radiotherapy : past present future kmio 2015
TRANSCRIPT
Radiation Therapy
Rays of HopeThe Past , The Present & The Future
Lokesh Viswanath M.DProfessor & Head of Unit II , Radiation Oncology, Kidwai Memorial Institute of Oncology 2015
Radiotherapy
Definition of Radiation Oncology• discipline of human medicine concerned with the
generation, conservation, and dissemination of knowledge concerning the causes, prevention, and treatment of cancer and other diseases involving special expertise in the therapeutic applications of ionizing radiation.
• radiation oncology is concerned with the investigation of the fundamental principles of cancer biology, the biologic interaction of radiation with normal and malignant tissue, and the physical basis of therapeutic radiation.
• As a learned profession, radiation oncology is concerned with clinical care, scientific research, and the education of professionals within the discipline.
Radiation Oncology
Principle & Practice of Oncology
Radiation therapy & Technology
Radiation Physics
Radiation Safety & Protection
Quality assurance
Regulations
Radiation Biology
Clinical -Basic Science / Cellular /
Genetic
The aim of radiation therapy
• to deliver a precisely measured dose of radiation to a defined tumor volume with as minimal damage as possible to surrounding healthy tissue, resulting in eradication of the tumor, a high quality of life, and prolongation of survival at competitive cost.
• under our care we take full and exclusive responsibility, exactly as does the surgeon who takes care of a patient with cancer.
• This means that we examine the patient personally, review the microscopic material, perform examinations and take a biopsy if necessary.
• On the basis of this thorough clinical investigation we consider the plan of treatment and suggest it to the referring physician and to the patient.
• We reserve for ourselves the right to an independent opinion regarding diagnosis and advisable therapy and if necessary, the right of disagreement with the referring physician.
• During the course of treatment, we ourselves direct any additional medication that may be necessary and are ready to be called in an emergency at any time.
Radiation Oncology Team
• Physician : Radiation Oncologist • Radiation Physicist• Dosimetrist• RT Technologist (RTTs) – Radiotherapist • RT Nurses
Radiation Therapy : Fundamentals
ELECTROMAGNETIC RADIATIONS
Photon E = h(energy = Planck’s const x frequency)
= hc/ (c = speed of light, = wave length)
10-9 10-8 10-7 10-6 10-5 10-4 10-3 10-2 10-1 1 10 102 103 104
rays
X-rays U.V.
visible
Infra Red Radio Waves
Microwaves Short Waves
T.V.Radio
Radar
IONIZINGRADIATION NON-IONIZING RADIATION
(cms)E (eV) 1.24x107 1.24x102 1.24x10-13
Incandescent Light Bulbs
Diagnostic X Ray tube
Voltage of a Lightning Bolt
110-240 Volts 80-140Kilo Volts 3 to 120 million volts
Telecobalt Machine Linear Accelerator
1.1 Mv (Mega = Million Volts)
Low Energy - 4-6 MVHigh Energy - 18 Mv
6 Million Volts18 Million Volts
Introduction• Basics of Radiation Therapy
– High energy Ionizing Radiation – X / γ Rays– Interaction of Radiation with matter
Transmission Attenuation
Scatter Absorption
Rad / Gray / cGy
Cancer Cell & Ionizing Radiation
• Cancer cell multiply faster than normal cell• DNA is primary target • Double Strand breaks
>>> Reproductive Cell Death
• Injury to DNA is the primary mechanism by which ionizing radiation kills cells . – Most DNA damage is repaired– Lethal double-strand breaks -persist (locally multiply damaged
sites (300) of about 15 to 20 nucleotides in size)– Micronuclei formation– Chromosome aberrations– Cell death through loss of the reproductive integrity of the
cell's genome.
• Many biologic factors affect the relationship between the amount of physical energy deposited, the extent of DNA damage that is caused, the number of cells that are killed, and the severity of the tissue response
• Radiation therapy is the art of using high energy ionizing radiation to destroy malignant tumors while being able to minimize damage to normal tissue.
