immobilization techniques are inadequate. In radiosurgery, a stereotactic
frame is attached to the patient’s skull by means of screws and is used for target
localization, patient setup on the treatment machine, and patient immobilization during
the entire treatment procedure. The frame is bolted to the treatment couch thereby
providing complete immobilization during the treatment.

245
  Patient data requirements
 In cases where only the dose along the central axis of the beam is sought (e.g.
treatment with a direct field, or parallel and opposed fields, and a flat beam
incidence), only the source-surface distance is required, since a simple hand
calculation for beam-on time or linac monitor units may suffice.

 Simple algorithms, such as Clarkson integration, may be used to determine the

dosimetric effects of having blocks in the fields, and calculate dose to off-axis
points if their coordinates and source to surface distance is measured. Since only
point doses are calculated, the patient shape or contour off-axis is not required.

 For simple computerized 2D treatment planning, the patient’s shape is

represented by a single transverse skin contour through the central axis of the
beams. This contour may be acquired using lead wire or plaster cast at the time
of simulation.

 The patient data requirements for more sophisticated treatment planning

systems
246
 The patient data requirements for more sophisticated treatment
planning systems such as those used in conformal treatment planning
are more elaborate than those for 2D treatment planning. They
include the following:
- The external shape of the patient must be outlined for all areas where
the beams enter and exit (for contour corrections) and in the
adjacent areas (to account for scattered radiation).
- Targets and internal structures must be outlined in order to
determine their shape and volume for dose calculation.
- Electron densities for each volume element in the dose calculation
matrix must be determined if a correction for heterogeneities is to
be applied.
 Attenuation characteristics of each volume element are required for
image processing.
247
  The nature and complexity of data required for sophisticated treatment planning
limits the use of manual contour acquisition. At the very best, patient external
contour information can be obtained through this method.

 Transverse CT scans contain all information required for complex treatment

planning and form the basis of CT-simulation in modern radiotherapy treatment.

 Conventional treatment simulation

 Simulators
 Simulators provide the ability to mimic most treatment geometries attainable on
megavoltage treatment units, and to visualize the resulting treatment fields on
radiographs or under fluoroscopic examination of the patient.

 They consist of a gantry and couch arrangement similar to that found on isocentric
megavoltage treatment units, with the exception that the radiation source in a
simulator is a diagnostic quality x-ray tube rather than a high-energy linac or a cobalt
source. Some simulators have a special attachment that allows them to collect patient
cross-sectional information similarly to a CT scanner, hence, the combination is
248
referred to as a simulator-CT.
 Figure shows a photograph of a conventional treatment simulator.
 The photons produced by the x-ray tube are in the kilovoltage range
and are preferentially attenuated by higher Z materials such as bone
through photoelectric interactions. The result is a high quality
diagnostic radiograph with limited soft-tissue contrast, but with
excellent visualization of bony landmarks and high Z contrast agents.

 A fluoroscopic imaging system may also be included and would be

used from a remote console to view patient anatomy and to modify
beam placement in real time.
 Localization of target volume and organs at risk
 For the vast majority of sites, the disease is not visible on the
simulator radiographs, therefore the block positions can be
determined only with respect to anatomical landmarks visible on the
radiographs (usually bony structures or lead wire clinically placed on
the surface of the patient).
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250
  Determination of treatment beam geometry
 Typically, the patient is placed on the simulator couch, and the final
treatment position of the patient is verified using the fluoroscopic
capabilities of the simulator (e.g., patient is straight on the table, etc.).
 The position of the treatment isocenter, beam geometry (i.e., gantry,
couch angles, etc.) and field limits are determined with respect to the
anatomical landmarks visible under fluoroscopic conditions.
 Once the final treatment geometry has been established, radiographs are
taken as a matter of record, and are also used to determine shielding
requirements for the treatment. Shielding can be drawn directly on the
films, which may then be used as the blueprint for the construction of the
blocks. A typical simulator radiograph is shown in Fig.
 Treatment time port films are compared to these radiographs periodically
to ensure the correct set up of the patient during the treatments.

251
252
  Acquisition of patient data
 After the proper determination of beam geometry, patient
contours may be taken at any plane of interest to be used for
treatment planning.
 Although more sophisticated devices exist, the simplest and most
widely available method for obtaining a patient contour is though
the use of lead wire.
 Typically, the wire is placed on a transverse plane parallel to the
isocenter plane. The wire is shaped to the patient’s contour, and
the shape is then transferred to a sheet of graph paper.
 Some reference to the room coordinate system must be marked
on the contour (e.g., laser position) in order to relate the position
of the beam geometry to the patient.

253
  Computed Computed tomography-based conventional
treatment simulation
 Computed tomography-based patient data acquisition
 With the growing popularity of computed tomography (CT) in the
1990s, the use of CT scanners in radiotherapy became widespread.
Anatomical information on CT scans is presented in the form of
transverse slices, which contain anatomical images of very high
resolution and contrast, based on the electron density.
 CT images provide excellent soft tissue contrast allowing for greatly
improved tumour localization and definition in comparison to
conventional simulation.
 Patient contours can be obtained easily from the CT data; in particular,
the patient’s skin contour, target, and any organs of interest.
 Electron density information, useful in the calculation of dose
inhomogeneities due to the differing composition of human tissues, can
also be extracted from the CT dataset.
254
 The target volume and its position are identified with relative ease on each
transverse CT slice. The position of each slice and therefore the target can
be related to bony anatomical landmarks through the use of scout or pilot
images obtained at the time of scanning.

 Shown in Fig. is a CT slice through a patient’s neck used in CT-based

conventional simulation.
 Pilot or scout films relate CT slice position to anterior-posterior and
lateral radiographic views of the patient at the time of scanning (see Fig).

 They are obtained by keeping the x-ray source in a fixed position and
moving the patient (translational motion) through the stationary slit beam.
The result is a high definition radiograph which is divergent on the
transverse axis, but non-divergent on the longitudinal axis.

255
256
257
  The target position relative to the bony anatomy on the simulator
radiographs may then be determined through comparison with the
CT scout or pilot films keeping in mind the different
magnifications between the simulator films and scout films.

 This procedure allows for a more accurate determination of

tumour extent and therefore more precise field definition at the
time of simulation.

 If the patient is CT scanned in the desired treatment position

prior to simulation, the treatment field limits and shielding
parameters may be set with respect to the target position, as
determined from the CT slices.

258
 Determination of treatment beam geometry
 The treatment beam geometry, and any shielding required can now be determined
indirectly from the CT data.
 The result is that the treatment port more closely conforms to the target volume,
reducing treatment margins around the target and increasing healthy tissue sparing.

