RADIATION

THERAPY

Presented by: Mark Jayson Gutierrez, RRT, MAEd

Program Director, Top Rank Review Academy
INTRODUCTION
 Radiation therapy, is one of three principal
modalities used in the treatment of cancer. The
others are surgery and chemotherapy.
Cancer treatment requires a multidisciplinary
approach:
1. Diagnostic Radiologic Studies
2. Biopsy (if cancerous):
3. Planning with SMR
HISTORICAL DEVELOPMENT
November 8,1895 – Wilhelm
Conrad Roentgen, while passing
an electric current through a
Hittorf-Geissler-Crooke’s high
vacuum tube, noticed a light
coming from the workbench
about a yard away, which
contains a piece of paper painted
by Barium Plantinocyanide.
Realizing that the light must have been
caused by a new kind of ray, he called
them X-rays.

He continued the investigation of these

rays and found out that if he placed the
fluorescent screen with photographic
plate it could obtain images.
 On December 22, 1895 – Roentgen convinced his
wife, Anna Bertha Ludwig to place her hand on a
cassette loaded with photographic plate upon which
he directed the x-rays from the tube for approximately
15 minutes, thus showing her bones as well as her
two rings on her fingers.

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Antoine Henri Becquerel
discovered radioactivity in
1896, when he began
investigating the possibilities
of similar rays being produced
by known fluorescent or
phosphorescent substances. https://images.app.goo.gl/JJ8bTGbVZvqz4hYW8
He discovered the darkening
of the photographic plate by
uranium salts and realized
that these rays were emitted
spontaneously and
continuously from uranium.
January 29,1896 – The discovery of X-rays and
radioactivity was promptly followed by their
therapeutic application, when Dr. Emile H.
Grubbe is reported to have irradiated a woman
with carcinoma of the left breast.

https://images.app.goo.gl/dcu7f4p6S53gKiJ46
However, it is not stated whether it has been cure
until 1899 wherein the first cancer, a Basal Cell
Epithelioma, has been cured by radiation.

A smooth, pearly tumor with

telangiectasia (tiny blood vessels)
on the nose. Tumor feels hard, is
well defined, and is asymptomatic.
It bleeds easily if scraped.
Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology Klaus Wolff,
Richard Allen Johnson, Dick Suurmond Copyright 2005, 2001, 1997, 1993
by The McGraw-Hill Companies.
All Rights reserved.
Pierre and Marie Curie discovered Polonium in
July 1898 and discovered radium in December
1898.

https://images.app.goo.gl/1oU3HdigfaER8B9X6
Pierre Curie applied
Radium in his arm and
described in detail the
various phases of a moist
epidermis and his
recovery from it.
He provided Radium to
physicians, who tested it in
patients having learned https://images.app.goo.gl/JytVoMb6qwHSfgSF7

that redness of the skin

was observed by the users
of these rays.
Several physicians began investigating their effects
on malignant tumors. The clinical pioneers in
radiation therapy, mostly surgeon and
dermatologist, used the “erythema dose” to
estimate the proper length of treatment.

The hope was soon followed by a wave of

disillusionment and pessimism when tumor
occurrences and injuries to normal tissues began to
appear.
“The treatment often involves single massive
exposure aimed at the eradication of tumors and the
patient who survived the immediate post irradiation
often developed major complication.”
 Because of these disappointing results, the
use of x-rays in the treatment of tumors would
soon have been abandoned had if not been for
the laboratory and clinical work of Henri Coutard
and Claude Regaud, who discovered fractioned
doses of radiation, found that by administering it
they could achieve the same tumor response but
without serious injury to the adjacent normal
tissues.
Henri Coutard showed
that both skin and mucosal
reactions are dependent on
the:
Dose
Time
Number of treatment

https://images.app.goo.gl/ZoxhY6JgG3KvTWn79
In 1927, Claude Regaud
published his data on
ram testis radiotherapy.
In summary, he found
that: Sterilization of a ram
testis without acute skin
reaction was only
possible with fractionated
treatment (3 treatments
15 days apart)
MALIGNANCIES

