Information Package for Residency in Radiation Oncology Physics


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Information Package for Residency in Radiation Oncology Physics

  1. 1. September 2010 Information Package for Residency in Radiation Oncology Physics Department of Medical Physics McGill University Health Centre The Montreal General hospital 1650 avenue Cedar Montréal, Québec, Canada H3G 1A4 Tel.: 514 934-8052 Fax: 514 934-8229 e-mail: web: 1
  2. 2. TABLE OF CONTENTS Page General Information ............................................................................................ 2 Teaching Faculty ................................................................................................ 3 Residency Training Committee ........................................................................... 3 Facts-in-brief ....................................................................................................... 4 Rights, Rules, and Regulations ........................................................................... 6 Regular Meetings, Seminars, and Colloquia ....................................................... 7 Recommended Literature ................................................................................... 8 Mandatory Courses ............................................................................................. 9 Clinical Rotations ................................................................................................ 14 Radiation Safety .................................................................................................. 20 2
  3. 3. Department of Medical Physics, McGill University Health Centre Medical Physics Unit, McGill University Montréal, Québec, Canada The residency program is of 2-years duration and provides the resident with clinical experience and theoretical knowledge in all aspects of modern radiation oncology physics. An important objective of the program is to prepare the resident for the professional examination and licensure process in the specialty of Radiation Oncology Physics. The residency program consists of four rotations and four didactic courses. Minimum requirement for admission is M.Sc. degree in Medical Physics; however, the preferred candidate will have a M.Sc. or Ph.D. degree in Medical Physics from a CAMPEP-accredited educational program in Medical Physics. Remuneration is comparable to that received by Post-Doctoral Fellows at McGill University. The four rotations are as follows: (1) Basic Treatment Planning and Standard Treatment Techniques (2) Advanced Treatment Planning and Special Treatment Techniques (3) Quality Assurance and Radiation Protection (4) Clinical Physics Practice and Clinical Physics Project Each rotation is followed by a comprehensive examination. The four didactic courses are as follows: (1) Radiation Physics (MDPH-601) (2) Applied Dosimetry (MDPH-602) (3) Radiation Biology (MDPH-609) (4) Health Physics and Radiation Protection (MDPH-613) A resident who already completed a particular course during graduate studies may obtain a course exemption. 3
  4. 4. Requirements for Successful Program Completion The residents complete the program after the following requirements are fulfilled: • All four rotations completed in a minimum time of 24 months. • All four rotation examinations passed. • Final examination passed. • Successful completion of course work (if required). • Completion of self directed anatomy course. • Satisfactory attendance record (better than 80%) at all prescribed seminars organized by the Medical Physics and Radiation Oncology departments. • The resident has completed the above requirements while behaving in a professional and ethical manner, respecting colleagues, staff members, and patients, demonstrating appropriate industry, competence, responsibility, and learning abilities. 4
  5. 5. Residency Training Committee Program Director: William Parker, M.Sc, FCCPM, Program Director/Clinical Coordinator Co-Chairs: William Parker, M.Sc, FCCPM, Program Director/Clinical Coordinator Jan Seuntjens, Ph.D., FCCPM, FAAPM, Graduate Program Director Clinical coordinator: William Parker, M.Sc, FCCPM, Program director/clinical coordinator Secretary: Michael D.C. Evans, M.Sc., FCCPM Physics Members: Horacio Patrocinio, M.Sc., FCCPM, DABR Russell Ruo, M.Sc., MCCPM Emilie Soisson, Ph.D., CMD, MCCPM, DABR Francois DeBlois, Ph.D., FCCPM (JGH) Physician Members: David Roberge, M.D., FRCPC Co-Chair of Residency Training in Radiation Oncology at McGill University Treatment Planning Dosimetry: Christopher Kaufmann, R.T. (A.C.), CMD (Dosimetry Coordinator) 5
  6. 6. Teaching Faculty and Staff List - MUHC Academic Staff (McGill University - Medical Physics Unit) Administrative Assistant Margery Knewstubb Medical Physicists Jan Seuntjens, PhD, FCCPM, FAAPM (Associate Professor, Director MPU) Issam El-Naqa, PhD (Associate Professor) Ervin Podgorsak, PhD, FCCPM, DABMP, FAAPM (Professor Emeritus) Clinical Staff (MUHC - Montreal General Hospital) Administrative Officer Tatjana Nisic, MA Medical Physicists William Parker, MSc, FCCPM (Chief, Department of Medical Physics, MUHC) Michael Evans, MSc, FCCPM (Radiation Safety Officer, Class II, MUHC) Horacio Patrocinio, MSc, FCCPM, DABR Russell Ruo, MSc, MCCPM, DABR Emilie Soisson, PhD, CMD, MCCPM, DABR Maritza Hobson, PhD (September 2010) Steve Davis, PhD (September 2010) Gyorgy Heygi, PhD (Medical Imaging Physicist) Residents Emily Poon, PhD (Staff in Residency program) Arman Sarfehnia, PhD (Staff in Residency program) John Kildea, PhD (Staff in Residency program) Dosimetrists Chris Kaufmann, RTT, CMD (Chief Dosimetrist) Cenzetta Procaccini, RTT Irene Belanger, RTT Line Comeau, RTT, CMD Mamdouh Mansour, RTT Dinesh Parmar, RTT Loudmila Dychant, RTT Collette Charrois, RTT, CMD Francesco Paolino, RTT, BSc Post Doctoral Fellow Naeem Anjum, PhD Electronic Engineers/Technicians/Machine shop Pierre Leger, BEng (Chief Engineer) Joe Larkin Bhavan Siva, BEng Robin Van Gils (Machine shop) Information Systems Technician Suzana Darvasi, BSc 6
