1

RADIOTHERAPY: BASIC CONCEPTS AND

RECENT ADVANCES

Maj Gen SR Mehta VSM1, Dr Manoj Semwal2,

Lt Col N Chakravarty3, Maj Virender Suhag4

1. Senior Consultant (Medicine)

Office of the DGAFMS, New Delhi

2. Scientist E, Radiation Physicist & RSO

Army Hospital R&R, Delhi Cantt

3. MD, DNB Radiotherapy

MO Radiotherapy
Army Hospital R&R, Delhi Cantt

4. MD, DNB Radiotherapy

MO Radiotherapy
Command Hospital Air-Force, Bangalore
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RADIOTHERAPY: BASIC CONCEPTS AND RECENT ADVANCES

ABSTRACT: Radiation oncology deals with management of patients with cancer and other diseases
by ionizing radiation, alone or combined with other modalities. The most important factors affecting the
results of radiation therapy are the tumor type, its local and regional extent, the anatomic area of
involvement, and the geometric accuracy with which a calculated radiation dose is delivered to a defined
target. Although higher doses of radiation can produce better tumour control, the dosage that can be given is
limited by the possibility of normal tissue damage. Approximately 2/3rd of all cancer patients require
radiation therapy as the sole treatment modality or in combination with surgery or chemotherapeutic drugs.
Keywords: radiotherapy, radiation biology, radiation physics, recent advances in radiotherapy

INTRODUCTION
With changing lifestyle & increasing longevity, cancer has become the 4th leading cause of
death in the adult Indian population. Every year approximately 800,000 new cases are diagnosed in the
country (1). About 70-80% of these patients will need radiation treatment at some point of their treatment.
Incidence of cancer has been projected to rise worldwide by around 50% in the next 20 years, most of
which will be in developing countries (2). Cancer in India is unique from the perspective that it usually
presents in a clinically advanced stage in about 75-80% percentages of cases (1,3). Radiation therapy when
indicated as a treatment modality can be highly effective. For instance, for early cancer of the larynx the
cure rate is over 90%, and palliative radiotherapy can reduce or eliminate pain from bone metastases in 80%
of patients. (4,5) Conventionally, patients who are treated for cure receive high radiation doses of 60 to 70
Gy (6000-7000 cGy), given in 30 to 40 daily fractions at the rate of 5 fractions per week (6). Table-1 shows
curative doses for radiocurable tumors of various sites. In addition to curative efforts radiation therapy
plays a major role in cancer management in the effective palliation or prevention of symptoms of the
disease: pain can be alleviated, luminal patency restored, skeletal integrity preserved, and organ function
reestablished with minimal morbidity in variety of clinical circumstances.
Two general types of radiation techniques are used clinically- teletherapy and brachytherapy.
Teletherapy uses a radiation source located at a distance from the patient, as is the case of supervoltage
machines. The radiation is either produced by a radioisotope such as cobalt-60 or by linear accelerators.
The later deliver both X-rays and electrons in the energy range of 4-25 MeV (million electron volt). In
brachytherapy, the radiation device is placed within or close to the target volume. The radioactive source
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can be either placed on the surface (Surface Mould), within a body cavity i.e. Intracavitary Brachytherapy
(Cervix, Vagina), Intraluminal Brachytherapy (Oesophagus, Anal Canal), Endovascular Brachytherapy
(within Blood Vessels), or into an organ or tissue i.e. Interstitial Brachytherapy (Breast, Soft Tissue
Sarcoma).
Traditionally, telecobalt units using Co-60 as the source of radiation has been used in most of
the centers in developing countries. The decay half-life of cobalt is 5.26 years and average photon energy is
1.25 MeV (5, 8). Though simple in operation and easy to maintain, these units are limited by the periodic
need to replace the radioactive source and disposal of the used source. Today in advanced centres, linear
accelerators (linacs), generating electron and photon energies between 4 and 25 MeV, are generally used.
Conventionally, these machines have collimators that produce rectangular fields between 4 x 4 cm2 to 40 x
40 cm2. The newer machines have collimators which are divided into multiple segments from two opposite
sides. The "leaves" in these "multileaf collimators" are motor-driven and computer-controlled and can
project shadows at the level of the patient that are 0.5 or 1 cm in width (9). In addition to simple field
shaping, computer-controlled multileaf collimators provide the capability of defining multiple field shapes
either for individual directions or for multiple fields aimed at the tumour from different directions.
BIOLOGIC BASIS OF RADIATION THERAPY
The exact mechanism of cell death due to radiation is still an area of active investigation. A large body of
evidence supports double-stranded breaks of nuclear DNA as the most important cellular effect of radiation
(14). This breakage leads to irreversible loss of the reproductive integrity of the cell and eventual cell death.
Radiation damage can be directly ionizing; however, in clinical therapy, damage is most commonly
indirectly ionizing via free-radical intermediaries formed from the radiolysis of cellular water. Radiation
can also affect the processes of the cell cycle necessary for cell growth, cell senescence, and apoptosis. The
therapeutic mechanism for radiation is based on the intrinsic ability of normal cells to repair damage and
the ability of the radiation oncologist to take advantage of any geometric separation between the malignant
and nonmalignant tissues. In addition to the intrinsic cellular radiosensitivity, cell survival is found to be
related to oxygen tension, position of the cell in the mitotic cycle, and dose rate. These features are
responsible for the 4 R's of radiobiology, namely, repair, redistribution, repopulation, and reoxygenation
(15,16).

