2. What is Cancer?
Cancers are growths of cells (cancerous tumors)
which are out of control. As a result of this, they
do not perform their intended function.
4. Treatment of Cancer
Cancerous tumors can be treated using the
following main methods:
Chemotherapy (drugs).
Radiation therapy:
Radiotherapy
Brachytherapy
Surgery (Best Option) taking the whole thing off.
5. Choice of Treatment
The choice of treatment depends on a
number of factors including:
Size of tumor
Position of tumor
Tumor stage
6. Objective of Radiation
Therapy
Radiation therapy may be used:
to cure an illness - for example, by
destroying a tumor (abnormal tissue)
to control symptoms - for example, to
relieve pain
before surgery - to shrink a tumor to
make it easier to remove
after surgery - to destroy small amounts
of tumor that may be left
7. Radiation Therapy
There are two techniques in radiation
therapy that are used to treat cancer using
ionizing radiation:
Radiotherapy
Brachytherapy
8. What is Radiotherapy?
Damaging the DNA inside cells causing them to be unable
to divide and reproduce.
Abnormal cancer cells:
divide more quickly than normal cells.
are more sensitive to radiation
die and the tumor shrinks by the time
Normal cells
can also be damaged by radiation
repair themselves more effectively, as when your skin heals
itself after sunburn
The goal of radiation therapy
maximize the dose to abnormal cells
minimize exposure to normal cells.
The effects of radiation are not immediate; the treatment
benefit occurs over time.
9. External Beam Irradiation
Photon energy (X-rays or γ-rays)
Particle Radiation (electrons, protons, neutrons)
Photon therapy advantages
Skin sparing, penetration, beam uniformity
Dual-energy linear accelerators generate:
Low energy megavoltage X-rays (4-6 MeV)
High energy X-rays (15-20 MeV)
Electron beam
Cobalt units and low-energy linacs (4-6 MeV) are used
primarily to treat bone cancer and tumors of the head,
neck, and breast.
High-energy linacs are used to treat deep-seated tumors
of the pelvis and thorax.
10. Radiotherapy Using X-rays
The x-rays are generated
by a linear accelerator
(linac).
The linac fires high
energy electrons at a
metal target and when the
electrons strike the target,
x-rays are produced.
The x-rays produced are
shaped into a narrow
beam that matches the
patient’s tumor using
movable metal shutters.
The beam comes out of a
gantry which rotates
around the patient.
11. Radiotherapy Using Gamma
Rays
Gamma rays are
emitted from a cobalt-
60 source – a
radioactive form of
cobalt.
The cobalt source is
kept within a thick,
heavy metal
container.
This container has a
slit in it to allow a
narrow beam of
gamma rays to
emerge.
12. Radiotherapy
The apparatus is arranged so that it
can rotate around the couch (table)
on which the patient lies.
This allows the patient to receive
radiation from different directions.
The diseased tissue receives
radiation all of the time but the
healthy tissue receives the minimum
amount of radiation possible.
Treatments are given as a series of
small doses because cancerous cells
are killed more easily when they are
dividing, and not all cells divide at the
same time – this reduces some of the
side effects which come with
radiotherapy.
13. Brachytherapy
This involves placing
implants made of a
radioactive source in the
form of seeds, wires or
pellets directly into the
tumor.
Such implants may be
temporary or permanent
depending on the implant
and the tumor itself.
The benefit of such a
method is that the tumor
receives nearly all of the
dose whilst healthy tissue
14. Brachytherapy
Uterus
Cervix
Prostate
Intraocular
Skin
Thyroid
Bone
Brachytherapy is used to treat the following cancers:
15. Brachytherapy
Radioactive source in direct contact with tumor
Radioactive sources are put inside the patient
The radioactive sources are sealed in needles,
seeds, wires, or catheters, and implanted directly
into or near a tumor on a temporary, interstitial
implants, intracavitary implants or surface molds.
Greater deliverable dose
Continuous low dose rate
Shorter treatment times
16. Brachytherapy
Limitations
Tumor must be accessible
Well-demarcated with defined boundaries
Cannot be the only modality for tumors with
high risk of regional lymph node metastasis
18. Radiobiology
Use of high-energy radiation to treat cancer
destroys the cancer cells' ability to reproduce, and
the body naturally gets rid of these cells.
Radiation destroys cancer cells by damaging their
DNA.
Cancer cells are particularly vulnerable to
radiation
Cancer cells divide more rapidly than normal
cells.
Normal cells are able to repair this damage
more efficiently.
19. Radiobiology
Random cell death
Deposition of energy & injury is random
Same proportion of cells is damaged per
dose
100 to 10 cell reduction = 106 to 105 cell reduction
Larger tumors require more radiation
105 cells = nonpalpable
Normal tissue is affected also
20. Radiobiology
Ionizing radiation ejects an electron from a
target molecule:
ionizes the water in the cell and induces formation
of free radicals which cause damage of the genetic
material (DNA).