259
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 END OF CHAPTER 6
ANY QUESTIONS

291
 Chapter 7

Brachtherapy
  Brachytherapy (sometimes referred to as curietherapy or endocurie
therapy) is a term used to describe the short distance treatment of cancer
with radiation from small, encapsulated radionuclide sources. This type
of treatment is given by placing sources directly into or near the volume
to be treated.
 The dose is then delivered continuously, either over a short period of
time (temporary implants) or over the lifetime of the source to a
complete decay (permanent implants). Most common brachytherapy
sources emit photons; however, in a few specialized situations b or
neutron emitting sources are used.
 There are two main types of brachytherapy treatment:

Intracavitary, in which the sources are placed in body cavities close to the
tumour volume;
Interstitial, in which the sources are implanted within the tumour volume.
293
  Intracavitary treatments are always temporary, of short duration, while
interstitial treatments may be temporary or permanent.

 Temporary implants are inserted using either manual or remote

afterloading procedures. Other, less common forms of brachytherapy
treatments include surface plaque, intraluminal, intraoperative and
intravascular source applications; for these treatments either gama or beta
emitting sources are used.

 The physical advantage of brachytherapy treatments compared with

external beam radiotherapy is the improved localized delivery of dose to
the target volume of interest. The disadvantage is that brachytherapy can
only be used in cases in which the tumour is well localized and relatively
small.
 In a typical radiotherapy department about 10–20% of all radiotherapy
patients are treated with brachytherapy.
294
  Several aspects must be considered when giving brachytherapy
treatments. Of importance is the way in which the sources are
positioned relative to the volume to be treated, and several different
models have been developed over the past decades for this purpose.

 The advantage of using a well established model is that one benefits

from the long experience associated with such models and that one
can take advantage of published results. The use of uniform models
and methods in brachytherapy treatments simplifies comparison of
treatment results.

 The important aspects of any brachytherapy treatment are:

1. Use of a suitable dosimetric model for the treatment time and dose
calculation;
2. Use of calibrated sources.
295
  Brachytherapy is a method of treatment in which sealed radioactive sources are used to
deliver radiation at a short distance by interstitial, intracavitary, or surface application.

 With this mode of therapy, a high radiation dose can be delivered locally to the tumor with
rapid dose falloff in the surrounding normal tissue. In the past, brachytherapy was carried
out mostly with radium or radon sources. Currently, use of artificially produced
radionuclides such as 137Cs, 192Ir, 198Au, 125I, and 103Pd is rapidly increasing.

 New technical developments have stimulated increased interest in brachytherapy: the

introduction of artificial isotopes, afterloading devices to reduce personnel exposure, and
automatic devices with remote control to deliver controlled radiation exposure from high-
activity sources.

 Although electrons are often used as an alternative to interstitial implants, brachytherapy

continues to remain an important mode of therapy, either alone or combined with external
beam.

296
  Brachytherapy (sometimes referred to as curietherapy or endocurie therapy) is a term
used to describe the short distance treatment of cancer with radiation from small,
encapsulated radionuclide sources.
 This type of treatment is given by placing sources directly into or near the volume to be
treated. The dose is then delivered continuously, either over a short period of time
(temporary implants) or over the lifetime of the source to a complete decay (permanent
implants).

 Most common brachytherapy sources emit photons; however, in a few specialized

situations beta or neutron emitting sources are used.

 There are two main types of brachytherapy treatment:

 Intracavitary, in which the sources are placed in body cavities close to the tumour
volume;
 Interstitial, in which the sources are implanted within the tumour volume

 Intracavitary treatments are always temporary, of short duration, while interstitial

treatments may be temporary or permanent.
297
  The dose rate of brachytherapy refers to the level or ‘intensity’ with which the radiation
is delivered to the surrounding medium and is expressed in Grays per hour (Gy/h).

 Low-dose rate(LDR) brachytherapy involves implanting radiation sources that emit

radiation at a rate of up to 2 Gy·h-1. LDR brachytherapy is commonly used for cancers of
the oral cavity, oropharynx, sarcomas and prostate cancer

 Medium-dose rate (MDR) brachytherapy is characterized by a medium rate of dose

delivery, ranging between 2 Gy·h-1 to 12 Gy·h-1.

 High-dose rate (HDR) brachytherapy is when the rate of dose delivery exceeds 12
Gy·h-1. The most common applications of HDR brachytherapy are in tumours of the
cervix, oesophagus, lungs, breasts and prostate.

298
 Duration of dose delivery
 Permanent brachytherapy is often performed for prostate cancer using "seeds" - small
radioactive rods implanted directly into the tumour.
 The placement of radiation sources in the target area can be temporary or permanent.

 Temporary brachytherapy involves placement of radiation sources for a set duration

(usually a number of minutes or hours) before being withdrawn. The specific treatment
duration will depend on many different factors, including the required rate of dose
delivery and the type, size and location of the cancer.

 In LDR brachytherapy, the source typically stays in place up to 24 hours before being
removed, while in HDR brachytherapy this time is typically a few minutes.

299
  Permanent brachytherapy, also known as seed implantation, involves placing small
LDR radioactive seeds or pellets (about the size of a grain of rice) in the tumour or
treatment site and leaving them there permanently to gradually decay.
 Over a period of weeks or months, the level of radiation emitted by the sources will
decline to almost zero. The inactive seeds then remain in the treatment site with no
lasting effect. Permanent brachytherapy is most commonly used in the treatment of
prostate cancer.

Mechanical source characteristics

 Cesium-137 is available in several forms, such as needles, tubes and pellets.
 Iridium-192 is available in the form of wires, are also available as seeds,
 Iodine-125, Pd-103 and Au-198 sources are only available as seeds. They are usually
inserted into the tumour volume using special delivery ‘guns’.
 Cobalt-60 brachytherapy sources are available as pellets with a typical activity of 18.5
GBq (0.5 Ci) per pellet.

300
  The physical advantage of brachytherapy treatments compared with external
beam radiotherapy is the improved localized delivery of dose to the target
volume of interest.

 The disadvantage is that brachytherapy can only be used in cases in which the
tumour is well localized and relatively small. In a typical radiotherapy
department about 10–20% of all radiotherapy patients are treated with
brachytherapy.

 Brachytherapy sources are usually encapsulated; the capsule serves several

purposes.

 The choice of an appropriate photon emitting radionuclide for a specific

brachytherapy treatment depends on several relevant physical and dosimetric
characteristics

301
302
303
304
305
 Clinical brachytherapy applications
A. Surface moulds
B. Intracavitary (gynaecological, bronchus,..)
C. Interstitial (Breast, Tongue, Sarcomas, …)
not covered here: unsealed source radiotherapy (Thyroid, Bone
metastasis, …) - this is dealt with in the IAEA training material on
radiation protection in Nuclear Medicine

306
Historical example

Surface applicator
with irregular
distribution of
radium on the
applicator surface
(Murdoch, Brussels
1933)

307
Treatment of
squamous cell
carcinoma of
the forehead
Intracavitary implants
 Introduction of radioactivity using an applicator placed in a
body cavity
 Gynaecological implants
 Bronchus
 Oesophagus
 Rectum

309
Vaginal applicators

 Single source line

 Different diameters and
length
Gammamed - on the right with shielding

Nucletron

310
Bronchus implants
 Often palliative to open air
ways
 Usually HDR brachytherapy
 Most often single catheter,
however also dual catheter
possible

