Radiation Oncology From Orthovoltage To Megavoltage Era

History
Radiation Oncology From
Orthovoltage To Megavoltage Era
Dr Kanhu Charan Patro
1
CRABECON VIRTUAL JAMMU /2020

Statistics
• >9.7 million cases are detected each
year
• 6.7 million people will die from
cancer
• Every day, around 1700 Americans
die of the disease
• 20.4 million people living with cancer
in the world today
• 1 in 3 people will be diagnosed with
cancer in the UK and 1 in 4 will die
from their disease
3

Oncologist
Diagnosis
Treatment
Radiologist
Cytopathologist
Surgeon
HistopathologistMolecular
Pathologist
Geneticist
psychiatrist
Nursing
And
Support staff
Audit
8

Role of radiotherapy in various cancers
• Needed for all most head and neck cancer
• Radical-
• Naso-pharynx, cervix,laryx,hypopharynx etc.
• post-op-adjuvant
• Rectum, cervix early, stomach, head and neck, other
abdominal malignancies
• Palliative
• compression, bleeding,obstruction,pian
9

History - radiation
1896 – Becquerel - Radioactivity
1898 – Madam Curie / Pierre Curie - Radium
1903 – Nobel Prize for Curie’s & Becquerel
1903 – First successful case of malignancy basal cell carcinoma of face
12

1. William Roentgen discovered X-Rays in 1895
while studying cathode rays in a gas
discharge tube.
2. He observed that another type of radiation
was produced that could be detected
outside the tube.
3. This radiation could penetrate opaque
substances,produce flourescence, blacken a
photographic plate and ionize a gas.
4. He named this new radiation as X-Rays.
14

1. He also noted that these X-rays could be used to image bones.
2. In fact one of the first known x-ray images ever produced was of his wife Bertha’s left
hand.
3. Roentgen characterized and validated his findings in a technical report within 6
weeks.
4. News of Roentgen’s remarkable discovery travelled rapidly around the world.
5. In recognition of his ground-breaking research, he was awarded the first Nobel Prize
in Physics in 1901.
15

1. Henri Becquerel's discovery of spontaneous radioactivity
2. When Henri Becquerel investigated the
newly discovered X-rays in 1896, it led to studies of
how uranium salts are affected by light.
3. By accident, he discovered that uranium salts
spontaneously emit a penetrating radiation that can
be registered on a photographic plate.
4. Although it was Henri Becquerel that discovered the
phenomenon, it was his doctoral student, Marie
Curie, who named it: radioactivity
5. Received the 1903 Nobel Prize in Physics
Antoine Henri Becquerel
16

1. Bequerel’s doctoral students Marie Curie with her
husband Pierre Curie showed that Bequerel rays
could be measured using ionising techniques , and
radiation intensity is directly proportional to the
amount of uranium in a substance.
2. They also isolated the first known radioactive
elements Polonium and Radium in 1898.
3. Marie Curie was a physicist, chemist and a pioneer in
the study of radiation. ... She and her husband, Pierre,
discovered the elements polonium and radium.
4. They and Henri Becquerel were awarded the Nobel
Prize in Physics in 1903, and Marie received the Nobel
Prize in Chemistry in 1911
Marie Skłodowska Curie
17

1. Medical student in Chicago named ‘Emil Grubbe’ noted
pealing of his hands on exposure to X- Rays.
2. He convinced his professor and assembled his x-ray
machine in Chicago in 1896 itself , and that same
year, used it to treat a woman named ‘Rose Lee’ with
recurrent carcinoma of the breast.
3. By 1960, Grubbe had instructed over 7000 other doctors
in the medical use of x-rays.
4. In the course of his lifetime, he underwent more than
90 surgeries for multiple cancers caused by his intense,
ongoing exposure to radiation
Emil Grubbe
18

1. Henri Coutard, an early French Radiation
Oncologist pioneered the use of
fractionated Radiotherapy in a wide
variety of tumors.
2. He reported impressive results using this
approach in patients with locally
advanced laryngeal cancers in 1934.
Henri Coutard
20

1. Despite their promise, an important
limitation of the early x-ray machines was
their inability to produce high energy,
deeply penetrating beams.
2. It was thus difficult to treat deep-seated
tumors without excessive skin reactions.
Drawbacks of orthovoltage
21

1. In 1949, Dr. Harold E. Johns , a Canadian
medical physicist sent a
request to the National Research
Council(NRC) asking them to produce Cobalt-
60 isotopes for use in a cobalt therapy unit
prototype.
2. On October 27, 1951, the world’s first cancer
treatment with COBALT 60
radiation took place at Victoria Hospital for a
43 year old cervical cancer patient.
3. This marked an important milestone
for the fight against cancer.
Dr. Harold E. Johns
23

1. Despite advances made in radiation therapy technology, the Cobalt-60
unit remains the world’s main radiotherapy machine.
2. Due to its cost effectiveness, reliability and ease of use, it is prevalent
in developing countries.
3. Cobalt-60 technology is currently used to treat roughly 70 per cent of the
world’s cancer cases treated by radiation.
25

1. An exciting development was the introduction
of high energy (megavoltage) treatment
machines, known as LINEAR
ACCELERATORS OR LINACS .
2. Such machines were capable of producing
high energy, deeply penetrating beams,
allowing for the very first time treatment of
tumors deep inside the body without
excessive damage to the overlying skin and
other normal tissues.
LINEAR ACCELERATORS
26

Dr. Henry Kaplan and physicist Edward
Ginzton developed the first medical
linear accelerator at Stanford University,
San Francisco in 1956.
First linear accelerator
27