  7. 7. Teaching Faculty and Staff List - JGH Administrative Officer Nicole Gendron, MBA Medical Physicists François DeBlois, Ph.D., FCCPM (Chief Physicist) Krum Asiev, M.Sc. MCCPM Jennifer Barker, M.Sc. MCCPM (Radiation Safety Officer Class II) Slobodan Devic, Ph.D. FCCPM Liheng Liang, M.Sc. MCCPM DABR (alternate RSO Class II) Gabriela Stroian, Ph,D. Nada Tomic, M.Sc. MCCPM Residents (MUHC) Jonathan Thébaut, M.Sc. (staff in residency program) Joseph Holmes, M.Sc. Dosimetrists Isbelle Lavoie (Coordinator) Sareoun Men Chris Papadopoulos Julie Skelly, CMD Electronic Engineers/Technicians Filippo Piccolo, B. Eng. Daniel Dufault 7
  8. 8. Medical Physics Unit – McGill University “FACTS IN BRIEF” Details regarding the graduate programs and research in medical physics can be found on the Medical Physics Unit website at: Established: in September 1979 by the Faculty of Medicine of McGill University in Montréal Directors: M. Cohen (September 1979 to August 1991) E.B. Podgorsak (September 1991 to date) M.Sc. and Ph.D. GRADUATE PROGRAMS: • Degrees offered: M.Sc. and Ph.D. in medical physics • Accreditation: CAMPEP* accredited the M.Sc. and Ph.D. programs in 1993 for a five-year term • Re-accreditation: CAMPEP* re-accredited the two programs in 1998 & 2003 for new five-year terms • M.Sc. degrees conferred to date: 130 • Ph.D. degrees conferred to date: 18 • Current M.Sc. student enrollment: 29 • Current Ph.D. student enrollment: 8 • Number of mandatory courses: 12 • Number of academic faculty: 6 • Number of clinical faculty: 14 • Number of affiliated members 2 RESIDENCY PROGRAM IN RADIATION ONCOLOGY PHYSICS: • Formally offered: Since 1997 • Accreditation: CAMPEP* accredited the Residency program in 2000 for a five-year term • Number of graduates to date: 8 • Current enrollment: 4 • Program duration (years): 2 • Number of mandatory rotations: 4 • Number of mandatory courses: 4 * CAMPEP, the Commission on Accreditation of Medical Physics Educational Programs, is sponsored by: • American Association of Physicists in Medicine (AAPM) • American College of Medical Physics (ACMP) • American College of Radiology (ACR) • Canadian College of Physicists in Medicine (CCPM) 8
  9. 9. Rights, Rules & Regulations Rights, Rules & Regulations governing the Residency Training Program in Radiation Oncology Physics • For the 2-year duration of the training the resident is considered a staff member of the MUHC Medical Physics Department and has the same rights, privileges and obligations as the permanent staff members, with the exception that the residentʼs position is classified as a temporary 2-year appointment. • Vacation allowance: 20 working days/year. • Statutory holidays: 13 days/year. • Sick days: up to 0.8 days/month, i.e., 9.6 days/year. • Remuneration: as per signed contract. • Office desk and computer: assigned upon start of residency. • Open access to libraries, xerox machine, and fax machine for official use. • Grievances are to be addressed to the program director who is also the Chairman of the Residency Training Committee. • Radiation safety concerns should be addressed to the Radiation Safety Officer (Class II) for the MUHC Medical Physics and Radiation Oncology Departments. • Normal working hours are 08:30-16:30; occasional evening and weekend work will be required to gain experience with QA procedures and equipment commissioning carried out by staff medical physicists. • Scheduling of rotations, end-of-rotation examinations, research colloquium, and vacation time is arranged with the clinical coordinator. 9
  10. 10. Recommended literature for Radiation Oncology Physics Residents 1. Bentel, Gunilla: “Radiation Therapy Planning”, Second edition, McGraw-Hill, New York, New York (1995). 2. Chao, Clifford KS; Perez, Carlos; Brady, Luther: “Radiation Oncology Management Decisions”, Second edition, Lippincott, Williams and Wilkins, Baltimore, Maryland (2002). 3. Johns, Harold E; Cunningham, John R: “The Physics of Radiology”, Fourth edition, Thomas, Springfield, Illinois (1984). 4. Khan, F: “The Physics of Radiation Therapy”, Third edition, Williams and Wilkins, Baltimore, Maryland (2003). 5. Khan, Faiz M; Potish, Roger A (Editors): “Treatment Planning in Radiation Oncology”, Williams and Wilkins, Baltimore, Maryland (1998). 6. Podgorsak, Ervin B (Editor): “Review of Radiation Oncology Physics: A Handbook for Teachers and Students”; International Atomic Energy Agency (IAEA), Vienna, Austria (2005). The book is also available at 7. Van Dyk, Jake (Editor): “The Modern Technology of Radiation Oncology: A Compendium for Medical Physicists and Radiation Oncologists”, Medical Physics Publishing, Madison, Wisconsin (1999). 8. BRITISH JOURNAL OF RADIOLOGY, Supplement 25, “Central Axis Depth Dose Data for Use in Radiotherapy”, The British Institute of Radiology, London, U.K. (1996). 9. INTERNATIONAL COMMISSION ON RADIATION UNITS AND MEASUREMENTS, ICRU Report 50, “Prescribing, Recording, and Reporting Photon Beam Therapy”, ICRU, Bethesda, Maryland (1993). 10. INTERNATIONAL COMMISSION ON RADIATION UNITS AND MEASUREMENTS, ICRU Report 62, “Prescribing, Recording, and Reporting Photon Beam Therapy (Supplement to ICRU Report 50)”, ICRU, Bethesda, Maryland (1999). 11. INTERNATIONAL COMMISSION ON RADIATION UNITS AND MEASUREMENTS, ICRU Report 58,”Dose and volume specification for reporting interstitial therapy”, ICRU, Bethesda, Maryland (1997). 12. INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION (ICRP), Publication 60, “ Recommendations of the ICRP on Radiological Protection”, Annals of the ICRP 21 (1-3), Pergamon Press, Oxford, U.K. (1991). 10