Neoplasia – literally
means “new growth”
and refers to an
abnormal proliferation
of cells that no longer
controlled by factors
govern the growth of
normal cells.
Neoplastic cells act as
parasites competing with
normal cells and tissues for
their metabolic needs. Thus
tumor cells may flourish
while the patient becomes
weak and emaciated: a
condition termed as https://images.app.goo.gl/D4HouaRN9Ljs6zD87

cachexia.
 Neoplasm – abnormal
mass of tissue as a
result of neoplasia. It is
usually on a form of a
lump or tumor. The study
of neoplasm is call
oncology which is
https://images.app.goo.gl/8wUVhSg6jGy2VgCu8
derived from the Greek
word “onco” meaning
tumor.
2 Types of Neoplasm

1. Benign Tumor – are characterized by entirely

localized growth and are usually separated from
neighboring tissues by the surrounding capsule.
Benign tumor generally grows slowly, and in
structure closely resembles the tissue of origin. The
term “benign” implies a mild and non-progressive
disease. Indeed, many kinds of benign tumors are
harmless to human health.
2. Malignant Tumor – has the ability to spread
beyond the site of origin. Tumor may invade the
neighboring tissue by direct extension of
infiltration or may disseminate to distance site
forming secondary growth known as metastases.

https://images.app.goo.gl/SqyVkWtzp6SaThcs9
3 Pathways of Malignant Neoplasm

• Seeding (Diffused Spread) – occurs when

neoplasm invade a natural body cavity.
• Lymphatic Spread – major metastatic site of
carcinomas, especially those of the lung and
breast. The pattern of lymph node involvement
depends on the site of the primary neoplasm and
the naturally lymphatic pathways of drainage of
that region.
Hematogenous Spread – wherein tumor cells
invade and penetrate blood vessels and are
released as neoplastic emboli into the circulation.
These emboli of tumor cells are trapped in small
vascular channels of distant organs where they
invade the wall of arresting vessels and infiltrates
and multiply in the adjacent tissue.

https://images.app.goo.gl/UArnjtzxgHTdsBMr5
CANCER
Cancer is a disease process that involves an
unregulated, uncontrolled replication of cells

When cells in a part of the body begin to grow out

of control, grow then divide, instead of dying, they
outlive normal cells and continue to form new
abnormal cells.

Cancer can occur in persons of any age,

although the majority of patients are diagnosed
after the age of 50 years.
Terminologies Regarding Cancer

Angiogenesis – is the physiological process

involving the growth of new blood vessels from pre-
existing vessels.
Vasculogenesis - spontaneous blood-vessel
formation
Intussusception - new blood vessel formation by
splitting off existing ones.
Unlimited Growth – Cancer cells do not exhibit the
regulating mechanism called “contact inhibition”.
Cancer cells multiply in an unregulated manner
independent of normal control mechanism, if this
occurs in an organ, a solid mass will occur.
Uncontrollable multiplication of bone marrow
stem cells gives rise to leukemia in which the
malignant progeny are detectable in the blood.
Risk Factors of Cancer
The overall lifetime risk of developing cancer is
44% for men and about 31% for women.

1.Personal Profile – (age, sex , genetic/ family

medical history)
2.Environment – (too much exposure to radiation,
pollution)
3.Lifestyle – (tobacco, improper diet, sun
exposure)
Note:

Having a risk factor for cancer means that a

person is more likely to develop the disease in
some point in their lives.
Symptom

It is a departure from normal function or feeling

which is noticed by a patient, indicating the
presence of disease or abnormality.
A symptom is subjective, observed by the patient,
and not measured.
It is an indication of disease, illness, injury, or that
something is not right in the body, they are felt or
noticed by the patient himself, but may not easily
be noticed by anyone else.
Sign

It is also an indication that something is not right

in the body, but they are defined as observations
made by the doctor, nurse, or other health care
professional.
Cancer signs and symptoms will depend on:

The size of the cancer

Location of the cancer

How much it affects the surrounding organs or

structure
General Cancer Signs and Symptoms
• Unexpected Weight Loss
Most people with cancer will lose
weight at some time with their
disease. An unexplained
(unintentional) weight loss about
10 lbs may be the first sign of
cancer, particularly cancer of the
pancreas, stomach, esophagus or https://images.app.goo.gl/Wx7hc6rw
LqYxhZ739

lung.
Fever

Fever is very common to cancer

but is often seen in advance
disease. Almost all patients with
cancer will have a fever at some
time, particularly if the cancer or
its treatment affects the immune
system and reduces resistance
to infection.
Fatigue
Fatigue may be a significant
symptom as a career
progresses. It may occur early,
however, especially if the cancer
causes a chronic loss of blood,
as in some colon or stomach
cancers.
 Pain
Pain may be an early sign
with some cancers such as
bone cancers or testicular
cancers. Most often, however,
pain Is a symptom of advance
disease.

https://images.app.goo.gl/cHoaoTxySeUTVVay8
Skin Changes
In addition to cancers of the
skin, some internal cancers can
provide visible skin signs such
as darkening
(hyperpigmentation), yellowing
(jaundice), reddening
(erythema), itching or excessive
hair growth.

https://images.app.goo.gl/LUvoAQwyNLzr2urv8
Specific Cancer Signs and Symptoms
Specific Cancer Signs and Symptoms

Change in Bowel Habits or Bladder Functions

Chronic constipation, diarrhea, or a change in the
size of the stool may indicate colon cancer.

Pain with urination, blood in the urine, or change

in bladder function could be related to bladder or
prostate cancer.
A sore that does not heal
Skin cancers may bleed and resemble sores that
does not heal.
A persistent sore in the mouth could be an oral
cancer and should be dealt with promptly,
especially in patients who smoke, chew tobacco, or
frequently drink alcohol.
Sores on the penis or vagina may either be signs of
infection or an early cancer, and should not be
overlooked.
Unusual Bleeding or Discharge
Unusual bleeding can occur in early or advanced
cancer.
Blood in the sputum may be a sign of lung cancer.
Blood in the stool (dark or black stool) could be sign
of colon or rectal cancer.
Cancer of the cervix or the endometrium can cause
vaginal bleeding.
Blood in the urine is a sign of possible bladder or
kidney cancer.
A bloody discharge in the nipple may be a sign of
breast cancer.
Thickening or Lump in Breast or elsewhere
Many cancers can be felt through the skin,
particularly in the breast, testicle, lymph nodes, and
the soft tissues of the body.
A lump or thickening may be an early or late sign of
cancer.
Any lump or thickening should be reported to your
doctor, especially if you’ve just discovered it or
noticed it has grown in size. You may be feeling a
lump that is an early cancer that could be treated
successfully.
Indigestion or Difficulty in Swallowing
These symptoms may indicate cancer of the
esophagus, stomach or pharynx.
Obvious Change in Wart or Mole
Any change in color or shape, loss of definite
borders, or an increase in size should be reported
to the doctor.
The skin lesion may be a melanoma which, if
diagnosed properly, can be treated successfully.
Nagging Cough or Hoarseness
• A cough that does not go away may be a sign of
lung cancer.
• Hoarseness can be a sign of cancer of the larynx or
thyroid.
 Biopsy

It remains the only

definitive method for the
diagnosis of cancer. It
involves the examination of
a section of a tissue
removed from the tumor
itself or from the
https://images.app.goo.gl/4RDxE9HgS1QMtrBW8
metastasis.
It is the medical removal of tissue from a living subject to
determine the presence or extent of a disease. The
tissue is generally examined under a microscope by a
pathologist, and can also be analyzed chemically.
Surgical Biopsy – Open
surgical biopsy means that a
large mass or lump is removed
during a surgical procedure.
Surgical biopsy requires an
approximately 3 to 5 centimeters
incision and is normally
performed in an operating room
in sterile conditions.
Excisional Biopsy –
when an entire lump or
suspicious area is
removed, the procedure
is called an excisional
biopsy.