A logarithmic curve of survival versus dose characterizes cell survival after exposure. The curve
forms an initial shoulder followed by a logarithmic decline in survival with the increasing dose. Several
models have been used to conceptualize radiation-induced cell death and to explain the cell survival curve.
The cell survival curve can be interpreted to follow a linear-quadratic model, ie, the surviving fraction is

equal to e-(αD - β D2 ) following a dose D where α and β are constants (17). In the linear-quadratic model, 2
 4
components of cell injury are present. The linear-alpha component is responsible for the initial shoulder on
the cell survival curve and is caused by repairable damage to the target. The quadratic-beta component
represents nonrepairable damage. The linear component is proportional to the dose, while the quadratic
component is proportional to the dose squared. Acute reacting tissues and tumors have a relatively larger
alpha component and a larger α:β ratio. Smaller α:β ratios characterize late responding tissues. Table-2
depicts values for α/β (Gy) for various tissues. (18)

BASICS OF RADIATION PHYSICS

X-rays and gamma ray photons are part of the electromagnetic spectrum. The dual nature
of electromagnetic radiation is used to explain its wave and particulate behavior (19). A photon is a packet
of energy that can be characterized by the equation E = hv, where h is Planck's constant (6.62 X 10 -34 J-sec)
and v is the frequency of the photon. Frequency is equivalent to the quotient of the speed of light (3 X 10 8
m/sec) divided by the wavelength. Thus, high-energy radiations have a short wavelength and high
frequency. The interaction of a photon beam with matter results in the attenuation of the beam. Five major
types of interactions typically occur, namely, coherent scattering, photoelectric effect, Compton scattering,
pair production, and photodisintegration. The particular type of interaction is related to photon energy and
target composition. In radiation therapy, the photoelectric effect, Compton effect, and pair production are
of interest, with the Compton effect being the predominant interaction (20,21).

Photoelectric effect involves the interaction of the incident photon with the tightly bound inner electrons of
target tissues and is proportional to the cube power of the absorbing matter's atomic number. This
interaction is responsible for the different radiographic densities seen on diagnostic radiographs (20,22).
Compton effect involves interaction with outer electrons that are bound more loosely. This effect is related
to electron density and, therefore, results in much more uniform tissue absorption than lower energy
photons. In radiation therapy, Compton effect predominates; therefore, the contrast observed on therapy
port films is inferior to diagnostic radiographs (20,23). Pair production involves interaction of the photon
with the atomic nuclear electromagnetic field. This interaction becomes significant at high energies (>10
MeV) and is proportional to the atomic number of the absorbing matter. Radiation dose or exposure is
measured in units of absorbed radiation per unit of tissue. The Gray (Gy) represents 1 J/kg of tissue. Older
literature uses the rad, which is equivalent to 0.01 Gy. The exposure and dose rate of radiation decrease
according to an inverse square law, such that the exposure decreases by 4 when the distance increases by
(24,25).