1. The first patient to be treated using
this machine was a 2 year old child
named ‘Gordon Isaacs’ with
retinoblastoma.
2. Treatment was highly successful .
For more than 40 years later, this
patient remained free of disease with
good vision.
Gordon Isaacs
29

1. With the advent of computers, of newer
technological advances, the radiotherapy planning
systems underwent a drastic makeover.
2. In subsequent years, the field of Radiation
Oncology experienced multiple technologic
revolutions
Computers
34

1. It was in 1990’s that 3-D Conformal
Radiotherapy, a form of radiation therapy
where the fields used are designed such that
the radiation dose is mostly delivered to the
tumor, while the surrounding tissues receive
little to no radiation dose.
2. This attempts to deliver a tumoricidal dose
to the tumor while minimizing the damage
to the surrounding healthy tissues.
3. 3-dimensional information about the
patient's body is supplied by the CT-
simulations process.
3-D Conformal Radiotherapy
35

1. Intensity-modulated radiation
therapy (IMRT) is an advanced
form of three-dimensional
conformal radiotherapy(3DCRT).
2. It uses sophisticated software and
hardware to vary the shape and
intensity of radiation delivered to
different parts of the treatment
area.
36
Intensity Modulated
Radiotherapy

1. Today, Radiation Therapy is in
the midst of yet another
important technologic
revolution, namely (IGRT).
2. While not truly new, IGRT is
rapidly growing in popularity
primarily due to the
widespread adoption of new
linear accelerators which
function both as treatment
and imaging machines.
Image-Guided Radiation Therapy
37

Thus we have seen that over a period of just 120 years,
the modality of radiotherapy has evolved rapidly from
some anonymous rays to the present scenario where
radiotherapy is almost indispensible when it comes to the
cure of cancer.
Growth means change and change involves risk,
stepping from the known to the unknown.
38

GOALS
 High dose to tumor tissue-Tumor control
 Normal tissue sparing
 Minimize long and short term toxicities
 Better Quality of life
39

Treatment
• Delivered 5 days per week over 6-8 weeks
• Typical treatment takes around 5 minutes
• Treatment is painless--like having an X-ray taken
• No radioactive substances involved; beam goes
on/off
• Side effects usually temporary; controlled with
medication/diet
• Covered by Medicare and many other insurance
companies
40

Types of radiotherapy
41
TELETHERAPY
BRACHYTHERAPY

IMAGE GUIDED RADIATION THERAPY
42
EQUIPMENT REQUIRED
CT-SCAN MRI PET-CT

Plaster of Paris Mould-older method
45

Evolution of Treatment
Techniques
51
CUSTOMISED BLOCKS
MULTILEAF COLLIMATOR
BASED 3D-CRT
1990s1980s

Treating Head & Neck with Sliding Windows
53

IMRT
• Divides each treatment field into
multiple segments
• Modulates beam intensity, giving
discrete dose to each segment
• Uses multiple, shaped beams
(~9) and thousands of segments
IMRT Initiated in 1995
Reached the clinic in 2000

Small Volume Adjacent to Critical Structure
60

3D Dose Shaping - H&N and Brain
61
Brain
Stem

Target Motion in
Radiotherapy
62
Caveman et al
Oops! The target
moves!
IGRT/GATED RT

•CONVENTIONAL
•3DCRT
•IMRT
•IGRT
•VMAT/RAPIDARC
•PET /FUNCTIONAL GUIDED
RADIOTHERAPY
69

Brachytherapy is a form of radiotherapy where a sealed
radiation source is placed inside or next to the area
requiring treatment. Brachy is Greek for short
78

1. Many early advocates of Radiation Therapy thus relied instead on the
placement of radioactive sources in close proximity or even within the
tumor, a technique known as BRACHYTHERAPY.
2. This modality dates back to when Pierre
3. Curie suggested to Danlos that a radioactive source could be inserted
into a tumour.
4. It was found that the radiation caused the tumour to shrink.
5. In the early twentieth century, techniques for the application of
brachytherapy were pioneered at the Curie institute in Paris by Danlos.
79

Ralston Patterson who was a
radiologist and who had keen interest
in newer advances related to the field
was appointed as Director of the Holt
Radium Institute in 1931, who went
on to build a world recognised centre
for the treatment of cancer by
radiation.
82

Herbert Parker who was a medical
physicist at the Holt Radium institute
who developed the MANCHESTER
SYSTEM for radium therapy along with
Patterson in 1932
83

1. Following initial interest in
brachytherapy in Europe and the US, its
use declined in the middle of the
twentieth century due to the problem of
radiation exposure to operators from the
manual application of the radioactive
sources.
2. However, the development of remote
afterloading systems, which allow the
radiation to be delivered from a shielded
safe, in the 1950s and 1960s, reduced
the risk of unnecessary radiation
exposure to the operator and patients.
84

ORGAN PRESERVATION
• HEAD AND NECK CANCERS
• BREAST CANCERS
• ESOPHAGUS CANCERS
• PENILE CANCER
• SOFT TISSUE SARCOMA
• BLADDER CANCERS
• CANAL CANCERS
97

Intra- operative Brachytherapy
procedure
99

ORGAN PRESERVATION FOR
CANCER ANAL CANAL
115

ORGAN PRESERVATION FOR
CANCER TONGUE
117

TONGUE IMPLANT IN PROGRESS
118

119
ORGAN PRESERVATION FORCANCER LIP

Applicator in situ with IOP
123

Complete response –towards healing
hypo-pigmentation
124

Just “Doing It” is not good enough !
You must know “what” to do and “where” to do it !
10/20/12 01:12 PM 139
139

Radiation Oncology From Orthovoltage To Megavoltage Era

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