Evolution of radiation 2012


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History of Radiation

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Evolution of radiation 2012

  1. 1. The Evolution of Radiation Therapy
  2. 2. Thomas Hodgkin in 1832 Boy with Hodgkin’s in 1920Until the 1960s, among patients with an advanced stage ofHodgkins disease the median survival was 2 years, and only 5% ofpatients lived beyond 4 years.Currently it is curable in 85 to 95% of cases, depending on its stage
  3. 3. History of Radiotherapy 1895 Roentgen discovers Xrays 1896 Becquerel discovers radioactivity 1898 Curie discovers radium late 1890’s therapeutic use 1920’s reliable Xray tubes (150-300Kv) 1950’s Cobalt (1Mv or million volt) 1960’s Linear Accelerator (4 - 25 million) 1970’s computers and CT scans 1980’s 3-D radiotherapy 1990’s 3D conformal therapy 2002 IMRT (intensity modulated radiotherapy) 2002+ IGRT (image guided and radiosurgery)
  4. 4. Wilhelm Conrad RöntgenOn the evening of November 8, 1895, hefound that, if the discharge tube is enclosed ina sealed, thick black carton to exclude all light,and if he worked in a dark room, a paper platecovered on one side with barium platinocyanide placed in the path of the rays became fluorescent even when it was as far as two meters from the discharge tube. ( 27 March 1845 – 10 February 1923) was a German physicist, an achievement that earned him the first Nobel Prize in Physics in 1901
  5. 5. Emil Grubbe Medical Student in ChicagoMarch 29, 1896 in an X-ray Tube factory in Chicago he beganto bombard Rose Lee an elderly woman with recurrent breastcancer and had the first documented response to radiation
  6. 6. Antoine Henri Becquerel In 1896, decided to investigate whether there was any connection between X-rays and naturally occurring phosphorescence. He had inherited from his father a supply of uranium salts, which phosphoresce on exposure to light. When the salts were placed near to a photographic plate covered with opaque paper, the plate was discovered to be fogged.(15 December 1852 – 25 August 1908) was a French physicist, Nobellaureate, and the discoverer of radioactivity along with Marie Skłodowska-Curie and Pierre Curie, for which all three won the 1903 Nobel Prize inPhysics.
  7. 7. Marie Curie The discovery of radioactivity by Henri Becquerel led to in 1898 the Curies to the isolation of polonium, named after the country of Maries birth, and radium. Mme. Curie developed methods for the separation of radium from radioactive residues in sufficient quantities to allow for its characterization and the careful study of its properties, therapeutic properties in particular.(7 November 1867 – 4 July 1934) was a French-Polish physicist and chemist, Shewas the first person honored with two Nobel Prizes—in physics and chemistry. Shewas the first female professor at the University of Paris, and in 1995 became thefirst woman to be entombed on her own merits in the Pantheon in Paris.
  8. 8. What is polonium-210, how can it kill you? Saturday, November 25, 2006 LONDON - Polonium-210 - the radioactive substance that killed a former Russian spy in London - is one of the worldsrarest elements, first discovered in the 19th century by scientists Marie and Pierre Curie. Alexander Litvenko
  9. 9. internet Nov. 2006
  10. 10. Pre- 1904 X-ray Machine
  11. 11. Radium Pack
  12. 12. Early Radium Applicators
  13. 13. 1902 Cervix Contact X-ray Tube
  14. 14. 1930 Radium Tele-Curie Machine
  15. 15. Radiation in the early 20th Century “Weak Discouraged Men! Now Bubble Over with Joyous Vitality Through the Use of Glands and Radium”Vita Radium Suppositories (ca.1930)
  16. 16. Any Risks of Harm from Radiation?