https://images.app.goo.gl/yqELxuk1uiXEe7wU8

Incisional Biopsy – when only a sample of tissue

is removed with preservation of the histological
architecture of the tissue’s cells, the procedure is
called an incisional biopsy or core biopsy.
 Fine Needle Aspiration
(FNA) Cytology – is a
procedure that uses a
fine needle and a syringe
to sample fluid from a
breast cyst or remove
clusters of cells from a
solid mass. With FNA,
the cellular material taken
from the breast is usually
https://images.app.goo.gl/xj9JrZCSHVcZ58727
sent to the pathology
laboratory for analysis.
Core Needle Biopsy – A
core needle biopsy is a
procedure that removes
small but solid samples
of tissue using a hollow
“core” needle.

https://images.app.goo.gl/MCYJTsKu6nweWtVb7
Endoscopy – the doctor
can look at areas inside
the body through a thin,
lighted tube. It allows the
doctor to see what’s
inside the body, take
pictures, and remove
tissues or cells for
examination, if necessary.

https://images.app.goo.gl/3e9c1UNZng2x8XYv7
INTRODUCTION TO RADIOTHERAPY

Radiation Oncology – is a clinical and scientific

endeavor devoted to the management of patient
with cancer and any other disease by ionizing
radiation alone or combined other modalities,
investigation of the biologic and physical basis of
radiation therapy, and training of professionals in
the field.
Radiation Therapy – is a clinical specialty
dealing with the use of ionizing radiation in the
treatment of patients with malignant neoplasia
(and occasionally with benign condition); is the
treatment of disease, primarily malignant tumor,
using electromagnetic and particle radiation.
The Aim of Radiation Therapy

“The aim of radiation therapy is to deliver a

precisely measure dose of radiation to a
defined tumor volume with as minimal damage
as possible to the surrounding healthy tissues,
resulting in the eradication of the tumor, a high
quality of life, and prolongation of survival at a
reasonable cost.”
 2 Major Categories of Radiotherapy

Brachytherapy - a
technique in which the
radioactive material is
placed within the
patient.

https://images.app.goo.gl/Ab44ovyQmF9pk3tT8
The theory behind
brachytherapy is to deliver
low-intensity radiation over
an extended period to a
relatively small volume of
tissue.

The low intensity isotopes are placed directly

into a tissue or cavity depositing radiation only a
short distance, covering the tumor area but
sparing surrounding normal tissue.
 Methods in Brachytherapy

1. Mould Technique-a
technique of delivering
brachytherapy by
customized applicator
designed to provide a
constant and reproducible
frame for source
positioning. https://images.app.goo.gl/en1JxVsvgYBcAVki8
2. Intracavitary implant
technique-placement of
a radioactive source or
sources in a body cavity
(i.e., uterine canal and
vagina).
3. Interstitial Implant Technique - placement of a
radioactive source or sources directly into the tumor
site and adjacent tissue.
 Brachytherapy Systems
Low Dose Rate
A low activity isotope is utilized to deliver a dose
of radiation at a slow rate of 40cGy to 500cGy
per hour.
This requires that patient to be hospitalized for 3
to 4 days until the desired dose is delivered.
Utilizes Cesium-137 for intraCavitary; Iridium-
192 for interstitial
Iodine-125 for Permanent Implant Therapy
High Dose Rate
This system utilizes a high activity isotope
capable of delivering greater than 1,200cGy per
hour.
This high dose rate allows the prescribed dose to
be delivered over a period of minutes allowing
this treatment to occur on an outpatient basis.
Utilizes high activity Iridium-192
 2 Major Categories of Radiotherapy

Teletherapy - the
patient lies
underneath a machine
that emits radiation or
generates a beam of
x-rays.

