16/01/2018

Radiotherapy Physics
Dr Simon Thomas.

Innovation and excellence in health and care Addenbrooke’s Hospital I Rosie Hospital

Overview of lectures
• What is Radiotherapy?
• Example of problem to be solved – prostate cancer
• Trade-off between tumour control, and normal tissues
• External beam therapy with x-rays
– Simple treatment plans
– Intensity Modulated Radiotherapy (IMRT)
– Image Guided Radiotherapy (IGRT) with x-ray imaging

• Image guided radiotherapy with MRI imaging

• Brachytherapy – treatment with radioactive sources
• Particle Therapy
– Electrons
– Protons

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 16/01/2018

What is Radiotherapy?
• The use of radiation to treat disease
• The vast majority of radiotherapy is for the treatment of
cancer, so this is what I will talk about.

• Of those patients who are cured of cancer, surgery is

the most important treatment (about 50% of cures),
followed by radiotherapy (about 40% of cancer cures),
with chemotherapy a poor third.
• 50% of cancer patients would benefit from having
radiotherapy (either for cure of palliation) at some part of
their cancer treatment.
• Often used in combination with other treatments.

Clinical sites
• Radiotherapy is widely used • Throughout this lecture I
for the following tumour sites will illustrate things
• Breast cancer primarily with examples
• Prostate cancer from prostate cancer,
• Gynaecological cancer except for a few examples
• Head and Neck cancers where the technique is
• Brain /CNS cancers relevant only to some
• Lung cancers
other body site.
• Plus many other rarer sites

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Prostate

Very close to both bladder and rectum.

Cancer can spread into Seminal Vesicles

Probability of destroying the cancer increases with dose

0.9
Prostate TCP
0.8
Prostate TCP
0.7

0.6
TCP
TCP

0.5

0.4

0.3

0.2

0.1

0
0 20 40 60 80 100
Dose/Gy
TCP=Tumour Control Probability

Doses are given in daily “fractions” of a lower dose, typically

2Gy. So 74Gy would be given in 37# over 7.4 weeks

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Unfortunately we can’t always give the dose that would be

certain to destroy the cancer, since we also end up
irradiating nearby normal tissues – in this example the
rectum is getting a high dose when we treat the prostate.

the probability of causing unacceptable side effects also

increases with dose
1

0.9
Prostate TCP
0.8
Rectum NTCP
0.7

0.6
NTCP
TCP

0.5

0.4

0.3

0.2

0.1

0
0 20 40 60 80 100
Dose/Gy

NTCP=Normal Tissue Complication Probability

Doses are given in daily “fractions” of a lower dose, typically

2Gy. So 74Gy would be given in 37# over 7.4 weeks

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Probability of destroying the cancer increases with dose

But so does the probability of causing side effects
1

0.9
Prostate
ProstateTCP
TCP
0.8

0.7
Rectum NTCP
TCP or NTCP

0.6
TCP

0.5

0.4

0.3

0.2

0.1

0
0 20 40 60 80 100
Dose/Gy

TCP=Tumour Control Probability

NTCP=Normal Tissue Complication Probability

Doses are given in daily “fractions” of a lower dose, typically

2Gy. So 74Gy would be given in 37# over 7.4 weeks

Probability of destroying the cancer increases with dose

But so does the probability of causing side effects
1

0.9
Prostate TCP

0.8

0.7 Rectum NTCP

0.6
TCP or NTCP

Bladder NTCP
0.5

0.4 Femoral Head NTCP

0.3

0.2

0.1

0
0 20 40 60 80 100
Dose/Gy

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The aim of radiotherapy is to design a treatment solution that gives the

organs at risk lower doses than the target, and hence enables us to give a
curative dose without getting unacceptable side effects.
1
0.9
Prostate TCP
0.8
0.7 Rectum NTCP
TCP or NTCP

0.6
Bladder NTCP
0.5
0.4 Femoral Head
0.3 NTCP
0.2
0.1
0 1
0 20 40 60 80 100 0.9
Prostate TCP
Dose/Gy 0.8
0.7 Rectum NTCP

TCP or NTCP
0.6 Bladder NTCP
0.5
Femoral Head
The ratio TCP/NTCP is 0.4
0.3
NTCP

sometimes called the 0.2

“therapeutic ratio”. Most 0.1
0
developments in radiotherapy 0 20 40 60 80 100

are aimed at increasing the Dose to Prostate/Gy

therapeutic ratio.