  17. 17. Undark and the Radium Girls
  18. 18. Undark and the Radium Girls
  19. 19. Undark and the Radium GirlsIn 1902, inventor William J. Hammer left Paris with a curious souvenir. The famous scientistsPierre and Marie Curie had provided him with some samples of their radium salt crystals.Radioactivity was somewhat new to science, so its properties and dangers were not wellunderstood; but the radium’s slight blue-green glow and natural warmth indicated that it wasclearly a fascinating material. Hammer went on to combine his radium salt with glue and acompound called zinc sulfide which glowed in the presence of radiation. The result was glow-in-the-dark paint.US Radium employed hundreds of women at their factory in Orange, New Jersey, After a fewstrokes a brush tended to lose its shape, so the women’s managers encouraged them to usetheir lips and tongues to keep the tips of the camel hair brushes sharp and clean. The glowingpaint was completely flavorless, and the supervisors assured them that rosy cheeks would bethe only physical side effect
  20. 20. Undark and the Radium GirlsAt their first appearance in court in January 1928, two were bedridden, and none could raise theirarms to take the oath. Grace Fryer, still described by reporters as “pretty,” was unable to walk,required a back brace to sit up, and had lost all of her teeth. The “Radium Girls” began appearing inheadlines nationwide, and the grim descriptions of their hopeless condition reached Marie Curie inParis. “I would be only too happy to give any aid that I could,” she said, adding, “there isabsolutely no means of destroying the substance once it enters the human body.” The last of thefamous Radium Girls died in the 1930s,the dial painters had ingested anywhere from a few hundred to afew thousand microcuries of radium per year. One tenth of amicrocurie is now considered to be the maximum safe exposure.Marie Curie herself died of radiation-related ailments in 1934.Because radium has a half-life of 1,600 years, her lab notebooksare said to be too highly contaminated to be safely handled eventoday. Radium continued to be used to illuminate watches untilabout 1968, but under much safer conditions.
  21. 21. At the recommendation of his doctor, Byers began drinking Radithor, and he continued to do so long averaged three bottles a day for two years. Byers stopped consuming Radithor in 1930 when his teeth started falling out and holes appeared in his skull. Perhaps more than anything else, his death in 1932 alerted the public, and much of the medicalRadithor (ca. 1928) profession, of the harmful effects of "mild" radium therapy.
  22. 22. Shoe-Fitting X-Ray MachineThe shoe fitting fluoroscope x-ray machine was a common fixture in shoe storesduring the 1930s, 1940s and 1950s. A typical unit consisted of a vertical woodencabinet with an opening near the bottom into which the feet were placed.When you looked through one of the three viewing ports on the top of the cabinet(e.g., one for the child being fitted, one for the childs parent, and the third for theshoe salesman or saleswoman), you would see a fluorescent image of the bonesof the feet and the outline of the shoes.
  23. 23. The Gra-MazeUranium Comforter(ca. 1965)"This is your personalradioactive uraniumcomforter. Actually yourown health mine inminiature, If youfollowed the suggestionon the pad and checked itwith a Geiger counter,you would find it to bemeasurably radioactive.
  24. 24. Sluys-KesslerRadium ApparatusParis. 1930
  25. 25. Radium TherapyDevice1934 Villejuif,France
  26. 26. Skull Film Roentgenogram circa 1923
  27. 27. Electron Charged Rays for Cancer, Vienna, 1938
  28. 28. Radium Bomb London 19344 Radium sources close to the patient’s skin. Each source focused on the cancer froma different angle, maximizing the dose to the localized area. Protective devices for themedical practitioner were non-existent at this time
  29. 29. COBALTThe use of 60Co sources forteletherapy was begun in the1950s as a replacement forthe 250 kVp x-ray treatmentmachines that were then incommon use.The skin-sparing effects of60Co treatment wereimmediately recognized andsuch effects were no longerlimitations on treatment.
  30. 30. Henry Kaplan"In the 1950s, I began to hearcocktail party conversations aboutan interesting new atom smasherbeing developed on the campus,"An atom smasher, otherwiseknown as a particle accelerator,uses electromagnetic fields topropel charged particles to greatenergies. By slammingaccelerated electrons into a targetmade of heavy metal, high-energyX-ray beams result.Kaplan thought this machinecould be harnessed to deliver X-ray therapy that was superior tothe unreliable, weak andunfocused radiation therapyapproaches of his day.
  31. 31. First Medical Linear Accelerator atStanford in 1956
  32. 32. In January 1956 the machine was ready to be used on their first patient, a boy with retinoblastoma in hisone remaining eye after surgeons had removed the tumor in the other eye. Destroying the tumor whilesparing the eye would have been impossible with earlier, less-focused radiation sources.
  33. 33. Linear Accelerator
  34. 34. Use of Cobalt in Cervix Cancer Patterns of Care Data1008060 Cobalt40 LinAc20 0 1978 1983 1988 Montana IJROBP 1995;32:14381
  35. 35. Penetration of Radiation by Energy Level
  36. 36. Skin Sparing and the Energy of the Beam
  37. 37. Selecting the Proper Dose of Radiation “It may be a bit over-exposed”
  38. 38. Prostate Cancer Outcome based on Dose of Radiation Biochemical relapse-free results by treatment modality. The study population comprised 2991 consecutive patients treated at the Cleveland Clinic Foundation or Memorial Sloan Kettering at Mercy Medical Center
  39. 39. How Much is Safe ?
