RADIOTHERAPY

INTRODUCTION
• Radiation therapy (also called radiotherapy) is the use of a certain
type of ionizing radiation to kill cancer cells and shrink tumors.
• Radiation therapy injures or destroys cells in the area being treated
by damaging their genetic material, making it impossible for these
cells to continue to grow and divide.
• The aim of radiotherapy is to cure cancer, where possible, or to
damage as many cancer cells as possible, while limiting harm to
nearby healthy tissue
• Where cure is not possible, the aim is the relief of symptoms of
cancer, thereby improving the person's well-being.
• Radiation therapy may be used to treat almost every type of solid
tumor.
• It is the principal treatment for various skin cancers; cancers of the
mouth, nasal cavity, pharynx and larynx; brain tumors and many
gynecological, lung cancers, and prostate cancers.
RADIATION THERAPY TEAM
• Radiation therapy team includes;
• Radiation oncologist
• Dosimetrist
• Radiation physicist
• Radiation therapist
• Radiologist
• Pathologist
• Pediatric oncologist and surgeon
BASIC PRINCIPLES OF
RADIOTHERAPY
• The higher the dose of the radiation delivered to the tumor, higher
the probability of the local control of the tumor.
• The lower the dose to the surrounding normal tissues, the lower the
associated morbidity.
• Larger tumors require higher doses of radiation for control.
• Hypoxic tumor cells are relatively radio resistant and require higher
doses of radiation to achieve cell kill
• Tumor cells usually proliferate faster than the normal tissues.
Shortening the time interval between surgery and radiation therapy
reduces the repopulation of tumor cells
ACTION OF RADIOTHERAPY
• Radiotherapy works by destroying cells, either directly or by
interfering with cell reproduction using high-energy X-rays, electron
beams or radioactive isotopes.
• Radiated cell attempts to divide and reproduce itself, it fails to do so
and dies in the attempt
COMMON SIDE EFFECT OF
RADIATION THERAPY
• Skin reaction
•  Fatigue
•  Mucositis
•  Xerostomia (dry mouth)
•  Change sense of test & smell
•  Nausea and vomiting
•  Diarrhea
•  Loss of Appetite
•  Low blood count
•  Lung fibrosis
•  Heart complications
•  Secondary cancer
TYPES OF RADIATION THERAPY
• There are different types of radiation and different ways to
• deliver the radiation.
• Radiation may come from a machine outside the body (external
• radiation), may be placed inside the body (internal radiation).
• 1. External Radiation Therapy
• External beam radiation, also called Tele Therapy, is administered by a machine
at a certain distance from the specific area of the body.
• Tele Therapy is a radiation technique in which the radiation source is external to
the person.
• Depending on the amount of energy x-rays can be used to destroy cancer cells at
the surface or deeper in the body.
2.Internal Radiation Therapy
• Internal radiation therapy, also called brachytherapy, is a radiation
technique in which the specific radioisotopes (radiation sources) placed
directly into or near the tumor.
• The radiation source is usually sealed in a small holder called an implant
• Implants may be in the form of thin wires, plastic tubes called catheters,
ribbons, capsules, or seeds into body cavities or interstitial compartments.

•.
TYPES OF TELETHERAPY

• Teletherapy is further divided into two types based

on the energy of ionizing radiation:
Kilovoltage Radiation Therapy
Megavoltage Radiation Therapy
1.Kilovoltage Radiation Therapy
Units
• X-rays were the first modality used for cancer treatment. Kilovoltage
radiation therapy unit utilizes X-rays energy to destroy cancer cells.
• The kilovoltage radiation therapy uses ionizing radiation of energy
less than 1MeV.
• Kilovoltage machines are used to deliver radiation for the treatment
of skin tumors. The kilovoltage radiation therapy has different types
based on the degree of penetrability, which includes-
 Contact therapy
 Superficial therapy
 Ortho Voltage Therapy or deep therapy
 1.CONTACT THERAPY
• It is a low energy therapy machine with energy ranging
between 40-50 KV with a tube current of 2 to 5 Ma.
• Aluminum filters of 0.5 to 1.0mm ate used as added filters.
• It has a very short source to a surface distance of less than
2cm.
• The X-ray intensity decreases rapidly over the first few
millimeters below the skin surface and completely
absorbed at 2 cm depthin soft tissues.
• Most commonly, it is used in rectal carcinomas treatment .
2.SUPERFICIAL THERAPY
• The energy of the superficial therapy machine ranges from
50.150KV with 5 to 10 Ma tube current.
• Aluminum and copper filter are used as added filters.
• They have an SSD of 15-20 cm. Superficial therapy is used to
treat tumors at depth of about 5mm.
• Most commonly, it is used in skin cancer treatment.