  11. 11. RESIDENCY IN RADIATION ONCOLOGY PHYSICS OUTLINES FOR MANDATORY COURSES* (1) MDPH 601 Radiation Physics (2) MDPH 602 Applied Dosimetry (3) MDPH 609 Radiation Biology (4) MDPH 613 Health Physics and Radiation Protection * These courses are given to graduate students registered in the M.Sc. program in Medical Physics at McGill University. Residents who did not take these courses during their graduate studies in Physics or Medical Physics must pass these courses in partial fulfillment of requirements for residency graduation. The typical course load for residents is one course per semester. 11
  12. 12. RADIATION PHYSICS COURSE MDPH 601 : 3 CREDITS Prerequisites : Undergraduate physics and mathematics Corequisites : None Instructors: E.B. Podgorsak, Ph.D.; J.P. Seuntjens, Ph.D. The course covers the fundamentals of radiation physics, including the production and properties of ionizing radiations and their interactions with matter. The course also includes the basic theoretical and experimental aspects of radiation dosimetry. COURSE OUTLINE 1. Review of relevant atomic and nuclear physics. Bohr atomic model. Rutherford scattering. Multi-electron atoms. Emission of photons. 2. Radiation from accelerated charges. Angular distribution of photons. Larmor relationship. 3. X-ray production and quality. X-ray spectra. Bremsstrahlung and characteristic radiation. Homogeneous and heterogeneous photon beams. Thin and thick x-ray targets. 4. Attenuation of photon beams in matter. Absorption and scatter of photon beams. Linear, mass, atomic and electronic attenuation coefficients. Energy transfer and energy absorption coefficients. Half-value layer and tenth-value layer: definition and measurement. 5. Interaction of photons with matter. Photoelectric effect. Rayleigh scattering. Compton effect. Pair production. Triplet production. Dependence of cross-sections on atomic number of material and photon energy. Photonuclear reactions. Interaction of neutrons with matter. 6. Interactions of charged particle beams (electrons, protons, heavy ions) with matter. Hard collisions, soft collisions, radiative collisions. Collisional and radiative stopping powers. Bremsstrahlung yield. Range of charged particles in matter. 7. Introduction to Monte Carlo techniques. Photon and electron transport. EGS4/PRESTA; BEAM and EGSNRC. 8. Concepts of dosimetry. Radiation quantities and units. Photon and particle fluence, exposure, kerma, dose, dose equivalent, activity. Buildup region. Electronic equilibrium. Dose to small mass of medium. 9. Cavity theory. 12
  13. 13. Bragg-Gray cavity. Averaging of stopping powers. Standard free air ion chamber. Thimble ion chamber. 10. Practical aspects of ionization chambers. Collection efficiency and ion recombination. Absolute and relative dosimetry techniques. Calibration methods for photon and electron beams. Cλ, CE, Ngas, the TG-21, TG-25 and TG-51 concepts. APPLIED DOSIMETRY COURSE MDPH 602 : 3 CREDITS Prerequisites : MDPH 601 Corequisites : None Instructor : E.B. Podgorsak, Ph.D. The course deals with the techniques, dosimetry, and equipment for external and internal irradiation of patients with sealed radiation sources. COURSE OUTLINE 1. The interaction of single beams of X and gamma rays with a scattering medium. Percent depth dose. Scatter function. Peak-scatter-factor. Tissue-air-ratio. Scatter-air-ratio. Tissue- maximum-ratio. Tissue-phantom ratio. Equivalent squares and circles. Irregular fields. Beam modifying devices. Phantoms. Bolus materials. 2. Treatment planning with single photon beams. Isodose distributions. Surface dose. Integral dose. Exit dose. Isodose distributions. Tissue inhomogeneities. Contour corrections. 3. Treatment planning for combinations of photon beams. Opposing pairs. Combinations of opposing pairs. Angled fields and wedged pairs. Three-field technique. Rotational therapy. CT in treatment planning. Non-coplanar beams. 4. Radiotherapy with particle beams: Electrons, pions, neutrons, heavy charged particles. Isodose distributions and percentage depth dose. Advantages and disadvantages of particle beams. 5. Special techniques in radiotherapy. Total and half-body irradiation with photon beams. Total skin electron irradiation. Electron arc therapy. Stereotaxy and radiosurgery. Rectal irradiation. Intensity-modulated radiotherapy. 6. Equipment for external beam radiotherapy. Cobalt units. Orthovoltage and superficial x-ray units. Betatrons. Neutron generators. Simulators. Computerized treatment planning systems. 7. Medical linear accelerators. Waveguide theory. Components of medical linear accelerators. 8. Relative dosimetry techniques. Thimble ionization chamber. End-window ionization chamber. Thermoluminescent dosimetry. Radiation sensitive diodes. Radiographic film. Thermally activated currents. Radioelectrets. 9. Dosimetry in radiotherapy using small sealed sources. Comparison of radium and radioisotope sources for brachytherapy. Source specification and calibration. Calculation of dose distribution in tissue around a sealed source. Sievert integral and more recent calculation algorithms. 13