  40. 40. Strategies to Improve the Effectiveness of Radiation Use chemical or chemotherapy to make the cancer cells more sensitive to radiation Design ways to focus the radiation more precisely and allow the use of higher doses (conformal 3D, IMRT or radiosurgery) Implant the radiation directly into the tumor (brachytherapy, with wires or seeds) or isotopes or monoclonal antibodies
  41. 41. Esophagus Cancer Survival - Radiation plus Chemotherapy versus Radiation Alone 5 Year SurvivalRadiation = 0%Radiation plusChemotherapy = 26%
  42. 42. Erbitux + RadiationERBITUX binds specifically to epidermal growth factorreceptor on both normal and tumor cells, andcompetitively inhibits the binding of (EGF)Over-expression of EGFR is detected in many humancancers. Survival with Advanced Head and Neck Cancer Radiation Alone: 19 months Radiation + Erbitux: 36 months
  43. 43. Strategies to Improve the Effectiveness of Radiation Use chemical or chemotherapy to make the cancer cells more sensitive to radiation Design ways to focus the radiation more precisely and allow the use of higher doses (conformal 3D, IMRT or radiosurgery) Implant the radiation directly into the tumor (brachytherapy, with wires or seeds, or isotopes or monoclonal antibodies)
  44. 44. Accuracy in Targeting
  45. 45. Targets and Spread of Cancer Cells
  46. 46. Definition of Targets
  47. 47. MR Spectroscopy to Define Cancer Target Determining the Tumor Target Volume for a GliomaT1 images (break down of the blood brain barrier) tend to underestimate the size of the cancer and T2 post contrast images (which includes the whole area of edema) tend to over-estimate the size. MR spectroscopy may be more accurate
  48. 48. Using PET Scans to Define Cancer
  49. 49. Improving and Refining Radiation Therapy•First use improved imaging technology (CT/MRI/PET scans) todefine the proper target•Then use increasingly sophisticated technology to bend the beamso it will conform to the shape of the target (conformal therapy)•Modulate the beam even more to get even better targeting (IMRTor intensity modulated radiation therapy)•Combine IMRT with technology that will more accuratelyidentify the target (IGRT or image guided radiotherapy)•Once the techniques are extremely accurate then use extremelyhigh doses of radiation that will completely eliminate the cancer(radiosurgery e.g. Gamma Knife or Cyberknife)
  50. 50. Conformal (3D) Radiation for Prostate CancerA Randomized trial at MD Anderson comparing conventional radiation with conformal therapy PSA Cures conventional 53% conformal 72% Pollack IRJOBP 1996;34:555
  51. 51. Treatment Results and Complications with Prostate CancerTherapy Cure Potent CompsImplant 87-96% 81-90% 2-12%External 80-96% 33-70% 3-17%Surgery 85-95% 22-90% 8-10%Conformal 96% 70% 3-4% D’Amico J Clin Onc 1996;14:304
  52. 52. Image Guided IMRT
  53. 53. In The Headof the linearaccelerator isthe beamshapingMLC
  54. 54. Using image guided IMRT totreat spinal cancer
  55. 55. Bone Metastases to the SpineInvolved vertebrae on the left and normal on the right
  56. 56. Kidney cancer inthe spinal vertebraesurrounding thecord, andappearance afterradiation…is itpossible to safelyradiate further?
  57. 57. Combine a CT scan and linear accelerator to ultimate intargeting (IGRT) and ultimate in delivery (dynamic, helicalIMRT) ability to daily adjust the beam (ART or adaptiveradiotherapy)
  58. 58. PROTONBEAM
  59. 59. Improved Survival with Head and NeckCancer and IMRT
  60. 60. Conformal proton therapyfor prostate carcinoma.Int J Radiat Oncol Biol Phys. 1998 Sep 1;42(2):299-304Department of Radiation Medicine, Loma Linda LinacUniversity Medical CenterWhen post-treatment prostate-specific antigen (PSA)was used as an endpoint for disease control, the 4.5- Proton beamyear disease-free survival rate 89%, 72%, and 53%for patients with initial PSA levels of 4.1-10.0, 10.1-20.0, and > 20.0, respectively. External Beam using modern techniques and a dose of at least 72Gy. Compared with most recent data on Proton Beam from Loma Linda
  61. 61. Best Radiation Treatment for Localized Prostate Cancer SEER Data 2000-2009. J Clin Onc 2012:30 (s5a3) Treatment GI Toxicity Hip Fxt RxFailure Conformal 9.7% + 25% + 24% + IMRT - - - Proton Beam 45% + - -Conformal therapy had higher GI toxicity and hip fractures than IMRT and ahigher relapse rate. Proton had more GI toxicity and no improvement inoutcome compared to IMRT
  62. 62. Radiosurgery – using extremely well targeted radiation to totally eliminate the tumor Gamma Knife or Cyberknife
  63. 63. RadioSurgery the Old Way Man Survives 18-Inch Drill Bit in HeadRon Hunt lost an eye but suffered no brain damage after a freak accident with a large drill bit. Sept. 2— 2003
  64. 64. Lars Leksell. (1907- 1986). ... introduced his stereotactic instrument for human functional neurosurgery in 1949. ...Professor Lars Leksell, Swedish physician and Professor of Neurosurgery atthe Karolinska Institute in Stockholm, introduced his stereotactic instrumentfor human functional neurosurgery in 1949.In 1951, using the Uppsala University cyclotron, Leksell developed theconcept of radiosurgery, employed proton beams coming from severaldirections into a small area into the brain, in experiments in animals and in thefirst treatments of human patients. Therefore, he achieved a new non-invasivemethod of destroying discrete anatomical regions within the brain whilepreserving the surrounding normal tissues. In 1967, the first Gamma Knifeunit was put into clinical use in Karolinska and this was a 179 cobalt 60source.
