Term 1 Aims:

 Basic Introduction
 Equipment in RT department (how it works…very
Session 1
general)
 QC of units
 Tumour localisation
Session 2
 Treatment planning systems
 RV systems and Treatment equipment
Session3
 And maybe …Cyclotron

Test for term one  first week of term 2

…Mostly RadPrac, but we will extract the physics (Physical Science) parts
Accurate Tumour LOCALIZATION and treatment
 Accurate Tumour LOCALIZATION and treatment

• Localization refers to geometric definition of the position and extent of

the tumour or anatomic structures by reference of surface marks that
can be used for treatment setup purposes.
How can we localize the tumour and critical normal
structures?

• Clinical
• Medical Imaging:
• Electric Impulses
• Nuclear Medicine Imaging
• Routine Radiographic Studies
• Computed Tomography (CT) scanner
• Magnetic Resonance Imaging (MRI)
• Diagnostic Ultrasound

…others also include:

• PET
• US
• Or in combination (Image Fusion)
ICRU 62 ( International commission
on radiation units and
measurements)
GTV
 Clinical LOCALIZATION

Medical history
Symptoms, current illness, condition, lifestyle, …

Physical
• Inspection (includes  colouration, warts, moles,
ulcerations, scars asymmetry, swelling,… )
• Palpation
• Percussion ( the act of striking or tapping the patient gently
 to determine pain, to cause vibrations (in a normal lung
percussion produces a resonant sound)
• Auscultation (listening to sounds within the body  in the
lungs sounds vary depending on the presence or absence of
air
• Vital signs (page 95 Charles Washington and Dennis Leaver)
• Pain (page 94 Charles Washington and Dennis Leaver)
 Medical Imaging:
Electric Impulses

• Electrocardiogram
• ECG records the electrical
activity generated by heart
muscle  electrical waves

• Electroencephalogram
• Records brain-wave activity

• Electromyogram
• Measures the electrical
conductivity of the muscle
How does the ECG work?
Electrical impulse (wave of depolarisation) picked up by
placing electrodes on patient

The voltage change is sensed by measuring the

current change across 2 electrodes - a positive
electrode and a negative electrode

If the electrical impulse travels towards the positive

electrode this results in a positive deflection

If the impulse travels away from the positive electrode

this results in a negative deflection
• Once an electrical cell generates an electrical impulse,
this electrical impulse causes the ions to cross the cell
membrane and causes the action potential, also called
depolarization
• Depolarization with corresponding contraction of
myocardial muscle moves as a wave through the heart
• Repolarization is the return of the ions to their previous
resting state, which corresponds with relaxation of the
myocardial muscle
• Depolarization and repolarization are electrical activities
which cause muscular activity
• The action potential curve shows the electrical changes
in the myocardial cell during the depolarization –
repolarization cycle
• This electrical activity is what is detected on ECG, not
the muscular activity
 Electroencephalogram

Electrical Signals

The electroencephalogram (EEG) measures the activity of large

numbers (populations) of neurons.

First recorded by Hans Berger in 1929.

EEG recordings are non-invasive, painless, do not interfere

much with a human subject’s ability to move or perceive
stimuli, are relatively low-cost.

Electrodes measure voltage-differences at the scalp in the

microvolt (μV) range.

Voltage-traces are recorded with millisecond resolution

 Electromyogram

EMG (electromyography) records the movement of our

muscles. It is based on the simple fact that whenever a muscle
contracts, a burst of electric activity is generated which
propagates through adjacent tissue and bone and can be
recorded from neighbouring skin areas.

The electrical activity of a muscle can be recorded by

measuring the voltage between two electrodes placed on the
skin above the muscle
 Medical Imaging:
Nuclear Medicine Imaging

Also known as nuclide imaging

• Introduce radioactive substance into
body
• Allow for distribution and uptake/metabolism of
compound
 Functional Imaging!
• Detect regional variations of radioactivity as
indication of presence or absence of specific
physiologic function
• Detection by “gamma camera” or detector array
• (Image reconstruction)
Gamma rays emitted from within a body (emission imaging)
Radioactivity
 Three major imaging modalities

• Planar Scintigraphy

• SPECT (single photon emission computed tomography)

• PET (Positron emission tomography)

 Nuclear Medicine Imaging

• Three major imaging modalities:

– Planar scintigraphy
– SPECT
– PET
• Principle of Anger camera: collimator, scintillation crystal, photomultiplier
• Imaging principles of planar scintigraphy and SPECT
– Both based on gamma decay
– Very similar to X-ray projection and CT, except for the attenuation factor
– Practical systems mostly ignore the attenuation factor
• Imaging principle of PET:
– Coincidence detection: detect two photons reaching two opposite detectors
simultaneously (within a short time window)
– Detected signal is the product of two terms, depending on the
radioactivity and attenuation separately
10 min break?
 Imaging in Radiotherapy
Image data sets used in treatment may be categorised into:
• Acquired
• Tomographic data from:
• CT
• MRI
• SPECT and
• US studies
• Processed images
• These are images derived from the acquired anatomical image data and are
synthesised or reduced from these initial sets to address specific treatment
planning objectives
• BEV
• DRR
• Image correlation
• Volume rendering
• Axonometric images
• Treatment images
• EPID (port films)
• Setup images (patient)
• Machine geometry
 Why is imaging important in Radiation therapy?

•Imaging is of great importance in cancer management

–Detection of tumour
–Evaluation of therapeutic-, and post-therapeutic
changes
–Complications of treatments
–Follow up for finding the early detection of recurrence

•Tumour staging is one of the most important prognostic

factors, it determines therapy (operability, radio-,
chemotherapy planning)

•Precise evaluation is only possible with strict technical

criteria, standard protocols and correct image interpretation
 Role of imaging

–To detect tumour (to find the primary and metastasis)

–To stage prior to treatment, T/N/M

•To give comparable information of tumour volume and structure
•To find nodal metastases
•To find distant metastases
–To evaluate therapy response

–To fix a baseline status following initial therapy,

–To follow the patient - to find the early recurrent

–To re-stage the patient.

–To give information about the “nature” of the disease (biopsy)

 Computed Tomography in Radiotherapy

• CT measures the relative linear

attenuation coefficient of each picture
element (pixel) in a transverse imaging
plane
• A fan beam of x-rays passes through the
patient and quantified by a ring of
detectors
• The pixel values are measured in
Hounsfield units (HU)
• These values are needed for therapeutic
dose calculations
 Magnetic Resonance Imaging in Radiotherapy
….how it works
• The human body is mostly water.
• Water molecules (H2O) contain hydrogen nuclei (protons),
which become aligned in a magnetic field.
• A MRI scanner applies a very strong magnetic field (about
0.2 to 3 Tesla, or roughly a thousand times the strength of a
typical fridge magnet), which aligns the proton "spins."
• The scanner also produces a radio frequency current that
creates a varying magnetic field.
• The protons absorb the energy from the magnetic field and
flip their spins.
• When the field is turned off, the protons gradually return to
their normal spin, a process called precession.
• The return process produces a radio signal that can be
measured by receivers in the scanner and made into an
image

Tesla (T) is the unit of measurement quantifying the strength of

a magnetic field
• PET is a non-invasive, diagnostic imaging technique for measuring the metabolic activity of cells in the
human body

• A PET scan uses a small amount of a radioactive drug, or tracer, to show differences between healthy
tissue and diseased tissue. The most commonly used tracer is called FDG (fluorodeoxyglucose), so the
test is sometimes called an FDG-PET scan. Before the PET scan, a small amount of FDG is injected into the
patient.

• The FDG is produced in a machine called a cyclotron and attached, or tagged, to a natural body
compound, most commonly glucose, but sometimes water or ammonia. Once this substance is
administered to the patient, the radioactivity localizes in the appropriate areas of the body and is
detected by the PET scanner.

• Different colours or degrees of brightness on a PET image represent different levels of tissue or organ
function. For example, because healthy tissue uses glucose for energy, it accumulates some of the tagged
glucose, which will show up on the PET images. However, cancerous tissue, which uses more glucose than
normal tissue, will accumulate more of the substance and appear brighter than normal tissue on the PET
images.
 What are the benefits vs. risks?

• Because PET allows study of body function, it can help physicians detect alterations in
biochemical processes that suggest disease before changes in anatomy are apparent with
other imaging tests, such as CT or MRI.

• Because the radioactivity is very short-lived, your radiation exposure is low. The substance
amount is so small that it does not affect the normal processes of the body.

• PET imaging has been shown to improve detection of a variety of cancers, and earlier tests
have suggested this technique may be useful in identifying small tumours in patients with
paraneoplastic neurological disorders.

• The radioactive substance may expose radiation to the foetus in patients who are
pregnant or the infants of women who are breast-feeding. The risk to the foetus or infant
should be considered in relation to the potential information gain from the result of the
PET examination.
 Limitations
• PET can give false results if a patient's chemical balances are not normal. Specifically, test
results of diabetic patients or patients who have eaten within a few hours prior to the
examination can be adversely affected because of blood sugar or blood insulin levels.

• Also, because the radioactive substance decays quickly and is effective for a short period of
time, it must be produced in a laboratory near the PET scanner. It is important to be on
time for the appointment and to receive the radioactive substance at the scheduled time.