RADIATION TREATMENT PLANNING

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Radiation treatment planning is necessary in radiation therapy as + 5% change in the dose
can result in + 20% change in the chances of tumor control (26,27). The aims of radiation treatment
planning are as follows : to achieve homogenous target volume dose of + 5%; the treatment volume should
ideally be the same as the target volume in size, shape and position; the dose to radiosensitive structures
should be below tolerance dose and the integral dose should be kept to a minimum (26,28). The process of
treatment planning calls for an integration of the physical findings and diagnostic imaging information with
knowledge of the pertinent anatomy, pathology, and natural history of the particular tumor type. The
radiation oncologist and other members of the multidisciplinary team must decide if radiation will play a
role in the treatment of the patient. Once the decision is made, consideration must be given to whether the
radiation is prescribed as definitive, palliative, or adjuvant therapy, and if it will be integrated with surgery
and chemotherapy. Main steps of radiation treatment planning are: tumor localization; outlining of
structures (example: patient contour, sensitive organs); target volume definition; computation of beams;
analysis of alternate plans; choice of treatment plan; films for verification; patient marking; determination
of optimal time, dose and fractionation; treatment execution; verification during treatment and
reproducability(29,30). Clinically, radiation treatment planning is most useful in cases where the target lies
close to the dose limiting organs such as spinal cord, liver and lens; in patients with a complicated shape of
target; in cases with a complicated dose distribution that should be planned with many portals; and in
patients with a target that should be treated with tangential fields. The main advantage of radiation
treatment planning is a possible increase in therapeutic ratio and the fact that dose escalation is possible
(31).
Contemporary treatment-planning computers allow for the incorporation of 3-dimensional anatomic
data to be used for planning of radiation fields. Using beam's-eye-view technology, the field of radiation
can be planned so that the physician is assured that the radiation field adequately covers the target and
spares or minimizes the dose to the non-target healthy tissues. Complex beam arrangements can be used
with the knowledge that a geometric miss can be avoided (32). The target volumes for radiation treatment
planning are defined according to International Commission on Radiation units and Measurements (ICRU)
report no. 50 (33). Gross tumor volume (GTV) is all known gross disease including abnormally enlarged
lymph nodes. The clinical target volume (CTV) encompasses the GTV plus regions considered to harbor
potential microscopic disease. The planning target volume (PTV) provides a margin around the CTV to
allow for variations in treatment setup and other anatomic motions during treatment such as respiration.
(34,35). In order to minimize any variation in patient positioning, meticulous immobilization is essential.