Safety is very important

• We are giving doses of typically 60Gy to 74Gy.
• Too little dose will fail to destroy the tumour.
• Too much dose, or dose to the wrong part of the patient,
will risk serious harm or death.
• (Whole body lethal dose is about 4Gy. Cancer induction
about 5% per Sv)

• Diagnostic radiology is dealing in doses of mGy.

• For them a reportable incident is giving more than 250%
of the intended dose.
• For us a reportable incident is giving an overdose of 10%

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Safety is very important.

• I’ve only got time in this lecture to talk
about applications of radiotherapy.
• However a lot of the work of a
radiotherapy physicist is concerned with
– Radiation Dosimetry, using detectors
traceable to national standards (at
NPL) and development of codes of
practice to ensure consistency
between radiotherapy departments.
– Regular Quality Assurance
measurements on equipment to
ensure that it delivers the intended
doses to the right place.
– Patient-specific QA, delivering the
radiation plan to a phantom, to
ensure that we do what we think we
are doing.

External beam radiotherapy

120

• The vast majority of

250kV
p e rc e n t a g e d e p t h d o s e

100
4M V
16M V
80

radiotherapy 60

treatments are done 40

20

with linear 0
0 5 10 15 20 25 30

accelerators that d e p th in c m

produce beams of x- Accelerating

Bending Magnet
waveguide
rays by accelerating Target
Ion chamber
electrons to between Collimators
4MeV and 16 MeV
and firing them into a
metal target.

The machines at Addenbrooke's use 6MV or 10MV

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Simple radiotherapy

one beam two opposed beams four beams

Until the late 1990s, most radiotherapy was given with square or rectangular
fields, and at best looked like the distribution on the right. This enabled a
uniform dose to the target, and about 50% of this to a large area outside. We
tended only to be able to plan in 2D.

Slightly less simple (“conformal”) radiotherapy.

• By the late 1990s,

multi-leaf collimators
(MLCs) and 3D
planning systems
were available.

Able to shape fields to spare far more of the rectum and

bladder. This enabled us to go up from 64Gy to 74Gy

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Intensity Modulated Radiotherapy (IMRT)

• As well as shaping the field, an MLC
can be used to vary the intensity of
radiation in the field by being in the
field for only part of the treatment.
• This gives the planning system many
more degrees of freedom.

Types of IMRT
• Multiple static fields (“step and
shoot”)
• Dynamic MLC (“Sliding
window”) – similar, but radiation
stays on whilst MLCs move.
Faster, but more to go wrong.
• Rotational IMRT – gantry
rotates continuously whilst
beam on and MLC varies.
Known as “Rapid Arc” or
“VMAT” (volumetric modulated
arc therapy)
• Tomotherapy – Rotational
IMRT on non-standard linac,
with CT-like gantry and helical
delivery.

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Helical Tomotherapy
• Purpose-built, integrated
device for IMRT & IGRT
(of which more later)
• Helical delivery
– Fast
– Potential for high level of modulation
• Designed for IMRT
– Low leakage/scatter
– No flattening filter => simple beam
modelling

Tomotherapy –IMRT
delivery
•Based on same idea as spiral CT
•50-300 rotations, treated as 51
projections per rotation.
•At each projection, choose how long
each of the 64 binary MLCs is open for

Delivery Sinogram for Helical Tomotherapy

Giving high dose to prostate,

medium dose to nodes, and
sparing the rectum.
Spiral CT

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The CTV is a tissue volume that

contains a demonstrable Gross Tumour

Geometric uncertainty Volume (GTV) and/or subclinical

malignant disease, which has to be
eliminated. This volume thus has to be
treated adequately in order to achieve
the aim of radical therapy. (ICRU62)

The PTV is a geometrical concept used

for treatment planning, and it is
defined to select appropriate beam
sizes and beam arrangements, to
ensure that the prescribed dose is
actually delivered to the CTV

Gross Tumor Volume

Clinical Target Vol.

Planning Target Vol.

