Radiation Oncology Roots & Progress Janet Saxon Pieck, M.D. Medical Director, Radiation Oncology Fremont Area Medical Center

“Father of the X-Ray” Wilhelm Roentgen born March 27th 1845 in Lennep in the Lower Rhine Province of Germany. 1869 PhD in Physics. 1901 Nobel Prize in Physics. 1977 Central Africa commemoration stamp.

Wilhelm Conrad Roentgen 1845-1923 Discovered the X-Ray on the evening of 8thNovember 1895

The Physical Institute of the University of Wurzburg Germany Roentgen lived and worked here.

Roentgen’s laboratory. Located at the Physical Institute of the University of Wurzburg Germany. Discovered the X-ray whilst experimenting with a Crooke’s tube.

An evacuated glass tube. Used with a power source such as a static generator or battery coil to produce X-Rays.

A power source. Used with an evacuated glass tube to produce X-Rays

“First Roentgenogram ever taken” Of Roentgen’s wife’s hand!

“On a new kind of rays” Submitted in the Proceedings of the Wurzburg Phisico-Medical Society. 12-28-1895 First public presentation 1-23-1896 before the same society.

X-Ray DISCOVERY MADE PUBLIC JANUARY 3rd 1896

Roentgen’s pamphlet Announcing the discovery of the X-Ray was reprinted twice in the Spring of 1896. By the time of the second reprint the pamphlet was considered a collectors item!

Henri Bequerel Discovered the phenomenon of radioactivity in February 1896 whilst working with double sulfate of uranium and potassium, and was awarded the Nobel prize for Physics in 1903 1852-1908

Image of Uranium Image obtained after wrapping some photographic film in lightproof paper, placing some uranium compound on top,and instead of placing it in sunlight, [because it was cloudy], Bequerel put it in a drawer. He subsequently exposed the film and was surprised to find an image!

Marie and Pierre Curie. 1867-1934 1859-1906 Awarded the Nobel Prize in Physics in 1903 for their work with radioactivity - a term coined by Marie in July 1898.

Marie Curie Awarded Nobel Prize in chemistry in 1910 for the discoveries of polonium [July 1898] and radium [Dec 1898] , both radioactive elements. She became the first person to win 2 Nobel Prizes! 1867-1934

“The miserable old shed.” It took over 3 years to isolate 1/10th gm of pure Radium Chloride from several tons of radioactive ore!

December 1898 Gamma Rays discovered by P Villard.

The Electromagnetic spectrum. The range of all possible electromagnetic radiation from the size of a fraction of an atom to thousands of kilometers.

The world discovers the X-Ray! “NEW LIGHT SEES THROUGH FLESH TO BONES!” Screamed the headlines of US newspapers in mid January 1896!

Worry over side-effects by 1896. March 3rd - First reports of X-Ray injury; damage to eyes. April 10th - Epilation noted from X-Ray exposure. April 18th - Skin effects first noted. July - Reports of accidental injury [burns].

First ad in English accompanied by a Radiograph April 1896 film of forearm achieved with “only” 30 minutes exposure!

“Soon every house will have a cathode ray machine!” Apparatus soon widely available. Low cost. Studios opened for bone portraits. Poems appeared in popular journals!

The necessary apparatus was easily acquired. An evacuated glass tube with anode and cathode and a generator, [coil or static machine], combined with photographic materials could set anyone up in business as a “skiagrapher.”

X-Ray enters medical practice! The simplicity of the apparatus allowed a variety of people to “try their hand”, among them electricians and photographers!

Test subjects! Wives and female assistants often were used as test subjects to ensure that the ‘tube’ was ready for the day’s work!

X-Ray studio X-Ray Studios like this one in New York opened in cities large and small to take “bone portraits,”often on subjects who had no physical complaints!

Foot in a high button shoe! Radiograph made in Boston by Francis Williams in March 1896. Typical of early images reproduced in the popular press

Experimental radiograph Coins in purse. Many tests conducted on the penetrating strength of the rays.