BRACHYTHERAPY
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Mold brachytherapy implies using sealed sources placed close to the skin for superficial
tumours (3). Surface Applicator such as called Strontium plaque therapy, is used for very superficial
lesions less than 1 mm thick. The plaque is a hollow, thin silver casing that encloses a radioactive
Strontium-90 (Sr-90) powdered salt. The beta (electron) particles produced from Strontium's radioactive
decay have a very shallow penetration. Typically the Sr90 plaque is placed on the bed of a resected
pterygium. A stat dose of around 10-12 Gy is delivered by timing the contact. As the electrons only
penetrate a few mm of air, radiation protection issues are slightly less but very different from other
radiation sources. Interstitial brachytherapy consists of inserting radioactive sources into tissue. Most
modern methods tend to use Iridium-192 wire (36). Prostate cancer treatment with Iodine-125 seeds is also
classified as interstitial brachytherapy. Intracavitary brachytherapy places the sources inside a pre-existing
body cavity. The most common applications of this method are gynaecological in nature, although it can
also be performed on the nasopharynx. Intravascular brachytherapy places a catheter with the sources
inside the vasculature for the treatment of coronary in-stent restenosis, and has also been investigated for
use in the treatment of peripheral vasculature stenoses.
In the early days of brachytherapy, the only way to place the radioactive material into the
hollow tubes or hollow body cavities was for someone to carry the source up to the patient's bedside (room
or operating theater) in a safe, take it out and place it inside the hollow destination. By necessity, the staff
member (usually the doctor) undertaking this received some radiation dose. This was manual afterloading
technique. Manual afterloading machines could not be activated from outside the room, as the source had to
be manually inserted. The source was prepared in a hot lab as a source train and inserted in a theater or
ward. The source could not be unloaded for nursing visits.
In High Dose Rate (HDR) brachytherapy, applicators in the form of catheters are arranged,
usually according to the Manchester or Paris system on, or in the patient (37). A high dose rate source
(often Ir-192) is then driven along the catheters on the end of a wire by a machine while the patient is
isolated in a room. The source dwells in a preplanned position for a preset time before stepping forward
along the catheter and repeating, to build up the required dose distribution. The advantage of this treatment
over implanting radioactive sources directly is that there is lower staff exposure and the source can be more
active due to low staff exposure, thus making treatment times quicker. The physical properties and uses of
various brachytherapy radionuclides are given in Table-3.
ELECTRON BEAM THERAPY
Linear accelerator is the source of high energy X-rays as well as electrons for clinical use.
Electron beams are 3-4 mm in diameter. They are monoenergetic on exit from wave-guide accelerating
component. They are magnetically steered and focused to interact with an energy-dependent selection of
electron scattering metallic foils which provide the circular, scattered, broad, uniform doses required for
 7
radiation therapy. The electron beam then passes through a dual parallel-plate ionization chamber for dose
monitoring. The circular electron beams are collimated to square beams using a set of individual electron
collimators, typically ranging in size from 4x4 cm to 25x25 cm. Unlike megavoltage photon beams,
electron beams exhibit rapid fall-off especially if the energy is below 15 MeV. Hence tissues beyond
practical range of electron beam receive almost no dose other than from Xray contamination. The most
commonly used prescription is to the depth of 90% depth-dose line. This therapeutic range is
approximately given by E/4 cm where E is the most probable energy of the electron beam at the patient
surface. The depth of 80% depth-dose line is given approximately by E/3 cm. Skin-surface percentage
depth doses range from approximately 80% for low-energy electrons to 93% for 18 Mev electrons.
Electron beam may be the primary mode of therapy or may be combined with photon
beams. Electron beams are mainly useful in the treatment of superficial and subcutaneous volumes of
tissue, particularly if the treatment should be limited to a unilateral lesion requiring a low dose to opposite
side of the body. These cases include tumours of the parotid, ear, oral cavity and oropharynx. Most lesions
located on the eyelids, external nose, cheeks or ears are not deeply invasive and are treated with electron
beams of 6-9 MeV. If the lesion approaches 2cm in thickness, 9-12 MeV electrons should be used.
Electron beams are also used to treat a radically dissected neck, areas with high risk of residual disease; and
as a boost to specific sites like breast and lymph nodes. The higher the electron beam energy, the greater is
the surface build up dose and the more intense are the skin reactions. With electron energies below 12
MeV, there is a significant skin sparing effect and hence a bolus may be used with 6-12 MeV electrons if
the skin is at risk for tumor involvement. (4,33)
TOTAL BODY IRRADIATION (TBI)
Low-dose TBI (less than 2 Gy given as a single fraction or multiple 0.05-0.15 Gy fractions
given 2-5 times per week) has been used for patients with autoimmune diseases. In allogenic BMT, a
higher dose (<9.5 Gy) is often required to prevent graft rejection, if it is used alone. When patients with
aplastic anaemia are prepared for BMT, a single dose of 3 Gy is used in conjunction with
cyclophosphamide to reduce the probability of graft rejection. Low dose TBI with 0.05 to 0.15 Gy 2-5
times per week is useful in inducing remissions in chronic lymphocytic leukemia and low grade Non
Hodgkin's Lymphomas in advanced stages. Generally, 4-8 weeks gap is given after each 0.5 Gy TBI to
avoid thromboctopaenia. High-dose TBI as cytoreductive therapy before BMT or PBSCT may be given as
1.2 Gy thrice per day, using partial lung blocks to protect the lungs. This hyperfractionation schedule
reduces the incidence of interstitial pneumonitis to 33%, compared to 70% with single-dose TBI of 10 Gy.
Nausea, vomiting and diarrhoea are common early side-effects of single fraction of 8-10 Gy
TBI. Dry mouth, reduction in tear formation and sore-throat develop within 10 days. Parotitis usually
occurs after first day of irradiation and subsides in 24-48 hours. About 85% of patients who receive single
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large dose of TBI develop cataracts in 11 years, the incidence is 34% when 12 Gy fractionated TBI is used.
High dose TBI results in primary gonadal failure in almost all the patients. Thyroid dysfunction occurs in
43% of patients receiving high-dose TBI. The major side-effect of low-dose TBI is thrombocytopaenia,
which usually occurs after doses exceeding 1-1.5 Gy. (7,33)
HEMIBODY IRRADIATION (HBI)
Subtotal body irradiation is usually divided into upper, middle and lower HBI. A line passing
through lower border of L4 vertebra separates upper and lower HBI. After treating one part,when
treatment of other half of the body is indicated, a gap of 6-8 weeks is allowed for sufficient recovery of
blood cells. Traditionally, HBI has been used to treat selective disseminated malignancies involving
multiple sites. Single-high dose HBI has been found to be as effective as conventional fractionated
irradiation in achieving pain control in patients with multiple metastases. A dose of 6 Gy for upper body
HBI and 8 Gy for lower and middle HBI results in 80% pain improvement in one week. Giving more than 6
Gy of upper HBI may result in potentially fatal interstitial pneumonitis. Hematological toxicities usually
disappear in 6-8 weeks (33).

