Radiotherapy

1.Basic mechanisms of interaction between ionizing radiation and biological matter

physical, chemical and biological phase.
Ionizing radiation is radiation composed of particles that individually carry enough kinetic
energy to liberate an electron from an atom or molecule, ionizing it. Ionizing radiation is
generated through nuclear reactions, either artificial or natural, by very high temperature via
production of high energy particles in particle accelerators, or due to acceleration of charged
particles by the electromagnetic fields produced by natural processes. When ionizing
radiation is emitted by or absorbed by an atom, it can liberate an atomic particle (typically an
electron, proton, or neutron, but sometimes an entire nucleus) from the atom. Such an event
can alter chemical bonds and produce ions, usually in ion-pairs, that are especially
chemically reactive. This greatly magnifies the chemical and biological damage per unit
energy of radiation because chemical bonds will be broken in this process. If the atom were
inside a crystal lattice in a solid phase, then a "hole" would exist where the original atom
was.
-Nuclear effects: Neutron radiation, alpha radiation and extremely energetic gamma can
cause nuclear transmutation and induced radioactivity. The relevant mechanisms are
Neutron activation, alpha absorption, and photodisintegration. A large enough number of
transmutations can change macroscopic properties and cause targets to become radioactive
themselves, even after the original source is removed.
-Chemical effects: Ionization of molecules can lead to radiolysis, (breaking chemical bonds)
and formation of highly reactive free radicals. These free radicals may then react chemically
with neighbouring materials even after the original radiation has stopped. Ionizing radiation
can disrupt crystal lattices in metals, causing them to become amorphous, with consequent
swelling, material creep and embrittlement. Ionizing radiation can also accelerate existing
chemical reactions such as polymerization and corrosion, by contributing to the activation
energy required for the reaction. Optical materials darken under the effect of ionizing
radiation. High-intensity ionizing radiation in air can produce a visible ionized air glow of
telltale bluish-purplish color.
-Electronic effects: Ionization of materials temporarily increases their conductivity,
potentially permitting damaging current levels. This is a particular hazard in semiconductor
microelectronics employed in electronic equipment, with subsequent currents introducing
operation errors or even permanently damaging the devices. Devices intended for high
radiation environments such as the nuclear industry and extra atmospheric (space)
applications may be made radiation hard to resist such effects through design, material
selection, and fabrication methods. Vacuum tubes are much less sensitive to radiation
effects.The electrical effects of ionizing radiation are exploited in gas-filled radiation
detectors, e.g. the Geiger tube.
-Biological effects: Ionizing radiation is generally harmful and potentially lethal to living
things but can have health benefits in radiation therapy for the treatment of cancer and
thyrotoxicosis. Its most common impact is the induction of cancer with a latent period of
years or decades after exposure. High doses can cause visually dramatic radiation burns,
and/or rapid fatality through acute radiation syndrome. Controlled doses are used for