RADIOACTIVE COCKTAILS ANYBODY?

Early newspaper article. By the late 1890’s radiation was being used to good effect in the treatment of superficial malignancies.

Early cures 1899 Stockholm. 49 year old treated for basal cell cancer of the nose by Thor Stenbeck. Patient treated for squamous cell cancer by Tage Stenbeck.

Early pioneers thought nothing of daily exposure to the RAYS! -Gauged the strength of the tubes -Positioned patients. -Steadied patients -Calculated “ERYTHEMA DOSE” on their hands!

Magic rays could kill as well as cure! POOR UNDERSTANDING of TIME DISTANCE SHIELDING Overexposure of early workers led to skin burns amputations and carcinogenesis! Mihran Kassabian 1870-1910 Obituaries of early pioneers appeared with somber regularity! First such death reported in 1904.

1899 April – Radiographer licensure recommended to protect public. May – MALPRACTICE AWARD for “X-Ray burns.” Listing of protective devices [gloves, aprons, etc] in X-ray catalogue.

American Roentgen Ray Society charter members Buffalo New York 1901 Formed to define and establish standards in diagnosis and therapy. Marginal practitioners soon purged and excluded.For $5 per year annual dues the new “ radiologist” could participate in the national activities of the specialty and receive the American X-Ray Journal.

Early Journals. [First X-Ray journal in English, the Archives of Clinical Skiagraphy became the British Journal of Radiology.]

By 1905 200 companies making X-Ray machines in the US! The construction room of the Waite and Bartlett Manufacturing Company in New York [ca 1903] [Most hospitals had X-Ray rooms by 1905]

Early Radium treatment using Gamma Rays. With small amounts of Radium leant by the Curies this child’s birthmark was cured in 1907 by a group of Parisian physicians.

Office based therapy by 1910 using kilovoltage X-Rays. Hermann Rieder’s Munich therapy office shows typical aspects of treatment in the period. Simultaneous patient treatments. Protective shielding. Sometimes sparks, loud cracklings and smoke! BUT TREATMENTS WERE EFFECTIVE!

Kellog’s Rice Krispies tried to increase sales by luring “radiation- crazed” consumers with a free X-Ray viewer included in each box of cereal!

1930’s death of the wrist watch dial painters! These young girls repeatedly ingested tiny amounts of radium-based paint while ‘tipping’ their paint brushes with their tongues.They were so thoroughly imbued with radiation that their teeth could expose photographic film!

TELECURIETHERAPY using Gamma Rays. These machines, popular in the 1930’s were the forerunners of the Cobalt 60 unit.They offered higher dose rates, longer source to patient distances and improved shielding and collimation.Cancers were treated curatively and palliativly at this time as were selected benign diseases.

Cobalt 60 Teletherapy using Gamma Rays. First unit brought on line in 1951.

How are X-Rays made? X-Rays are produced when electrons strike a metal target.The electrons are liberated from the heated filament and accelerated by a high voltage towards the metal target. The X-Rays are produced when the electrons collide with the atoms and nuclei of the metal target.

Mullard Phillips 4 MeV Linac. First installed at Newcastle Hospital in 1953.

6 Mev Linac installed at Stanford 1955. The first patient, a boy with retinoblastoma, was treated in 1956 and remained cancer free 40 years later.

Still having “fun” with X-Rays??? I remember loving to see my bones and would go to the shoe shop in town whenever possible in the late 1950’s! No wonder I have such trouble with my feet!

Siemens MevatronVIII. A pioneering device for dual energy photon beams which underwent further upgrades after it’s initial appearance in 1966.