GAMMA KNIFE

Gamma Knife surgery or radiosurgery, allows noninvasive cerebral surgery to be performed

in one session and with extreme precision, sparing tissues adjacent to the target. Based on preoperative
radiological examinations, such as CT scans, MR scans and angiography, the unit provides highly accurate
irradiation of deep-seated targets, using a multitude of collimated beams of ionizing radiation with scalpel-
like precision. Gamma Knife enables patients to undergo a non-invasive form of brain surgery without
surgical & anaesthetical risks, a long hospital stay or subsequent rehabilitation. This effective single session
treatment may require an overnight hospital stay, but is often done in an outpatient surgical setting with
periodic follow-up. The "blades" of the Gamma Knife are the beams of gamma radiation programmed to
target the lesion at the point where they intersect. In a single treatment session, 201 Cobalt 60 sources in a
fixed hemispheric array are focused on a small stereotactically defined target volume (38). Over time, most
lesions slowly decrease in size and dissolve. The exposure is brief and only the tissue being treated receives
a significant radiation dose, while the surrounding tissue remains unharmed. Gamma Knife may be used as
an alternative to standard neurosurgical operations or as an adjunctive therapy in the treatment of residual
or recurrent lesions left unresected by conventional surgery. Radiosurgery can be especially useful for those
patients who are not suitable for standard surgical techniques due to illness or advanced age. Conditions for
which the Gamma Knife is considered most effective are given in Table-4. X-knife is another form of
sterotactic radiosurgery where Linear accelerator is used to deliver treatment. If treatment is giving in
multiple fractions, then it is known as stereotactic radiotherapy. (SRT) (39).
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THREE-DIMENSIONAL CONFORMAL RADIOTHERAPY (3DCRT)
Three-dimensional conformal radiotherapy is a complex process that begins with the creation of
individualized, 3D digital data sets of patient tumors and normal adjacent anatomy (5,40). These data sets
are then used to generate 3D computer images and to develop complex plans to deliver highly “conformed”
(focused) radiation while sparing normal adjacent tissue. Because higher doses of radiation can be
delivered to cancer cells while significantly reducing the amount of radiation received by surrounding
healthy tissues, the technique may increase the rate of tumor control while decreasing side effects. 3DCRT
is used to treat tumors that in the past might have been considered too close to vital organs and structures
for radiation therapy.
3DCRT begins with computed tomography (CT) scans of the region of interest are obtained. This
session also includes the development of special molded devices that help the patient maintain the same
position for each treatment; and the placement of colored, 3-millimeter permanent ink tattoos on the
patient’s skin to help align radiation equipment with the target area. Each such session lasts between 30 and
90 minutes. The virtual simulation creates a permanent digital file that can be accessed by the entire
treatment planning group to develop multiple, individualized courses of therapy. Scanned images are then
linked into treatment planning software that allows physicians to visualize the treatment area in three
dimensions. With this capability, radiation beam direction and intensity can be selected to more precisely
target the tumor while sparing surrounding tissue. Clinicians input these selections into computer systems
that control treatment delivery. Following virtual simutation, it usually takes three to seven days for the
team to create a treatment plan. A typical treatment session lasts about 15-30 minutes. The radiation
technologist operates the machines from a nearby control room, where he can see patients on a television
screen or through a window and can talk with them through an intercom (41). Various steps for 3DCRT are
given in Table-5.

