1. Physics and Imaging in Radiation Therapy
Giovanni Maria Piacentino
Modulo di radioterapia

2. 95% of Radiation Therapy is to Treat Cancer
X-ray of a Crab

3. Outline Introduction Brachytherapy
Production of External Beam Radiation
Quantifying the Amount of Radiation
Interaction of Radiation with Matter
Conventional Radiotherapy Treatment Processes
3-D Imaging for Radiation Oncology
3-D Conformal Radiation Therapy
Tomotherapy
Conclusions

4. Brachytherapy
Literally, close-up therapy, it is the treatment of cancer with radioactive sources.
The oldest form of radiation therapy and the most often used until the advent of megavoltage (energies of more than 1 million electron volts) photon beams.
Naturally occurring radium, discovered by Marie Curie, dominated the practice until artificial radioactive sources introduced.
Modern practice:
intracavitary treatments for GYN malignancies.
permanent implants of radioactive seeds, for example, for prostate cancer.
intraluminal treatments with radioactive beta sources.
superficial sources for superficial lesions.

5. Common Photon Sources for Brachytherapy
Isotope
Half-Life
Half-Value
Layer (Water)
Layer (Lead)
Cs-137
30 years
8.2 cm
6.5 mm
Au-198
2.7 days
7.0 cm
3.3 mm
Ir-192
74 days
6.3 cm
3.0 mm
I-125
59 days
2.0 cm
0.02 mm
Pd-103
17 days
1.6 cm
0.01 mm

6. Brachytherapy Processes
Image the patient with anterior-posterior and lateral x-rays.
Given the prescription, determine the source strengths to use.
Place the applicators into the patient.
Load the sources into the patient.
In high-dose rate (HDR) brachytherapy the patient returns for several treatments.
In low-dose rate (LDR) the patient is treated as an in-patient.
Short-lived radioactive seeds are left in permanently.

7. Intracavitary Brachytherapy
Protocol
X-rays
A: Anterior Posterior
B: Lateral
Dose
Distribution A B

8. Production of External Beam Radiation
Block diagram of a linear accelerator. A magnetron or klystron produces radio waves.

9. Animation of Electron Acceleration in a Linac
Linear Accelerator Waveguide with 4 Cavities E
The vectors indicates the electric field, E, (volts / cm) in the linac waveguide. The maximum strength of the electric field ~200,000 V/cm travels with the electron bunches traveling down the waveguide.

10. Treatment head configuration for megavoltage photon (A) and electron beams (B).
Accelerated Electrons
Photon
Beam
Electron
Beam

11. Quantifying the Radiation Dose
The unit of radiation dose is the Gray, which is an SI unit equal to 1 Joule of energy absorbed per kilogram of matter.
The energy absorbed is in the form of ionization and atomic excitation of matter.
Both the ionization and excitation of matter can be measured.
The most common measuring systems are the ion chamber for accurate quantification, thermoluminescent dosimeters (TLD) for convenience and radiographic film for spatial resolution.

12. Measuring Ionization with an Ion Chamber
Anode - + - - + - + A + -
Cathode
Radiation ionizes air in an ion chamber. Negative ions migrate toward the anode and positive ions towards the cathode. Ions reaching the electrodes cause current to flow in the circuit. Recombination of ions in flight reduces the measured current.

13. Photon Beam Penetration with Depth
Notice the low dose near the surface and nearly an exponential fall-off with depth.

14. Electron Beam Dose Distribution
A is the image of the beam on a sheet of radiographic film. B is the isodose plot (lines of equal dose). Notice the high dose on the surface and the finite range of the electron beam.

15. Interaction of Radiation with Matter
Interaction of neutrally-charged particles.

16. Animation of Radiation Interaction
Water Molecule
Ions Created
+ -
+ -
+ -
Photon Interacts, Setting in Motion a Fast Electron

17. Formation of Radicals and Long Lived Products
+ - OH
OH- 2 H
H2O2
H2O-
H2O + H+ H
Hydroxyl
Radical
Hydrogen
Radical
Hydrogen and Hydrogen Peroxide Products

18. Conventional External Beam Radiotherapy Treatment Process
Conventional radiotherapy planning relies on 2-D images from conventional planar x-rays which delineates well the position of bony anatomy but is not useful for visualizing soft-tissue.
Often opposing beam directions are used.
The boundary of the field is determined from the planar x-rays.
The field shape determines the shape of custom-made blocks that need to be fabricated.
The patient is treated from each beam direction daily.
Process is very labor intensive, and without rigorous quality assurance, may be prone to errors.