medical imaging and radiotherapy. Some effects of ionizing radiation on human health are
stochastic, meaning that their probability of occurrence increases with dose, while the
severity is independent of dose. Radiation-induced cancer, teratogenesis, cognitive decline,
and heart disease are all examples of stochastic effects. Other conditions such as radiation
burns, acute radiation syndrome, chronic radiation syndrome, and radiation-induced
thyroiditis are deterministic, meaning they reliably occur above a threshold dose, and their
severity increases with dose.
2.Fundamentals of radiotherapy as local treatment modality and as alternative to systemic
treatment
Radiotherapy: The medical use of ionizing radiation aiming to deliver prescribed dose to
affected by disease tissues.
Radiation is loco-regional treatment of cancer. Surgery is local treatment and chemotherapy
is systemic treatment. Radiation therapy is the treatment of cancer and other diseases with
ionizing radiation. Ionizing radiation deposits energy that injures or destroys cells in the area
being treated (the "target tissue") by damaging their genetic material, making it impossible
for these cells to continue to grow. Briefly, radiation causes damage by delivering energy
(the amount of which is measured as a "dose" of radiation) to the tissues. Free radicals are
thereby created, which in turn cause the damage to the cellular DNA. Since cancer cells
cannot repair this damage as effectively as normal tissues, they are preferentially killed by
radiation treatments.Unlike cancer cells, most normal tissues recover from the effects of
radiation. To protect normal cells, radiation oncologists carefully limit the doses of radiation
and spread the treatment out over time. External beam radiotherapy uses machines to focus
radiation on a cancer site. The higher the energy of the beam, the deeper the radiation can
penetrate into the target tissue. Radiation is used with curative intent, as primary, adjuvant or
combined modality treatment. Radiation is also used for palliative benefit. Radiation
treatment depends on the availability of a highly trained team and increasingly advanced
equipment. Access to cancer centres is a major determinant of treatment.
-Radiation for Cure: Radiation may be given for local control of disease or with curative
intent. Curative treatment occurs over a longer period of time with a lower dose per
treatment (fraction). The acute side effects may be severe and late side effects need to be
considered as well. The following factors determine therapeutic and side effect response to
treatment. Radiation can be primary treatment for organ preservation (larynx, anus, bladder),
when the tumour is too extensive for surgery (nasopharyngeal, cervix, prostate) or the
patient is unfit for surgery (lung, esophagus). Highly radiosensitive tumours: seminoma
testis, Hodgkins Disease, epithelial skin cancer.
-Radiation as Adjuvant Therapy: Radiation can enhance local-regional control of disease and
may be considered to allow preservation of function or cosmesis. Breast cancer recurrence
rates drop from 30% to 8% with adjuvant radiation therapy and rectal cancer recurrence
rates drop from 40% to 15 %.
-Combined Modality Treatment: Radiation is most commonly used for combined modality
treatment of rectal, lung, anal and esophageal cancer. In combination radiation can improve
cure rates, decrease toxicity and decrease morbidity.

-Radiation for Palliation: Radiation provides palliative benefit in:

bone pain

spinal cord compression

brain metastases

bronchial obstruction

hemoptysis

esophageal obstruction

pelvic pain or bleeding

ulcerating subcutaneous masses

In palliative situations radiation treatment tends to occur at a higher dose per fraction over a
shorter period of time.
3.Radiotherapy methods in patients managements combination of radiotherapeutic
modalities
Radiotherapy: use of ionizing radiation, generally as part of cancer treatment to control or
kill malignant cells. Radiation therapy may be curative in a number of types of cancer if they
are localized to one area of the body. It may also be used as part of adjuvant therapy, to
prevent tumor recurrence after surgery to remove a primary malignant tumor (for example,
early stages of breast cancer). Radiation therapy is synergistic with chemotherapy, and has
been used before, during, and after chemotherapy in susceptible cancers. RT is commonly
applied to the cancerous tumor because of its ability to control cell growth. Ionizing radiation
works by damaging the DNA of exposed tissue leading to cellular death. the three main
divisions of radiation therapy are external beam radiation therapy (EBRT or XRT) or
teletherapy, brachytherapy or sealed source radiation therapy, and systemic radioisotope
therapy or unsealed source radiotherapy. The differences relate to the position of the
radiation source; external is outside the body, brachytherapy uses sealed radioactive
sources placed precisely in the area under treatment, and systemic radioisotopes are given
by infusion or oral ingestion.
RT combined with surgery
Preoperative RT
Postoperative RT
Intraoperative RT
RT combined with Chemotherapy
Simultaneous
Postponed
Radiotherapy alone
Combined RT- different RT methods