311
Cervical Cancer

Tandem and ovoids

afterloader
Cervical Cancer
Breast Cancer
Tube and button

Administered twice a day for

five days
 Interstitial implants - tongue implant

315
 Close-up view

316
 Other intracavitary applicators
 Vaginal  Bronchus

317
Interstitial applicators

 Needles
 hollow and rigid
 may use templates for
placement
 usually have pusher during
implantation in tissue

318
 HDR brachytherapy procedure
 Implant of applicators, catheters or needles in theatre
 For prostate implants as shown here use transrectal ultrasound guidance

319
320
321
322
323
 Quick question:

Why is afterloading the method of choice from a

radiation safety perspective?
 END OF CHAPTER 7
ANY QUESTIONS

325
 Chapter 8

SPECIAL PROCEDURES AND TECHNIQUES IN RADIOTHERAPY

  In addition to routine conventional radiotherapy techniques used in standard
radiotherapy departments and clinics, several specialized techniques are known
and used for special procedures. These techniques deal with specific problems
that usually require equipment modifications, special quality assurance
procedures, and heavy involvement and support from clinical physicists.
Because of their increased complexity and the relatively low number of patients
who require them, these specialized techniques are usually available only in
larger, regional centers.

 The radiotherapy techniques that currently fall into the specialized category are:
(1) Stereotactic irradiation
(2) Total Body Irradiation (TBI) with photon beams
(3) Total Skin Electron Irradiation (TSEI)
(4) Intraoperative radiotherapy (IORT)
(5) Endorectal irradiation
(6) Conformal radiotherapy and Intensity Modulated Radiotherapy (IMRT)
(7) Image-Guided Radiation Therapy (IGRT)
(8) Respiratory Gated Radiation Therapy
(9) PET/CT fused images
327
 STEREOTACTIC IRRADIATION
 A specialized type of external beam radiation therapy called stereotactic
radiation uses focused radiation beams targeting a well-defined tumor, relying
on detailed imaging, computerized three-dimensional treatment planning and
precise treatment set-up to deliver the radiation dose with extreme accuracy
(i.e., stereotactically).

There are two types of stereotactic radiation:

 Stereotactic radiosurgery (SRS) refers to a singe or several stereotactic radiation
treatments of the brain or spine. SRS is delivered by a team involving a radiation
oncologist and a neurosurgeon.
 Stereotactic body radiation therapy (SBRT) refers to one or several stereotactic
radiation treatments with the body, excluding the brain or spine.
 SRS/SBRT is best for very small tumors. Doctors use specialized scans to
pinpoint exactly where within the body the tumor target is located. A
customized holder may be used to keep the body perfectly still during
treatment, or the treatment machine may have the ability to adjust for patient
motion such as during breathing.
 These techniques allow doctors to give a high dose of radiation to the tumor in
a short amount of time. SRS/SBRT is a type of external beam radiation therapy
328
that can be completed in one to five days rather than over several weeks.
  The advantage of SRS/SBRT is it delivers the right amount of radiation to
the cancer in a shorter amount of time than traditional treatments. Plus
the treatment is delivered with extreme accuracy, minimizing the effect
on nearby organs.
 A disadvantage to SRS/SBRT is that this technique is suitable only for
small, well-defined tumors that can be seen on imaging such as CT or MR
scans, thus the approach is not suitable for all situations. Also, the amount
of radiation that may be safely delivered may be limited if the cancer is
located close to a sensitive normal structure, such as the spinal cord or
bowel.
 There is sometimes confusion about the branding of equipment separate
from the terminology of SRS or SBRT. Stereotactic radiation may be
delivered by a number of different devices; brand name stereotactic
treatment machines you may hear mentioned include: Axesse,
CyberKnife, Gamma Knife, Novalis, Primatom, Synergy, X-Knife,
TomoTherapy or Trilogy. It is important not to confuse these brand names
with the actual type of stereotactic radiation under consideration.
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  From an obscure irradiation technique practiced in the 1960s and 1970s in only a few
specialized centers, stereotactic irradiation has during the past 15 years developed into a
mainstream radiotherapeutic technique practiced in most major radiotherapy centers
around the world.
 Stereotactic irradiation is the term used to describe focal irradiation techniques that deliver
a prescribed dose of ionizing radiation to preselected and stereotactically localized lesions
primarily in the brain, although attempts have been made to extend the technique to other
parts of the body.

 Main characteristics of stereotactic irradiation are as follows:

 Total prescribed doses are on the order of 10 Gy to 50 Gy and the planning
targets are small with typical volumes ranging from 1 cm3 to 35 cm3.
 The requirements for positional and numerical accuracy in dose delivery are ±1
mm and ±5%, respectively.
 The dose in stereotactic irradiation may be delivered through a stereotactic
implantation of radioactive sources (stereotactic brachytherapy) or, more
commonly, with one or several external radiation sources (stereotactic external
beam irradiation).

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 With regard to dose fractionation, external beam stereotactic irradiation is divided into two
categories:
 Stereotactic radiosurgery: the total dose is delivered in a single session.
 Stereotactic radiotherapy: like in standard radiotherapy, the total dose is delivered in multiple
fractions.
 From a technical point of view there is essentially no difference between stereotactic radiosurgery
and stereotactic radiotherapy, and often the term radiosurgery is used to describe both techniques.
 Essentially any radiation beam that was found useful for external beam radiotherapy has also found
use in radiosurgery (cobalt gamma rays, megavoltage x rays, proton and heavy charged particle
beams, and even neutron beams).

 Physical and clinical requirements for radiosurgery

 Accurate determination of target volume and its location with stereotactic techniques.
 Calculation of 3-D dose distributions inside and outside the target volume.
 Calculation of dose-volume histograms (DVHs) for the target and specific sensitive organs.
 Dose distributions which conform to target shapes and give a sharp dose fall-off outside the target
volume.
 Direct superposition of isodose distributions on diagnostic images, showing the anatomical location
of the target and surrounding structures.
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  Accurate knowledge of the total dose and fractionation scheme required for
treatment of particular disease.
 Accurate positional (within ±1 mm) delivery of dose to the predetermined
target.
 Accurate numerical (within ±5%) delivery of dose to the predetermined target.
 Dose delivery accomplished in a reasonable amount of time.
 Low skin dose (to avoid epilation) and low eye lens dose (to avoid cataracts).
 Low or negligible scatter and leakage dose to radiosensitive organs (to avoid
subsequent somatic and genetic effects of radiation).

Diseases treated with stereotactic irradiation

- Functional disorders.
- Vascular lesions.
- Primary benign and malignant tumours.
- Metastatic tumours.
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Stereotactıc Irradiation Summary….

