Beam Arrangement and
Radiotherapy Techniques
Radiation Therapy
• Radiation therapy: or is the What is
specialty that uses a high dose of ionizing
Radiotherapy medical
the
Radiothera
(high energy
radiation photons or particles) to treat cancer py
and some benign diseases.
• Radiotherapy is local cancer treatment that can
be used alone or with other treatment
modalities including surgery and chemotherapy.
• The goal of radiation therapy is to
maximum
deliver the amount of radiation needed to
kill the cancer, while sparing normal
surrounding tissue.
• To this goal, radiation therapy
heavily on physics
accomplish and biological sciences,
relies
including radiobiology and computer science.
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Standards
Type of Radiotherapy
• Radiation therapy can basically classified according to the
source of radiation to:
▪ External Beam Radiotherapy (EBRT): Where the source of
radiation will be outside the body (from the machine “Linear
Accelerator – LINACS).
▪ Internal Beam Radiotherapy (Brachytherapy): where the
source of radiation implanted as a seeds (solids) or (liquid)
inside the body (near to the tumor). Brachytherapy is mostly
used for treatment of prostate, cervical, endometrial, vaginal
and breast cancers.
▪ A systemic radiation therapy called radioactive iodine, or I-131,
is most often used to treat certain types of thyroid cancer.
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Standards
Types of
Radiotherapy
Radiotherapy
Do You
Know
External Beam Radiotherapy Internal Beam Radiotherapy Choosing radiotherapy model
to treat tumors is not
(Brachytherapy) random, and its choose
based on many factors
including:
1 tumor size
2 tumor location
3 tumor type
4 tumor depth and
dimensions
5 tumor stage
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Standards
Treatment Purposes of Radiotherapy
• Radiotherapy can be given for two main treatment reasons:
• Curative Treatment – in this model, radiotherapy try and destroy tumor and
cure the cancer.
• Controlled treatment - in this model, radiotherapy aim to reduce the volume
of the tumor by destroying the cancerous cells, This can often be given with
other treatments, such as surgery or chemotherapy.
• Palliative treatment – in this model radiotherapy to help relieve the
symptoms when it’s not possible to cure the cancer.
• The type of radiotherapy given will depend on the type of cancer, where
it is located and an individual’s situation (stage).
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Standards
Beam Arrangement in Radiotherapy
❑ 1. Single Field Treatment: Treatment by a single photon beam is seldom used
except in some cases in which the tumor is superficial.
• The following criteria of acceptability may be used for a single field treatment:
A) The dose distribution within the tumor volume is reasonably uniform (e.g.,
within ±5%)
B) The maximum dose to the tissues in the beam is not excessive (e.g., not more
than 110% of the prescribed dose).
C) Normal critical structures in the beam do not receive doses near or beyond
tolerance.
Beam Arrangement in Radiotherapy
• Whereas single fields of superficial x-rays are routinely used for treating skin
cancers that are confined to a depth of a few millimeters, single megavoltage
beams are used only in rare cases for which a combination of beams is either
technically difficult or results in unnecessary or excessive irradiation of the
normal tissues.
• Although the dose distribution is not ideal, the single-field technique in these
cases results in simplicity of setup without violating the previous criteria of
acceptability.
• Examples of a few areas that use single megavoltage beams include the
supraclavicular nodes, internal mammary nodes (anterior field), and spinal cord
metastases (posterior field).
Beam Arrangement in Radiotherapy
• For the treatment of most tumors, however, a combination of two or more
beams is required for an acceptable distribution of dose within the tumor and
the surrounding normal tissues.
❑ 2. Parallel Opposed Field: The simplest combination of two fields is a pair of fields
directed along the same axis from opposite sides of the treatment volume.
• The advantages of the parallel opposed fields are the: Simplicity and
reproducibility of setup, homogeneous dose to the tumor, and less chance of
geometric miss (compared with angled beams), given that the field size is large
enough to provide adequate lateral coverage of the tumor volume.
• A disadvantage is the excessive dose to normal tissues and critical organs above
and below the tumor.
Beam Arrangement in Radiotherapy
• 3. Multiple Field: One of the most important objectives of treatment planning is
to deliver maximum dose to the tumor and minimum dose to the surrounding
tissues. In addition, dose uniformity within the tumor volume and sparing of
critical organs are important considerations in judging a plan.