Intracavitary curietherapy
Interstitial curietherapy
Metabolic curietherapy
Define tumor target: staging tumor node metastasis system- prognostic factors
Tumour histopathological characteristics - prognostic factors determined tumour biology
Definition of the goal of RT: curative or palliative
Patients status (Karnofski index)
Anatomical and topographical planning of RT: Optimal tumor volume, staging, histological
parameter, lymph node involvement, tumor and normal tissue anatomy, and topometry
4.Orthovoltage radiotherapy
Orthovoltage is a type of radiation therapy. The x-rays are strong enough to kill cancer cells
but do not penetrate more than a few millimeters beyond the surface of the skin.
Orthovoltage treatments are given for very superficial, small tumors such as skin cancers.
Orthovoltage is an excellent alternative to surgery for skin cancer in sensitive locations such
as the folds of the nose or the eyelids. Treatments take 15 minutes per day and are given
everyday for 3 to 4 weeks. Orthovoltage X-rays are produced by X-ray generators and when
used to treat patients, they penetrate to a useful depth of about 46 cm. That makes them
good for treating skin, superficial tissues, and ribs, but not for deeper structures such as
lungs or pelvic organs.
By convention, the voltage is used to characterize X- and gamma-ray beams (in volts), whilst
electron beams are characterized by their energies (in electronvolts).
5.External beam radiotherapy. Megavoltage equipment telecobalt machines, linear
accelerators
External beam radiotherapy is the most common form of radiotherapy. The patient sits or lies
on a couch and an external source of radiation is pointed at a particular part of the body.
External beam radiotherapy directs the radiation at the tumour from outside the body.
Kilovoltage (superficial) X-rays are used for treating skin cancer and superficial structures.
Megavoltage (deep) X-rays are used to treat deep-seated tumours (e.g. bladder, bowel,
prostate, lung, or brain). A linear particle accelerator is a type of particle accelerator that
greatly increases the velocity of charged subatomic particles or ions by subjecting the
charged particles to a series of oscillating electric potentials along a linear beam line.
Linacs have many applications: they generate X-rays and high energy electrons for
medicinal purposes in radiation therapy, serve as particle injectors for higher-energy
accelerators, and are used directly to achieve the highest kinetic energy for light particles
(electrons and positrons) for particle physics.
Cobalt machine: artificial radioactive substance Cobalt-60 is used which emits gamma
radiation, with the help of this radiation that cancer cells are destroyed.
Besides Co-60 machine there are other machines, example: Linear Accelerators (high
energy machines). For treatment like head, neck, esophagus which is very common side of
cancer, Co-60 machine is the best. Also depending on the size of the patient especially in
this region, there is no need of high energy machine. Linear Accelerators is a very complex
machine, machine problems occurs more frequently.
6.Brachytherapy intracavitary, interstitial, methabolic
Brachytherapy (internal radiation therapy) is delivered by placing radiation source(s) inside
or next to the area requiring treatment. Brachytherapy is commonly used as an effective
treatment for cervical, prostate, breast, and skin cancer. As with stereotactic radiation,

brachytherapy treatments are often known by their brand names. For example, brand names
for breast cancer brachytherapy treatments include SAVI, MammoSite, and Contura. Brand
names for prostate cancer include Proxcelan, TheraSeed, and I-Seed.
In brachytherapy, radiation sources are precisely placed directly at the site of the cancerous
tumour. This means that the irradiation only affects a very localized area exposure to
radiation of healthy tissues further away from the sources is reduced. These characteristics
of brachytherapy provide advantages over external beam radiation therapy the tumour can
be treated with very high doses of localized radiation, whilst reducing the probability of
unnecessary damage to surrounding healthy tissues. A course of brachytherapy can often be
completed in less time than other radiation therapy techniques. This can help reduce the
chance of surviving cancer cells dividing and growing in the intervals between each radiation
therapy dose. As one example of the localized nature of breast brachytherapy, the SAVI
device delivers the radiation dose through multiple catheters, each of which can be
individually controlled. This approach decreases the exposure of healthy tissue and resulting
side effects, compared both to external beam radiation therapy and older methods of breast
brachytherapy.
7.Radiotherapy in the multidisciplinary approach for tumour control
Classical treatment methods
Surgery
Radiotherapy
Chemotherapy = Drug therapy with cytostatic hormones, immunomodulators, vaccines
Non-classical methods alone or combined with classical methods
Photodynamic treatment: combines a drug (called a photosensitizer or photosensitizing
agent) with a specific type of light to kill cancer cells. In the first step of PDT for cancer
treatment, a photosensitizing agent is injected into the bloodstream. The agent is absorbed
by cells all over the body but stays in cancer cells longer than it does in normal cells.
Approximately 24 to 72 hours after injection, when most of the agent has left normal cells but
remains in cancer cells, the tumor is exposed to light. The photosensitizer in the tumor
absorbs the light and produces an active form of oxygen that destroys nearby cancer cells
Hyperthermia: a type of cancer treatment in which body tissue is exposed to high
temperatures (up to 45C) to damage and kill cancer cells. Makes some cancer cells more
sensitive to radiation or harm other cancer cells that radiation cannot damage. When
hyperthermia and radiation therapy are combined, they are often given within an hour of
each other. Hyperthermia can also enhance the effects of certain anticancer drugs.
Cryotherapy: local or general use of low temperatures in medical therapy. Treat a variety of
benign and malignant lesions. a technique for freezing and killing abnormal cells. It is used
to treat some kinds of cancer and some precancerous or noncancerous conditions, and can
be used inside the body and on the skin
8.Tumour tissue radiosensitivity. Therapeutic windows
Tumour tissue radiosensitivity.
High radiosensitive tumours malignant lymphomas, seminoma, dissgerminomas
Moderately radiosensitive tumours epithelial neoplasmas carcinomas SCC (G1-G3
Ca cutis, colli uteri, ORL; adenocarcinomas
Radioresitant tumours- mesenhymomas- bone and soft tissue sarcomas, some epithelial
blastomas (adenosquamous or mucoepidermoid type)
An important concept when considering the effect of radiotherapy is the therapeutic index.