Types of errors

• Gross errors
– include incorrect anatomical site or patient orientation, incorrect
field size, shape or orientation or incorrect isocentre position of 3
standard deviations or more of the random error.
• Systematic errors
– occur in the same direction and are of a similar magnitude for
each fraction throughout the treatment course. They may arise
due to target delineation error, a change in the target position,
shape and size, phantom transfer errors or set up errors.
• Random errors
– vary in direction and magnitude for each delivered treatment
fraction. They arise from varying, unpredictable changes in the
patients position, internal anatomy or equipment between each
delivered fraction. (Radiotherapy usually delivered over a large
number of daily fractions)

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Margin Recipe
•For a group of patients, determine the
standard deviations of random errors σ
and of systematic errors Σ. Also need to
know how sharp the penumbra is
(characterized by σp ).

((
mar gin = 2.5S + 1.64 s 2 + s p2 )
0.5
-s p )
mar gin » 2.5S + 0.7s
•Systematic errors are worse than random
errors

Practical process of radiotherapy

treatment planning.
• CT scan (and possibly MRI and/or PET)
• Outline on the images to delineate the target
volumes and organs at risk.
• Add CTV margin for microscopic spread
• Add appropriate margins for geometrical
uncertainty.
• Decide on appropriate doses
• Choose appropriate arrangement of beams
– either: Forward Planning (choose arrangement of
beams until you get what you want).
– or: Inverse Planning (specify what you want, and
get the computer choose the beams to achieve it).

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Forward planning – OK for simple techniques

Inverse planning
• IMRT is too complex to just choose
arrangement of beams manually until the plan
“looks OK”
• Instead have software that optimises the plan
to produce the “best” treatment plan
• For this to work, you need to have some
measure of what makes a good plan; you
need some mathematical objective function
that you can minimise.
• These can be based on Dose (minimum,
maximum etc. to volume), or on Dose Volume
Histograms

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Dose Volume Histograms ComparisonIMRT

of DVH for proposed Standard and
breast RT treatment

300.0
250.0 standard
Either: 200.0 IMRT

150.0

cc
• What volume 100.0

receives a particular
50.0
0.0

dose (differential 80 85 90 95 100 105

percentage dose
110 115

DVH)
• What volume
receives at least a
particular dose
(cumulative DVH)

The Ideal DVH

120

100

80
% volume

60
OAR
40
PTV
20

0
0 20 40 60 80 100 120
% dose

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Dose-based penalty

400
350
300
Penalty increases with square of
Penalty

250
200 difference.
150
100
50
0
40 45 50 55 60 65 70 75 80

Dose to point in target

400
350
300
penalty

250 OAR has no penalty for under

200 dosing.
150
100
50
0
30 40 50 60 70

Dose to point in OAR

DVH objectives and constraints

• Target
D – At least X% of the target
should receive at least dose
Y
Target
• OAR (and some targets)
– No more than X% of the
volume should receive more
than dose Y
D • Hard Constraint
– If it does not achieve the
constraint, then do not allow
the solution.
• Objective or soft constraint
– Apply a penalty for failure,
D increasing the more you fail

- penalty = w D2
– The larger w the harder the
constraint

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Optimise to reduce objective function

• Gradient based – (need to be able to take
derivative of objective function relative to
weight of all the sub-beams). Relatively fast,
but can potentially get trapped in local minima
• Stochastic (e.g. simulated annealing) – much
slower, but less risk of local minima.
• In practice you need to keep modifying your
objective function to produce a clinically
acceptable plan – mathematically optimal is
not always clinically optimal.

Image-guided Radiotherapy
• If you can image the patient every day in the
treatment position, you can reduce the
systematic and random errors. This should
enable a smaller margin to be used, and hence
reduce normal tissue damage.
• Image patient from exit beam.
• Can reconstruct CT-image
– Cone-beam using detector on conventional linac
– Dedicated “tomotherapy unit” based on CT gantry

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IGRT

MV helical CT on Tomotherapy unit kV cone-beam CT on Elekta

Synergy.

IGRT

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IGRT

Effect of IGRT on margins

• Daily imaging should reduce both the
systematic and random positional uncertainties.
• However there are still a number of residual
uncertainties.

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What remains after daily IGRT?

Systematic:
• (Doctor Delineation Error) – will assume this is completely in the
CTV.
• Intrafraction Motion
• Systematic Matching Error (Intra- and Inter Observer)
• Treatment Beam / Imaging System misalignment
• Systematic Rotational Shifts
• Couch Drive Inaccuracy
Random:
• Intrafraction Motion
• Random Matching Error (Intra / Inter)
• Random Rotational Shifts
• Couch Drive Inaccuracy

Rotations
Residual rotations can be an important source of
residual error, dependent on shape

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Intrafraction motion

60

50

40
frequency

30

20

10

0
-7.5
-6.5
-5.5
-4.5
-3.5
-2.5
-1.5
-0.5
0.5
1.5
2.5
3.5
4.5
5.5
6.5
7.5
shift (mm)
LR SI AP

Combined effect of residual errors

Yellow boxes are measured data. Green boxes are estimates.