• Some of the strategies useful in achieving these goals are (a) using fields of
appropriate size, (b) increasing the number of fields or portals, (c) selecting
appropriate beam directions, (d) adjusting beam weights (dose contribution from
individual fields), (e) using appropriate beam energy, and (f) using beam
modifiers such as wedge filters and compensators.
Beam Arrangement in Radiotherapy
• As we discussed the case of two parallel opposed fields. Although the technique
results in uniform irradiation of the tumor, there is little sparing of the
surrounding normal tissue. In fact, the dose to the peripheral tissues can be
significantly higher than the midline dose.
• Reduction of dose to subcutaneous tissue and normal tissue surrounding the
tumor can be achieved by using a combination of three or multiple fields.
• Figure 11.13 illustrates various multiple-field arrangements in which the beam
enters the patient from various directions, always directed at the tumor. Thus, by
using multiple fields, the ratio of the tumor dose to the normal tissue dose is
increased.
Beam Arrangement in Radiotherapy
• Although multiple fields can provide good distribution, there are some clinical
and technical limitations to these methods. For example, certain beam angles are
prohibited because of the presence of critical organs in those directions. Also, the
setup accuracy of a treatment may be better with parallel opposed than with the
multiple angled beam arrangement.
• It is therefore important to realize that the acceptability of a treatment plan
depends not only on the dose distribution on paper, but also on the practical
feasibility, setup accuracy, and reproducibility of the treatment technique.
Radiotherapy Delivery Techniques
• Conventional (Traditional) 2D Radiotherapy
• Conventional, or 2D radiation therapy, uses x-ray films to guide and position
radiation beams and was widely used in the 1960s-70s. CT scans that provide
3-dimensional imaging are not used to plan this type of treatment.
Radiotherapy Delivery Techniques
• 3D Conformal Radiation Therapy (3DCRT)
• (3DCRT) uses three-dimensional scans to determine the exact
shape and size of the tumor.
• Radiation beams are shaped by tiny metal leaves arranged to fit
the tumor. This minimizes the side effects to healthy tissues.
Several cancer types have seen improved outcomes from this
including brain cancer, head and neck cancer, liver cancer,
lung cancer and prostate cancer.
Radiotherapy Delivery Techniques
• 3D conformal radiation therapy directs multiple energy beams toward the
tumor that “conform” or fit the tumor’s exact size and shape.
• First, assisted with computer software, the oncologist analyzes images of
the body (most commonly from a CT scan). Other imaging such as PET or
MRI scans acquired during the diagnosis process may be used to locate the
tumor.
• The images show the tumor’s size, shape and location. The computer uses
this information to create a 3D model of the tumor in relation to the other
healthy tissue. The radiation oncology team uses this model to design the
energy beams that target cancer cells.
Radiotherapy Delivery Techniques
• Intensity modulated radiation therapy (IMRT)
• Intensity-modulated radiation therapy (IMRT) is an advanced
type of radiation therapy used to treat cancer and
noncancerous tumors. IMRT uses advanced technology to
manipulate photon and proton beams of radiation to conform to
the shape of a tumor.
• IMRT uses multiple small photon or proton beams of varying
intensities to precisely irradiate a tumor. The radiation intensity
of each beam is controlled, and the beam shape changes using
multileaf collimator (MLC) throughout each treatment.
Radiotherapy Delivery Techniques
• The goal of IMRT is to conform the radiation dose to the target
and to avoid or reduce exposure of healthy tissue to limit the
side effects of treatment.
• As mentioned before IMRT is an advanced form of 3D conformal
radiation therapy. The energy beams not only fit to the shape of the
tumor, but each beam also contains several small beams with variable
intensities, or strength. IMRT can send higher doses of radiation to
concentrated areas of cancer cells while sparing healthy tissue.
• Step-and-shoot intensity modulation is one of the common technique
used in IMRT, where is radiation stop during gantry and leaf motion.
Radiotherapy Delivery Techniques
• Volumetric Modulated Arc Therapy (VMAT)
• VMAT uses multiple radiation beams of different intensities. As the
treatment machine rotates, radiation is delivered at every angle. This
focuses the highest dose of radiation on the tumor, while reducing
radiation to healthy organs. VMAT can be used to treat several types of
solid tumors, including prostate cancer, liver cancer and pancreatic
cancer.