  14. 14. 10. Dosimetry of distributed radioisotope sources. Absorbed dose per disintegration from internally administered radionuclides. Dosimetry of beta-type and gamma-type radiations. MIRD system. Integral dose from radioisotopes. Permissible doses and concentrations. 11. Dosimetry in radiobiology and radiation protection. Dose equivalent. Patient dose (entrance and organ doses) in diagnostic radiology and nuclear medicine. Irradiation of experimental specimens and animals. RADIATION BIOLOGY COURSE MDPH 609 : 2 CREDITS Prerequisites : None Corequisites : None Instructor : S. Lehnert, Ph.D. The course deals with the effects of ionizing radiation on biological material from molecular interactions, through sub-cellular and cellular levels of organization, to the response of tissues, organs and the whole body. Includes the application of radiation biology in oncology and the biological aspects of environmental radiation exposure. COURSE OUTLINE 1. Physico-chemical aspects of interaction of ionizing radiation with the cell.. Energy deposition and LET. Direct and indirect effect. Radiation chemistry of aqueous solutions. 2. Radiation effects on macromolecules. DNA damage and repair. Radiation-induced chromosome damage. Modes of cell killing by radiation and the nature of the lethal lesion. 3. Cellular radiation biology. In vitro and in vivo assays of clonogenicity. Radiation survival curves and their analysis. Physical, chemical and biological factors which modify radiation survival. 4. Radiobiology of tissues and organs. Acute radiation response of tissues and organs including the immune system. Acute radiation syndrome. Delayed and late effects of radiation. Radiation pathology. Radiation damage to the fetus. 5. Radiation biology as applied to radiation therapy. a) Tumor cell kinetics: repopulation, reassortment, repair hypoxia and reoxygenation in solid tumors. b) Therapeutic ratio: fractionation and iso-effect relationships interpreted by the linear quadratic model. c) Interaction of radiation with chemotherapy, specific radiosensitizers and radioprotectors. d) Clinical use of hyperthermia, Photodymaic Therapy and High LET radiation. 6. Effects of radiation doses in the environmental and occupational range. Stochastic and non-stochastic radiation effects. Mutagenesis. Carcinogenesis. 14
  15. 15. HEALTH PHYSICS AND RADIATION PROTECTION COURSE MDPH 613 : 2 CREDITS Prerequisites : MDPH 601, MDPH 609, Undergraduate physics and mathematics Corequisites : None Instructor : E. Meyer, Ph.D., M.D.C. Evans, M.Sc., W. Parker, M.Sc., C.Janicki, Ph.D. The course is concerned with the hazards of ionizing and non-ionizing radiations and with safe handling and use of radiation sources. Covered are: basic principles; safety codes, laws and regulations; organization; and practical safety measures and procedures. COURSE OUTLINE 1. Dosimetric Quantities and Sources of Radiation. Natural and man-made sources, internal and external. Annual dose from various sources. Basic quantities for activity, annual limit on intake, exposure, exposure rate, specific exposure rate constant, absorbed dose, equivalent dose, effective dose, genetically significant dose, and tissue weighting factors. 2. Regulatory Aspects and Licensing. International organizations. National regulatory bodies (Canadian Nuclear Safety Commission, Transport Canada, Health Canada, etc.) and provincial legislation. Negotiating licensing, inspections and audits for radiation therapy. 3. Risk Assessment and Dose Limits. Determination and quantification of risk. Historical methods and population groups used for determining risk. International, federal and provincial dose limits. 4. Biological Aspects of Radiation Protection. Radiation induced damage and mutations. Stochastic and deterministic effects. Acute and Late effects of radiation. Dose thresholds and recommendations, radiation accidents. 5. Radiation Measurement. External vs.internal measurements. Dose rate, dose, bioassay. Gas detectors, Geiger-Mueller counters (GMs), direct reading dosimeters (DRDs), electronic personal dosimeters (EPDs). Gamma vs. beta measurements. Scintillation detectors, counting chain. Film and thermoluminescent (TLDs) dosimeters. Energy dependence. Semiconductor detectors. Neutron detectors, bubble dosimeters. 6. Open Sources and Radiation Labs. Review of the CNSC Act and Regulations for the use of nuclear substances. Classification of radioisotope laboratories. Safework procedures in laboratories. Contamination monitoring, inventory and waste management. 7. Medical Internal Radiation Dosimetry. Calculation of radiation dose to organ: time activity curve; cumulated activity; S-factors for internal organs based on the standard man; Voxel MIRD method; patient specific dosimetry; FFT convolution method for internal dose calculations; using animal pharmacokinetic data for human dosimetry. 8 Radiation Shielding - Therapy. Considerations for Bunker and room design for high energy linear accelerators and brachytherapy facilities. NCRP recommendations, workload considerations, materials, space requirements, costs. 9. Radiation Shielding - Diagnostic 15
  16. 16. Room design for CT, and diagnostic X-ray and fluoroscopic facilities. Emphasis on radiation oncology aspects, ie. CT-SIM, and simulator installations. 10. Diagnostic Radiation – Regs. and Applications Review of the Canadian Radiation Emitting Devices (RED) Act and Regulations. Review of the document 20A from Health Canada “X-Ray Equipment in Medical Diagnostic Part A: Recommended Safety Procedures for Installation and Use”. Also, review of the Quebec regulations for Diagnostic X-Ray laboratories. 11. Radiation Safety Programs Radiation safety programs and regulations for Class II installations. Survey meter requirements. Manda-tory training, worker designation and personal dosimetry programs. Emergency procedures and policies. 12. Cyclotrons / Power Reactors / Lasers (A visit to the Medical Cyclotron of the MNI will be organized as part of this lecture.) Positive and negative ion machines, medical applications, shielding and radiation protection aspects. CANDU power reactors, working principle. Sources of radiation hazards, fission and activation products. Radiation safety issues. Laser basics. Applications in medical physics. Biological effects, eye and skin damage. Protective equipment and standards. 16