• To be practiced like a Religion• SOPs
RT is a Double Edge Sword
↑ RT Dose
↓ RT Dose
↑ T – Control ↓↓ T – Control
↑↑ Normal Tissue Toxicitites
↓ Normal Tissue Toxicitites
Radiation therapy
Brachytherapy
Teletherapy
Tele Radiation Equipments
γ –Rays (Radioactive Source based) -
Radium BombTele
CesiumTelecobalt
Gamma Knife
X - RaysLinear Accelerato
r2D
Electrons3DCRT
SRS/SRTIMRTIGRT
Rapid ArcFFF
SBRT 4DRT – Target
tracking6D Couch
IORT
Tomotherapy
Cyber Knife
Particle Beam
ProtonsCarbon
Neutrons
Brachytherapy :
Radioactive source loading
Temporary
Pre Loaded After loading
Remote
LDR
HDR
Manual
Permanent
After PlanPre Plan
– Intracavitory / Luminal– Interstitial– Surface Mould
THE PAST1895- 1920s : Seeding - X - Ray & Radium1920 – 1930 : embryo Phase1930 -1950 : Quisent phase : World War I & II
•Artificial Radioactivity, •Development in Radar Technology
1950 – 1970 : Development Phase: Telecobalt & Linear Acclelrator –
1980 – 2000 : Infancy2000-2005 : Growth Phase2005 – 2010 : Maturation Phase2010 – 2015 : Flower> 2015 : Fruits
Marie Curie (1867 – 1934)
Born in Poland
University of Paris age 24
Discovered Radium 1898
t1/2 = 1602 years
Irene Joliot-Curie and Frederic Joliot Curie
• Artificial radioactivity
Emil Grubbe (1875-1960)
: the World’s first Radiation Oncologist.
• medical student in Chicago
• convinced his professor to allow him to irradiate a cancer patient, a woman named Rose Lee
• Ms. Lee benefited greatly from Grubbe’s intervention, demonstrating the potential value of x-ray treatments.
Claude Regaud (1870-1940) : Paris
• recognized that treatment may be better tolerated and more effective if delivered more slowly with modest doses per day over several weeks.
Henri Coutard (1876-1950) Paris
• pioneered the use of fractionated Radiotherapy in a wide variety of tumors.
• Note, he reported impressive results using this approach in patients with locally advanced laryngeal cancers. His seminal 1934 report of the outcome of these patients is still quoted today.
Ralston Patterson (1897-1981) : England
• Holt Radium Hospital - center for radiation treatment and research
Gilbert Fletcher
• MD Anderson Cancer Center• established optimal
treatment regimens in a wide variety of tumor sites including head and neck cancers and cervical cancer.
Brief History of Radiation Therapy
Chronologic Milestones:• 1895 W.K.Rontgen discovered X-Rays.• The first patient was treated with radiation in 1896,
two months after the discovery of the X-ray.• 1896 Becquerel reported natural radioactivity in
Uranium compounds.• 1898 Marie and Pierre Curie isolated radium from
pitchblende.• 1900 Villard reported that radium emitted alpha, beta
and gamma radiations.• 1934 Frederic and Irene Joliot (Curie’s daughter)
discovered artificial radioactivity.
FIRST CURE OF CANCER BY X-RAYS 1899 - BASAL CELL CARCINOMA
X-rays were used to cure cancer very soon after their discovery
Natural radioactivity was discovered by Becquerel, who was awarded the Nobel Prize in Physics in 1903 along with Marie and Pierre Curie "in recognition of the extraordinary services they have rendered by their
joint researches on the radiation phenomena"
“One wraps a Lumiere photographic plate with a bromide emulsion in two sheets of very thick black paper, such that the plate does not become clouded upon being exposed to the sun for a day. One places on the sheet of paper, on the outside, a slab of the phosphorescent substance, and one exposes the whole to the sun for several hours. When one then develops the photographic plate, one recognizes that the silhouette of the phosphorescent substance appears in black on the negative. If one places between the phosphorescent substance and the paper a piece of money or a metal screen pierced with a cut-out design, one sees the image of these objects appear on the negative. One must conclude from these experiments that the phosphorescent substance in question emits rays which pass through the opaque paper and reduces silver salts.” Paris 1896
Maltese crossHenri Becquerel Marie Curie
Radioisotopes also were soon being used to treat and cure cancer.
Radium applicators were used for many other conditions!