INTENSITY MODULATED RADIATION THERAPY (IMRT)

Intensity modulated radiation therapy is a state-of-the-art radiation delivery system, which

shapes radiation beams to closely approximate the shape of the tumor. IMRT enables a more precise
conformal radiation dose distribution to the target area by allowing the physician to control the intensity of
the radiation beam within a given area (42). The dose distribution is non-uniform across several radiation
beams, which summate to produce an optimum dose distribution conforming closely to the shape of the
target volume. Because of this an increased dose of radiation can be delivered to the tumor without an
increase in radiation delivered to the normal tissue. This type of conformal radiation utilizes beams or
multileaf collimators that can turn on or off or be blocked during treatment, varying the radiation beam
intensity across the targeted field. Intensity modulated radiotherapy can generate concave dose
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distributions, which can be advantageous in the treatment of pharynx or larynx cancer and the draining of
lymph nodes in the neck. IMRT employs a powerful, advanced computer program to plan a precise dose of
radiation in three dimensions, based on individual tumor size, shape and location (43). Frequently, a
localization device is molded to fit the precise contours of the individual patient. Alternatively, a body
frame may be used. The molded device or body frame will be placed on the patient each time he receives a
treatment. The areas most commonly treated with IMRT are: prostate, spine, lung, breast, kidney,
pancreas, liver, larynx, tongue and sinus. The brain is treated with IMRT when one-session radiosurgery is
not appropriate or unavailable. Patients who have previously received the maximum amount of radiation
deliverable by conventional radiation therapy can also be treated with IMRT. For some patients, IMRT
replaces external beam treatments; however, in most cases, IMRT is used in conjunction with or after
another primary treatment (44).

IMAGE GUIDED RADIOTHERAPY (IGRT)

A recent development in the field of radiation oncology is up gradation of linear accelerator to

include the technology of IGRT that allows physicians to target tumors more accurately and adjust patients'
positioning prior to treatment, thereby improving the precision and effectiveness of cancer treatments. It
has been made feasible by means of an On-Board Imager, an automated system that uses high-resolution X-
rays to produce contrasting images of cancerous tumors and surrounding soft tissue (45). Because it is
natural for some movement of tumors due to a patient's normal breathing or other movement, it can be
challenging to locate the tumor precisely during radiation therapy. Before the advent of IGRT,
radiotherapists have to treat a larger area of the normal tissues around the tumor to compensate for any
tumor movement, thereby resulting in increased rate of normal tissue complications. Now, the On-Board
Imager works on the existing Lineacs to allow physicians to increase the accuracy of a patient's position
during treatment. The “On-Board” imaging system allows physicians to adjust the positioning of patients
with central nervous system, head and neck cancers and carcinoma prostate immediately prior to treatment.
In the future, physicians will be able to track and adjust for tumor movement during individual treatment
sessions rather than beforehand (46).

TOMOTHERAPY

Tomotherapy, ie “slice therapy" is a new modality of radiation treatment that combines the
use of very sophisticated computer-controlled radiation beam collimation with an on-board computed
tomography (CT) scanner to image the treatment site. It provides unprecedented accuracy in beam delivery
allowing for an increase in tumour dose, thereby increasing the likelihood of cancer cure while at the same
time reducingtreatment complications in healthy tissues. Unlike traditional radiation therapy systems which
 11
have beams projecting onto the tumor from a few different directions, tomotherapy rotates the beam source
around the patient, thus allowing the beam to enter the patient from many different angles in succession,
allowing delivery of a precise and powerful doses of radiation therapy from 360-degrees (47). It can be
provided as an add-on accessory to existing linear accelerators. The add-on feature consists of a set of
multileaf collimators that provide a narrow “fan” beam shape projecting a maximum width at the patient of
about 20 cm. The fan beam thickness can be either 0.8 or 1.6 cm and each leaf projects a shadow of about 1
cm width at the patient. When the leaves are in the beam, that portion of the beam is fully shielded except
for a minor (0.5%) transmission component. Either the leaf is open or closed for that slice providing
“binary” dose delivery, i.e., for that portion of the beam, the beam is either on or off. The open beam
components are generally referred to as "beamlets" or "pencil beams".. After two simultaneous slices have
been delivered, the patient is translated by two slice thicknesses and the next two slices are delivered until
the total treatment volume is covered, hence the nomenclature, “serial tomotherapy”. The advantage is that
instead of having, for example, six beams, each with 1/6 the dosage necessary to irradiate the tumor, the
tomotherapy beam has only 1/72 the dosage and is projected into the tumor from 72 different positions as it
rotates. Also, unlike other precision radiotherapy devices being tested, the patient is continuously moved
through the device while the beam source rotates thus creating a spiral scan pattern. This continuous helical
delivery pattern is faster, more accurate and avoids "seams" between scan slices that can occur with some
other methods. Thus the tumor is more precisely targeted and the healthy tissue surrounding the tumor is
subjected to much lower dosages of radiation (48).