Even with IGRT, margins of up to 5mm may be needed.

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Breathing motion (example from breast cancer)

Free breathing Deep inspiration breath hold

In normal breathing, the left breast is very close to the heart.

By getting the patient to control her breathing, so that imaging
and treatment is given only at deep inspiration, it is possible
to spare the heart.

Relationship between delivered dose and toxicity

• The DVH constraints on the rectum are based

on studies that link the doses in the treatment
plan with clinical data on side effects.
• But for organs like the rectum the shape
changes from day to day. So the doses
actually received by the rectum may differ
considerably from the dose in the treatment
plan.
• The VoxTox project is collecting data on a few
thousand patients, using the daily IGRT data to
determine the dose to organs at risk, and
collecting detailed toxicity data.

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Accumulated DVH can be different from Planned DVH

•Some patients have a

fairly consistent rectal
shape over the 7
weeks of treatment
•Some patients have
more of the rectum in
the high dose region
than at planning
1!
!
1!
!
•Some have the
0.9!
!
0.9!
!
0.8!
opposite.
0.8!
! !
Fraction*of*rectum*
Fraction*of*rectum*

0.7! 0.7!
! !
0.6! 0.6!
! !
0.5! 0.5!
! !
0.4! 0.4!
! !
0.3! 0.3!
! !
0.2! Accumulated* 0.2! Accumulated*
! !
0.1! Planned* 0.1! Planned*
! !
0! 0!
!!!!!!!!!!!!!!0!!!!!!!!!!!10!!!!!!!!!!20!!!!!!!!!!30!!!!!!!!!!40!!!!!!!!!!50!!!!!!!!!60!!!!!!!!!!70!!!!!!!!!!80!!!!!!!!!!
!!!!!!!!!!!!!!0!!!!!!!!!!!10!!!!!!!!!!20!!!!!!!!!!30!!!!!!!!!!40!!!!!!!!!!50!!!!!!!!!60!!!!!!!!!!70!!!!!!!!!!80!!!!!!!!!!
Rectum*dose*in*Gy* Rectum*dose*in*Gy*
Figure* showing* DVH* results* for* patient* 1.* Daily* Figure* showing* DVH* results* for* patient* 1.* Daily*
delivered*DVHs*are*shown,*along*with*the** delivered*DVHs*are*shown,*along*with*the**
accumulated*DVH.*The*planned*DVH*is*also*shown.* accumulated*DVH.*The*planned*DVH*is*also*shown.*
! !

Problems with the use of DVH

•Combining DVHs from different fractions by adding them up is not correct
•The part of the rectum receiving the high dose in one fraction may not be
the same as in another fraction
•However the MV CT is not good enough to enable us to identify which
voxel in one CT set maps to which voxel in another CT set
•The Dose Volume Histogram suffers from the problem that much of the
volume included is rectal contents (gas and faeces). The dose to these is
not clinically relevant, only to the rectal wall.
•However the MV CT images are not good enough to distigusih the inside
and outside of the rectal wall separately.

•One potential solution to these problems is the use of the normalised

dose surface map (DSM)
1! 1!
!
!
0.9!
0.9!
!
!
0.8!
0.8!
!
!
Fraction*of*rectum*

0.7!
Fraction*of*rectum*

0.7!
!
! 0.6!
0.6!
!
! 0.5!
0.5! !
! 0.4!
0.4! !
! 0.3!
0.3! !
! 0.2! Accumulated*
0.2! Accumulated* !
! 0.1! Planned*
0.1! Planned* !
! 0!
0! !!!!!!!!!!!!!!0!!!!!!!!!!!10!!!!!!!!!!20!!!!!!!!!!30!!!!!!!!!!40!!!!!!!!!!50!!!!!!!!!60!!!!!!!!!!70!!!!!!!!!!80!!!!!!!!!!
!!!!!!!!!!!!!!0!!!!!!!!!!!10!!!!!!!!!!20!!!!!!!!!!30!!!!!!!!!!40!!!!!!!!!!50!!!!!!!!!60!!!!!!!!!!70!!!!!!!!!!80!!!!!!!!!!
Rectum*dose*in*Gy*
Rectum*dose*in*Gy*
Figure* showing* DVH* results* for* patient* 1.* Daily*
Figure* showing* DVH* results* for* patient* 1.* Daily* delivered*DVHs*are*shown,*along*with*the**
delivered*DVHs*are*shown,*along*with*the** accumulated*DVH.*The*planned*DVH*is*also*shown.*
accumulated*DVH.*The*planned*DVH*is*also*shown.* !
!