Distributed randomly within cell
Double-strand DNA breaks – lethal
Cell death: no longer able to undergo unlimited
cell division
Direct vs. Indirect injury (free radicals – O2)
Inadequate cellular repair mechanisms implied
21. Direct vs. Indirect Action
Direct Action:
Radiation may impact the DNA directly, causing ionization
of the atoms in the DNA molecule (“direct hit”).
Indirect Action:
Radiation interacts with non-critical target molecules as
water.
This results in the production of free radicals, which are
atoms or molecules that have an unpaired electron.
Electrons like to be in pairs, thus free radicals are highly
unstable seeking out other electrons so they can become
a pair.
These free radicals can then attack critical targets such as
the DNA, causing its ionization and a chain reaction
occurs.
Damage from indirect action is much more common than 22
23. Cancer Treatment using
Radiotherapy
Kilovoltage X-ray units:
Uses X-rays generated at voltages up to
500kVp
Superficial: 50-150 KVp X-ray, useful for
irradiating tumor confined to about 5 mm depth
(~90% depth dose)
Orthovoltage (or deep therapy): 150- 500 KVp
X-ray, Treatment to a depth of only a few
centimeters
Megavoltage linear accelerators (LINAC)
Magnetron
Cyclotron
Cobalt-60 machines
24. Diagnostic and Therapeutic X-
Ray
Diagnostic X-ray
uses low energy X-rays for imaging
Therapeutic X-ray
uses high energy X-rays to treat tumor.
ionizes the water in the cell and induces formation of
free radicals which cause damage of the genetic
material (DNA).
Often the damage is not enough to cause tumor cell
death. i.e. it is sublethal.
Lethal damage occurs by repeated exposure to
radiation.
Normal cells are also affected adversely by radiation
but have the capacity of repair, i.e., reversible.
25. Measurement of radiation
Absorbed dose:
refers to the energy deposited at a specific point in a
medium.
Measured in the SI unit of the gray (Gy), where
1Gy =1 Joule/kg
1 Gy = 100 cGy (100 rad)
Depth: distance beneath the skin surface where the
prescribed dose is to be delivered.
Depth affects measurements of dose attenuation.
Source to Skin Distance (SSD): the distance from the X-
ray source to the surface of the patient.
26. Measurement of radiation
Percent Depth Dose (PDD): measures the
attenuation of the dose as it travels through matter.
Is the percentage ratio of the absorbed dose at a
given depth to the absorbed dose at a fixed
reference depth usually DMAX , where dose reaches
its maximum value.
Dependant on:
↑ Energy (Beam quality)- more penetrating- ↑ PDD
↑ Field size- more scatter- ↑ PDD
↑ SSD- ↑ PDD
↑ Depth- ↓ PDD due to dose attenuation through matter
27
27. Kilovoltage X-ray units
“Conventional” X-Ray tube with electrons accelerated by an
electric field.
Stationary anode made of tungsten 2-3 mm thick embedded in
a large mass of copper for heat dissipation, with direct water
cooling of the copper block.
Is sufficient (in contrast to diagnostic tubes which have a
rotating anode) as short, low-dose exposures are intended.
Also, to allow for a more compact, space-saving and less
expensive model.
Metal–ceramic tube
28. Beam Filtration
Filtration is important to harden the beam to a desired
degree:
Lower-energy photons are quickly attenuated in tissue and
contribute little dose at greater depths.
Depending on the intended depth of treatment, this low-
energy component needs to be substantially reduced as it
increases dose in superficial tissue without clinical benefit.
29
A filter holder and applicator
mount are attached to the
tube housing at the beam exit
aperture.
A filter storage box contains
interchangeable filters that
can be inserted beneath the
beam exit aperture to produce
beams of different qualities
29. Beam Collimation
The primary collimator
usually consists of a
conical hole within a block
of lead, or other heavy
metal, set into the tube
housing.
Secondary collimation is
accomplished using a set
of interchangeable
applicators covering the
range of available
treatment sizes.
The main collimation from
an applicator is provided
by a diaphragm of the
30. Beam Collimation
Applicators accurately define the
treatment area and the dose rate:
The applicator end defines the
shape and size of the radiation
beam (field size at the skin
surface).
The applicator end sets a fixed
distance from the source
(SSD), typically in the range of
20 to 50 cm.
The axis of the applicator is
mechanically aligned to the
axis of the radiation beam.
31
31. Dose Control
A transmission ionization chamber is placed
downstream of the filter holder. Such
equipment is a radiation monitor to indicate
the tube output rate.
Can be calibrated to deliver the intended dose
in terms of monitor units (MU).
Ionization chamber shuts down beam after a
predetermined dose is given.
32
34. Limitations of Kilovoltage X-
ray Machines
Can not reach deep-seated tumors with
an adequate dosage of radiation.
Do not spare skin and normal tissues:
Beyond certain depth, the dose drop-off is
too severe to deliver adequate depth dose
without considerable overdosing of the skin
surface
Machine Learning Spring 2014 Inas A.
Yassine 35