Definition of Radiation Oncology
• discipline of human medicine concerned with the
generation, conservation, and dissemination of
knowledge concerning the causes, prevention, and
treatment of cancer and other diseases involving
special expertise in the therapeutic applications of
• radiation oncology is concerned with the investigation
of the fundamental principles of cancer biology, the
biologic interaction of radiation with normal and
malignant tissue, and the physical basis of therapeutic
• As a learned profession, radiation oncology is
concerned with clinical care, scientific research, and
the education of professionals within the discipline.
The aim of radiation therapy
• to deliver a precisely measured dose of
radiation to a defined tumor volume with as
minimal damage as possible to surrounding
healthy tissue, resulting in eradication of the
tumor, a high quality of life, and prolongation
of survival at competitive cost.
• under our care we take full and exclusive responsibility,
exactly as does the surgeon who takes care of a patient
• This means that we examine the patient personally, review
the microscopic material, perform examinations and take a
biopsy if necessary.
• On the basis of this thorough clinical investigation we
consider the plan of treatment and suggest it to the
referring physician and to the patient.
• We reserve for ourselves the right to an independent
opinion regarding diagnosis and advisable therapy and if
necessary, the right of disagreement with the referring
• During the course of treatment, we ourselves direct any
additional medication that may be necessary and are ready
to be called in an emergency at any time.
Photon E = h(energy = Planck’s const x frequency)
= hc/ (c = speed of light, = wave length)
10-9 10-8 10-7 10-6 10-5 10-4 10-3 10-2 10-1 1 10 102 103 104
Infra Red Radio Waves
Microwaves Short Waves
RADIATION NON-IONIZING RADIATION
E (eV) 1.24x107 1.24x102 1.24x10-13
X Ray tube
Voltage of a Lightning Bolt
110-240 Volts 80-140Kilo Volts 3 to 120 million volts
Telecobalt Machine Linear Accelerator
1.1 Mv (Mega =
Low Energy - 4-6 MV
High Energy - 18 Mv
6 Million Volts
18 Million Volts
• Basics of Radiation Therapy
– High energy Ionizing Radiation – X / γ Rays
– Interaction of Radiation with matter
Rad / Gray / cGy
Cancer Cell & Ionizing Radiation
• Cancer cell multiply faster than normal cell
• DNA is primary target
• Double Strand breaks
>>> Reproductive Cell Death
• Injury to DNA is the primary mechanism by which
ionizing radiation kills cells .
– Most DNA damage is repaired
– Lethal double-strand breaks -persist (locally multiply
damaged sites (300) of about 15 to 20 nucleotides in size)
– Micronuclei formation
– Chromosome aberrations
– Cell death through loss of the reproductive integrity of the
• Many biologic factors affect the relationship between
the amount of physical energy deposited, the extent of
DNA damage that is caused, the number of cells that
are killed, and the severity of the tissue response
• Radiation therapy is the art of using high
energy ionizing radiation to destroy malignant
tumors while being able to minimize damage
to normal tissue.
• To be practiced like a Religion
Radioactive source loading
Pre Loaded After loading
– Intracavitory / Luminal
– Surface Mould
1895- 1920s : Seeding - X - Ray & Radium
1920 – 1930 : embryo Phase
1930 -1950 : Quisent phase : World War I & II
•Development in Radar Technology
1950 – 1970 : Development Phase: Telecobalt & Linear
1980 – 2000 : Infancy
2000-2005 : Growth Phase
2005 – 2010 : Maturation Phase
2010 – 2015 : Flower
> 2015 : Fruits
Marie Curie (1867 – 1934)
Born in Poland
University of Paris age 24
Discovered Radium 1898
t1/2 = 1602 years
Irene Joliot-Curie and Frederic Joliot Curie
• Artificial radioactivity
Emil Grubbe (1875-1960)
: the World’s first Radiation Oncologist.
• medical student in Chicago
• convinced his professor to
allow him to irradiate a
cancer patient, a woman
named Rose Lee
• Ms. Lee benefited greatly
from Grubbe’s intervention,
demonstrating the potential
value of x-ray treatments.
Claude Regaud (1870-1940) : Paris
• recognized that treatment may be better tolerated
and more effective if delivered more slowly with
modest doses per day over several weeks.
Henri Coutard (1876-1950) Paris
• pioneered the use of fractionated
Radiotherapy in a wide variety of
• Note, he reported impressive
results using this approach in
patients with locally advanced
laryngeal cancers. His seminal
1934 report of the outcome of
these patients is still quoted
Ralston Patterson (1897-1981) : England
• Holt Radium Hospital - center for radiation
treatment and research
• MD Anderson Cancer Center
• established optimal
treatment regimens in a
wide variety of tumor sites
including head and neck
cancers and cervical cancer.