  65. 65. The Mayo Clinic gamma knife experience:indications and initial results.
  66. 66. On average, about 92% of acoustic neuromas treated with GammaKnife radiosurgery demonstrate tumor shrinkage or growthcessation over two to five years. Hearing is preserved at pre-Gamma Knife levels in as many as 51% of patients
  67. 67. Brain MetastasesTreatment Median Survival Local FailureWhole brain external 8 – 15 w 52%surgical resection 33 – 38 w 20%rasdiosurgery 44 w 14%
  68. 68. Brain Metastasis and External BeamIrradiation
  69. 69. Brain Metastasisand Radiosurgery
  70. 70. Cyberknife Radiosurgery
  71. 71. Cyberknife Radiosurgery of the Spine
  72. 72. Strategies to Improve the Effectiveness of Radiation Use chemical or chemotherapy to make the cancer cells more sensitive to radiation Design ways to focus the radiation more precisely and allow the use of higher doses (conformal 3D, IMRT or radiosurgery) Implant the radiation directly into the tumor (brachytherapy, with wires or seeds, or isotopes or monoclonal antibodies)
  73. 73. HDR Treatments
  74. 74. GYN Intracavitary Cesium
  75. 75. Interstitial Implant
  76. 76. Prostate Seed Implantation
  77. 77. Prostate Cancer Cure RatesExternal Beam versus Seeds versus Surgery
  78. 78. Mammosite for Breast Cancer
  79. 79. HDR = high dose rate machine that can runradiation through a tube that reaches the patientthrough skin applicators
  80. 80. Radiation for Skin CancerHDR skin applicators – three times a weekfor 6 treatments over a two week period
  81. 81. The HDR Skin applicator is taped inplace over the cancer
  82. 82. The applicator is attached by cable to the machine thatmakes it radioactive for a few minutes
  83. 83. Small squamouscancer of the chin,appearance 3.5weeks afterradiation (HDR)
  84. 84. Radiation Isotope Therapy for Bone MetastasesSamarium 153 (SM 153) or Quadramet Samarium is nowbeing used along with Strontium. Samarium has a short half-life (46 hours) with 75% of the dose absorbed within 4 days.The beta particle energy (233keV) penetrates 1.7mm in boneand 3.1 mm in soft tissue. In trials, 48-54% get pain relief.Metastron or Strontium-89 (Sr-89) Sr-89 is a beta-emittingradionuclide with a long physical half-life (50.5 days)
  85. 85. Radio-active Monoclonal Antibodiesmonoclonal antibody targets the CD20 antigen, which is found on the surface of B-cell tumors
  86. 86. Radio-active Monoclonal AntibodiesIn February 2002, Zevalin was the first radioimmunotherapy toreceive FDA approval. Zevalin consists of a monoclonal antibodylinked to the radioactive isotope yttrium-90. After infusion into apatient, the monoclonal antibody targets the CD20 antigen, whichis found on the surface of B-cell tumors. In this manner, cytotoxicradiation is delivered directly to malignant cells.On June 30, 2003 announced FDA approval of BEXXAR(Tositumomab and Iodine I 131 Tositumomab)
  87. 87. www.aboutcancer.comCancer Information anatomy and imagingGeneral Cancer Statistics site mapCancer News, Stages, Old StagesMost Common Cancers* brain* breast* colon/rectum* gynecologic* head and neck (mouth, tongue, oral, etc.)* lung* metastatic* prostate* skin cancerOther Specific CancersRadiation or Chemotherapy or SurgeryCancer CalculatorsBest Web SitesAdvice for Everyone