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Dose Surface Maps

Ant Sup

Right Left

Post

Inf
P R A L P

Plot the dose on the surface that would be achieved by cutting along
the posterior side of the rectum, and stretching to normalise

Dose Surface Maps over 37 fractions

+ =

Summed MV DSM kV DSM where MV not available final summed DSM

•We are working to correlate the measured toxicities with whatever

parameters in the summed DSM give the best predictive measure. The
ultimate aim is to identify part way through a treatment whether it is safe to
give extra dose.

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Fractionation in radiotherapy
• If radiation given as a course of small “fractions” of
radiation, recovery occurs between fractions
• If normal tissue can recover more quickly than tumour,
this improves the therapeutic ratio
• Most fractionation schemes are empirical, based on
clinical experience

Linear Quadratic theory

ln(target cell survival) = -(ad + bd 2 )

• If dose Dx is given in fractions of dx , this is gives
equivalent cell killing to a dose of D2 in 2 Gy
fractions, where
(a b + d x )
D2 = Dx
(a b + 2Gy )
• can also define a Biologically Equivalent Dose equal
to dose in notional tiny fractions
æ d ö
BED = Dçç1 + ÷÷
è a b ø
• a/b is typically 10-20Gy for tumours, typically 2-3 Gy
for later-responding side effects

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Linear Quadratic theory

æ d ö
BED = Dçç1 + ÷÷
a/b is typically 10-20Gy for tumours, è a b ø
typically 2-3 Gy for later-responding side
effects

e.g. D=60Gy d=2Gy per #

BED = 72 Gy if a/b =10Gy
BED = 99.96 Gy if a/b =3Gy

e.g. D=36Gy d=6Gy per #

BED = 72 Gy if a/b =10Gy
BED = 108 Gy if a/b =3Gy

Giving a higher dose in smaller fractions

can help to reduce the side effects

a/b = approx 2-3Gy for prostate (and for normal

tissues) æ d ö
BED = Dçç1 + ÷
è a b ÷ø
• Using a value of 2.5

• 74 Gy in 37# (2Gy per #)

• BED= 133Gy

• 60Gy in 20# (3Gy per #)

• BED= 132Gy

• A recent large-scale clinical trial on prostate cancer

showed that 74Gy/37# and 60Gy/20# has
indistinguishable clinical outcomes.

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MRI linacs
• Current area of interest is putting a linear accelerator
and an MRI scanner together, to enable MRI-guided
radiotherapy.

Reasons for doing IGRT with MRI - guidance

• No worries about the imaging dose
• Can therefore image during irradiation
• Many structures more visible on MRI than on CBCT
– Soft tissue contrast generally better with MRI than CT
• Potentially able to image moving targets in real time
• Functional imaging may allow for adaptive focal boosting

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Reasons for not having MRI-guided IMRT

• Linac technology is badly affected by magnetic fields
– Need to design special magnets to keep field low in vicinity of linac
components, whilst still giving uniform field for imaging in the area you are
irradiating
• Charged particle interactions are affected by magnetic fields
– All the dose deposition models used in treatment planning have to be
changed. Monte-Carlo models are the only ones that can currently model
this.
• Measurement of radiation dose is affected by magnetic fields
– All the assumptions made in the standard dosimetry chain using ionisation
chambers calibrated by NPL cease to be valid in the presence of high
magnetic fields.
• MRI images cannot be directly used for radiotherapy dose calculation
– Radiotherapy dose calculation requires information on relative electron
density, which is easy to obtain from CT, but not from MRI.
– Geometric distrotion more of an issue in MRI than in CT
• Vastly more expensive than conventional x-ray guided linacs

4 groups working on developing MRI linac

• Elekta/Philips consortium. Collaboration between major linac
manufacturer and major MRI manufacturer. Usinf 1.5T
magnet. Research systems installed in several hospitals
(Utrecht, Amsterdam, Manchester, Royal Marsden, MD
Andreson Texas, Wisconsin, Sunnybrooke). Not yet licensed
for non-research clinical use.
• ViewRay. New company – initially clinical with a Co-60
gamma unit, now a linac, combined with a 0.35T magnet.
Has FDA clearence for clinical use. Intsalled in a few US
centres.
• Australian Group. Prototype only. 1.5T magnet in an inline
configuration – radiation axis along same axis as magnetic
field (first two are perpendicular)
• “Aurora” – Being developed by Canadian company, 0.5 T
inline.