Brief History of Radiation Therapy
• 1895 W.K.Rontgen discovered X-Rays.
• The first patient was treated with radiation in 1896,
two months after the discovery of the X-ray.
• 1896 Becquerel reported natural radioactivity in
• 1898 Marie and Pierre Curie isolated radium from
• 1900 Villard reported that radium emitted alpha,
beta and gamma radiations.
• 1934 Frederic and Irene Joliot (Curie’s daughter)
discovered artificial radioactivity.
FIRST CURE OF CANCER BY X-RAYS
1899 - BASAL CELL CARCINOMA
X-rays were used to cure cancer very soon after their discovery
Natural radioactivity was discovered by Becquerel, who was awarded the Nobel Prize
in Physics in 1903 along with Marie and Pierre Curie "in recognition of the
extraordinary services they have rendered by their joint researches on the radiation
“One wraps a Lumiere photographic plate with a bromide emulsion in two sheets of very thick black paper, such that the plate does not become clouded upon
being exposed to the sun for a day. One places on the sheet of paper, on the outside, a slab of the phosphorescent substance, and one exposes the whole to
the sun for several hours. When one then develops the photographic plate, one recognizes that the silhouette of the phosphorescent substance appears in
black on the negative. If one places between the phosphorescent substance and the paper a piece of money or a metal screen pierced with a cut-out design,
one sees the image of these objects appear on the negative. One must conclude from these experiments that the phosphorescent substance in question emits
rays which pass through the opaque paper and reduces silver salts.” Paris 1896
Maltese crossHenri Becquerel Marie Curie
Radioisotopes also were soon being used
to treat and cure cancer.
Radium applicators were used for many
and implants are still
in common use, for
example in prostate
cure of cancer
plaque - 1922
• 1898 Becquerel’s vest-pocket skin erythema and reports
of x-ray ‘burns’.
• 1903 Bergonie and Tribondeau described radiosenstivity
of proliferating cells.
• 1930 Coutard proposed treatment fractionation.
• 1950 Paterson’s definition of Therapeutic Ratio: Normal
Tissue Tolerance/ Tumor Control Dose.
THE EVOLUTION OF RADIOTHERAPEUTIC
TECHNIQUES :EARLY CHALLENGES
• Detection of Ionizing Radiation
• Defining the Quality of Radiation
• Defining the Quantity of Radiation
• Understanding the Mechanism of Action of
• Optimizing Radiation Delivery Equipments
THE EVOLUTION: Measuring Radiation Dose:
• Skin Erythema Dose.
• 1902 Holzknecht in Vienna developed the Chromoradiometer -
An apparatus once used for estimating radiation exposure by
means of the color changes produced in slides placed next to
• 1904 Sabouraud and Noire in France modified Holzknecht’s
method to Pastille-dose technique using pastilles of barium
• 1913 Ionization current measurement developed in Paris, and
adopted in 1928 at the ICR as the standard unit “r”: x or gamma
radiation producing 1 e.s.u in 1 cc of air.
• 1953 at the ICR the ‘rad’ was introduced as the unit of absorbed
dose: equal to 100 ergs per gram.
• 1970 the rad was redefined in a metric system: the Gray: joules
absorbed per kg. 1 Gray = 100 rads.
THE EVOLUTION : Quality of Radiation
1913 Coolidge in the USA engineered the first successful X-ray
tube using hot-filament and Tungsten target.
1920 higher voltages X ray units with more powerful
transformers and rectifiers:
Contact therapy @ 50 KV,
Superficial @ 100-150 KV
Deep X-rays @ 200-400 KV.
Effect of added filtration.
Quality measured by HVL.
1933-1950 the evolution Megavolt era:
Van de Graaff electrostatic,
the Cobalt units and
the Linear accelerator.
History of Particle Beam Therapy
1938 Neutron therapy by John Lawrence and R.S. Stone
1946 Robert Wilson suggests protons
1948 Extensive studies at Berkeley confirm Wilson
1954 Protons used on patients in Berkeley
1957 Uppsala duplicates Berkeley results on patients
1961 First treatment at Harvard (By the time the facility closed
in 2002, 9,111patients had been treated.)