  17. 17. CLINICAL ROTATION 1 Basic Treatment Planning and Standard Treatment Techniques Purpose: To familiarize the resident with all basic aspects of radiotherapy treatment planning and treatment delivery. The rotation duration is 6 months and is divided into three sub-rotations: (1.1) Simulation (1 month); (1.2) Basic training in treatment planning (2 months), and; (1.3) Clinical treatment planning (3 months). Objectives: • The resident will be familiarized with the radiation oncology information system including the electronic charting aspects, treatment planning system, and transfer of information. • The resident is introduced to basic and intermediate treatment planning concepts (ICRU 50 and 62). • The resident will aid dosimetrists and MDs in contouring of target volumes, normal tissues, organs at risk, and critical structures. • The resident will learn virtual simulation and simple planning concepts for palliative cases. • The resident will learn 3D conformal radiation therapy (3D CRT) treatment planning techniques and plan assessment and evaluation • The resident will work full time in the “planning room” for a minimum period of 3 months as a dosimetrist producing 3D CRT treatment plans. Resource faculty: Rotation Coordinator: Emilie Soisson Chris Kauffman Horacio Patrocinio Russell Ruo William Parker Francois DeBlois (JGH) 1.1 Simulation The resident will become familiar with: 1.1.1 Patient positioning and immobilization: Standard radiotherapy treatment positioning, immobilization techniques, use of fiducial markers, tattooing, and marking of patients. 1.1.2 Treatment simulation: Principles of treatment simulation and patient data acquisition. Differences between conventional and virtual (CT-based) simulation. 1.1.3 Target and structure delineation: 17
  18. 18. The contouring of target structures and organs at risk following the ICRU 50 and 62 documents and guidelines for organ and target definition. 1.1.4 Field definition: Basic treatment techniques and concepts including: SSD direct field setups, SAD isocentric setups, AP/PA beams, lateral opposed fields, mounted blocks, multileaf collimator, field matching techniques. 1.1.5 Simulation techniques for curative intent cases: Tangential breast irradiation, tangential breast and supra-clavicular lymph node irradiation, head and neck, lung, whole CNS, Hodgkin lymphoma, seminoma. 1.1.6 Simulation techniques for palliative intent and emergency cases: Whole brain irradiation, irradiation for various bone metastatic sites, irradiation for superior vena cava (SVC) syndrome, and irradiation for spinal cord compression. 1.1.7 Treatment time and monitor unit calculations Manual calculations based on simulation data. 1.2 Basic training in treatment planning The resident will become familiar with: 1.2.1 Data transfer and planning tools including: The basic operation of the treatment planning computer including data transfer, beam placement, mounted block and MLC design, dose calculation, and printing. 1.2.2 Basic treatment planning concepts including: Basic treatment planning techniques, the use of multiple fields, static wedges, dynamic wedges, field weighting, step-and-shoot dose compensation, the use of bolus, basic plan evaluation, and dose volume histograms (DVH). 1.2.3 Prescription, evaluation, and dose reporting guidelines: The ICRU 50 and 62 documents and guidelines for treatment plan evaluation and dose reporting. 1.2.4 Treatment planning techniques for the following sites: Central nervous system (CNS) Whole brain Brain tumors Whole CNS irradiation Head and neck Nasopharynx Oropharynx Hypopharynx Larynx Parotid tumors Thyroid Gastro-intestinal (GI) Upper GI – esophagus Gastric Lower GI – rectum, anal canal 18
  19. 19. Lung Genito-urinary (GU) Prostate Bladder Seminoma Gynecological (GYN) Breast Tangential irradiation Tangential and supra-clavicular Lymphoma Mantle irradiation for Hodgkinʼs lymphoma Para-aortic irradiation Sarcoma Sarcoma of the extremities 1.2.5 Clinical trials treatment planning and electronic submission 1.3 Clinical treatment planning 1.3.1 Clinical aspects of treatment planning: The resident will perform treatment planning duties as part of the medical physics dosimetry service under the supervision of the treatment planning coordinator. 1.3.2 Clinical treatment delivery (treatment room): The resident will spend 5 days on a treatment machine (dual energy linear accelerator with electron beam capability) and observe the treating technologists perform their routine work including chart checks, patient setup, treatment delivery, production of treatment records, and the entering of treatment parameters into the record and verify system. 1.3.3 Clinical treatment planning and delivery of electron beams: The resident will become familiar with all aspects of treatment planning, setup, delivery, and dosimetric considerations for electron beam treatments. 1.3.4 Clinical treatment planning and delivery of superficial, orthovoltage, and supervoltage beams: The resident will become familiar with all aspects of treatment planning, setup, delivery, and dosimetric considerations for kilovoltage x-ray beam treatments. 19
  20. 20. CLINICAL ROTATION 2 Advanced Treatment Planning and Special Treatment Techniques Purpose: To familiarize the resident with advanced treatment planning techniques. The rotation is divided into 2 sub-rotations: (2.1) Brachytherapy treatment planning and dose delivery (3 months), and (2.2) Advanced external beam treatment planning and dose delivery techniques (3 months). Objectives: • The resident will learn treatment planning and QA procedures for various advanced radiotherapy treatment techniques including: Intensity modulated radiation therapy (IMRT), Stereotactic body radiation therapy (SBRT), and Stereotactic radiosurgery (SRS). • The resident will learn treatment planning, delivery, and QA techniques for total body irradiation (TBI) and total skin electron irradiation (TSEI). • The resident will learn radiation safety concepts in brachytherapy treatments. • The resident will learn how to treatment plan and perform QA for various types of brachytherapy cases. Resource faculty: Rotation Coordinator: Horacio Patrocinio Russell Ruo Emilie Soisson William Parker Michael Evans Chris Kauffman Francois DeBlois (JGH) 2.1 Brachytherapy treatment planning and dose delivery The resident will become familiar with: 2.1.1 High dose rate brachytherapy (HDR) basics: All aspects of high dose-rate brachytherapy treatment delivery, radiation safety, and emergency procedures. 2.1.2 Treatment time calculations for HDR brachytherapy: Dose rate tables for pre-determined source configurations. 2.1.3 2D Treatment planning for HDR brachytherapy: Treatment planning using plain radiographic orthogonal films. 2.1.4. 3D Treatment planning for HDR brachytherapy: Treatment planning using CT data. 20