 Also called “stereotaxy”

 Non-invasive form of “surgery”
 A type of radiation therapy
 Called surgery because the results
compare to conventional surgery
 A highly precise delivery of radiation
 Accurate to within 1 to 2 mm of
target
 Relies on:
 3D imaging (such as CT scan)
 Determine location of target
 Highly focused gamma ray beams
 Image-guided radiation therapy (IGRT)
 Improves accuracy of delivery
 Has broad range of applications
 How Are These Treatments Alike?
 Use multiple narrow radiation beams.
 Target small, well-defined areas with precision.
 Use immobilization devices or techniques that limit monitor and adjust for
any movement during treatment.
 Give high doses of radiation safely and accurately over just a few treatments
(usually one to five sessions overall).

How Are These Treatments Different?

 Different capabilities: Some stereotactic systems can treat only tumors in the
head, others in the head and neck, and others anywhere in the body.
 Different schedules: Some stereotactic treatments may be best given in a
single session, others may be given in a few treatments over several days.
 Different ways to achieve accuracy: Different systems use different ways to
keep patients in the correct position. Some use customized holders that keep
the patient immobile, and others have the machine track any movement of the
patient.
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 Conditions Treated With Stereotactic Radiation
 Stereotactic radiosurgery (SRS) is used to treat conditions involving the
brain or spine including:
 Cancers that start in the brain (gliomas and other primary brain tumors).
 Cancers that spread to the brain (brain metastases).
 Benign tumors arising from the membranes covering the brain
(meningiomas).
 Benign tumors of the inner ear (acoustic neuromas).
 Abnormal blood vessels in the brain (arteriovenous malformations).
 Stereotactic body radiation therapy (SBRT) is used to treat small tumors
in the chest, abdomen or pelvis that cannot be removed surgically or
treated with conventional radiation therapy, including:
 Small lung cancers.
 Cancers that started elsewhere and spread to the lung (lung metastases).
 Cancers that started elsewhere and spread to the liver (liver metastases).
335
 Current technology
 Gamma Knife® by Elekta
 Uses 192 to 201 beams of highly-focused
gamma rays
 All beams aim at target region
 Linear accelerator (LINAC) machines
 Deliver high-energy x-rays = photons
 Uses microwave technology to accelerate
photons
 Novalis Tx™ by Brainwave AG
 XKnife™ by Integra
 Axesse™ by Elekta
 CyberKnife® by Accuray
 Proton beam machine
  Radiosurgical techniques
 The Gamma knife (Elekta, Stockholm, Sweden) is a radiosurgical device that has
been associated with, and dedicated to, radiosurgery for the past 35 years.
Despite great technological advances during this time, the fundamental design
and principles of the Gamma unit have not changed much since the Swedish
neurosurgeon Leksell introduced the prototype unit in the late 1960s.
 The unit incorporates 201 cobalt-60 sources housed in the central body of the
unit. These sources produce 201 collimated beams directed to a single focal point
at a source-focus distance of about 40 cm.

 The final definition of the circular beam field size is provided by one of four
helmets delivering circular fields with nominal diameters between 4 and 18 mm
at the machine focal point.

The main components of the Gamma unit are:

- radiation unit with upper hemispherical shield and central body
- operating table and sliding cradle
- set of four collimator helmets providing circular beams with diameters of 4, 8, 14,
and 18 mm at the isocenter
- control unit
337
 Gamma Knife surgery is a type of radio-
surgery that was invented by Lars Leksell in
1951. It treats brain tumors, lesions, and
other abnormalities without surgical cutting
of the skin and the procedure is completed in
a one-time therapy in one day.
What is inside the Gamma Knife machine?
Inside of the Gamma knife is 201 cobalt gamma ray
beam sources that is inside of the covering and
includes a head frame with four pins to attach to
the patients head.
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 Advantages of Gamma Knife Treatment
 The Gamma Knife ensures only abnormal tissue is treated while
surrounding healthy tissue remains unaffected.
 Because the Gamma Knife does not require an incision, risk
associated with infection and bleeding is not a concern.
 While conventional neurosurgery requires lengthy hospital stays
and a potentially long recovery period, Gamma Knife patients are
able to resume normal activities within 24-48 hours.
 Gamma Knife radiosurgery costs 30-70% less than a craniotomy.
 Gamma Knife radiosurgery is a one time treatment.

344
 What is CyberKnife?
 CyberKnife is a non-invasive option for patients who have
inoperable or surgically complex tumors, or who may be looking
for an alternative to surgery. The CyberKnife system enables our
radiation oncologists to deliver high doses of radiation with
pinpoint accuracy to a broad range of tumors throughout the body.
 Potential benefits of the CyberKnife system include:
 No incision
 No pain
 No anesthesia or hospitalization
 Greater comfort (patient can breathe normally during treatment)
 Little or no recovery time
 Immediate return to normal activities

345
 How it works
 The CyberKnife system’s continual image guidance software allows
us to deliver high radiation doses with pinpoint accuracy, while
automatically correcting for tumor movement. Since radiation
beams adjust in real-time to the patient’s breathing cycle, there is
less damage to surrounding healthy tissue.
 “The CyberKnife VSI is the latest CyberKnife technology available
and offers faster, higher radiation energy, as well as upgraded
software,” says Dr. Michael Payne, Medical Director of Radiation
Oncology.
 Prior to the procedure, a high-resolution CT scan determines the
size, shape and location of the tumor. The image data is then
digitally transferred to the CyberKnife System’s workstation,
where we precisely plan treatment to match the desired radiation
dose to the exact tumor location.
346
  Once treatment planning is complete, the patient is comfortably
positioned on a cushioned table and the system’s computer-
controlled robot slowly moves around the table, targeting
radiation to the tumor from various angles while sparing
surrounding healthy tissue.

 The system’s sophisticated software allows us to track the tumor

and continually adjust the radiation treatment to account for
patient or tumor movement.

 Each treatment session lasts between 30 to 90 minutes for one to

five days, depending on the location and type of tumor being
treated. Patients can typically complete treatment in 1 to 5 days
versus several weeks for traditional radiation therapy.
347
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  TOTAL BODY IRRADIATION
 Total body irradiation (TBI) is a special radiotherapeutic technique that delivers to a
patient's whole body a dose uniform to within ±10% of the prescribed dose.
Megavoltage photon beams, either cobalt-60 gamma rays or megavoltage x rays, are
used for this purpose.
 In a broader sense, the treatment concepts of whole body irradiation encompass all
irradiations with large photon fields such as half-body irradiation, total nodal
irradiation and irradiation of whole body except for a few specific organs which are
partially or fully shielded from the prescribed dose.

349
  Clinical TBI categories
 Depending on the specific clinical situation, TBI techniques are divided into the
following four categories:
(1) High dose TBI with dose delivery in a single session or in up to six fractions
of 200 cGy each in three days (total dose: 1200 cGy).
(2) Low dose TBI with dose delivery in 10 to 15 fractions of 10 to 15 cGy each.
(3) Half body irradiation with a dose of 8 Gy delivered to the upper or lower
half body in a single session.
(4) Total nodal irradiation with a typical nodal dose of 40 Gy delivered in 20
fractions.
 Most notable diseases treated with BMT are:
(1) various leukemias (acute nonlymphoblastic; acute lymphoblastic; chronic
myelo-genous)
(2) malignant lymphoma
(3) aplastic anemia
350
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352
 Intensity Modulated Radiation Therapy (IMRT)
 Intensity-modulated radiation therapy (IMRT) is an advanced mode of
high-precision radiotherapy that uses computer-controlled linear
accelerators to deliver precise radiation doses to a malignant tumor or
specific areas within the tumor. IMRT allows for the radiation dose to
conform more precisely to the three-dimensional (3-D) shape of the
tumor by modulating—or controlling—the intensity of the radiation
beam in multiple small volumes.