• Finally, the value of a PET scan is enhanced when it is part of a larger diagnostic work-up.
This often entails comparison of the PET scan with other imaging studies, such as CT or MRI.
 Let’s recap…

• Computed tomography (CT) provides the primary dataset for most aspects of conformal
therapy treatment planning.
• The data from CT are used to construct geometric and physical models of the patient.
• The geometric models are used to define anatomic structures, target volumes and to aid
in radiation beam placement and shaping.
• The physical models provide density information required by most dose calculation
algorithms.
• The planning CT dataset is also used to generate graphical aids such as beams-eye-view
(BEV) displays and digitally reconstructed radiographs (DRRs) for planning and treatment
verification.
• The major drawback of CT data is the limited soft tissue contrast, which can hinder
accurate tissue discrimination.
 Let’s recap…

• Magnetic resonance imaging (MR) now plays an important role in treatment planning for
several tumour sites, offering several advantages over CT.
• The excellent soft tissue contrast provided by MR, permits better discrimination between
normal tissues and many tumours .
• A wide variety of MR imaging pulse sequences are available that can improve image
contrast by enhancing or suppressing specific tissues such as fat and conditions such as
oedema.
• Also, MR images can be directly acquired along sagittal and coronal planes, offering
better visualization of certain tissues.
• While these features make MR an excellent choice as a primary dataset for treatment
planning, several limitations have prevented the use of MR data alone.
• These drawbacks include the greater susceptibility of MR to spatial distortions and
intensity artefacts,
• the lack of signal from cortical bone, and image intensity values that have no relationship
to electron or physical density
 Let’s recap…

• SPECT and PET permit imaging of the transport and accumulation of biologically active
tracers.
• Examples of tracers for PET include 18F-deoxyglucose and 82Rb. and for SPECT include
131I and 99mTc.
• SPECT and PET studies provide information about physiology rather than anatomy.
• The data from these modalities can provide important information about tumour
metabolism and partial-volume tissue function.
• For patient monitoring, PET imaging has proven useful for discriminating between
tumour recurrence and radiation necrosis.
• For treatment planning SPECT data has been used to demonstrate regional lung function
to help determine beam directions and to quantify the distribution of radiolabelled
mono-clonal antibodies.
 Let’s recap…

• Ultrasound imaging uses mechanical (sound) energy rather than electromagnetic energy
to image tissue.
• It can also be used to image blood flow.
• The major advantages of ultrasound are that images are produced in real-time, the
required apparatus is relatively small, and it does not involve ionizing radiation.
• Three-dimensional data acquisition with ultrasound is now also possible.
• A disadvantage of ultrasound is that not all regions of the body, such as the brain and
lung can be imaged effectively due to signal loss at large tissue density changes such as at
tissue-bone and tissue-air interfaces.
 Image Fusion
While the imaging strengths of CT, MR, PET, SPECT, and ultrasound imaging
techniques make them important tools in patient management, each method has its
drawbacks.

The goal of image fusion is to overlap the strengths of each modality.

After the planning process….

….How can we assure accurate treatment?

 Accurate Treatment

• In modern radiotherapy using ultra-tight treatment margins to spare normal tissues, accurate
target delineation is very important.

• Traditional 2-Dimensional (2D) simulators we used for decades are now replaced by
computed tomography (CT) and magnetic resonance imaging (MRI).

• Modern radiotherapy relies on 3D imaging data that require contouring of the gross target
volume (GTV), clinical target volume (CTV) and planning target volume (PTV).

• GTV includes the tumour imaged and all other pertinent information,

• CTV includes clinical at risk area of microscopic spread and lymph nodes at risk,

• Internal target volume (ITV) includes CTVs from different respirator phases, and

• PTV includes the set up

Treatment Accuracy
• The impact of geometric errors increases with the
conformity of the radiation therapy treatment.
• There are essentially 2 different errors ; Mechanical and
Set‐up errors
• Systematic errors have the largest impact on the margin
needed to adequately dose the target.
• The greatest benefit is gained from strategies to reduce
systematic errors.
• Example is where:
• no immobilisation device is used to stabilise the
patient,
• the careless use of an immobilisation device,
• inaccurate recording of positioning co‐ordinates or
• A badly constructed immobilisation system that has
poor configuration and freedom of movement.
 10 Min break…

….Or Should we continue with TPS next

time??
 Small assignment…

Explain the following in radiation therapy…

 Record and verify systems (RV)

 Biological modelling
 DICOM formats
 Commissioning
 Normalization
 Name some treatment equipment (at least 10) in your department and their functions