  21. 21. 2.1.5 Eye treatments: Treatment planning and delivery for choroidal melanoma eye-plaque treatments with I-125 or Ru-106 and Pterygium treatments using Sr-90. 2.1.6 LDR brachytherapy (not practiced at McGill)* Treatment planning and delivery for LDR brachytherapy. 2.1.7 Permanent implants (not practiced at McGill)* Treatment planning and delivery for permanent implants of prostate cancer with I-125 and Pd-103. *2.1.6 and 2.1.7 imply only theoretical knowledge, since the technique is not practiced at McGill. 2.2 Advanced external beam treatment planning and delivery techniques The resident will become familiar with the theoretical and practical aspects of (including QA): 2.2.1 Single fraction stereotactic radiosurgery 2.2.2 Multi-fraction stereotactic radiotherapy 2.2.3 Stereotactic Body Radiation Therapy (SBRT) 2.2.4 Inverse planned IMRT 2.2.5 Image Guided Radiation Therapy (IGRT) 2.2.6 Total body photon irradiation (TBI) 2.2.7 Total skin electron irradiation (TSEI) 2.2.8 Electron-arc irradiation 2.2.9 Intra-operative radiation therapy (IORT)* *2.2.9 implies only theoretical knowledge, since the technique is not practiced at McGill. 21
  22. 22. CLINICAL ROTATION 3 Quality Assurance and Radiation Protection Purpose: To familiarize the resident with quality assurance (QA) techniques and radiation protection issues applicable to a radiation therapy facility. The rotation consists of two sub-rotations: (3.1) Quality assurance (5 months) and (3.2) Radiation Safety (1 month). Objectives: • The resident will be familiarized with all aspects of quality assurance including: Comprehensive QA programs, QA equipment, QA measurement techniques, acceptance and commissioning, QA audits, and absolute dosimetry. • The residents will be familiarized with the following aspects of radiation protection as applied to radiation oncology: radiation safety programs, regulations, licensing, radiation safety issues, and basic radiotherapy facility design. Resource faculty: Rotation Coordinator: Michael Evans William Parker Francois DeBlois (JGH) 3.1 Quality Assurance The resident will become familiar with: 3.1.1 QA program: All aspects of the quality assurance program in the medical physics and radiation oncology department. 3.1.2 Guidelines for radiation oncology QA programs: The AAPM TG reports 40 and 45, describing quality assurance procedures for radiation oncology facilities in general and linear accelerators in particular. 3.1.3 QA equipment: The resident will become proficient with the use of all required equipment for QA procedures including: ionization chambers, electrometers, XV film and film scanner, radiochromic film and densitometer, thermo-luminescent dosimetry (TLD), and 3D water phantom and isodose plotter. 3.1.4 QA measurement: The resident will assist in all aspects of scheduled quality assurance including daily, weekly, monthly, bi-annual, and annual QA procedures. 3.1.5 Technical specification, acceptance testing, and commissioning of treatment units. 3.1.6 Technical specification, acceptance testing, and commissioning of treatment planning systems. 22
  23. 23. 3.1.7 Clinical reference dosimetry: Implementation of the AAPM TG-51 or IAEA TRS-398 protocol. 3.1.8 External QA audits: Radiological physics center (RPC), protocols, quality assurance review center (QARC). 3.1.9 Absolute dosimetry: Dealing with issues related to securing the calibration of secondary standard dosimeters in a standards laboratory. 3.1.10 QA of imaging systems: Basic quality assurance and functional testing of imaging systems used in radiation therapy (CT, MRI, MVCT, CBCT, Simulator). 3.2 Radiation protection The resident will become familiar with: 3.2.1 Radiation safety program: All aspects of the radiation safety program in the medical physics and radiation oncology departments. 3.2.2 Regulations: The relevant regulations and legislation (local, provincial, federal) applicable to the medical physics and radiation oncology department. 3.2.3 Licensing: Licensing requirements for a CNSC Class II radiation facility and specific radiation devices and sources. 3.2.4 Radiation safety issues: Radiation safety issues with workers in the radiation oncology department including personnel monitoring, exposure reports, pregnancies, emergencies, lost dosimeters. 3.2.5 Facility design: Facility design and radiation surveying techniques. 23
  24. 24. CLINICAL ROTATION 4 Clinical Physics Practice and Project Purpose: The resident will assist in the daily clinical physics tasks required in the radiation oncology and medical physics departments. The resident will also work on a clinical physics project and prepare a report detailing the specifics of the project. The rotation duration is 6 months and it is expected that the resident will work on the project simultaneously with clinical work. Objectives: • The resident will work full time as a clinical medical physicist (supervised). • The resident may embark on a clinical project or research idea. Resource faculty: Rotation Coordinator: William Parker/Francois DeBlois (JGH) Clinical Medical Physics Staff 4.1 Clinical rotation 4.1 Clinical practice: The resident will provide clinical physics support with minimal supervision in the radiation oncology and medical physics departments including: Treatment planning, treatment plan verification, treatment delivery support, treatment setup verification, routine quality assurance, and brachytherapy. 4.2 Project (if required) 4.2 Project: The resident will undertake a clinical physics project in collaboration with one or more staff medical physicists. A written and oral report will be presented to the department upon completion of the project. 4.3 Colloquium (if required) 4.3 Colloquium: The resident will present their clinical project at the Medical Physics Colloquium series before the completion of their residency. 24