The therapeutic index is the tumor response for fixed level of normal tissue damage. The
therapeutic window describes the possible difference between the tumor control dose and
the normal tissue tolerance dose. Response rates to radiotherapy differ widely depending on
tumor type.
Therapeutic ratio = TD50/ED50.
Effective dose (ED) in pharmacology is the dose or amount of drug that produces a
therapeutic response or desired effect in some fraction of the subjects taking it, in 50% of
the population that takes it.
The median toxic dose (TD50) of a drug or toxin is the dose at which toxicity occurs in 50% of
cases.
9.Normal tissue and organ radiosensitivity. Early and late radiation reactions.
Early effects are produced by radiation doses
Late effects include malignancy and genetic effects due to long radiation exposure
Intrinsic radiosensitivity of the tissue TD concept TD5/5 TD 50/5
Tissue with low toleramce to radiation: hemopoetic sys\tem, reproductive organs, lens, sinal
cord, liver, lung.
Tissue with high tolerance to radiation: bones, muscles, nerves
Volume of the irradiated normal tissue: whole, parts dose-volume histograms
Tumour response modifiers: chemotherapy (Cisplatin nephrotoxicity, Adriablastincardiotoxicity
Early reactions:
Reversible, temporary:
1-slight function changes 10%;
2- moderate 25%
3- strong 50%
4- severe life treatening75%
5- fatal 100%
Late reactions:
After 6 months to 5 years
Non reversible
Higher in hypofractionation
Lower in hyperfractionation
10.Main algorithms for prescribing and delivering radiotherapy
Two algorithms for booking courses of radiotherapy treatment sessions for the dynamic
arrival of patients in a parallel machine environment are developed. Patients vary by due
date, by which they should start their treatments, clinical category and treatment machine
requirement. The first algorithm, mimicking current practice, books patients forward from the
release date (ex. the date when the patient can start radiotherapy treatment). The second
algorithm books patients backwards from the due date. Feasible schedules of treatment
sessions are generated for each patient with the aim to minimize the total number of patients
who do not meet waiting time targets, the total length of waiting time breaches, and the total
number of interruptions to treatment.
Algorithms are step by step processes which are used in planning systems (and otherwise)
to complete specific tasks.
The simplest of algorithms perform as accurately as the most sophisticated algorithms for
ideal conditions.

 Time is a critical factor in the development of treatment planning algorithms.

Heterogeneities pose the greatest challenge to predicting accurate dose distributions in
patients.
-The Monte Carlo method is the most accurate method for calculating dose in
heterogeneities. The most accurate currently available algorithms incorporate Monte Carlo
kernels.
Discrepancies in calculations more likely to arise from low density media than from high
density media
Safer to rely on your convolution-superposition algorithm than your verification
calculation, since your verification calculation uses a simpler, less accurate algorithm.
11.Radiotherapy in treatment of breast cancer
Anatomy: the mammary gland lies over the pectoralis major muscle and extends from the
2nd-6th rib. The mamma consists of glandular tissue arranged in multiple lobes composed of
lobules connected in ducts, areolar tissue, and blood vessels.
Treatment should be based on clinical extent and pathologic characteristics of the tumor,
biologic prognostic factors, patients age (menopausal status) and the preference and
psychological profile of the patient.
The rational for postmastectomy radiotherapy is to prevent recurrence of cancer in the chest
wall, skin, mastectomy scar, and the regional nodes, including the axillary supraclavicular
and internal mammary nodes. The second goal of postmastectomy RT is to improve overall
survival.
After radical or modified radical mastectomy, postoperative irradiation of the chest wall and
peripheral lymohatics occasionally is indicated in patients with high risk characteristics (for
example when more than 4 of the axillary nodes are histologically positive, tumor is located
in the central or inner quadrant of the breast etc). It is used after surgery to get rid of any
remaining cancer cells left behind in the breast area. This reduces the risk of the cancer
coming back. The whole breast is irradiated with lateral and medial tangential portals. The
entire breast and chest wall should be included in the irradiated volume. The irradiation
should be started within 6 weeks from breast surgery for patients not receiving
chemotherapy and within 16 weeks for those treated with adjuvant chemotherapy.
Doses and beams: min tumor doses of approx. 50 Gy are delivered to the entire breast in 56 weeks
12.Radiotherapy in treatment of cervix cancer
Radiotherapy for cancer of the cervix can be external or internal, and is often given as a
combination of the two. Treatment with radiotherapy may last for 5-8 weeks. Radiotherapy
may be given to treat early-stage cervical cancer. Its also usually given for larger tumours
contained in the cervix, or if the cancer has spread beyond the cervix and is not curable with
surgery alone. Radiotherapy may also be used after surgery if there is a high risk that the
cancer may come back. Its often given in combination with chemotherapy (chemoradiation).