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Elekta/Philips MRI-linac at 1.5T

• Active magnetic shielding to avoid any

magnetic field at the electron gun, and to
minimise field along accelerator tube.
• Split gradient-coil design to allow beam to
go through.
• Linac mounted on rotatable gantry outside
the MRI magnet.
• Many compromises to design of linac and
MRI to enable each to work with the other.

View-Ray 0.35T system

• Split superconducting magnet – less

obstruction to beam path
• Lower field – avoids some of the
dosimetric problems with high field
systems, at a price of worse image quality

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• Dose in x-ray therapy is nearly all

Electron return effect from photons liberated by
Compton scattering or
Photoelectric effect
• In a magnetic field the path of
these electrons is curved by the
Lorentz force
• This can lead to unexpectedly
high doses at exits of beam.
• This effect is less at lower field
strength
• Inline magnets avoid this, but for
multiple field directions you need
to rotate the entire magnet
system (or rotate the patient).

Effect of magnetic field on radiation detectors

• Dose response of ionisation chambers is changed by
presence of magnetic field.
• Most of the assumptions made in the theory of ionisation
chambers are not valid in the presence of magnetic
fields.
• The response of a chamber varies with orientation and
with field strength, by over 10%
This is one of the many
challenges that make MRI
linacs an interesting
research area, but not yet
necessarily the best option
for clinical treatment.

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Brachytherapy

What is Brachytherapy?

The placement of radiation sources in or near the patient.

Three categories :-
1) Interstitial - sources surgically implanted in and around
tumour. e.g. iridium in breasts. iodine seeds in prostate
2) Intra-cavity - sources placed inside natural body cavity.
e.g. Ca cervix treated with uterine / vaginal sources.
3) Mould - the use of surface applicators to hold sources
next to patients skin. e.g. skin tumours

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• Radiotherapy delivered by radioactive

Interstitial
seeds implanted into the patient
Brachytherapy

• For early stage prostate cancer which has not spread into
the seminal vesicles, brachytherapy (with I-125 seeds,
gamma energy 30keV half life 59 days) can give a high dose
to the prostate whilst sparing the rectum and bladder.

Intracavity brachytherapy

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Ideal Source for Brachytherapy

1) γ-ray emitter. High enough energy to minimise scatter and avoid
increased energy deposition in bone by PE. Low enough energy
to minimise protection requirements. This gives the range 200 -
400 keV.
2) Half life. Long enough to minimise decay corrections during
treatment. Too avoid frequently buying new sources, a very long
half-life is desirable. For permanent implants, shorter half-lives
are needed.
3) Charged particle emissions absent or easily screened.
4) No gaseous disintegration products.
5) High specific activity
6) Insoluble and non-toxic chemical form.
7) Does not powder/ disperse if casing damaged.
8) Can be made into different sizes and shapes (tubes, needles,
spheres, flexible wires). If in wire form must be able to be cut
without causing contamination.
9) Not damaged during sterilisation.
10) Cheap/ easily available.

Sources - what is available:

Isotopes :-
• naturally occurring.
• reactor produced :- fission products.
• neutron activation (n,γ) products.

• Radium and Radon no longer used.