https://images.app.goo.gl/V86PefBocoMyaxtj9
Skin Sparing Effect

As the energy of the beam

increases into the
megavoltage range, the
maximum dose absorbed
by the patient occur at
some point below the skin
surface.
 Cobalt-60 Unit
The first skin sparing machine.
Emits two gamma rays of 1.17MeV and 1.33MeV
energies with a half-life of 5.26 years.
 The unit was known as a "workhorse" because
it was extremely reliable, mechanically simple,
and had little downtime.
It was the first radiation therapy unit to rotate 360
degrees around a patient. A machine that
rotates around a fixed point, or axis, and
maintains the same distance from the source of
radiation is called an isocentric machine.
Linear Accelerator (Linac)
Greater skin-sparing capabilities
More sharply defined radiation fields and less
penumbra compared to Cobalt-60 units
Capable of producing high-energy beam of
photons (x-rays) or electrons in the range of 4
million to 35 million volts.
Types of Treatment for Linear Accelerator

X-ray or Photon – for deep therapy (underlying

tumors)

Electrons – for superficial therapy (superficial

lesions)
LINEAR ACCELERATOR ASSEMBLY

Power supply
-provides DC power to the modulator
Modulator
-supplies DC pulses of a few microseconds
duration to the electron gun and the magnetron or
klystron.
Wave Guide – a copper tube filled with an
insulating gas that conducts the microwave from
the klystron or magnetron into the accelerator
structure.

Electron Gun – consist of a concave tungsten

cathode backed by the tungsten heating coil that
produces electron injected into the accelerator
structure. It produces the x-ray beam or electron
beam.
Magnetron – is a device that produces
microwaves. It functions as a high power
oscillator, generating microwave pulses of several
microseconds duration with a repetition rate of
several hundred pulses per second.

Klystron – it is not a generator of microwaves

but rather a microwave amplifier. It needs to be
driven by a low powered microwave oscillator.
Accelerator Structure – an evacuated cylindrical
chamber 1 to 2 cm long, divided into
compartments, called cavities. Each cavity has a
diameter of about 10 cm and a length of 2.5 cm to
5 cm, and a polished to a mirror like finish.
The interaction of the electrons magnetic field with
the electromagnetic microwave accelerates the
electrons the accelerator section in a manner
analogous to the forward propulsion of a surf rider
by water waves.
• The longer the accelerator structure, the higher the
speed of electron and therefore the higher the
energy of x-ray or electron beam produced.

Bending Magnet – this is used to turn the electron

beam downward vertically before striking the target.
- made from one or more magnets that
turn the electron beam, 90° or 270°.
Treatment Head – provides sufficient shielding
against leakage radiation in accordance with
radiation protection guidelines.
-consist of a thick shell of high density
shielding material such as lead, tungsten, or lead
tungsten alloy.
Gantry – body of the machine here the major
components are constructed.
 Radiation therapy is used for the treatment
of malignant cancer, and may be used as a
primary or adjuvant modality. It is also common to
combine radiation therapy with chemotherapy,
hormone therapy, immunotherapy or some
mixture of the four.
 Most common cancer types can be treated with
radiation therapy in some way. The precise
treatment intent (curative, prophylactic or palliative)
will depend on the tumor type, location and stage, as
well as the general health of the patient.
KEYSTAFF FUNCTION IN RADIATION
THERAPY

 Input from all members of the radiation

oncology team is crucial in developing the
optimum treatment plan or approach for a
patient.
 The precision and accuracy necessary to
administer high doses of radiation to tumors
while not harming normal tissue require the
combined effort of all members of the radiation
oncology team.
Radiation Oncologist – Doctor of medicine
specializing in use of ionizing radiation in the
treatment of disease.

Scope of Work:
Prescribes the quantity of radiation
Determines the anatomic region(s) to be
treated
 Medical Physicist – A specialist in the study of the
laws of ionizing radiation and their interactions with
matter.

Scope of Work:
Responsible for calibration/maintenance
Advises the physician about dosage calculations
and complex treatment technique
 Dosimetrist – Person responsible for calculation of
the proper radiation treatment dose who assists the
radiation oncologist in designing individual treatment
plans.

