Part 1Introduction to Radiotherapy and External Beam Radiation

Deepak Khuntia, MDVice President, Medical Affairs

Varian Medical Systems

Part 3Internal Radiation:

BrachytherapyJohn Christodouleas, MD, MPH

VP of Medical Affairs and Clinical ResearchElekta, AB

Role of Radiation Therapy in the Management of Cancer

In the US, about 50-60 % of cancer patients receive radiation therapy at some point during their management.

Direct and indirect effects

Photon and charged particles

Photon and charged particles

Radiation Treatments

External

Photon

Proton

Electron

Internal

Brachytherapy

Unsealed Sources

Radiation Work-flow

Consultation Simulation Planning Treatment

1 to 14 days

Simulation

Positioning ImagingImmobilization

– uses CT and MRI-based image sets to

accurately target tumors and avoid sensitive normal tissues

– permits multiple different beam approaches

Treatment Planning: Spares normal tissue while ensuring adequate dose to the tumor

Treatment Delivery

Tools at the machine to verify appropriate patient and target positioning before and during treatment– MV X-ray, U/S, MVCT,

CBCT, KV X-ray, MR, fiducial markers, surface monitoring systems

– Can gate the machine

Radiation and Imaging Workflow

Consultation Simulation Planning Treatment

Adaptive Radiotherapy

Khuntia 2010

Fraction 1

Khuntia 2010

Fraction 2

Khuntia 2010

Fraction 3

Khuntia 2010

Fraction 4

Khuntia 2010

Fraction 5

Khuntia 2010

Fraction 6

Khuntia 2010

Fraction 7

Khuntia 2010

Fraction 8

Khuntia 2010

Fraction 9

Khuntia 2010

Fraction 10

Khuntia 2010

Fraction 11

Khuntia 2010

Fraction 12

Khuntia 2010

Fraction 13

Khuntia 2010

Fraction 14

Khuntia 2010

Fraction 15

Khuntia 2010

Fraction 16

Khuntia 2010

Fraction 17

Khuntia 2010

Fraction 18

Khuntia 2010

Fraction 19

Khuntia 2010

Fraction 20

Khuntia 2010

Fraction 21

Khuntia 2010

Fraction 22

Khuntia 2010

Fraction 23

Khuntia 2010

Fraction 24

Khuntia 2010

Fraction 25

Khuntia 2010

Fraction 26

Khuntia 2010

Fraction 27

Khuntia 2010

Fraction 28

Khuntia 2010

Fraction 29

Khuntia 2010

Fraction 30

Khuntia 2010

Fraction 31

Khuntia 2010

Fraction 32

Khuntia 2010

Adaptive Radiotherapy

Consultation Simulation Planning Treatment

Radiosurgery

Sub millimeter accuracyOne to 5 fractionsCones or MLC basedBrain or outside brainFrame or no frame

External Radiation:Photons, electrons, protons

Caterina Brusasco, PhDCompliance Manager

IBA SA

3 Types of Therapeutic Radiation

P

e

Photon Radiation (x-rays, gamma rays)

Electron Radiation

Particle Radiation (Proton)

Ionization DNA Damage

Different forms of radiation interacts with tissue differently

Photon

Electron

Proton and Charged Particles

Pediatric medulloblastoma Ref: Presentation Dr. Jay S. Loeffler, NPTC/MGH, ASTRO 2001

Standard RT:Use mostly open fields with blocks on critical structures

Conformal RT: Block shaping to more precisely match the target

Intensity Modulated RT: Each area may have a different intensity depending on how deep, and if there are critical structures.

Internal Radiation:Brachytherapy

John Christodouleas, MD, MPHVP of Medical Affairs and Clinical

ResearchElekta, AB

Brachytherapy definition

• Placing a radiation source internally, either into or immediately next to the tumor, allowing precise radiation dose delivery1

1. Stewart AJ & Jones B. In Devlin Brachytherapy: Applications and techniques. 2007.

Brachytherapy works ‘from the inside, out’

External Beam Therapy works ‘from the outside, in’

Brachytherapy has a long history

Brachytherapy – history

• Brachytherapy first used to treat lupus and then malignant tumors1,2

1901

• Use of brachytherapy to treat a gynaecologic malignancy first reported3

1903

• Techniques developed to treat prostate cancer4

1917

• New radioactive sources, techniques and equipment, which prevented unnecessary radiation exposure to patients and clinicians led to a renaissance for brachytherapy1

1950s and 1960s

• Brachytherapy is established as a safe and effective standard of care for many gynaecological cancers5

1970s

• Brachytherapy a valued treatment option for many types of cancer, with a wealth of supporting evidence4,5

Present day

1. Gupta VK. J Medical Physics 1995;20(2):31-5. 2. Nag S. American Brachytherapy Society.3. Aronowitz JN, Aronowitz SV Robison RF. Brachyther 2007;6:293-7. 4. Blasko JC, Wallner K, Grimm PD et al. J Urol 1995;154:1096-9. 5. Viani GA, Manta GB, Stefano EJ et al. J Exp Clin Cancer Res 2009;28:47.

Three major brachytherapy methods

69

Intracavitary

Interstitial Surface

Brachytherapy Clinical Indications

In some indications, it is an option. In others, it is the standard of care.

Han K et al. Int J Radiat Oncol July 2013

Survival with and without BT boost in localized cervical cancer

Software Systems in Radiation Oncology

Software drives all aspects of the radiation oncology workflow

Consultation Simulation Planning Treatment

Clinical Care SoftwareElectronic medical record systems

(EMRs)

Stores the patient’s medical record

Tools for charting and medical ordering

Radiation Treatment Planning Systems

Identify tumor and normal tissues

Define beam/implant characteristics to reach a safe/effective plan

Radiation Treatment Management System

Pre-treatment verification – Right patient, position, body part, treatment

parameters, etc

Post-treatment record

Software Decision Support Tools

Thank you