• Most commonly used isotopes are Ir-192 and
I-125
• Cs-137, Co-60 and Pd-103 used in some
applications

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Commonly used gamma-

emitting Nuclides
Nuclide Co-60 Cs-137 Ir-192 Pd-103 I-125
Transmission 19 12 1.9 (<0.1%) (<0.1%)
through 2cm HVL=1.3cm
Pb (%) tissue

Gamma- 1.17 and 0.66 0.3-0.6 0.02 0.03

ray energy 1.33 (mean=
(MeV) 0.36)

Half life 5.3 years 30 years 74 days 17 days 59 days

Particle Therapy
• Proton Therapy

• Electron Therapy

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Particle Therapy
• X-ray interactions (PE, Compton, PP) lead to exponential
attenuation over distance.
• Heavy charged particles (e.g. protons), each interaction
leads to loss of energy from the charged particle, giving
it a finite range in tissue.
• The rate of energy loss from heavy charged particles can
be approximated using the Bethe-Bloch formula
2
dT æ 1 ö æ 4p z 2 e 4 NZ ö é é 2me v 2 ù Cù
- =ç ÷ ç ÷ êln ê ú-b - ú
2

( )
dx çè 4pe 0 ÷ø çè me v 2 ÷ø ë ë I 1 - b 2 û Zû
N = no. of atoms per unit volume
Z = no. of electrons per atom
b = v/c
I = average excitation energy
C = shell correction

• term in square brackets varies slowly with v

dT constant
- »
dx b2

• Very high
stopping power at
Bragg Curve end of track

dT - k
1200 40

= 1000
35

dx T 800
30

T = T02 - 2kx
25

600 20

dT -k
15

=
400

10

dx T02 - 2kx
200

0 0

First discovered experimentally by William H Bragg

(published December 1904)

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Bragg curve in practice

Depth dose curves for protons and carbons-ions: The broad

Bragg peak of 160 MeV protons (solid line) exhibits no exit
dose. The narrow Bragg peak of 260 MeV carbons ions
(dashed line) - shows the distal dose tail caused by light
beam fragments

Protons v photons – depth dose curve

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Extending the peak over a greater range of

depths

Passive scattering v pencil beam scanning

Passive scattering
is used in the
majority of clinical
centres in the
world.

Most new centres

being build today
(including the
Manchester and
UCL ones) will use
pencil beam
scanning

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Proton delivery

A beam from one

direction can
conform to the
target, but will
deliver dose
upstream of the
SOBP
Multiple beams can
give very
conformal
treatments.

Pros and Cons of Proton Therapy

• Much more expensive (capital costs
• Sharp fall-off at end of •
£120million for proton unit £2million for linac. )
The Radiobiological effectiveness is not well
track gives excellent known, and varies with energy. Roughly, 1Gy
of protons has the same biological
sparing of organs at risk consequences as 1.1 Gy of x-rays
beyond tumour. • Variations in density change range, and can
cause geographical miss (OK for brains and
• Some tumours (especially spines, but large issue if using for prostates).
• The PTV concept needs modifying when used
spinal tumours in with protons.
children) have much
lower side effects than
with photon therapy

Cyclotron (Italy) Sychtotron (France)

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Range uncertainty
• The fact that protons have a sharp fall-off
at the end of their range is great for
avoiding normal tissues.
• But a small uncertainty in range (caused
by variations in tissue thickness or density)
can lead you to miss the tumour.
This example (courtesy of
Tony Lomax, PSI) shows
the difference of dose
caused by the patient
wearing tighter clothers for
the CT scan than for
treatment.

Electrons.
100

90 6MV
9MV
80 15MV
21MV

• Much lighter than 70

60

protons
percent

50

40

– (e 0.511 MeV p 938 Mev) 30

20

• Each interaction causes 10

a change in direction
0 2 4 6 8 10 12 14 16
de pth in cm

• Electrons tracks are very

•Fewer clinical applications now than
tortuous 10-20 years ago, as most cases
• No Bragg peak is where electrons were used are now
better treated with IMRT.
observed for electrons. •Some superficial tumours where
• Easy to produce with electrons are still the best solution
•Some places use them in inter-
medical linac (just operative radiotherapy. Some places
replace the target with a use them for total skin electron
scattering foil) therapy.

• RBE = 1.00

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Summary
• Radiotherapy involves the use of ionising radiation to destroy cancer
cells without causing unacceptable damage to normal tissue.
• The aim of all advances in radiotherapy are to maximise the
therapeutic ratio between control and complication.
• Most Radiotherapy worldwide is given with linear accelerators
producing x-rays in the 4MV-25MV range.
• Image Guided Radiotherapy (IGRT) generally uses x-ray CT
imaging, but some groups are developing MRI-guided linacs
• Other forms of radiotherapy include
– Brachytherapy (with radioactive γ-ray sources)
– Electron therapy (4MeV-25MeV range)
– Proton therapy (Typical KE of 150-300 MeV)
• Safety is crucial

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