26/11/2018
BE908 / 404 – Biomedical Instrumentation
Radiotherapy
Mario E Giardini
Cancer
• Cancer: 2nd largest cause of death in the UK (25%)
• Caused by damage to DNA: cells change and lose the control that stops them
from dividing: uncontrolled growth.
• Benign tumours: self-contained, do not invade surrounding tissues
• Malignant tumours (cancer) do not remain self-contained, and spread to other sites.
• Cancer: catch-all word for >200 diseases
• Sarcomas: connective tissue (e.g. muscle, bone cancer).
More common in younger people.
• Carcinomas: epithelial tissue (e.g. lung, breast, prostate, colon cancer).
More common in older people.
• Leukaemia: cancers of te blood / blood forming organs.
• Lymphomas: cancers of the lymphatic system (e.g. Hodgkin’s disease).
Causes:
• Lifestyle: diet, tobacco products, alcohol
• Exposure to chemicals (asbestos, radon, benzene, creosote, tar, smoke, etc.)
• Radiation exposure (ionising radiation)
• Some viruses (Hepatitis B, C, HPV, etc.)
• Some cancers are hereditary
• Risk increase above age 50
Cancer treatment options
• Surgery
• Radiotherapy
• Systemic approaches
• A combination of the above
BE908 / BE404 - Do not redistribute 1
26/11/2018
Surgery
• Mainstay of treatment for majority of patients with solid tumours
• Role:
• Diagnosis
• Treatment
• Reconstruction
• Prevention
• Low morbidity for non-involved tissue
• Affects
• Cosmesis
• Function
Systemic therapy
Many forms of systemic therapy:
• Chemotherapy
• Hormone therapy
• Chemical adjuncts
• Immunotherapy
• Biological agents
• Systemic radiotherapy
Chemotherapy: cytotoxic agents destroy cancer cells by targeting:
• Chemistry of nucleic acids
• DNA/RNA production
• Mechanics of cell division
Limited by non-selectivity of agents
Radiotherapy
Treatment of cancer using penetrating beams of electromagnetic waves
at high energy (ionising radiation) or streams of particles
• After surgery, most effective treatment, with ~50% patients requiring it
• Delivery:
• External beam radiotherapy
• Brachytherapy
BE908 / BE404 - Do not redistribute 2
26/11/2018
Observations on effects of radiation
• Cancer deaths in early radiation researchers
• High leukaemia incidence in early radiologists
• Osteosarcoma incidence in radium dial painters
• Leukaemia in atomic blast survivors
• Secondary tumours from therapeutic irradiation
• X-ray treatment for benign head & neck conditions
• Fluoroscopic X-ray exams in tuberculosis patients
Image source: Rutgers University via Wikimedia Commons (Public Domain)
Balancing benefits and harm
• Background radiation is all around us
• All exposure to radiation carries a risk
• Medical radiation must be justified: benefits must be balanced
against risks.
• Radiation doses to patients and staff must be kept as low as
reasonably possible.
How does radiotherapy work?
• Radiation beam provides electrons:
• Compton effect (when using electromagnetic radiation)
• Electron beams
• Particle beams
• Damage to cell DNA by free radicals or direct collision by electrons
• Both normal and cancer cells are damaged, but normal cells
are more efficient in repairing the damage:
• The more mature a cell is, the more radioresistant (bone, muscle, nerves)
• Younger / faster dividing cells are more radiosensitive
(blood, reproductive system)
• Divided into small doses (fractions) to allow normal cell repair between sessions:
more cancer cells can be killed than if a single treatment is administered.
Radiation effect increases with
• Total dose
• Dose rate
• Irradiated area
• Patient age
BE908 / BE404 - Do not redistribute 3
26/11/2018
External beam radiotherapy
External radiation source (typically, linear accelerator) delivers a radiation beam
Image source: Tousey, Sinclair (1915) via Wikimedia Commons (public domain)
Steps in the EBRT process
1. Medical imaging to locate the cancer
2. Treatment planning to design the treatment
3. Treatment verification to ensure treatment accuracy
4. Treatment delivery to give the treatment
Radiation dosimetry
Calibration of the accelerator’s radiation beam in a wide range of clinical
situations. Typically performed in a water phantom.