1968 Dubna proton facility opens
1969 Moscow proton facility opens
1972 Neutron therapy initiated at MD Anderson (Soon 6 places in
1974 Patient treated with pi meson beam at Los Alamos (Terminate
in 1981) (Starts and stops also at PSI and TRIUMF)
1975 St. Petersburg proton therapy facility opens
1975 Harvard team pioneers eye cancer treatment with protons
1976 Neutron therapy initiated at Fermilab. (By the time the
facility closed in 2003, 3,100 patients had been treated)
1977 Bevalac starts ion treatment of patients. (By the time the
facility closed in 1992, 223 patients had been treated.)
1979 Chiba opens with proton therapy
1988 Proton therapy approved by FDA
1989 Proton therapy at Clatterbridge
1990 Medicare covers proton therapy and Particle Therapy
Cooperative Group (PTCOG) is formed:
1990 First hospital-based facility at Loma Linda (California)
THE EVOLUTION OF RADIOTHERAPEUTIC
Understanding the biology of Cancer:
The natural history of different tumors based
on cell types.
The importance of cancer staging.
Retrospective outcome studies and
prospective Clinical Trials.
Identifying Dose Response expectations.
• >1985 – CT scan for RT Planning , Involved Manual
Digitization of Contours only
• > 1990 – CT Scan Data was used for Target localization
– 3 D Rendering of Body contours and Tumour and normal
– Beams Eye view
• > 1995
– 3D Planning
– 3D Conformal Bocks
• CD Scan data of Tissue Density used for RT calculation
• > 1998 - 3 D Conformal RT
• 2000 : Evolution of IMRT (Conceptualized in 1960s)
• Early 2000 IGRT – Cyber knife , non-isocentric
mount , Celing mounted KV Imaging and
advanced verification and repositioning
• 2005 IMRT as a routine
• With IGRT – Adaptive Radiotherpay need for
• CT on Rails or Onboard Mv/Kv Cones CT
• Integration of ceiling mounted KV imaging
THE EVOLUTION OF RADIOTHERAPEUTIC
Impact of Modern Technology:
Impact of Computer technology.
New Imaging technology.
Advances in Molecular biology.
The multidisciplinary approach to Cancer
Image based treatment planning.
3-d conformal treatment planning.
Intensity Modulated Radiation Treatment
Image Guided Radiation Treatment and
Adaptive Radiation Treatment.
Investigational: Proton and Particle Therapy.
Key Mile stone
• Use of CT Scan DICOM image for RT Planning
• 3 D rendering
MLC Multileaf collimator
• Maximum field size: 72 x 63 mm
•Number of leaves: 40 per side
•Leaf thickness: 1 mm
• Maximum field size: 100 x 100
•Number of leaves: 26 per side
•Leaf thickness: 5.5, 4.5, 3 mm
t ½ = 60 days
Energy 35 kV
Control of Radiation Delivery
Present : KMIO RO
• Orthovoltage – 1 (not
• Telecobalt – 3 (1 due for
• Linear Accelerator
– Low energy : Simple – 1
– High – Dual energy : 3DCR
/IMRT/Electorns - 1
• HDR – 1
– ICBT - 2
– ISBT – due for
– ILBT - 1
• LDR – 2 sets
Fully Automated ,
State of the Art
High energy Linear Accelerators
4 IMRT – Advanced rotational
4D / 6D
Advanced tumor tracking
Whole body SBRT
HDR Brachytherapy 2 IR / Cobalt
Virtual Widebore CT Simulators 2
Permanent Implant Brachytherapy
suit with advanced planning system
1 Capable of handling Iodine seed –
BARC / Imported
Intra operative Electronic
Brachytherapy / Electorns suit
Advanced Doismetry equipments Set
Future - Research
• Cell biology - understand effects of ionizing radiation on cells,
tumors, and normal tissues.
• molecular cancer biology - clinical decision-making in oncology
• development of novel biology-driven strategies in the
multidisciplinary clinical environment.
– Molecular pathology of tumors - basis for improved
treatment stratification in oncology .
– Molecular pathophysiology - manifestation of radiation
sequelae in normal tissues .
– Molecular imaging - staging , biologic characterization of
tumors, and for determination of target volumes in
radiation oncology, including new approaches such as dose
– Molecular targeting in radiotherapy - enhancing the
therapeutic gain of the treatment.
1-25 MeV Major improvements in RT
during the mid-1900s came
from improved penumbra
and decreased skin dose
associated with higher
energy x-rays, cobalt, and
high energy photons.
More recently conformal
RT, IMRT, IGRT,
tomotherapy, SRS, SRT,
protons, heavy ions, etc.
have added considerable
variety to the choices for
physical radiation delivery
and present radiobiological