3.Ortho Voltage Therapy or
Deep Therapy
• The energy of the ortho voltage machine ranges from 150-
500KV with tube current of 10 to 20 Ma.
• Copper filters are used as added filters.
• The SSD is 50cm.
• Ortho voltage therapy is used to treat tumors ata a depth
of about 2cm.
LIMITATIONS OF KILOVOLTAGE X-
RAY MACHINE
• Kilo voltage x-ray machine have the following limitations:
 Higher skin dose
Increased absorbed dose in bone
Increased scattering
• The above factors make the units unsuitable for treatment of tumors
behind bone, as well as deep seated tumors.
2.MEGAVOLTAGE RADIATION
THERAPY UNITS
• Megavoltage radiation therapy unit has an energy of more than 1
MeV.
• The megavoltage radiation therapy has different types, which
include-
Cobalt 60
Linear Accelerator
• Cobalt 60 teletherapy unit was invented by H.F. Johns from Canada
in early 1950.
• The first cobalt therapy unit was installed in Canada in 1951.
PRODUCTION OF COBALT 60
RADIOISOTOPE
• The radioactive cobalt60 was discovered by Glenn T. Seaborg and
John Livingood.
• Cobalt 60 is a radioactive material that is produced bombarding
neutrons on stable Co59 in a nuclear reactor.
• The resultant isotope is unstable radioactive cobalt60, which decays
into nickel by means of beta emission as unstable cobalt-60 decay
into a stable nickel-60 isotope.
• In this process, two wavelengths of high energy gamma rays of 1.17
and 1.33 MeV are emitted.
COMPONENTS OF COBALT 60
TELETHERAPY MACHINE
• The aim of teletherapy is to give maximum dose to entire volume
and minimum dose to surrounding normal tissue
• Method of treatment in which radiation sources are kept at a
distance from patient.
• The distance is called the source to skin distance. ( SSD )
• Telecobalt machine are simple, economical and more reliable.
• About 50% of all cancer, in term of anatomy and thickness are
amenable to tele cobalt therapy.
PARTS OF COBALT MACHINE
• Mainframe or base
• Gantry
• Treatment head
• Collimator assembly
• Beam stopper
• Treatment couch
• Control console
1.MAINFRAME OR BASE
• The mainframe is made of metal and stainless steel.
• It is fixed on the floor.
• The whole unit of teletherapy is attached to stand.
• It has an electrical circuit that provides an electric supply to
the unit.
• It also provides a circular scale to indicate the position and
angles of the gantry during the rotation.
2.GANTRY
• The gantry of a teletherapy machine can rotate at an
angle of 360°.
• The gantry movement is monitored and controlled in
2 directions along with adjustable speed.
• The gantry is attached to the stan, which allows it to
rotate around 360° about the ISO center.
3.TREATMENT HEAD
• Source head or treatment head consists of following
components:
Source
Shutter
Collimator
Head Shielding
A.SOURCE
• Co60 source is the cylinder of 1-2cm diameter and height of
the 2-3cm and it is positioned with its circular end facing
the patient.
• The source is in the form of solid cylindrical discs or pellets
placed in stainless steel capsule and sealed by welding.
• This capsule is again placed in other steel capsule to
prevent leakage or contamination.
B.HEAD SHIELDING
• The source is surrounded by sufficient thickness of
tungsten or lead for shielding purpose.
• The shielding thickness depends on the nature of
material used either lead, tungsten or depleted
uranium.
• The shielding material should have higher atomic
number and high density.
C.SHUTTER MECHANISM
• The shutter is the device which bring the source infront of
an opening from which the useful beams comes out.
• The shutter is used to shielding off the radiation beam
when it is not needed.
• There are four types of shutter mechanism.
a. Rotating wheel
b. Shielding drawer
c. Mercury shutter
d. Moving jaw
A.ROTATING WHEEL
• The source is attached on a rotating wheel and it is at the off
position, the source is protected by approximately 20HVL of lead all
around.
• When the power is on the wheel is driven by the motor and it is
turned 180° in clockwise direction.
• At the same tim, the electromagnet is activated so that the source is
held.
B.MERCURY SHUTTER
• The source is at a stationary position in the off position.
• The source is protected by filling the space with mercury.
• If the beam is turned on, the mercury is pumped out to a reservoir.
• At the end of the exposure, a valve V is opened, and mercury
automatically fills the space again.
C.MOVING JAW
• The source is at fixed position, and the shutter mechanism simply
consists of a pair of moving jaws.
• When the machine is ON, the jaws are moved away.
• In the off position, the jaws are move towards each other.
D.SLIDING DRAWER
• In this case, the source is attached on a sliding drawer.
• The drawer is slide out to the ON position by a compressed air
cylinder at the termination of exposure.
• The pressure of the cylinder is released and the drawer
automatically slides back to the off position.