Radioactive plaques and implants are still in common use, for example in prostate implant seeds.
cure of cancer by radium plaque - 1922
• 1898 Becquerel’s vest-pocket skin erythema and reports of x-ray ‘burns’.
• 1903 Bergonie and Tribondeau described radiosenstivity of proliferating cells.
• 1930 Coutard proposed treatment fractionation.• 1950 Paterson’s definition of Therapeutic Ratio: Normal
Tissue Tolerance/ Tumor Control Dose.
Chronologic Milestones
THE EVOLUTION OF RADIOTHERAPEUTIC TECHNIQUES :EARLY CHALLENGES
• Detection of Ionizing Radiation• Defining the Quality of Radiation• Defining the Quantity of Radiation• Understanding the Mechanism of Action of
Radiation• Optimizing Radiation Delivery Equipments
THE EVOLUTION: Measuring Radiation Dose:
• Skin Erythema Dose.• 1902 Holzknecht in Vienna developed the Chromoradiometer -
An apparatus once used for estimating radiation exposure by means of the color changes produced in slides placed next to the skin.
• 1904 Sabouraud and Noire in France modified Holzknecht’s method to Pastille-dose technique using pastilles of barium platinocyanide.
• 1913 Ionization current measurement developed in Paris, and adopted in 1928 at the ICR as the standard unit “r”: x or gamma radiation producing 1 e.s.u in 1 cc of air.
• 1953 at the ICR the ‘rad’ was introduced as the unit of absorbed dose: equal to 100 ergs per gram.
• 1970 the rad was redefined in a metric system: the Gray: joules absorbed per kg. 1 Gray = 100 rads.
THE EVOLUTION : Quality of Radiation 1913 Coolidge in the USA engineered the first successful X-ray
tube using hot-filament and Tungsten target. 1920 higher voltages X ray units with more powerful
transformers and rectifiers: Contact therapy @ 50 KV, Superficial @ 100-150 KV Deep X-rays @ 200-400 KV. Effect of added filtration.
Quality measured by HVL. 1933-1950 the evolution Megavolt era:
Van de Graaff electrostatic, the Betatron, the Cobalt units and the Linear accelerator.
History of Particle Beam Therapy1938 Neutron therapy by John Lawrence and R.S. Stone
(Berkeley)1946 Robert Wilson suggests protons1948 Extensive studies at Berkeley confirm Wilson1954 Protons used on patients in Berkeley1957 Uppsala duplicates Berkeley results on patients1961 First treatment at Harvard (By the time the facility closed in 2002, 9,111patients had been treated.)1968 Dubna proton facility opens 1969 Moscow proton facility opens1972 Neutron therapy initiated at MD Anderson (Soon 6 places in
USA.)1974 Patient treated with pi meson beam at Los Alamos (Terminated in 1981) (Starts and stops also at PSI and TRIUMF)
(Cont)
1975 St. Petersburg proton therapy facility opens1975 Harvard team pioneers eye cancer treatment with protons1976 Neutron therapy initiated at Fermilab. (By the time the facility closed in 2003, 3,100 patients had been treated)1977 Bevalac starts ion treatment of patients. (By the time the facility closed in 1992, 223 patients had been treated.)1979 Chiba opens with proton therapy1988 Proton therapy approved by FDA1989 Proton therapy at Clatterbridge1990 Medicare covers proton therapy and Particle Therapy Cooperative Group (PTCOG) is formed: 1990 First hospital-based facility at Loma Linda (California)
KMIO: 100 Kv : Orthovoltage / Superficial X Ray Unit
Telecesium
• At KMIO Decomissioned few years back
Selectron
• Remote controlled after loading brachytherapy unit
• Pneumatic driven
1951 – First Cobalt machine
• Saskatoon, Saskatchewan
• London, Ontario
• Co 60– t ½ = 5.26 years– Gamma emitter – Energy 1.25 MV
1956, Henry Kaplan, MD• The first patient to
receive radiation therapy from the medical linear accelerator
• Stanford • 2-year-old boy with
retinoblastoma
History of Radiation Delivery• Linear Accelerators: 1950 to present
– Traveling wave systems– Standing wave systems
– Microtron– Reflexotron
THE EVOLUTION OF RADIOTHERAPEUTIC TECHNIQUES 1970 & 80s
Treatment Planning: Central Axis % Depth Dose. Plotting Isodose Curves. Multiple Fields Cross-Fire. Manual Patient Contouring and Manual Isodose
Curve Summation. Computer Treatment Planning Central Axis and Off-
Axis. Image Based 3-D Dose Distribution.