Radiotherapy treatment for cervical cancer will affect the ovaries. For younger women who
are still having their monthly periods, radiotherapy will stop the ovaries producing eggs and
the hormones oestrogen and progesterone. This will make you infertile, so that its no longer
possible to have a child. It will also bring on an early menopause, usually about three
months after the treatment starts. Some women may be offered an operation before
radiotherapy to reposition their ovaries higher in the abdomen, out of the radiotherapy site.
The aim of this surgery is to prevent an early menopause; its known as ovarian transposition
and is usually carried out at the same time as initial surgery if its thought that radiotherapy
will be needed afterwards. It may also be possible to have an ovarian transposition using
laparoscopic (keyhole) surgery.
External radiotherapy is normally given as an outpatient, as a series of short daily treatments
in the hospital radiotherapy department. High-energy x-rays are directed from a machine
(called a linear accelerator) at the area of the cancer.
Internal radiotherapy (also called brachytherapy) gives radiation directly to the cervix and the
area close by. Its usually given following external radiotherapy. To give brachytherapy, a
piece of radioactive material called a source is put close to the cancer or the area where the
cancer was before it was removed. If youve not had a hysterectomy, you will have
intrauterine brachytherapy, a doctor inserts the applicators into the vagina and passes them
up through the cervix into the womb. If you have had a hysterectomy, a single larger hollow
tube applicator is placed in the vagina. With intravaginal brachytherapy you wont need an
anaesthetic or sedation to insert the applicator and padding isnt necessary. Once its
confirmed that the applicators are in the correct position, they are connected to the
brachytherapy machine. The machine is then used to place the source into the applicators
and deliver the radiotherapy treatment. Brachytherapy may be given in several short bursts
or in one long slow treatment, depending on the systems used. With high-dose rate
treatment, a machine containing a radioactive source of iridium or cobalt is used to give a
high dose of radioactivity over a few minutes. Low-dose rate treatment is usually given over
12-24 hours as an inpatient, one type of brachytherapy machine thats used to give low-dose
rate treatment is known as a Selectron. A Selectron places a radioactive source of small
balls of caesium into the applicator tubes to deliver the treatment.

13.Radiotherapy in treatment of endometrial cancer

Radiation therapy is the use of high-dose X-rays to destroy cancer cells. Radiation therapy
may be used to treat endometrial cancer after hysterectomy or as the primary therapy,
particularly for women who cannot have surgery. The two types of radiation therapy that may
be used to treat endometrial cancer are: Internal radiation therapy (brachytherapy), in which
radioactive materials (radioisotopes) are placed into the vagina, uterus, or other areas where
the cancer cells are found. And external beam radiation therapy, in which radiation comes
from a machine outside the body. During this procedure you lie on a table while a machine
directs radiation to specific points on your body. In brachytherapy, tiny tubes of radioactive
material are inserted into the vagina or the uterus. Ultrasound may be used to guide the
placement. The radioactive tubes will be left in place for 2 to 3 days.
14.Radiotherapy in treatment of cancer of larynx
Radiation therapy uses high-energy x-rays, gamma rays, or particles to kill cancer cells. It
may be used in different situations for laryngeal and hypopharyngeal cancers. As primary