  Table 1: Improved Percent of Survival of Several Types of Cancer When Treated with Megavoltage Radiotherapy Improved percent of survival of several types of cancer when treated with megavoltage Radiotherapy.   Type of Cancer With Kv X-rays (1950’s) With MeV X-rays (1970’s) Hodgkin’s Disease 30 - 35 70 - 75 Cancer of the Cervix 15 - 45 55 - 65 Cancer of the Prostate 5 - 15 55 - 60 Cancer of the Nasopharynx 20 - 25 45 - 50 Cancer of the Bladder 0 - 5 25 - 35 Cancer of the Ovary 15 - 20 50 - 60 Retinoblastoma 30 - 40 80 - 85 Seminoma of the Testes 65 - 70 90 - 95 Embryonal Cancer of the Testes 55 - 70 Cancer of the Tonsil 25 - 30 40 – 50  

Varian Clinac treatment unit, 1990’s. Dual energy linear accelerator enables radiation team to choose the most effective energy beam to treat deep seated or more superficial lesions.Controls are computerized for easier operation.

RADIATION THERAPY Radiation therapy is a very common treatment method prescribed for almost half of all cancer patients. It can be given alone or in combination with chemo or biotherapy. It is given for cure or for palliative purposes. It can be delivered externally or internally and sometimes a combination of the two methods is used. Side effects depend on the part of the body that is treated. Side effects are minimized by careful treatment planning and appropriate symptomatic treatment. Cure rates are improving all the time due to earlier detection and more effective treatment strategies!

SOME RADIATION MYTHS Radiation therapy is painful. Radiation therapy will cause me to be radioactive. Radiation therapy will cause me to lose my hair. Radiation therapy will cause nausea and vomiting. Radiation therapy causes cancer. Radiation therapy will make me sterile.

DID YOU KNOW THAT “Cancer cell growth is unwieldy and uncontrolled- these cells just don’t have their act together like normal cells do. When normal cells are damaged by radiation, they are like a big city with a fire and police department and trained emergency squads to come and put out the fire.Damaged cancer cells are more like a disorganized mob with a bucket.” -Marisa Weiss MD.

RADIOTHERAPY TREATMENT PROCESS

Immobilizing your body. In order to ensure accurate positioning on a daily basis immobilizers are used such as this Vac-Lock bag which is like a bean bag with the air removed.It holds its shape and cradles the patient in the optimal position enabling precise and reproducible treatment sessions.

Immobilizing your head. A thermoplastic mask is used for immobilizing the head.It is often used to treat patients with head and neck or brain cancer and it ensure accurate daily positioning and reproduction of treatments.

CT simulation and treatment planning. Done before treatment in most patients to image the treatment area in cross section. Each CT slice is scrutinized, the areas of interest are outlined, the images reconstructed, and blocks drawn to include the tumor and areas at risk for spread with an appropriate margin of surrounding normal tissue. After computer planning the patient is ready to begin treatment.

Treatment planning Once the radiation oncologist has prescribed a course of treatment the dosimetry and physics team develops a plan that works best for you.This may involve a single beam of radiation or it could include multiple beams. Depending on the complexity of the plan you may need to wait several days after simulation before you can begin treatment.

Before starting treatment Reference marks. Check films are taken of the treatment fields and are compared with the treatment planning reconstructed radiographs. They should be identical! Once this is confirmed a minimum of tattoos are used to replace the temporary skin marks and to ensure accurate daily set-up.

TREATMENTS BEGIN In summary Radiation is a local, targeted therapy designed to kill cancer cells. The actual delivery of the radiation treatment is painless. External radiation treatment, the most common kind of radiation treatment does not make you radioactive. You will receive treatment 5 days a week up to 7 weeks. Since the daily appointments are about a half hour, you will most likely be able to keep to your normal routine. You will not lose your hair during treatment unless your head is being treated or if you are taking chemo. Over the course of your treatment you may notice some fatigue. The side effects of radiation are usually temporary. In summary

Potential for improvement Maximize the therapeutic index. Minimize treatment failure. Increase delivery system precision with innovations such as IMRT.

THE END