Scope of Work:
Devises a plan for delivering the treatments in a
manner to best meet the physician's goals of
irradiating the tumor while protecting vital normal
structures.
 Radiation Therapy Technologist – Person
trained to assist and take directions from
radiation oncologist in the use of ionizing
radiation for the treatment of disease.
Scope of Work:

Responsible for obtaining radiograph that localize the

area to be treated
Administering the treatment
Keeping accurate record of the dose delivered each day
Monitoring the patient‘s physical and emotional well-
being.
 Oncology Nurse

Scope of Work:

Educating patient about potential radiation side

effects
Assisting patients with the management of
these side effects
TNM system

The TNM system is the one used most often

in staging cancer. It gives three key pieces of
information.
• T describes the size of the tumor, and whether the
cancer has spread to nearby tissues and organs.
• N describes how far the cancer has spread to
nearby lymph nodes.
• M shows whether the cancer has spread to the
other organs of the body.
• Letters or numbers after the T, N, and M give more
details about each of these factors.
• In general, the lower the number, the less the cancer
has spread. A higher number, such as stage IV (4)
means a more serious, widespread cancer.
https://images.app.goo.gl/e3CTL4Miy6CvJuDD7
Classification of Tumor Diagnosis

Grading – the grading of a malignant tumor

assesses its aggressiveness of degree of
malignancy. The grade of a tumor usually
indicates its biologic behavior and may allow
prediction of its responsiveness to certain
therapeutic agents.
Staging – refers to the extensiveness of a tumor
at its primary site and the presence or absence of
metastases to lymph nodes and distant organs,
such as liver, lung and skeleton. The staging of
tumor is often critical to the choice of appropriate
therapy and also to give the health care team a
clearer idea on the outlook of recovery.
• Stage 1: Early localized tumor, often in situ,
usually without lymph nodes or metastatic
involvement.

• Stage 2: Primary tumor has involved underlying

tissues but is still localized, metastatic potential
is somewhat greater, though very small.
• Stage 3: Primary tumor has spread to regional lymph
nodes, metastatic potential is moderate to high.

• Stage 4: Primary tumor has spread beyond

anatomical bounds of organ to regional lymph nodes,
metastatic potential is very high.
3 Major Subtypes of Cancer

• Sarcoma – arises from the connective and

supportive tissues, such as bone cartilage, nerve,
blood vessels, muscle or fat.

• Carcinoma – includes the most frequently

occurring forms of human cancer, arise from
epithelial tissue, such as skin and lining of the
body cavities and organs and the glandular tissue
of the breast and prostate.
• Lymphoma – includes cancers that involves
blood-forming tissue and are typified by the
enlargement of the lymph nodes, invasion of the
spleen, bone marrow, and overproduction of
immature white cells.
Formulation of Therapeutic Strategy
(Purpose of Treatment)

Curative – it is projected that the patient has a

probability of surviving after adequate therapy,
even if that chance is low. This kind of treatment
is intended to cure the patient of his/her disease.
In such patients, the area to be treated includes
the tumor and any area where there is known risk
of microscopic disease being present.
Palliative – in which there is no hope of the
patient surviving for extended periods. If symptom
produces discomfort or an impending condition
that may impair the comfort or self-sufficiency of
the patients required treatment.

Prophylactic – sterilization, to alleviate patient

pain, to preserve skeletal integrity, to stop
excessive bleeding.
Choice of Treatment for Cancer

The choice of treatment can depend on a number

of patient variable such as:
Patient‘s overall physical
Patient’s emotional condition
Histologic type of the disease
Extent and anatomic position of the tumor
Types of Treatment for Cancer

Surgery
Branch of medicine that deals with the
diagnosis and treatment of injury, deformity and
disease by natural and instrumental means.
It comes from the Greek word
“cheirourgen”, made up of “cheir” (hand), and
“ergo” (to work). Literally means to work with the
hand. Thus, surgery can be defined as those
manual procedures used in the management of
injuries and disease.
Surgery
If a tumor is small and its margins are well
defined, a surgical approach alone may be
prescribed.
Chemotherapy

If the disease is systemic, a chemotherapeutic

approach may be chosen.