treatment at early stages, if the cancer is small, it can often be destroyed by radiation without
surgery (used also to treat patients whose health is too poor for surgery). This treatment can
help to preserve better voice quality. It may be used after a cancer is removed with surgery,
to try to kill any small areas of cancer that may remain and lower the chance the cancer will
come back. This is called adjuvant treatment. Also, it can be used to ease symptoms of
advanced laryngeal and hypopharyngeal cancer such as pain, bleeding, trouble swallowing,
and problems caused when cancer spreads to the bones. Often, chemotherapy is given
along with the radiation. This combination, called chemoradiation, can be more effective than
radiation alone, but it also has more side effects.
2 main types of radiation therapy
External beam radiation therapy: most common type of radiation therapy to treat laryngeal
and hypopharyngeal cancer. Radiation from a source outside the body is focused on the
cancer. Before treatments starts, the radiation team will take careful measurements to
determine the correct angles for aiming the radiation beams and the proper dose of
radiation. Radiation therapy for laryngeal and hypopharyngeal cancer is usually given in
daily fractions (doses), 5 days per week, for about 7 weeks.
Hyperfractionation means giving the total radiation dose in a larger number of doses (2
smaller doses per day instead of 1 larger dose, for example).
Accelerated fractionation means that the radiation treatment is completed faster (6 weeks
instead of 7 weeks, for instance).
Hyperfractionation and accelerated fractionation schedules may reduce the risk of laryngeal
and hypopharyngeal cancer coming back in or near the place it started (called local
recurrence) and may help some patients live longer. The drawback is that these schedules
also tend to have more severe side effects.
Modern techniques help doctors focus the radiation more precisely.
Three-dimensional conformal radiation therapy (3D-CRT): 3D-CRT uses the results of
imaging tests such as MRI and special computers to precisely map the location of the tumor.
Intensity modulated radiation therapy (IMRT): IMRT is an advanced form of 3D therapy. It
uses a computer-driven machine that actually moves around the patient as it delivers
radiation. In addition to shaping the beams and aiming them at the tumor from several
angles, the intensity (strength) of the beams can be adjusted to limit the dose reaching the
most sensitive nearby normal tissues. This may let the doctor deliver a higher dose to the
tumor. Many major hospitals and cancer centers now use IMRT as the standard way to
deliver external beam radiation.
Brachytherapy: Internal radiation therapy, uses radioactive material placed directly into or
near the cancer. Brachytherapy may be used alone or combined with external beam
radiation therapy. It is rarely used to treat laryngeal and hypopharyngeal cancer.
15.Radiotherapy in treatment of cancer of nasopharynx
Radiation therapy uses high-energy x-rays or particles to destroy cancer cells or slow their
rate of growth. It is usually at least part of the main treatment for nasopharyngeal cancer
(NPC) because most of these cancers are very sensitive to radiation. For many cases of
NPC, chemotherapy is given with radiation to try to increase its effects. This treatment,
known aschemoradiation, can be better than radiation alone at fighting the cancer, but it also
tends to have more side effects. Radiation therapy is usually given both to the main
nasopharyngeal tumor and to nearby lymph nodes in the neck. Even if the lymph nodes are
not abnormally firm or large, radiation is still used in case a few cancer cells have spread
there. If the lymph nodes are known to have cancer cells, higher radiation doses are used.
Different types of radiation therapy can be used to treat NPC:

External beam radiation therapy (EBRT): This type of radiation therapy uses x-rays from
a machine outside the patients body to kill cancer cells. It is the most common form of
radiation therapy for NPC. Before treatments starts, the radiation team takes careful
measurements to determine the correct angles for aiming the radiation beams and the
proper dose of radiation.
Three-dimensional conformal radiation therapy (3D-CRT): uses the results of imaging tests
such as MRI and special computers to precisely map the location of the tumor(s). Radiation
beams are shaped and aimed at the tumor(s) from several directions, which makes it less
likely to damage nearby normal tissues.
Intensity-modulated radiation therapy (IMRT): an advanced form of 3D therapy. It uses a
computer-driven machine that moves around the patient as it delivers radiation. Along with
shaping the beams and aiming them at the tumor from several angles, the intensity
(strength) of the beams can be adjusted to limit the dose reaching the most sensitive normal
tissues.
Stereotactic radiosurgery: a type of radiation treatment that delivers a large, precise radiation
dose to the tumor area in a single session. (There is no actual surgery involved in this
treatment.) The radiation may be delivered in 2 ways. First, in one approach, radiation
beams are focused at the tumor from hundreds of different angles for a short period of time.
One machine used to deliver this type of radiation is known as a Gamma Knife. Or, another
approach uses a movable linear accelerator (a machine that creates radiation) that is
controlled by a computer. Instead of delivering many beams at once, this machine moves
around the head to deliver radiation to the tumor from different angles. Several machines,
with names such as X-Knife, CyberKnife, and Clinac, do stereotactic radiosurgery in this
way.
Brachytherapy (internal radiation): another way to deliver radiation is to insert (implant)
very thin metal rods or wires containing radioactive materials into or very near the cancer.
The radiation travels a very short distance, so it affects the cancer without causing much
harm to nearby healthy body tissues. The implant is usually left in place for several days.
16.Radiotherapy in treatment of skin cancer
Radiation therapy is not suitable for all types of skin cancers. Some of the factors affecting
whether radiation therapy can be used include: type of cancer, site of the cancer, previous
use of radiation therapy, suitability of other treatments, and patient preference.
Type of cancer: different cancers vary in their sensitivities to radiation induced damage,
which influences how successful the radiation therapy will be. For example, melanomas are
less sensitive to radiation, and are rarely treated with radiation therapy. Skin cancers which
are relatively sensitive to radiation and commonly treated with radiation therapy include:
Basal cell carcinoma, Squamous cell carcinoma, Cutaneous lymphomas
Site of the cancer: radiation therapy is often used in sites in which surgery may be difficult,
such as the eyelids. Some areas of the body are more likely to develop side effects from
radiation therapy, such as the lower legs, and in these areas other treatments may be
preferred.
Administration of radiation therapy: The dose of radiation is usually divided into several
smaller doses, called fractions. This is done as the time between doses (fractions) allow the
normal cells to recover from the radiation induced damage. This ultimately reduces side
effects and allows a higher total dose of radiation to be safely used. For most skin cancers a
total of 10-25 fractions of radiation treatment are administered. The radiation therapy is
administered by a specially trained radiation therapist, and each fraction usually takes 15-20
minutes to administer. Fractions are usually given on a daily basis and a full treatment
course can take between 2-5 weeks to complete.
17.Radiotherapy as a treatment modality in malignant lymphomas

Malignant lymphomas consist of Hodgkin and non-Hodgkin lymphomas.

Radiotherapy in Hodgkins lymphoma: Radiotherapy is often used to treat stage 1 and 2
lymphomas, when the cancer cells are in only one part of the body. For classical Hodgkin's
lymphoma, radiation therapy can be used alone, but it is often used after chemotherapy.
People with early-stage lymphocyte-predominant Hodgkin's lymphoma typically undergo
radiation therapy alone. Radiation can be aimed at affected lymph nodes and the nearby
area of nodes where the disease might progress. Some side effects are redness of the skin
and fatigue. More serious risks include heart disease, stroke, thyroid problems, infertility and
other forms of cancer, such as breast or lung cancer.
Radiotherapy in non-Hodgkins lymphoma: when radiation is used to treat non-Hodgkin
lymphoma, its most often done with a carefully focused beam of radiation, delivered from a
machine outside the body. This is known as external beam radiation. Most often, radiation
treatments are given 5 days a week for several weeks. Radiation can also be given as a
drug in some cases. Radiation might be used as the main treatment for some types of
lymphoma if they are found early (stage I or II), because these tumors respond very well to
radiation. For more advanced lymphomas and for some lymphomas that are more
aggressive, radiation is sometimes used along with chemotherapy. People who are getting a
stem cell transplant may get radiation to the whole body along with high-dose chemotherapy,
to try to kill lymphoma cells throughout the body. Radiation therapy can also be used to ease
(palliate) symptoms caused by lymphoma that has spread to internal organs, such as the
brain or spinal cord, or when a tumor is causing pain because its pressing on nerves.
18.Radiotherapy as a treatment modality in benign disease (borderline tumours, benign
disease expansion, degenerative disease etc.)
Most benign tumors do not respond to chemotherapy or radiation therapy, although there
are exceptions. Benign intercranial tumors are sometimes treated with radiation therapy and
chemotherapy under certain circumstances. Radiation can also be used to treat
hemangiomas in the rectum. Benign skin tumors are usually surgically resected but other
treatments such as cryotherapy, curettage, electrodesiccation, laser
therapy, dermabrasion, chemical peels andtopical medication are used.