 IMRT also allows higher radiation doses to be focused to regions within

the tumor while minimizing the dose to surrounding normal critical
structures. Treatment is carefully planned by using 3-D computed
tomography (CT) or magnetic resonance (MRI) images of the patient in
conjunction with computerized dose calculations to determine the dose
intensity pattern that will best conform to the tumor shape. Typically,
combinations of multiple intensity-modulated fields coming from different
beam directions produce a custom tailored radiation dose that maximizes
tumor dose while also minimizing the dose to adjacent normal tissues.
353
  Because the ratio of normal tissue dose to tumor dose is reduced to a
minimum with the IMRT approach, higher and more effective radiation
doses can safely be delivered to tumors with fewer side effects compared
with conventional radiotherapy techniques. IMRT also has the potential
to reduce treatment toxicity, even when doses are not increased. Due to
its complexity, IMRT does require slightly longer daily treatment times
and additional planning and safety checks before the patient can start the
treatment than conventional radiotherapy.

 Currently, IMRT is being used most extensively to treat cancers of the

prostate,head and neck and central nervous system. IMRT has also been
used in limited situations to treat breast, thyroid, lung, as well as in
gastrointestinal, gynecologic malignancies and certain types of sarcomas.
IMRT may also be beneficial for treating pediatric malignancies.

 Radiation therapy, including IMRT, stops cancer cells from dividing and
growing, thus slowing or stopping tumor growth. In many cases,
radiation therapy is capable of killing all of the cancer cells, thus
shrinking or eliminating tumors.
354
 What equipment is used?
 A medical linear accelerator (LINAC) generates the photons, or x-rays,
used in IMRT. The machine is the size of a small car—approximately 10
feet high and 15 feet long. The energy of the photon or x-ray, in the order
of 10 millions of volts, is generated by the LINAC to penetrate the
patient's body to the tumor. During the 15 or so minutes of treatment,
the patient is required to lie still on the treatment couch while the linear
accelerator delivers multiple beams of radiation to the tumor from
various directions.

 The intensity of each beam's radiation dose is dynamically varied

according to treatment plan. The patient usually will not feel any
sensation while the radiation is on, but will hear noise from the machine,
and may smell an odor from the electronic equipment, or see the
warning indicator light. The noises and odors from the machine are
normal. The patient will be in the room alone during the treatment
period with constant monitoring from the radiation therapists from
outside the treatment room.

355
 How is the procedure performed?
 IMRT often requires multiple or fractionated treatment sessions. Several
factors come into play when determining the total number of IMRT
sessions and radiation dose. The oncologist considers the type, location
and size of the malignant tumor, doses to critical normal structures, as
well as the patient's health. Typically, patients are scheduled for IMRT
sessions five days a week for five to eight weeks.

 At the beginning of the treatment session, the therapist positions the

patient on the treatment table, guided by the marks on the skin defining
the treatment area. If molded devices were made, they will be used to
help the patient maintain the proper position. The patient may be
repositioned during the procedure. Imaging systems on the treatment
machine such as x-ray or CT may be used to check positioning and
marker location. Treatment sessions usually take between 10 and 30
minutes.

356
  Radiation therapy can cause early and late side effects. Early side effects
occur during or immediately after treatment and are typically gone
within a few weeks. Common early side effects of radiation therapy
include tiredness or fatigue and skin problems. Skin in the treatment
area may become more sensitive, red, irritated, or swollen. Other skin
changes include dryness, itching, peeling and blistering.

 Depending on the area being treated, other early side effects may
include:

 hair loss in the treatment area

 mouth problems and difficulty swallowing
 eating and digestion problems
 diarrhea
 nausea and vomiting
 headaches
 soreness and swelling in the treatment area

357
urinary and bladder changes
  IMAGE-GUIDED RADIATION THERAPY
 Over the past decade, there have been substantial advancements in the
technology used to plan and deliver precision radiation therapy. Inverse
treatment planning and virtual simulation aided by fusion of multi-modality
images (CT, MR, and PET) of patient anatomies have revolutionized the planning
of radiation therapy treatments.

 The efficacy of treatment delivery has also been improved with the recent
introductions of intensity modulated radiation therapy (IMRT) and tomotherapy.

 The accuracy of dose delivery with these new techniques has been limited by
uncertainty in target localization at the time of treatment. Inter-fraction target
movement relative to reference landmarks coupled with setup errors and other
inaccuracies add to this uncertainty.

 The standard approach has been to add margins to the target volume, usually at
the expense of most of the potential benefit of the more precise treatment
delivery techniques.
358
  Image-guided radiation therapy (IGRT) is the use of frequent
imaging during a course of radiation therapy to improve the
precision and accuracy of the delivery of treatment.

 In IGRT, machines that deliver radiation, such as a linear

accelerator (for x-ray or photon) or cyclotron/synchrotron (for
proton), are equipped with imaging technology so that the
physician can image the tumor immediately before or even during
the time radiation is delivered, while the patient is positioned on
the treatment table.

 Using specialized computer software, these images are then

compared to the images taken during simulation. Any necessary
adjustments are then made to the patient's position and/or
radiation beams in order to more precisely target radiation at the
tumor and avoid healthy surrounding tissue.
359
  Computed tomography (CT), magnetic resonance imaging (MRI),
positron emission tomography (PET), ultrasound (US) and x-ray
imaging may be used for IGRT. Newer methods for IGRT use a
non-radiation light-emitting diode (LED) light on the patient's
body surface or implanted magnetic transponder inside the
patient's body.

 IGRT is used to treat tumors in areas of the body that are prone to
movement, such as the lungs (affected by breathing), liver, and
prostate gland, as well tumors located close to critical organs and
tissues. It is often used in conjunction with intensity-modulated
radiation therapy (IMRT), proton beam therapy, stereotactic
radiosurgery, or stereotactic body radiotherapy (SBRT), which are
advanced modes of high-precision radiotherapy that utilize
computer-controlled x-ray accelerators to deliver precise radiation
doses to a malignant tumor or specific areas within the tumor.
360
 What equipment is used?
 In IGRT, imaging equipment is mounted on or built into the
machine that delivers radiation, such as a linear accelerator.
Imaging equipment may also be mounted in the treatment room.
Imaging technologies used in IGRT include x-rays, computed
tomography (CT), magnetic resonance imaging (MRI), positron
emission tomography (PET), and ultrasound (US).

