Part 1 Introduction to Radiotherapy and External Beam Radiation Deepak Khuntia, MD Vice President, Medical Affairs Varian Medical Systems

Part 2 Proton-therapy Caterina Brusasco Compliance Manager IBA SA

Part 3 Internal Radiation: Brachytherapy John Christodouleas, MD, MPH VP of Medical Affairs and Clinical Research Elekta, AB

Role of Radiation Therapy in the Management of Cancer  In the US, about % of cancer patients receive radiation therapy at some point during their management.

Direct and indirect effects Photon and charged particles

Radiation Treatments External PhotonProtonElectron Internal Brachytherapy Unsealed Sources

Radiation Work-flow ConsultationSimulationPlanningTreatment 1 to 14 days

Simulation PositioningImagingImmobilization

–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 ConsultationSimulationPlanningTreatment

Adaptive Radiotherapy Khuntia 2010

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Adaptive Radiotherapy ConsultationSimulationPlanningTreatment

Radiosurgery  Sub millimeter accuracy  One to 5 fractions  Cones or MLC based  Brain or outside brain  Frame or no frame

External Radiation: Photons, electrons, protons Caterina Brusasco, PhD Compliance Manager IBA SA

3 Types of Therapeutic Radiation P e Photon Radiation (x-rays, gamma rays) Electron Radiation Particle Radiation (Proton) IonizationDNA 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

Radiation as a Treatment Modality  Linear accelerators create x-rays or electrons –Metal filament is heated to a high temperature within electric field –Electrons boil off and accelerate to metallic target –Deceleration of electrons in target emits x-rays –X-ray beam is contoured to conform to treatment needs Nucleus of atom in “ target ” e- e- electron from filament Brehmsstrahlung (braking) x-rays + -

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.

Proton-therapy Caterina Brusasco Compliance Manager IBA SA

Proton-therapy as external RT Proton- therapy (nuclei of H atoms) Photon radiotherapy (gamma, x- rays) External radiation therapy

The proton Bragg peak  The p dose deposition increases quadratically with penetration depth  the maximum is located at the end of the p range in matter (Bragg peak)  The p range depends on the initial p kinetic energy

The Spread-out Bragg Peak  The extension in depth of the tumor is covered by modulating the p energy and intensity into a Spread-out Bragg peak Tumor

Shaping of the dose distribution  The tumor volume is irradiated by painting it slice by slice, combining the magnetic steering of the pencil beam and the protons energy modulation

The accelerator  cyclotron  synchrotron  The magnetic fields guide the proton beam  The electric fields accelerate the protons to the desired energy

Transport of beam to the treatment room Magnetic steering of the p beam Gantry rotating around the patient Cyclotron Treatment room

4 treatment rooms: ft² / 1672 m² 1 treatment room: 3600 ft² / 334 m² Examples of PT facility

Internal Radiation: Brachytherapy John Christodouleas, MD, MPH VP of Medical Affairs and Clinical Research Elekta, AB

Brachytherapy definition Placing a radiation source internally, either into or immediately next to the tumor, allowing precise radiation dose delivery 1 1. Stewart AJ & Jones B. In Devlin Brachytherapy: Applications and techniques 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 tumors 1, Use of brachytherapy to treat a gynaecologic malignancy first reported Techniques developed to treat prostate cancer New radioactive sources, techniques and equipment, which prevented unnecessary radiation exposure to patients and clinicians led to a renaissance for brachytherapy s and 1960s Brachytherapy is established as a safe and effective standard of care for many gynaecological cancers s Brachytherapy a valued treatment option for many types of cancer, with a wealth of supporting evidence 4,5 Present day 1. Gupta VK. J Medical Physics 1995;20(2): Nag S. American Brachytherapy Society. 3. Aronowitz JN, Aronowitz SV Robison RF. Brachyther 2007;6: Blasko JC, Wallner K, Grimm PD et al. J Urol 1995;154: 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 ConsultationSimulationPlanningTreatment

Clinical Care Software Electronic 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

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