• The sliding drawer seems to be the most modern system available.
4.COLLIMATOR
• The collimator is used to control the size and shape of beam.
• Collimator directs useful beams to patient.
• The collimator consists of two pairs of heavy metal bars ( blocks ) of
depleted uranium or tungsten.
• Each pair can be moved independently towards or away from the
axis of beam obtain square and rectangular fields.
5.BEAM STOPPER
• Beam stopper act as counter weight.
• It absorbs exit radiations.
6.TREATMENT COUCH
• It is integral part of the machine in which the patient
is positioned during treatment.
• The couch can be moved up, down, laterally,
longitudinally and about the central axis of beam.
• Couch is made partly with wire mesh.
• The top of couch is made with low z material to offer
low attenuation to radiation.
7.CONTROL CONSOLE
• The control console is kept upside of the treatment room and
connected to machine by means of cable.
• It has dual timer, ON and OFF switches with light indicator.
• The function of timer is to set the required time ON the
source and OFF the source after the termination of present
time.
• For patient viewing /monitoring, lead glass viewing and
video camera facility is provided.
• Th room is provided with interlocks.
ADVANTAGES OF TELETHERAPY
• Large no of patients can be treated daily.
• Radiation reaction can be checked regularly therefore one
can monitor the doses of radiation.
• Dose distribution in relation to anatomy can be better
controlled due to various field sizes and diaphragms.
Disadvantages of teletherapy
• Patient has to come daily for few weeks for therapy.
• Surrounding tissues also get radiations.
LINEAR ACCELERATOR (LINAC)
• A linear accelerator accelerates the charged particles to
higher energy.
• Linear accelerator uses high frequency electromagnetic
waves to accelerate a charged particle such as electron
when the high energy electron strike the tungsten target
and this results in the high energy X-rays are produce that
are used to treat deep cancer tumors.
• Linear accelerator are capable of producing radiation
energy greater than 1MeV.
• The first LINAC was designed by rolf widerore in 1928 using
electron as accelerating particle.
• The first clinical LINAC was designed in 1950.
• Over the period, different types of linear accelerators have been
developed.
• These generations of linear accelerators are classified as follows:
1st generation: Low energy photons ( 4-8 Mev) and electrons.
2nd generation: Medium energy photons ( 10-15 MeV )
3rd generation: High energy photons ( 18-25 MeV )
COMPONENTS OF LINEAR
ACCELERATOR
• The linear accelerator consists of:
1. Stand
2. Gantry
3. Treatment head
4. Couch
5. Control console
1.STAND
• The stand consists of klystron, cooling system, wave guide,
circulator.
• The cooling system cool various components it establishes
temperature above the room temperature.
• It also provides the condensation of moisture from air.
• The klystron acts as a source of microwave and the waveguide
forward the microwave power to accelerator structure in the
gantry.
• The circular isolate the klystron from microwave reflected back
from accelerator structure.
2.GANTRY
• The gantry consists of accelerating structure, electron gun, bending
magnet, treatment head and beam stopper.
Accelerating structure: The accelerator tube provides a path of
travelling for the electron beam.
• The klystron supply microwave energy to the accelerating structure.
• The electrostatic field generated by the microwave energy,
accelerate the electron to entire length of the wave guide.
• When the electron beam passes through the accelerating wave guide
a magnetic field is used to focus the beam, so that it travels in a
straight line and retains a small diameter.
Electron gun: The electron gun produce and injects the
electron into the accelerator tube.
Bending magnet: As the electron beam reaches the output
end, it passes through a bending magnet.
• The bending magnet deflects the electron emerging from
the accelerating structure around a loop in order to strike
the target to produce x-rays.
Treatment head: The treatment head has the beam
shaping and beam monitoring device.
• This includes the primary collimator, beam flattening filter,
scattering foil, ion chamber and secondary collimator.
Beam stopper: The beam stopper attenuates the exit beam
and this reduce the shielding/ of required room.
• The beam finally strikes the x-ray target scattering foil,
depending on whether the accelerator is being operated in
the x-ray mode or electron mode.
3.TREATMENT COUCH
• The treatment couch motions are controlled by a hand
pendant.
• The three dimensional positioning of the patient on the
couch is done a motor driven mechanism.
4. Control console:
• The control console is the operation centre of linac.
• It provides visual and electronic monitors for linac
operating parameter including patient dose prescription.
MONITOR IONIZATION CHAMBER
• The monitor ionization chamber is located in the path of
the beam to measure the integrated dose and dose rate.
• Radiation that passes from the target through a monitor
ionization chamber produces an ionizing current. This
current is proportional to the beam intensity.
• This current is monitored, and an integrated dose and
dose rate is calculated.