• The main advantages of Volumetric Modulated Arc Therapy (VMAT) are
precision and speed. Volumetric Modulated Arc Therapy (VMAT) focuses
the radiation on the tumor while protecting healthy tissues.
Radiotherapy Delivery Techniques
• Each Volumetric Modulated Arc Therapy
(VMAT) treatment is completed in less than two
minutes. Faster treatments improve the
accuracy of radiation delivery, in addition to
improving patient convenience and quality of
• life.
Volumetric Modulated Arc Therapy uses
photons
(VMAT) generated medical linea
accelerator.
(X-rays) by a small with varyingr
intensities
Very are aimed at a tumor and then rotated
beams
360 degrees around the patient. This results in
attacking the target in a complete
three-dimensional manner.
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Traditional RT vs IMRT Planning
Traditional IMRT
• Simple • Complex
• No need of volume or OAR. • Target and OAR must be presented
• Inverse Calculation
• Forward Calculation.
• Require dose-volume constraint and
• Give what you wish to target volume. cost function.
• Exact solution • Approximate solution
• Uniform dose • High gradient dose
• Low MU • High MU
• Analog dose • Digital dose
• Dose define to volume but specified at • Isocenter dose is not define and
meaningless.
the isocenter.
Brachytherapy
Brachytherapy Radioactive
Seeds
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Standards
Brachytherapy
• Internal radiation therapies use a radioactive source in or near the
cancer
site.
• Brachytherapy: It delivers radiation therapy with small pieces of
radioactive material (usually about the size of a grain of rice) placed
inside the patient’s body via a special needle or catheter. It is as close to
the tumor as it is possible.
• This allows delivery of very high doses of radiation directly to the
patient’s
tumor while limiting radiation exposure to healthy tissue.
• This is done as an outpatient procedure. Brachytherapy is used for the
treatment of prostate, cervical, endometrial, vaginal, and breast cancers.
• Brachytherapy used Gamma ray for cancer treatment.
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Standards
Brachytherapy
• Brachytherapy used Gamma ray for cancer treatment.
• Common radioactive materials used in brachytherapy is
• Cesium-137: Half-Life = 30 Years
• Iridium-192: Half-Life = 74 Days
• Palladium-103: Half-Life = 7 Days
• Iodine-125: Half-Life = 60 Days
Advantages and Disadvantages of Brachytherapy
• Main Advantages of Brachytherapy:
• Less dose to surrounding tissue due to sharp fall-off of radiation dose
• Highly targeted radiotherapy.
• Minimized side effects.
• Main Disadvantages of Brachytherapy:
•Hazard of radiation exposure
•Potential patient hospitalization
•Surgical trauma in the case of interstitial techniques
Types of Brachytherapy
• Interstitial Brachytherapy: is the use of an applicator that is placed in and close to a
tumor, in which the radiation source is placed within the tumor. This technique is used
for prostate cancer, for instance. The implants are placed directly into the tumor.
• Temporary Brachytherapy: In temporary brachytherapy, implants are removed
after the treatment has ended. Implants, such as hollow needles, catheters
(hollow tubes), or balloons filled with fluid, are inserted into or near the
cancer for a period of time, then removed. Either high-dose or low-dose
brachytherapy may be used.
• Permanent Brachytherapy: This is also called low-dose rate brachytherapy.
Permanent brachytherapy uses implants called pellets or seeds. These
implants are very small, about the size of a grain of rice.
Types of Brachytherapy according to Dose
Rate
• According to ICRU Brachytherapy classified into 5 categories according to dose rate:
• 1. Ultra low dose rate: Dose range 0.03 – 0.3 Gy\h.
• 2. Low dose rate (LDR): Dose range 0.4 – 2 Gy\h.
• 3. Medium dose rate (MDR): Dose range 2- 12 Gy\h.
• 4. High dose rate (HDR): over 12 Gy\h.
• 5. Pulsed-dose rate (PDR): include short pulses of radiation, (1 pulse \ h), its use to
simulate the overall rate and effectiveness of LDR.
REMOTE AFTERLOADING UNITS
• Remote Afterloading Unit: Most brachytherapy is now practiced with
devices that allow loading of radioactive sources after the source
containers (applicators or catheters) are put in place in the patient
and have been checked out radiographically for proper positioning
using radiopaque markers or source dummies.