Clinical Practice 4: Radiotherapy

Clinical Practice 4
RADIOTHERAPY
LECTURE 4
MODERN RADIATION THERAPY
TECHNIQUES
Shortcomings of Traditional Radiation Therapy
Until the 1980s, radiation oncologists devised treatment plans using plain
radiography, which rarely visualized a tumor directly.
This treatment approach was associated with uncertainties, inconveniences, and
toxicities.
Because only an approximate location of the cancer could be determined, the
radiation field needed to include a generous margin. For example, in prostate
cancer therapy, the treatment volume usually included portions of the
gastrointestinal and genitourinary tracts.
This led to radiation proctitis (characterized by fecal urgency and rectal pain
and bleeding) in up to 40 percent of patients; sexual dysfunction in up to 50
percent of patients; and urinary complications (e.g., incontinence, hematuria,
strictures) in up to 10 percent of patients.
Because radiation was typically administered over 30 or more daily fractions
(fractional doses), the location of the target tumor varied throughout treatment.
Slight changes in patient position were inevitable, and shifting rectal contents
altered the prostate's anatomic position. In some patients, such organ movement
led to underdosing of the target tumor and increased relapse rates.
EXTERNAL BEAM RADIATION THERAPY
A series of incremental technologic advances has improved the targeting of external

beam radiation therapy.
Computed tomography (CT) and magnetic resonance imaging (MRI) have largely
replaced plain radiography in radiation treatment planning. Because CT and MRI
permit the direct visualization of soft tissue structures, tumors can be precisely
located, instead of approximated. These detailed images have been directly
integrated with computer-based modulation of the radiation beam outline, a
technique known as three-dimensional conformal radiation therapy
Contemporary imaging modalities, such as CT and MRI, have also been directly
incorporated into radiation delivery machines, allowing for frequent confirmation
of the tumor and patient positioning throughout the course of treatment.
This approach, which may be applied to a number of radiation therapy
techniques, is called image-guided radiation therapy.
If critical healthy structures, such as nerves or vessels, are adjacent to or
surrounded by the target tumor, the radiation beam may be subdivided into
multiple component beams (“beamlets”), each of which may be modified
individually; this technique is called intensity-modulated radiation therapy.
Image-guided radiation treatment unit. Daily imaging of the radiation target permits
ongoing modification of the radiation plan to accommodate changes in patient and
tumor positions.
Concept of intensity-modulated radiation therapy for prostate cancer. Each radiation treatment is
divided into separate beams. Each beam, subdivided into multiple “beamlets”, delivers a unique pattern
of radiation. The highly conformal radiation dose maximizes radiation to the tumor while minimizing
exposure of healthy structures (e.g., the rectum
Modern radiation treatment plan using intensity-modulated radiation therapy techniques. The panel shows an axial
computed tomography image used to plan radiation delivery for an oropharyngeal tumor. The colored lines
represent isodose lines, depicting areas that receive a certain percentage of the radiation dose. These plans spare
critical tissues, such as the parotid glands, the toxicities (e.g., xerostomia) of conventional modalities.
IGRT is a radiation
therapy with a help of
imaging. This is useful
because of the
variation of tumor
after each treatment
and the difference of
patient position.
With three-dimensional conformal radiation therapy for prostate cancer, urinary
and rectal toxicity rates have decreased substantially compared with conventional
external beam radiation therapy ; these complications have declined even further
with intensity-modulated radiation therapy.
Tumors susceptible to repeated movement, such as those in the lungs, may be

tracked and targeted with rapidly acquired anatomic images (four-dimensional
radiation therapy).
STEREOTACTIC RADIOTHERAPY AND RADIOSURGERY
Despite substantial improvements in tumor targeting, technologies such as three-

dimensional conformal and intensity-modulated radiation therapy are prone to the
inherent uncertainties and limitations associated with dose fractionation.
If the target tissue was immobile and its localization highly dependable, normal tissues
would receive minimal radiation, thus decreasing or eliminating the need for
fractionation.
A single treatment is more convenient than six weeks of daily sessions.
A one-time, high-potency radiation dose also provides greater tumor kill rates than an
equal or higher radiation dose divided over multiple administrations because there is less
opportunity for cancer cells to repair damage to DNA.
This is the concept behind stereotactic radiosurgery, a specialized type of external
beam radiation therapy. Stereotactic radiosurgery has primarily been used as an
alternative to surgery for the treatment of intracranial lesions, such as brain
metastases, arteriovenous malformations, acoustic neuromas, trigeminal neuralgia,
and meningiomas.
The brain is an ideal location for this approach because there is essentially no
internal organ movement. The Gamma Knife stereotactic radiosurgery system
involves attaching a positioning device (i.e., a stereotactic frame) directly to the
patient, then to the treatment unit.
Outside the brain, stereotactic body radiation therapy also relies on patient
immobilization equipment for accurate targeting of tumors.
Concept of Gamma Knife stereotactic radiosurgery. Multiple separate
small beams of radiation converge at the tumor target.
The Cyberknife is a linear accelerator mounted on a robotic arm that provides more
than 1,000 radiation beam orientations. It has been used to treat tumors in the lung,
liver, spine, kidney, prostate, and pancreas.
Although stereotactic radiation is often more effective than conventional radiation,
the high radiation doses required for these treatments can lead to distinct radiation
toxicities.
Tubular structures, such as bronchi and bile ducts, are particularly prone to
damage, which may manifest as luminal obliteration and obstruction.
The advanced technology behind CyberKnife uses real-time image guidance technology and
computer controlled robotics to deliver an extremely precise dose of radiation to the tumor,
avoiding the surrounding healthy tissue and adjusting for patient and tumor movement during
treatment.
BRACHYTHERAPY
With brachytherapy, the radiation source is permanently or temporarily placed

within the patient, near the target tumor. For example, permanent iodine-125
radiation seed implants have become an established treatment for early-stage,
low-risk prostate cancer.
Temporary brachytherapy, administered via intracavitary catheters or larger
applicators, is used to treat gynecologic malignancies, such as cervical cancer.
Balloon catheters, filled with liquid radioisotopes, are used to limit local
recurrence after the initial treatment of breast cancer and brain tumors; they
are placed during surgical resection, then removed after several days.
SYSTEMIC RADIATION THERAPY
If adequate targeting is feasible, internal radiation may be administered

systemically. Because thyroid tissue naturally concentrates iodine, iodine-131 may
be given orally to treat localized and metastatic thyroid cancer or benign causes of
hyperthyroidism.
Although this treatment almost always leads to hypothyroidism requiring thyroid
hormone replacement, other organs are not affected. Similarly, the radioisotopes
strontium-89 and samarium-153, which have affinity for bone, have been used to
palliate painful skeletal metastases from prostate, breast, and lung cancers.
More recently, radioisotopes have been attached to monoclonal antibodies that
target cancer cells (i.e., radioimmunotherapy) to treat non-Hodgkin
lymphoma. Because these antibodies may be recognized as foreign proteins,
patients must be closely monitored for infusion reactions.
Thank You
PROF DR OMAR SHEBL ZAHRA

Clinical Practice 4: Radiotherapy

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Clinical Practice 4: Radiotherapy

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Clinical Practice 4

A series of incremental technologic advances has improved the targeting of external

Tumors susceptible to repeated movement, such as those in the lungs, may be

Despite substantial improvements in tumor targeting, technologies such as three-

With brachytherapy, the radiation source is permanently or temporarily placed

If adequate targeting is feasible, internal radiation may be administered

PROF DR OMAR SHEBL ZAHRA

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