19. Fixation used for head and neck treatment.

20. A treatment simulator has an x-ray tube to image the patient in treatment position.

21. Image from a treatment simulator to determine the shape of the treatment field.

22. Tracing out the shape of the field to make custom blocks to shield normal tissue.

23. The custom block is fabricated out of low-melting temperature heavy metal alloy (mainly lead)

24. The custom block is mounted is attached to the linac to treat the field.

25. 3-D Imaging for Radiation Oncology
Cormack and Houndsfield won the Nobel prize in Medicine for the invention of the computed tomography (CT) scanner.
A CT scan is a representation of the patient’s electron density (# electrons/volume). Density differences as little as 0.3% can be detected.
The magnetic resonance imaging (MRI) scanner is becoming the most important diagnostic tool in medicine.
MRI can produce a variety of images related to the amount of hydrogen nuclei present and the coupling of their nuclear spins to surrounding matter.

26. Computed Tomographic Scanning
Photograph of a cross-section through a human abdomen.
CT scan through the same section.

27. 3-D Visualization
Volume rendered image of a head and neck representation obtained from fast CT using a contrast agent. The neck nodes are clearly visible as is the vasculature.

28. Magnetic Resonance Imaging
Abdominal MRI. From the National Library of Medicine Visual Human Project.

29. Comparison Between CT and MRI
Tumor seen
only on MRI.
Axial CT
Axial MRI
Coronal CT
Coronal MRI

30. MRI Angiography (MRA)
AVM Nidus
Arteriol-venous malformations (AVM) are often treated with radiation therapy. The nidus of malformed vessels is clearly visualized using MRA.

31. 3-D Conformal Radiation Therapy (3-D CRT)
3-D CRT relies on obtaining a 3-D representation of the patient from CT or MRI.
It is much easier to plan the delivery of oblique and non-opposed beam directions.
The beams can be much better delineated with respect to soft-tissue boundaries.
Modern accelerators have multileaf collimators which produce irregular field shapes without having to cast heavy metal blocks.
Treatment verification is still a problem.

32. CT for planning the radiation treatments.

33. CT slices forming a patient representation.

34. The tumor and sensitive structures are outlined.

35. The beam directions and boundaries are chosen to treat the tumor and avoid sensitive structures.

36. Shaping a field with a multi-leaf collimator system.

37. Modern treatment unit.

38. Verification with a radiograph obtained using the treatment beam.

39. Tomotherapy

40. Tomotherapy
X-Ray Beam
Binary MLC Leaves
Binary Multileaf
Collimator

41. Tomotherapy Helical Scanning Binary Multileaf Collimator
Helical Fan Beam
Helical
Scanning

42. Tomotherapy Megavoltage (MV) Detector Binary Multileaf Collimator
Helical Fan Beam
Helical
Scanning
Megavoltage
(MV) Detector

43. Tomotherapy MV Scan Binary Multileaf Collimator Helical Scanning
Helical Fan Beam
Helical
Scanning
Megavoltage
(MV) Detector

44. UW Clinical Helical Tomotherapy Unit
Siemens RF System
Siemens Linac
GE Gantry
GE CT
Detector
May 2000 at UW Physical Sciences Laboratory, Stoughton WI

45. Clinical Installation Finished
January 16, 2001 at UW Radiotherapy Clinic

46. Patient Treatments To Start Soon
Status May 3, 2002
Acceptance testing complete, i.e., specifications verified.
Treatment planning beam data commissioning complete.
FDA 510(k) cleared.
UW Animal Subjects Committee approval.
Megavoltage CT scans obtained on client dogs.
UW Investigational Review Board palliative protocol approved.
Final integration tests underway.

47. Mesothelioma Case

48. Mesothelioma
Movie
ROI slice 27
Dose Rate
Cumulative Dose

49. Slice 27 Slice 31 Slice 36 50 % 50 % 50 % 80 % 80 % 80 % 90 % 90 %

50. MVCT vs. kVCT for the Rando Phantom
MVCT Obtained
On the UW
Tomotherapy
Benchtop Unit

51. Volume Rendering of Rando Phantom Scans
Helical MVCT
Siemens Hi-Q kVCT

52. Adaptive Radiotherapy
3-D Imaging
Determine the
Dose Delivered
Intensity-Modulated
Treatment
Optimized
Planning
Modify the
Delivery
MV CT
Imaging

53. Imagine if Radiation Were A Drug
It could target arbitrarily-defined anatomic sites.
It would cause little damage to normal tissue away from the tumor.
The site of its action could be verified precisely.
Its side effects were well known.
It could be non-invasively measured in small quantities.
It would make other drugs more potent.
Drug tolerance would not develop.
Saving hundreds of thousands of people a year in the U.S., it would surely be considered our most important drug.

54. Conclusions
Radiation therapy can be broadly classified into brachytherapy and external beam radiotherapy.
Linear accelerators are used to treat patients with photon (megavoltage x-rays) and electron beams.
Photons and electrons behave quite differently when they interact with matter.
Conventional radiotherapy uses 2-D images for planning the treatments.
3-D imaging using CT and MRI provides a representation of the patient used for planning conformal radiation delivery.
The accurate verification processes of tomotherapy will form the basis for adaptive radiotherapy.