IK/2007
IK/2007
IK/2007
IK/2007
IK/2007
THE EVOLUTION OF RADIOTHERAPEUTIC TECHNIQUES
Understanding the biology of Cancer:The natural history of different tumors based
on cell types.The importance of cancer staging.Retrospective outcome studies and
prospective Clinical Trials. Identifying Dose Response expectations.
• 1970's Computed Tomography (CT) Ultrasound (US)
• 1980's Magnetic Resonance Imaging (MRI) Digital Subtraction Angiography (DSA) Computed Radiography (CR) • 2000's Digital Radiography (DR)
• >1985 – CT scan for RT Planning , Involved Manual Digitization of Contours only
• > 1990 – CT Scan Data was used for Target localization & Contouring – 3 D Rendering of Body contours and Tumour and normal
tissue Grids– Beams Eye view
• > 1995 – 3D Planning– 3D Conformal Bocks
• CD Scan data of Tissue Density used for RT calculation• > 1998 - 3 D Conformal RT• 2000 : Evolution of IMRT (Conceptualized in 1960s)
• Early 2000 IGRT – Cyber knife , non-isocentric mount , Celing mounted KV Imaging and advanced verification and repositioning
• 2005 IMRT as a routine• With IGRT – Adaptive Radiotherpay need for
advanced Imaging• CT on Rails or Onboard Mv/Kv Cones CT
imaging,• Integration of ceiling mounted KV imaging
THE EVOLUTION OF RADIOTHERAPEUTIC TECHNIQUES
Impact of Modern Technology: Impact of Computer technology.New Imaging technology.Advances in Molecular biology.The multidisciplinary approach to Cancer
treatment.
MODERN RADIOTHERAPEUTIC TECHNIQUES
Image based treatment planning.3-d conformal treatment planning. Intensity Modulated Radiation Treatment
(IMRT). Image Guided Radiation Treatment and
Adaptive Radiation Treatment. Investigational: Proton and Particle Therapy.
Key Mile stone
• Use of CT Scan DICOM image for RT Planning• 3 D rendering• BEV
MLC Multileaf collimator
Advanced computerization and
Hardware control and processing.
Advanced radiation safety devices
Lateral Isocenter Verification
Portal Imaging
Collimator Orientation
Multileaf CollimationMicroMLC
• Maximum field size: 72 x 63 mm •Number of leaves: 40 per side •Leaf thickness: 1 mm •Material: tungsten
• Maximum field size: 100 x 100 mm •Number of leaves: 26 per side •Leaf thickness: 5.5, 4.5, 3 mm •Material: tungsten
• Electronic portal imaging
• Motion management
Image Guidance Technology
Advanced Image Guidance
Elekta Synergy
Varian Trilogy
Solid state imaging panel
Kilovoltage X-ray source
90cm
Clearance
Image Guidance - Components
Tele Radiation Equipments
γ –Rays (Radioactive Source based) -
Radium BombTele
CesiumTelecobalt
Gamma Knife
X - RaysLinear Accelerato
r2D
Electrons3DCRT
SRS/SRTIMRTIGRT
Rapid ArcFFF
SBRT 4DRT – Target
tracking6D Couch
IORT
Tomotherapy
Cyber Knife
Particle Beam
ProtonsCarbon
Neutrons
Tomotherapy - 2003
Synchrony™
camera
Treatment couch
Linearaccelerator
Manipulator
Imagedetectors
X-ray sources
Targeting System
Robotic Delivery System
Cyber Knife – 2003+
IGRT - 2005
True beam - All in One FFF SBRT / 4DRT –
True Beam - 2010
Proton Beam therapy 2012
Brachytherapy :
Radioactive source loading
Temporary
Pre Loaded After loading
Remote
LDR
HDR
Manual
Permanent
After PlanPre Plan
– Intracavitory / Luminal– Interstitial– Surface Mould
125 I Seed Implant
Interstitial Brachytherapy
Prostate Brachytherapy
Prostate Brachytherapy
Iodine 125
t ½ = 60 days
Gamma emitter
Energy 35 kV
Treatment Planning
MLC
Control
Linac
Control
MLC
User Interface
CommonMemory
Linac MLC
ConsoleUser