X-RAY MODE
• A LINAC can produce both x-ray photons and electrons of variable
energy. When the accelerator is in the x-ray mode the electron beam
strikes the x-ray target and electrons transfer their energy into x-ray
photons.
• The x-rays then pass through the primary beam flattening filter, dual
x-ray ion chamber to the treatment area on patient. These x-rays are
heterogenous in nature, and this energy in denoted by Mv.
• To make the beam intensity uniform across the field. The flattening
filters are inserted in the beam. These filters are made of lead and
uranium.
ELECTRON MODE
• When the accelerator is in the electron mode the electron beam
strikes the scattering foil, where the electron are scattered and
forms electron beam.
• The electron beam passes through the dual electron dose
chamber and electron application to the treatment area on the
patient.
• Since the electrons are monoenergetic, the energy is denoted by
MeV.
• The electron applicators are provided to avoid scattering of
electron with air.
WORKING PRINCIPLE OF LINAC
• The modulator generates high voltage pulsed DC to the
magnetron, klystron, and to electron gun.
• The electron gun emits electrons in the form of a narrow pencil
beam.
• The produced electron are then injected into the accelerator.
• The magnetron produces microwaves, and the klystron
amplifies the microwave.
• The waveguide system is an evacuated tube that transmits the
microwaves.
• The emitted electron gain energy from RF ( microwave ) and
become accelerate.
• The electron beam accelerated at the speed of light.
• The electron beam is bent by bending magnets.
• The high speed electrons are then incident on a target.
• The target absorbs the energy of the converts some of its energy
into x-rays by the bremsstrahlung process.
• The radiation passes through the collimator.
• The primary and secondary collimators reduce the penumbra and
define the field size and shape of the beam.
• The patient lies on a treatment couch, and lasers are used to make
proper positioning.The gantry can be rotate at any angle around the
patient.
• The radiation can be delivered to the tumor from many angles.
BRACHYTHERAPY
• Brachytherapy is a branch of radiotherapy which deals with
radiation sources being place din close contact with the tumor.
• The meaning of brachy in Greek is a short distance. It is also
known as internal radiotherapy or sealed source radiotherapy.
• Brachytherapy allows delivering high doses of radiation to more
specific area of the body, compared with the external beam
radiation.
• Brachytherapy can be delivered the radioactive dose directly
within or adjacent to the tumor.
• It is used to treat early stage cancer that have not spread .
• Brachytherapy successfully delves a particular dose in a
very short line radiating specific tumors separating the
surrounding normal tissues.
• In brachytherapy, the radioactive source derives radiation
at a short distance of approx < cm.
• It is an effective treatment for cervical, prostate, breast
and skin cancer.
• It can be used for tumors with the unreachable site where
other therapies fail to deliver dose.
• Brachytherapy is used to treat some kinds of cancer, which includes:
Vaginal cancer
Breast cancer
Cervical cancer
Endometrial cancer
Head and neck cancer
Lung cancer
Rectal cancer
Pancreatic cancer
TYPES OF BRACHYTHERAPY
• Brachytherapy can be categorized according to the following
aspects-
Based on source placement
Based on treatment duration
Based on the Dose rate
1. Based on source placement-
a) Surface mould: Sources are placed over the tissue to be treated.
b) Interstitial Therapy: In this type of brachytherapy, the source is
placed in the target tissue of the affected site.
C) Intracavitary Therapy: In this type of brachytherapy, the source is
placed in a space next to the target tissue. This space may be a body
cavity such a uterus and vagina.
d) Intra Luminal: In this type of brachytherapy, the source is placed inside
the body human such as esophagus.
e) Intra vascular: In this type of brachytherapy, the radiation source is
placed inside blood vessels for the treatment of coronary stenosis.
2. Based on treatment duration-
a) Temporary: The radiation source is temporarily placed inside the
tumor. The dose is delivered over a short period of time then the
source is removed after the prescribed dose has ben reached.
b) Permanent: It is also known as seed implantations, which involves
planning small radioactive seeds or pellets inside the tumor.
3.Based on dose rate-
a)Low dose rate brachytherapy: It involves radiation dose delivered at a
rate of 0.4-2Gy/hour. Lower dose rates take longer treatment times. The
radioactive source may be placed in the treatment site for one or several
days.
b)Medium dose rate: It involves radiation dose which ranges from 2-12
Gy/hour.
c)Pulsed dose rate: It involved a short pulse of high radiation, typically once
an hour.
EQUIPMENT
1. Afterloader machine: It is a special machine that is used during
brachytherapy.
• It contains radiation source. It is an automatic computerized device
that drives small radioactive sources in the patients body through the
catheters for a specific time.
• The operator can remotely control the afterloader from a separate
room.
2. Applicator: It is a device that is used to hold a radioactive source.
Applicators are usually needles or plastic catheters.
3.BRACHYTHERAPY SOUIRCES