It works by interrupting cell growth and division

in general. Different agents interact with the cell
and it’s DNA in different ways. While the
particular form of chemotherapy that is
administered is selected for its activity against a
specific cancer, most drugs also interrupts
normal cell growth and division.
The human body processes excrete all drugs
given through either the liver or the kidneys.
Therefore, when a patient has a liver or kidney
damage, giving chemotherapy becomes
dangerous.
Administration of chemotherapy can be:
• Oral
• Intravenous
• Intramuscular
• Intrathecal
• Intraperitoneal
Chemotherapy is mostly administered in 1-
2 day cycles that are repeated every four weeks,
for a period of 3-9 months.
Common Side Effects of Chemotherapy
Side effects on chemotherapy depends on the type of drugs, the amounts
taken, and the length of treatment.

• Alopecia
• Stomatitis
• Dysphagia
• Nausea and Vomiting
• Constipation
• Diarrhea
• Skin Reactions
• Effects on Bone Marrow (Anemia, Neutropenia, Thrombocytopenia)
• Infertility
Biologic Therapy

It uses the body’s immune system to fight

cancer or to lessen the side effects of some
cancer treatments. Cancer immunotherapy refers
to a diverse set of therapeutic strategies designed
to induce the patient’s own immune system to
fight the tumor. Contemporary methods for
generating an immune response against tumors
include the use of interferons and other
cytokines to induce an immune response in
renal cell carcinoma and melanoma patient.
Hormone Therapy
• Hormones are chemicals that act naturally produced
by the organs making up the body’s endocrine
system. These chemicals travel throughout the body
via bloodstream, coordinating the functions of
various organs from head to toe.
• Researchers have determined that some cancers
are “fueled” by hormones, and may rely on them to
grow. In those cases, blocking the reaction of these
hormones could possibly stop the cancer from
growing.
• The growth of some cancers can be inhibited by
providing or blocking certain hormones. Common
examples of hormone-sensitive tumors include
certain types of breast and prostate cancers.
Removing or blocking estrogen or
testosterone is often an important additional
treatment.
4 R’s of Radiotherapy

Repair of DNA – it is assumed that tumor cells

are less able to repair DNA damage.

Reoxygenation – the proliferative cells of a

tumor, unrestrained as they are by any
homeostatic control, divide and proliferate as
rapidly as they are able to, LIMITED only by their
own inherited characteristics and the availability of
an adequate supply of nutrients.
• Redistribution – cells are more sensitive to
radiation during some phases of their cycles than
others.

• Repopulation – radiation will often stimulate cell

division. In normal tissues, this is kept under
control by normal homeostatic mechanism, but it
is not true in tumors. Thus, we need another dose
to counteract the repopulation.
Remission

It is a period of time where the cancer is

responding to treatment or is under control.
COMPLETE REMISSION - all the sign and
symptoms disappear.
PARTIAL REMISSION - the cancer shrinks but
does not completely disappears.
Recurrence

It is a period of time when a cancer returns after a

period of remission.
A cancer recurrence means it’s the same cancer
coming back after some period of time.
In rare cases, a patient may be diagnosed with a
new cancer that’s completely unrelated with
his/her first cancer. This is referred to as a
SECOND PRIMARY CANCER.
Cancer can recur in the same place it was
originally located, or it can migrate to other parts
of the body.
The risk of recurrence is considered to be
increased in the following situations:
When the surgical margin between normal tissue
and cancerous tissue is minimal (less than 2 cm)
When the margin is positive for cancer, (i.e.,
when cancerous tissue is not completely
removed)
When the tumor is incompletely resected
because of its large size and/or its relationship
with normal vital structures
When the cancer has spread to adjacent lymph
nodes
• LOCAL RECURRENCE – When a cancer
reappears in the same place where it was
found, or very close by. The cancer hasn’t
spread to the lymph nodes or other parts of the
body.
• REGIONAL RECURRENCE – Occurs in the
lymph nodes and tissue located in the vicinity of
your local cancer.
• DISTANT RECURRENCE – This refers to the
cancer reappeared to areas farther away from
where your cancer was first located.
 RADIOBIOLOGIC AND
PHYSICAL PRINCIPLES
IN RADIOTHERAPY
Absorbed Dose