Image source: PTW (public domain)
BE908 / BE404 - Do not redistribute 4
26/11/2018
Treatment planning
The treatment plan is limited by the amount of radiation healthy tissue can tolerate:
a good treatment plan delivers a uniform dose to the tumour volume whilst
minimising the radiation dose to healthy tissue
Image source: IOP via [Link] (image used within the terms at [Link])
Treatment planning
Radiation dosimetry data
measured on radiation source
Medical images (linear accelerator)
• Image handling and registration
• Image segmentation and contouring
• Beam placement
• Dose calculation
• Dose distribution analysis
Treatment plan: • Dose distribution and images
• Set-up details and structures
• Admin data
Treatment verification
Treatment verification confirms the accuracy
of the proposed radiation treatment:
• The treatment covers the intended volume
• There are no errors in treatment design
It uses a treatment simulator, a machine that has
the same shape and movements as the radiotherapy
equipment, but only takes x-ray images (portal imager)
Image source: NHS Devon
BE908 / BE404 - Do not redistribute 5
26/11/2018
Treatment delivery (EBRT)
Use a radiation beam source to deliver the beam and treat
the patient’s tumour as accurately as possible
Image source: National Cancer Institute via Stanford University, Image AV-5700-3472, 1957 (public domain)
Historical EBRT sources
Cobalt 60
Radium
Early EBRT sources: radioactive material in a shielding case.
Image sources: Popular Science 1951, National Cancer Institute (public domain)
Gamma knife (1968)
Image source: NRC, Leskell (public domain)
BE908 / BE404 - Do not redistribute 6
26/11/2018
Linear accelerator (linac)
• X-ray emission using electron beam against a tungsten target.
• Replaces Cobalt 60 / Radium sources
Image sources: Liz West via Wikimedia Commons (CC-BY 2.0), linac manual (public domain)
On-board imaging during delivery
• Provides dynamic x-ray images during treatment
• Improves patient alignment accuracy
• Monitors and compensates patient motion during treatment
Image source: Varian (Public Domain)
Cyberknife
Lightweight LINAC on robotic arm
Image source: Textefuermedizin via Wikimedia Commons (CC-BY-4.0)
BE908 / BE404 - Do not redistribute 7
26/11/2018
Brachytherapy
Small sealed radioactive sources placed inside, or very close to, tumour to be treated.
A very large dose is delivered to the tumour, with minimal dose to surrounding tissue.
Image source: Rock mc1 via Wikimedia Commons (CC-BY-SA 3.0)
Brachytherapy
Small sealed radioactive sources placed inside, or very close to, tumour to be treated.
A very large dose is delivered to the tumour, with minimal dose to surrounding tissue.
Image source: Rock mc1 via Wikimedia Commons (CC-BY-SA 3.0)
Brachytherapy
Image source: PBAG via Wikimedia Commons (CC-BY-SA 3.0)
BE908 / BE404 - Do not redistribute 8
26/11/2018
High Dose Rate (HDR) afterloading
Automated remote afterloading:
• Source attached to (or embedded) in the end of a wire or cable
• Wire driven through catheters into applicators pre-implanted in patient
• Source dwells in planned positions for a pre-set time, then is advanced along catheter.
This process creates the desired dose distribution.
• 2-10 treatment sessions
Image source: Eckert & Ziegler (image used within the license terms at [Link])
Radioactive sources
Image source: [Link] (public domain)
Penetration of radiation
Image source: stannered via Wikimedia Commons (CC-BY 2.5)
BE908 / BE404 - Do not redistribute 9
26/11/2018
Radiation sources for brachytherapy
• Intracavitary insertions (e.g. cancer of the cervix, uterus, etc.)
• Interstitial implants (cancer of the breast, anus, vagina, tongue)
• Implanted “seeds” (cancer of the prostate)
• Ruthenium 106 and strontium 90 eye (beta-emitting sources) plaques
• Iridium 192 wire (gamma-emitting source) afterloaded
into beam direction shell and/or using an HDR afterloader
Image source: US-gov via Wikimedia Commons (public domain)
Risks from radiation sources
At risk:
• Patients
• Public: relatives, visitors
• Staff: nurses, radiographers, physicists, radiotherapists, anaesthesists,
mould room staff, …
• Domestic, portering and ancillary staff
Core principles of radiation protection
Minimise contact time
Maximise distance from sources
Maximise shielding
Use engineering controls (e.g. machine interlocks)
Use procedural controls (local rules)
BE908 / BE404 - Do not redistribute 10
26/11/2018
BE908 / BE404 - Do not redistribute 11