 Sometimes, IGRT is performed by a special camera in the room

that emits LED light and tracks the patient's body surface. For
selected areas affected by breathing, a special small device is
placed on the patient's chest or abdomen that emits light. This
gives feedback regarding the respiratory stage.

361
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  ELECTRON BEAM THERAPY
 Megavoltage electron beams represent an important treatment modality in modern
radiotherapy, often providing a unique option in treatment of superficial tumours (less
than 5 cm deep). Electrons have been used in radiotherapy since the early 1950s, first
produced by betatrons and then by linear accelerators (linacs). Modern high-energy
linacs typically provide, in addition to two megavoltage photon energies, several
electron beam energies in the range from 4 MeV to 22 MeV.
 General shape of depth dose curve
 The general shape of the central axis depth dose curve for electron beams differs from
that of photon beams, as seen in Fig. 8.1. that shows depth doses for various electron
beam energies in part (a) and depth doses for 6 MV and 15 MV x-ray beams in part (b).

 Typically, the electron beam central axis depth dose curve exhibits a high surface dose
(compared with megavoltage photon beams) and the dose then builds up to a maximum
at a certain depth referred to as the electron beam depth dose maximum zmax. Beyond
zmax the dose drops off rapidly, and levels off at a small low-level dose component
referred to as the bremsstrahlung tail. These features offer a distinct clinical advantage
over the conventional x-ray modalities in treatment of superficial tumours.
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 END OF CHAPTER 8

368 ANY QUESTIONS

 Chapter 9
BASIC RADIOBIOLOGY
RADIATION PROTECTION AND SAFETY IN RADIOTHERAPY
  Radiobiology, a branch of science that deals with the action of ionizing
radiation on biological tissues and living organisms, is a combination of
two disciplines: radiation physics and biology. All living things are made
up of protoplasm that consists of inorganic and organic compounds
dissolved or suspended in water. The smallest unit of protoplasm
capable of independent existence is the cell.

 Cells contain inorganic compounds (water and minerals) as well as

organic compounds (proteins, carbohydrates, nucleic acids, lipids).
 The two main constituents of a cell are the cytoplasm, which supports
all metabolic functions within the cell, and the nucleus, which contains
the genetic information (DNA).

370
  Human cells are either somatic cells or germ cells.
 Cells propagate through division; division of somatic cells is called
mitosis, division of germ cells meiosis.
 When a somatic cell divides, two cells are produced, each carrying a
chromosome complement identical to that of the original cell. The
new cells themselves may undergo further division and the process
continues.
 Somatic cells are classified as:
Stem cells: exist to self-perpetuate and produce cells for a
differentiated cell population (e.g., stem cells of the hematopoietic
system, epidermis, mucosal lining of the intestine).
Transit cells: cells in movement to another population (e.g., a
reticulocyte which is differentiating to become an erythrocyte).
Mature cells: cells that are fully differentiated and do not exhibit
mitotic activity (e.g., muscle cells, nervous tissue).
371
  A group of cells that together perform one or more functions is referred to as
tissue.
 A group of tissues that together perform one or more functions is called an organ.
 A group of organs that perform one or more functions is a system of organs or an
organism.
CLASSIFICATION OFRADIATIONS IN RADIOBIOLOGY
 For use in radiobiology and radiation protection the physical quantity that is useful
for defining the quality of an ionizingradiationbeamis the linear energytransfer
(LET).In contrast to the stopping power that focuses attention on the energy loss
by an energetic charged particle moving through a medium, the LETfocuses
attention on the linear rate of energy absorption by the absorbing mediumas the
charged particle traverses the medium.

 The International Commission on Radiological Units and Measurements (ICRU)

defines the LETas follows: "LET of charged particles in a medium is the quotient
dE/dl, where dE is the average energy locally imparted to the medium by a charged
particle of specified energy in traversing a distance of dl".
372
  In contrast to the stopping power with a typical unit of MeV/cm, the unit usually
used for the LET is keV/µm. The energy average is obtained by dividing the
particle track into equal
 energy increments and averaging the length of track over which these energy
increments are deposited.
 X rays and gamma rays are considered low LET(sparsely ionizing) radiations,
while energetic neutrons, protons and heavy charged particles are high
LET(densely ionizing) radiations. The demarcation value between low and high
LET is at about 10 keV/µm.

373
 CELL CYCLE AND CELL DEATH
 The cell proliferation cycle is defined by two well-defined time periods:
(1) mitosis M where division takes place, and
(2) the period of DNA synthesis S.

 The S and M portions of the cell cycle are separated by two periods
(gaps) G1and G2when DNA is not yet synthesized but other metabolic
processes take place.

 The time between successive divisions (mitoses) is called cell cycle time.
For mammalian cells growing in culture the S phase is usually in the
range of 6-8 hours, M less than an hour, G2 in the range of 2-4 hours,
and G1from1-8 hours, making the total cell cycle in the order of10-20
hours. In contrast, the cell cycle for stem cells in certain tissues is up to
about 10 days.
374
  In general, cells are most radiosensitive in the M and G2 phases,
and most resistant in the late S phase.

 The cell cycle time of malignant cells is shorter than that of some
normal tissue cells, but during regeneration after injury normal
cells can proliferate faster.

 Cell death for non-proliferating (static) cells is defined as the loss

of a specific function, while for stem cells it is defined as the loss
of reproductive integrity (reproductive death). A surviving cell
that maintains its reproductive integrity and proliferates
indefinitely is said to be clonogenic.

375
 IRRADIATION OF CELLS
 When cells are exposed to ionizing radiation the standard physical
effects between radiation and atoms or molecules of the cells
occur first and the possible biological damage to cell functions
follows later. The biological effects of radiation result mainly from
damage to the DNA which is the most critical target within the
cell; however, there are also other sites in the cell which, when
damaged, may lead to cell death.

 When directly ionizing radiation is absorbed in biological

material, the damage to the cell may occur in one of two ways:
director indirect action.

376
 Direct action in cell damage by radiation
 In direct action the radiation interacts directly with the critical target in
the cell. The atoms of the target itself may be ionized or excited through
Coulomb interactions leading to the chain of physical and chemical
events that eventually produce the biological damage.
 Direct action is the dominant process in interaction of high LET
particles with biological materials.

 Indirect action of cell damage by radiation

 In indirect action the radiation interacts with other molecules and atoms
(mainly water, since 80% of a cell is composed of water) within the cell
to produce free radicals that can, through diffusion in the cell, damage
the critical target within the cell.

 In interactions ofradiation with water short-lived yet extremely reactive

free radicals suchas H2O+ (water ion) and OH• (hydroxyl radical) are
produced. The free radicals in turn can cause damage to the target
within the cell.
377
  The free radicals that break the chemical bonds and produce
chemical changes that lead to biological damage are highly
reactive molecules because they have an unpaired valence
electron.

 About two thirds of the biological damage by low LET radiations

(sparsely ionizing radiations), such as x-rays or electrons, is due
to indirect action.

 The indirect action can be modified by chemical sensitisers or

radiation protectors.