The dose prescribed for and received by the

patient.
The required dose of energy actually absorbed by
the patient, at the tumor site, from the radiation
beam.
Gray (Gy) is the SI unit of absorbed dose.
1 rad= 0.01 Gy or 1cGy
Clinical Methods of Treatment

PROTRACTION TECHNIQUE

The dose is delivered continuously but at a lower

dose rate, it is much less effective because of
lower dose rate and longer irradiation time.
FRACTIONATION TECHNIQUE
Division of total planned dose into a number of
smaller doses to be given over longer period.
This allows recovery of normal cells while
depleting the number of surviving tumor cells.
Conventional fractionated courses consist of
once-daily doses given 5 days a week with
recovery period at the weekend.
Classification of Tumor

• Radiosensitive Tumor – requires low dose for

eradication.

• Radioresistant Tumor – requires high dose for

eradication.
Tolerance Dose

The largest amount of dose that can be accepted

by the normal tissue without the production of
injurious symptoms.

Every tissue of a human body has specific

tolerance dose to be observed.
Tolerance Dose of Tissue

• Testes 1-2 Gy
• Ovary 6-10 Gy
• Eye (Lens) 6-12 Gy
• Lungs 20-30 Gy
• Kidney 20-30 Gy
• Skin 30-40 Gy
Tolerance Dose of Tissue

• Thyroid 30-40 Gy
• Liver 35-40 Gy
• Heart 40-50 Gy
• Lymphoid 40-50 Gy
• Bone Marrow 40-50 Gy
• Spinal Cord 40-50 Gy
Tolerance Dose of Tissue

• Gastrointestinal 50-60 Gy
• Peripheral Nerve 65-77 Gy
• Mucosa 65-77 Gy
• Brain 60-70 Gy
• Bone & Cartilage >70 Gy
• Muscle >70 Gy
Dose Rate/ Dose per Fraction/ Fraction
Dose

The dose that can be tolerated by the normal

tissue in the treatment zone varies with the total
time over which the dose is given.

For a given volume, the size of each fraction

dose and the time interval between fraction alters
the biological effect.
The higher the fraction dose (dose rate), the
greater the damage potential.

Missed treatment would lead to an overall

treatment period which significantly longer than
intended.

Some patients (for head and neck) are at survival

disadvantage if treatment duration is lengthened
because once some cells are killed the cell
kinetics change and there is a potential for very
rapid repopulation.
Treatment Volume
Treatment Volume
• Gross Tumor Volume (GTV) – is the gross palpable
or visible/ demonstrable extent and location of
malignant growth. The GTV usually correspond to
those parts of the tumor where the tumor cell density
is greatest.

• Clinical Target Volume (CTV) – is a tissue volume

that contains a demonstrable GTV and subclinical
microscopic malignant disease that must be
eliminated.
• Planning Target Volume (PTV) – contains the
tissues that are to be irradiated to a specified
time dose pattern. This volume consists of a
tumor and adjacent tissue where tumor is
presumed to be present, in some instances also
the regional lymph nodes.
• Treatment Volume – is the volume enclosed by an
isodose surface, selected and specified by the
radiation oncologist as being appropriate to achieve
the purpose of treatment.

• Irradiated Volume – is the volume of tissue that

receives a dose considered significant in relation to
tissue tolerance.
Additional important Terminologies

• Hot Spot – accumulation of radiation is high

due to fall-off of beams, overlapping of beams,
and skinfolds of patients.
• Cold Spot – accumulation of radiation is low
due to missed areas of radiation.
• Lead Blocks – made of cerrobend (1/2
bismuth, ¼ lead, ¼ cadmium & tin).
-1 cm thickness for electron and 7 cm
thickness for photons.
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