  25. 25. Meetings and conferences for residents Unless otherwise specified all meetings are held at the HE Johns conference room D5-227, MUHC, Montreal General Hospital. MON TUE WED THUR FRIDAY 08:00 Rad. Onc. Patient Patient Rounds (1) Management Management Rounds Rounds (3) (2 or 10) 09:00 Med. Phys. Research Seminar (7) 10:00 11:00 12:00 Medical Physics Colloquia (8) 13:00 14:00 Med. Phys. Medical Meeting (4,5) Residents Clinical (9) 15:00 Physics Residents Clinical (6) 16:00 1. Radiation Oncology Rounds (Scientific or clinical presentations, 1 hrs/wk) 2. Curative Patient Management Rounds (chart rounds, 1 hrs/wk) 3. Palliative Patient Management Rounds (chart rounds, 1 hrs/wk) 4. Medical Physics Departmental meeting (Administrative meeting, 0.5 hrs/wk) 5. Medical Physics Clinical meeting (Clinical cases/issues, 0.5 hrs/wk) 6. Medical Physics Residency teaching session (Teaching, 1.5 hrs/wk) 7. Medical Physics Research Seminar (Seminar, 1 hr/wk) 8. Medical Physics Colloquia, Osler Amphitheatre MUHC (Seminar, 1hr/month) 9. Radiation Oncology Residents teaching session (teaching, 2hrs, when relevant) 10. Patient Management Rounds JGH Rad Onc meeting room (chart rounds, 1 hrs/wk) 25
  26. 26. Major Radiotherapy Equipment list - MUHC Equipment Features Accelerators 120 DMLC, EPID (LIC), IMRT, Ultrasound guided prostate 2 Varian Clinac 6EX localization 120 DMLC, EPID (aSi), OBI, CBCT, resp gating, IMRT, VMAT, 2 Varian Clinac 21EX Ultrasound guided prostate localization 120 HDMLC, EPID (aSi), OBI, CBCT, resp gating, Exactrack, IMRT, 1 Varian Novalis TX VMAT, SRS cones 1 Tomotherapy HiArt V3 MVCT, IMRT 1 Theratron T780 Cobalt Modified for TBI only Simulators Philips Brilliance Big Bore 1 4DCT, 16 slice, Ultrasound guided prostate localization CT-Sim 1 Odelft/Nucletron Simulix CBCT Philips Panorama 0.23T 1 Open magnet MRI Sim Brachytherapy Nucletron HDR 1 30 channels microselectron V3 Information system 1 Varian ARIA 8.8 Clinic operates in a paperless environment, 140 client stations Treatment Planning 22 Varian Eclipse 8.8 10 Calculation, 10 Contouring, 2 teaching stations 1 Nomos Corvus V6.2 1 Brain Lab iPlan IV Oncentra MasterPlan 2 Brachytherapy MimVista advanced 2 contouring 26
  27. 27. Major Radiotherapy Equipment list - JGH Equipment Features Accelerators 120 DMLC, EPID (aSi), IMRT, Ultrasound guided prostate 1 Varian Clinac 21EX localization 120 DMLC, EPID (aSi), OBI, CBCT, resp gating, IMRT, VMAT, 1 Varian Clinac iX Ultrasound guided prostate localization 1 Varian Trilogy 120 HDMLC, EPID (aSi), OBI, CBCT, resp gating, IMRT, VMAT Simulators 1 Philips AcQSim CT-Sim Brachytherapy suite 1 GE Lightspeed 16 RT 4DCT, 16 slice, Ultrasound guided prostate localization 1 Varian Acuity Brachytherapy Nucletron HDR 1 30 channels microselectron V3 Information system 1 Varian ARIA 8.8 50 client stations Treatment Planning 19 Varian Eclipse 8.8 6 Calculation, 13 Contouring 1 Nomos Corvus V6.2 Oncentra MasterPlan 1 Brachytherapy Velocity advanced 2 contouring 27
  28. 28. Medical Physics Resident and Radiation Oncology Resident Pairing Program Summary Each radiation oncology physics resident will be paired with a radiation oncology medical resident for a one-year term based on calendar year, in order to achieve the aims below. Aims 1. To provide radiation oncology physics residents with a clinical resource person they can consult on matters pertaining to radiation oncology knowledge. 2. To provide radiation oncology medical residents with a physics resource person they can consult on matters pertaining to medical physics knowledge. 3. To foster an exchange between the two groups of residents in terms of both clinical and physics knowledge as well as promote research interests common to both groups. Components 1. Radiation oncology physics residents will be paired with a radiation oncology medical resident prior to the beginning of the calendar year, as determined jointly by the radiation oncology physics residency clinical coordinator and the radiation oncology residency coordinator. 2. Each radiation oncology physics resident/radiation oncology medical resident pair will be required to collaborate on a research or literature review project. 3. Each radiation oncology physics resident/radiation oncology medical resident pair must present on their project at both radiation oncology and medical physics rounds. 4. The radiation oncology resident should assist the physics resident in the preparation of the clinical teaching sessions for which the latter is responsible, and be present for the session. 5. The medical physics resident should assist the radiation oncology resident in the preparation of physics teaching sessions for which the latter is responsible, and be present for the session. 28