 For the indirect action of x-rays the steps involved in producing

biological damage are as follows:

378
  Step 1: Primary photon interaction(photoelectric effect,
Compton effect, pair production) produces a high energy
electron.
 Step 2: The high-energy electron in moving through tissue
produces free radicals in water.
 Step 3: The free radicals mayproduce changes in DNA from
breakage of chemical bonds.
 Step 4: The changes in chemical bonds result in biological effects.

 Step (1) is in the realmof physics; step (2) in chemistry; steps (3)
and (4) in radiobiology.

379
 Fate of irradiated cells
 Irradiation of a cell will result in one of the following four possible
outcomes:
(1) No effect

(2) Division delay: the cell is delayed from going through division.

(3) Apoptosis: the cell dies before it can divide or afterwards by

fragmentation into smaller bodies which are taken up by
neighbouring cells.
(4) Reproductive failure: the cell dies when attempting the first or
subsequent mitosis.

380
 TYPE OF RADIATION DAMAGE
Time scale
 The time scale involved between the breakage of chemical bonds and the
biological effect may be hours to years, depending on the type of damage.

 If cell kill is the result, it may happen in hours to days when the damaged cell
attempts to divide (early effects of radiation).

 If the damage is oncogenic (cancer induction), then its expression may be

delayed for years (late effects of radiation).

 If the damage is a mutation in a germ cell, the effects may not be expressed for
generations.

 In addition to carcinogenesis (induction of cancer) the late effects of radiation

include: (i)lifespan shortening; (ii) genetic damage, and(iii) potential effects to
the fetus. Ionizing radiation has been proven to cause leukemia and has been
implicated in development of many other cancers in tissues such as bone, lung,
skin, thyroid and breast.
381
 Classification of radiation damage
 Radiation damage to mammalian cells is divided into three
categories:
(1) Lethal damage is irreversible, irreparable, and leads to cell
death;
(2) Sublethal damage can be repaired in hours unless additional
sublethal damage is added and eventually leads to lethal damage;
and
(3) Potentially lethal damagecan bemanipulated byrepair whencells
are allowed to remain in a non-dividing state.

382
 Somatic and genetic effects
 The effects of radiation on the human population can be classified as either
somatic or genetic.
 Somatic effects are harm that exposed individuals suffer during their lifetime,
such as radiation-induced cancers (carcinogenesis), sterility, opacification of
the eye lens, and life shortening.
 Genetic or hereditary effects are radiation-induced mutations to an individual's
genes and DNA that can contribute to the birth of defective descendants.
 Carcinogenesis expresses itself as a late somatic effect in the form of acute or
chronic myeloid leukemia or some solid tumours, for example, in skin, bone,
lung, thyroid or breast.
 Human data on carcinogenesis have been collected from the following sources:
(1) Low level occupational exposure.
(2) Atomic bomb survivors in Hiroshima and Nagasaki.
(3) Medical radiation exposure to patients(for example, treatment of ankylosing
spondylitis, treatment of thyroid abnormalities, radiotherapy of cancer) and
383 staff (for example, radiologists in the early part of last century).
 Stochastic and deterministic (non-stochastic) effects
 The harmful effects of radiation may be classified into two general
categories: stochastic and deterministic (non-stochastic). The
NCRP defines these effects as follows:
 A stochastic effect is one in which the probability of occurrence
increases with increasing dose but the severity in affected
individuals does not depend on the dose (induction of cancer, i.e.,
radiation carcinogenesis, genetic effects).
 There is no threshold dose for effects that are truly stochastic.
 A deterministic (non-stochastic)effect is one which increases in
severity with increasing dose, usually above a threshold dose, in
affected individuals (organ atrophy, fibrosis, lens opacification,
blood changes, decrease in sperm count).

384
 Acute vs. chronic effects
 An organ or tissue expresses response to radiation damageeither as an acute
effect or as late (chronic)effect.
 Acute effects manifest themselves soon after exposure to radiation and are
characterized by inflammation, edema, denudation of epithelia and hemorrhage.
 Chronic effects are delayed and are characterized by fibrosis, atrophy, ulceration,
stenosis or obstruction of the intestine.
Total body radiation response
 The response of an organismto acute total body radiation exposure is influenced
by the combined response to radiation of all organs constituting the organism.
Depending on the actual total body dose above 1 Gy, the response is described
as a specific radiation syndrome:

385
 Human data on specific radiation syndromes have been collected
from the following sources:
- Accidents in industry and research laboratories
- Accidents involving exposure from radioactive fallout from nuclear
testing of weapons or the Chernobyl nuclear power plant accident
- Exposure of humans to high levels of radiation in Hiroshima and
Nagasaki
- Medical exposure of humans to total body irradiations

Fetal irradiation
Between conception and birth the fetus passes through three basic stages of
development:
- pre-implantation(day: 1to 10);
- organogenesis(day: 11 to 42); and
- growth stage(day: 43 to birth).
386
  Soon after the discovery of x rays by Roentgen in 1895 and of natural radioactivity by
Becquerel in 1896 it became apparent that ionizing radiation was not only useful for
diagnosis and treatment of disease but also harmful to human tissues. It has been
recognized since early studies on x rays and radioactive minerals that exposure to high
levels of radiation can cause clinical damage to tissues of the human body.

 In addition, long term epidemiological studies of populations exposed to radiation,

especially the survivors of the atomic bombing of Hiro-shima and Nagasaki in Japan in
1945, have demonstrated that exposure to radiation also has a potential for delayed
effects such as induction of malignancies or damage to genetic materials.

 Ionizing radiation and radioactive substances are natural and permanent features of the
environment, and thus the risks associated with radiation exposure can only be
restricted, not eliminated entirely. Additionally, the use of human-made radiation is now
widespread. Sources of ionizing radiation are essential to modern health care:
disposable medical supplies sterilized by intense radiation have been central to
combating disease; radiology and nuclear medicine are a vital diagnostic tool; and
radiotherapy is commonly part of the treatment of malignancies.
387
  Applications of ionizing radiation are growing in industry, agriculture, medicine
and many other fields of industry and research, benefiting the humanity.
Irradiation is used around the world to preserve foodstuffs and reduce wastage,
and sterilization techniques have been used to eradicate disease-carrying insects
and pests. Industrial radiography is in routine use, for example, to examine
welds and detect cracks, and to help prevent failure of engineered structures.

 The acceptance by society of risks associated with radiation is conditional on the

benefits to be gained from the use made of radiation. Nonetheless, the risks
must be restricted and protected against by the application of radiation safety
standards. It is therefore essential that activities involving radiation exposure be
subject to certain standards of safety in order to protect the individuals that are
exposed to radiation, be it:
 (i) occupationally;
 (ii) for medical diagnostic or therapeutic purposes;
 (iii) as members of the public.

388
  RADIATION EFFECTS
 Exposure to radiation can cause detrimental health effects that fall into
one of two categories: (i) deterministic and (ii) stochastic.