The intensity of the beam is modulated through the use of a multi-leaf collimator system, thus
further improving the conformability of the treatment. By moving the radiation-blocking leaves in and out
of the beam path with speed and precision, the location and intensity of the radiation entering the patient is
accurately controlled. Also aiding in the precision targeting offered by tomotherapy is the inclusion of CT
imaging technology within the tomotherapy device itself. This allows technicians to precisely locate the
tumor before and during treatment. Highly Integrated Adaptive Radiotherapy (HI-ART) is a new radiation
therapy option available in selected European oncocenters (49). HI-ART system combines an advanced
form of IMRT with the accuracy of CT scanning technology to sculpt small, powerful and precise radiation
beams to hit hard-to-reach tumors. It uses built-in CT scanner to confirm the shape and position of the
tumor seconds before your treatment begins. Traditional radiation therapies project radiation on a tumor
from a few directions. An on-board CT scanner helps radiation oncolgist determine if the tumor has shifted
or changed shape since the last treatment, thereby allowing a better treatment plan to avoid damage to
muscle tissue, the spine, the lungs and other sensitive organs. Its also useful when maximum tolerance
dose of traditional radiation has been reached , or if the tumor is in a hard-to-reach area.
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ROLE OF RADIOTHERAPY IN PALLIATIVE & EMERGENCY CARE

Radiotherapy is an indispensable modality in the palliation of cancer. All palliative care

programs should be acquainted with its indications and have a close working relationship with a radiation
oncology department. The main indications are: pain relief (particularly bone pain), control of hemorrhage,
fungation and ulceration, dyspnea, blockage of hollow viscera, and the shrinkage of any tumors causing
problems by virtue of space occupancy. In addition, it has an important role in the palliation of three
oncological emergencies: superior vena caval obstruction, spinal cord compression, and raised intracranial
pressure due to cerebral metastases. The doses and schedules applies include 500cGy/fraction,
800cGy/fraction, 20Gy in 5 fractions, 30 Gy in 10 fractions and 40Gy in 20 fractions (23). The oncological
emergencies warranting radiation therapy are given in Table-6.

ACUTE AND LATE NORMAL TISSUE REACTIONS

The acute (occurring within 90 days) and late normal tissue complications of radiotherapy at
different anatomic sites are compiled in Table-7. The time course for developing acute radiation reactions
depends on the cycling time of the cells affected. The tissues that divide rapidly (eg, mucous membranes)
respond acutely to radiation and are responsible for much of the acute morbidity of the treatment. With the
development of aggressive radiation and chemoradiation schedules in recent years, prolonged acute effects
have been noted which can last beyond the 90 day window. Much of the effort that goes into the treatment
planning regards minimizing the normal tissue effects of treatment (50). Chronic effects can manifest
anytime from weeks to years after the treatment; mainly due to chronic injury to the microvasculature, or
depletion of stem cells. Just as with the acute effects, the chronic effects are related to site, dose, volume,
and time. Other therapies, such as surgery and chemotherapy, can increase the probability and severity of
radiation-related morbidity (50).

CONCLUSION
The role of radiation oncology has gradually evolved from providing palliation to advanced cancer
patients to a definitive curative form of treatment, either alone or as a part of multimodal therapy. Newer
modalities in radiotherapy are still undergoing refinements and modifications, and appear promising in
attaining better tumour-control at a reasonable level of complications. Though the cost benefit issue may
take a longer time to be answered the treatment scenario envisaged appears scientifically sound. These
developments also mandate a fresh look at our physician training programs. Appropriate training in image
acquisition and interpretation would be highly useful in this scenario to prevent systematic errors in
treatment planning. The need of the hour in our country is to encourage the setting-up of newer modern
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facilities and upgrading the existing ones in the larger interest of patient care and also for physician
training. However prudent clinical judgment must be used in applying these new tools as indiscriminate
and over enthusiastic usage may not auger too well in this era of evidence-based medicine.

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