  29. 29. Radiation Safety for Radiation Oncology Physics Residents The Radiation Oncology Department of the McGill University Health Centre (MUHC) is licensed by the Canadian Nuclear Safety Commission (CNSC) to use Class II Prescribed Equipment and radioactive material in its facilities. MUHC is committed to the achievement of compliance in accordance with the relevant CNSC regulations and license conditions. Furthermore, the MUHC is committed to ensure that: a) Radiation doses to all staff and the public during routine use of radioactive materials and Class II Prescribed Equipment and in the event of an emergency remain As Low As Reasonably Achievable (ALARA). b) A high standard of radiological safety is maintained at all times in the work environment. c) All relevant laws and regulations with respect to the use of licensed materials and activities related to license conditions are respected. The ultimate responsibility for radiation safety lies with the Chief Executive Officer of the MUHC. This responsibility is exercised in three ways: First, the responsibility for safety is delegated to those managers who are responsible for work involving radioactive materials or equipment that generates ionizing radiation. Managers are responsible for ensuring that all work conducted is in accordance with the relevant CNSC license and MUHC procedures. Responsibility for safety also rests with each individual working with radioactive materials or radiation generating equipment. Second, the Radiation Safety Officer for the MUHC Radiation Oncology and Medical Physics departments as well as all Class II equipment installed in the MUHC (RSO/Class II) is delegated by and reports directly to the Director of Medical Physics to advise him on the status of radiation safety issues, including standards of compliance with current regulations and license conditions. The RSO/Class II also maintains a link with the MUHC Director of Quality and Risk Management for administration of matters with regard to radiation safety in the MUHC. The RSO/Class II is a Canadian College of Physicists in Medicine (CCPM) certified physicist who is directly involved with the clinical, administrative, research and teaching activities of the Departments of Radiation Oncology and Medical Physics. Third, the radiation safety at the MUHC is overseen by the MUHC Radiation Safety Committee (RSC). The radiation safety committee is composed of responsible managers and relevant parties, and reports to the Chief Executive Officer of the MUHC. Terms of Reference of the MUHC Radiation Safety Committee (RSC): Accountability of the RSC The Radiation safety Committee reports to the Chief Executive Officer of the MUHC. Responsibilities of the RSC The responsibilities of the Radiation Safety Committee are as follows: a) To provide overall co-ordination of the MUHC radiation safety program for all MUHC hospital sites and research institutes. 29
  30. 30. b) To ensure that the MUHC conforms to all applicable legislation and internal policies. c) To review reports from committee members and/or representations from other individuals. d) To provide a platform for the resolution of conflict on Radiation Safety issues. e) To evaluate and respond to results of inspections and/or audits by the CNSC. f) To promote adherence to good radiation safety and legal compliance to management and staff throughout the MUHC within the framework of ALARA (As Low As Reasonably Achievable). g) To ensure adequate standards of radiation safety for staff, general public and all other individuals covered by MUHC licenses. h) To rule on the suspension or approval of license activities when specifically requested to do so in writing. i) To maintain written records of all meetings. Composition of the RSC The membership of the Committee shall be as follows (total of 18 members): - Chief Executive Officer Representative - Manager*: Radiation Protection - Manager*: Nuclear Medicine - Manager*: Radiation Oncology - Manager*: Diagnostic Imaging - Director*: Medical Physics - Director*: Quality Assurance and Risk Assessment - Manager*: Occupational Health and Safety - Radiation Safety Officer Class II - Researcher: Research Institute - Physicist: Nuclear Medicine - Physicist: Diagnostic Radiology - Clinician Representative: Council of Physicians, Dentists and Pharmacists - Clinician Representative: Nursing - User Representative: Radioisotopes or Class II - Management Representative: Research Institute - MUHC-Montreal Childrenʼs Hospital – Radiation Safety Committee - MUHC-Montreal Neurological Hospital – Radiation Safety Committee *Delegate may attend. 30
  31. 31. MUHC Radiation Safety Committee Organigram Chief Executive Officer Chief of Staff Director Director Hospital Services Quality and Risk Management Radiation Safety Officer Director Nuclera Medicine, Labs, Medical Physics Diagnostic and Research Institute Radiation Safety Officer Class II Radiation Oncology, Medical Physics & all Class II Appointed Appointed Appointed Appointed Radiation Safety Committee (some members not shown) (Reports to C.E.O.) Medical Physics Residents are declared “Nuclear Energy Workers” as defined by the Canadian Nuclear Safety Act. They are given the “Mandatory Training” as described in the Radiation Safety and Quality Assurance Manual for Class II and Associated Radiation Oncology and Medical Physics CNSC Licenses. Medical Physics Residents are issued whole body thermoluminescent dosimeters (TLD) which are read on a three monthly basis by the National Dosimetry Service of Health Canada. Dose limits and action levels as defined by license are reviewed by a competent medical physicist, and dosimetry results are posted. Medical Physics Residents are declared “Authorized Users” as defined by the Radiation Safety and Quality Assurance Manual for Class II and Associated Radiation Oncology and Medical Physics CNSC Licenses. 31
  32. 32. Relevant Organizations and References on Radiation Safety MUHC Class II Radiation Safety Manual: MUHC Radiation Safety Manual Canadian Nuclear Safety Commission (CNSC) Health Canada Canadian Radiation Protection Association (CRPA) U.S. Nuclear Regulatory Commission (USNRC) National Council on Radiation Protection and Measurements (NCRP) NCRP 49 International Commission on Radiological Protection (ICRP) ICRP 60 International Atomic Energy Agency (IAEA) 32