 Deterministic effects
 At large doses, radiation effects such as nausea, reddening of the skin or,
in severe cases, more acute syndromes are clinically expressed in exposed
individuals within a relatively short period of time after the exposure;
such effects are called deterministic because they are certain to occur, if
the dose exceeds a threshold level.
 Deterministic effects are the result of various processes, mainly cell death
or delayed cell division, caused by exposure to high levels of radiation. If
extensive enough, these effects can impair the function of the exposed
tissues. The severity of a particular deterministic effect in an exposed
individual increases with dose above the threshold for the occurrence of
the effect.
389
  Stochastic effects
 Radiation exposure can also induce delayed effects such as malignancies, which are
expressed after a latency period and may be epidemiologically detectable in a
population; this induction is assumed to take place over the entire range of doses
without a threshold level. Hereditary effects due to radiation exposure have been
statistically detected in other mammalian populations and are presumed to occur in
human populations also.

 These epidemiologically detectable effects (malignancies and hereditary effects) are

termed stochastic effects because of their random nature.

 Stochastic effects may ensue, if an irradiated cell is modified rather than killed.
Modified cells may, after a prolonged delay, develop into a cancer. The body's repair
mechanisms make this a very improbable outcome at small doses; nevertheless, there is
no evidence of a threshold dose below which cancer cannot result.

 The probability of occurrence of cancer is higher for higher doses, but the severity of
any cancer that may result from irradiation is independent of dose. If the cell damaged
by radiation exposure is a germ cell whose function is to transmit genetic information
to progeny, it is conceivable that hereditary effects of various types may develop in the
descendants of the exposed individual. The likelihood of stochastic effects is presumed
to be proportional to the dose received, and this without a dose threshold.
390
  The many aspects of the concept of radiation detriment make it undesirable to
select any single quantity to represent it. The concept of detriment as
recommended by the International Commission on Radiation Protection
(ICRP) for stochastic effects includes the following quantities: the probability of
fatal cancer attributable to radiation exposure; the weighted probability of
incurring a non-fatal cancer; the weighted probability of severe hereditary
effects; and the length of lifetime lost, if the harm occurs.

 Effects on embryo and fetus

 In addition to deterministic and stochastic health effects in adults, other health
effects may occur in infants due to exposure of the embryo or foetus to
radiation. These effects include a greater likelihood of leukaemia (stochastic
effect) and, for exposure above various threshold dose values during certain
periods of pregnancy, severe mental retardation and congenital malformations
(deterministic effect). For more details on effects on the fetus see the ICRP
Publication 84.

391
 INTERNATIONAL CONSENSUS AND RADIATION SAFETY STANDARDS
 Safety Standards are based on the knowledge of radiation effects and on the principles of
protection described below. In this respect, the development of Safety Standards by the
International Atomic Energy Agency (IAEA) follows a well-established approach.

 The United Nations Scientific Committee on the Effects of Atomic Radiation

(UNSCEAR), a body set up by the United Nations in 1955, compiles, assesses and
disseminates information on the health effects of radiation and on levels of radiation
exposure due to different sources; this information was taken into account in developing
the Standards. Following a decision made in 1960, the IAEA safety standards are based on
the recommendations of the ICRP that also take account of the scientific information
provided by UNSCEAR.

 The current version of a safety standards document entitled International Basic Safety
Standards for Protection against Ionizing Radiation and for the Safety of Radiation
Sources (hereinafter referred to as the BSS document) was issued in 1996 under a joint
sponsorship of the following organizations: the Food and Agriculture Organization of the
United Nations (FAO), the International Atomic Energy Agency (IAEA), the
International Labour Organisation (ILO), the Nuclear Energy Agency of the Organisation
for Economic Co-operation and Development (OECD/NEA), the Pan American Health
Organization (PAHO) and the World Health Organization (WHO).

392
 TYPES OF RADIATION EXPOSURE
 Certain industrial or medical practices will result in some radiation
exposure with predictable magnitudes, albeit with some degree of
uncertainty; such expected exposures are referred to in the BSS as
normal exposures.

 In addition, scenarios can be envisaged for which there is a potential for

exposure, but no certainty that an exposure will in fact occur; such
unexpected but feasible exposures are termed potential exposures.
Potential exposures can become actual exposures; if the unexpected
situation does occur; for example, as a consequence of equipment
failure, design problems or operating errors.

 The means specified in the BSS document for controlling normal

exposures is the restriction of the doses delivered. In the case of
exposure to patients, exposures are controlled through delivering only
the doses that are necessary to achieve the diagnostic or therapeutic
objective.
393
  The primary means for controlling potential exposures is by
optimizing the design of installations, equipment and operating
procedures:
(i) To restrict the probability of occurrence of events that could lead to
unplanned exposures.
(ii) To restrict the magnitudes of the exposures that could result, if
such events were to occur.

 The radiation exposures covered by the BSS document encompass

the exposures, both normal and potential, of:

(i) Workers pursuing their occupations (occupational exposures),

(ii) Patients in diagnosis or treatment (medical exposures), and
(iii) Members of the public.
394
  The radiation exposures are, therefore, divided into three categories:
 Occupational exposure is defined as all exposures of workers incurred
in the course of their work (with the exception of exposures excluded
from the BSS and exposures from practices or sources exempted by the
BSS).
 Medical exposure is defined as exposure incurred:
- by patients as part of their own medical or dental diagnosis or treatment;
- by persons, other than those occupationally exposed, knowingly while
voluntarily helping in the support and comfort of patients;
- by volunteers in a programme of biomedical research involving their
exposure.
 Public exposure is defined as exposure incurred by members of the
public from radiation sources, excluding any occupational or medical
exposure and the normal local natural background radiation but
including exposure from authorized sources and practices and from
intervention situations.
395
 QUANTITIES AND UNITS USED IN RADIATION PROTECTION
 Physical quantities
 Although most of the requirements of the BSS are qualitative, they
also establish quantitative limits, and guidance levels. The main
physical quantities used in safety standards are the activity and
absorbed dose:

396
397
  Radiation protection quantities
 The absorbed dose is the basic physical dosimetry quantity, but it is not entirely
satisfactory for radiation protection purposes because the effectiveness in damaging
human tissue differs for different types of ionizing radiation.
 In addition to the physical quantities, other dose-related quantities were introduced to
account not only for physical effects but also for biological effects of radiation upon
tissues. These quantities are: organ dose, equivalent dose, committed dose and collective
dose.

398
  Equivalent dose H
 The biological detriment (harm) to an organ depends not only on the physical
average dose received by the organ, but also on the pattern of dose distribution
that results from the radiation type and energy. For the same dose to the organ,
alpha or neutron radiation will cause greater harm compared to gamma rays or
electrons.
 This is because the ionisation events produced by alpha or neutron radiation will
be much more closely spaced (densely ionizing radiations) and so there is a
higher probability of irreversible damage to the chromosomes and less chance of
tissue repair.
 Consequently, the organ dose is multiplied by a radiation-weighting factor wR to
account for the effectiveness of the given radiation in inducing health effects; the
resulting quantity is called the equivalent dose HT.

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404 ANY QUESTIONS