Interface
Linac
LinacControl
MLCControl
MLC
Control
Linac
Control
MLCLinac
AddedGUI
Record/VerifyDB
User Interface
Electronics
Hardware
Control of Radiation Delivery
Present : KMIO RO
Teletherapy• Orthovoltage – 1 (not
working)• Telecobalt – 3 (1 due for
decomissioning)• Linear Accelerator
– Low energy : Simple – 1– High – Dual energy :
3DCR /IMRT/Electorns - 1
Brachytherapy• HDR – 1
– ICBT - 2– ISBT – due for
decomissioning– ILBT - 1
• LDR – 2 sets
Telecobalt 1970s
Linear Accelerator• 3DCRT > 1998+• IMRT > 2000+
Linear Accelerator : 3DCRT / IMRT
HDR - Brachytherapy
Future : KMIO RO
• KMIO has been granted a status of State cancer Institute : Apex Institution in the State of Karnataka to forsee cancer related activities in the region.
SCI
Radiation OncologyExpansion Plans
>2015Radiation Oncology Block
Fully Automated , Paperless environment
Sanctioned
Equipments Number
State of the ArtHigh energy Linear Accelerators
4 IMRT – Advanced rotationalIGRT4D / 6D Advanced tumor trackingFFFSRS/SRTWhole body SBRT
HDR Brachytherapy 2 IR / Cobalt
Virtual Widebore CT Simulators 2
Permanent Implant Brachytherapy suit with advanced planning system
1 Capable of handling Iodine seed – BARC / Imported
Intra operative Electronic Brachytherapy / Electorns suit
1
Advanced Doismetry equipments Set
Future - Research• Cell biology - understand effects of ionizing radiation on cells,
tumors, and normal tissues. • molecular cancer biology - clinical decision-making in oncology• development of novel biology-driven strategies in the
multidisciplinary clinical environment. – Molecular pathology of tumors - basis for improved
treatment stratification in oncology . – Molecular pathophysiology - manifestation of radiation
sequelae in normal tissues . – Molecular imaging - staging , biologic characterization of
tumors, and for determination of target volumes in radiation oncology, including new approaches such as dose painting.
– Molecular targeting in radiotherapy - enhancing the therapeutic gain of the treatment.
Proton Therapy vs. IMRTProton Beam
Thank you
Cobalt- 60
Co 60 Radiosurgery – “Gamma Knife”
Linear Accelerator
Linac Radiosurgery – “X Knife”
• High energy beam
• 1 moving source
• 5mm – 4cm target
Linac Radiosurgery – “X Knife”
Advantages
• Allows multiple fractions
• More widely available
• Linac has other uses
Couch
CT Simulator
Treatment Planning
Beam Placement
Multileaf Collimator (MLC)
No more lead blocks!
Synchrony™
camera Linearaccelerator
Manipulator
Imagedetectors
X-ray sourcesTargeting System
Robotic Delivery System
Proton Therapy Center Czech
Photons Protons
rapid dose fall-off
unecessary radiation in normal tissues
beam exit beam exit
Physical and technical principles
Leksell gamma knife
Exposure to the gel dosimeters by Leksell Gamma Knife of varying diameter collimator
4 mm 18 mm14 mm8 mm
Name: B. H. DOB: 1941SCLC extensive disease
Name: B. H. DOB: 1941SCLC extensive disease
Grenz Rays
Megavoltage
Orthovoltage
Superficial Therapy
Contact Therapy
20 KeV
50 KeV
150 KeV
500 KeV
1-25 MeV Major improvements in RT during the mid-1900s came from improved penumbra and decreased skin dose associated with higher energy x-rays, cobalt, and high energy photons.
More recently conformal RT, IMRT, IGRT, Gammaknife, Cyberknife, tomotherapy, SRS, SRT, protons, heavy ions, etc. have added considerable variety to the choices for physical radiation delivery and present radiobiological challenges.