Walter and Miller’s Textbook of

Radiotherapy: Radiation Physics,

Therapy and Oncology 8th Edition
Edition Paul Symonds
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Walter and Miller’s

TEXTBOOK OF
RADIOTHERAPY
This page intentionally left blank
Walter and Miller’s

TEXTBOOK OF
RADIOTHERAPY
Radiation Physics, Therapy and Oncology
EIGHTH EDITION

Edited by

Paul Symonds TD MD FRCP FRCR

Emeritus Professor of Clinical Oncology, University of Leicester, Leicester, UK; Honorary
Consultant Oncologist, University Hospitals of Leicester, Leicester, UK

John A. Mills PhD MIPEM CPhys

Physicist, MACS-Quality Control Provider, James Watt House, Hinckley, UK

Angela Duxbury FCR TDCR MSc

Emeritus Professor of Therapeutic Radiography, Sheffield Hallam University, Sheffield, UK
© 2019, Elsevier Limited. All rights reserved.

First edition 1950

Second edition 1959
Third edition 1979
Fourth edition 1979
Fifth edition 1993
Sixth edition 2003
Seventh edition 2012

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 CONTENTS

Contributors, xix Beam Hardening, 21

International System of Units and Prefixes for Physical Energy Absorption, 22
Quantities, xxiii Photo-Nuclear Interactions, 22
Photon Depth Dose and the Build-Up Effect, 22
Kerma and Absorbed Dose for Radiotherapy
SECTION 1
beams, 24
Kerma, 24
1 Atoms, Nuclei and Radioactivity, 2
Absorbed Dose, 24
Elizabeth M. Parvin
Units of Kerma and Dose, 25
Introduction, 2
Heavy Charged Particle Interactions, 25
Atomic Structure, 2
Protons, 25
Particles, 2
Carbon Ions and Pions, 25
The Atom and the Nucleus, 3
Neutron Interactions, 26
The Forces, 3
References, 27
Electron Energy Levels, 4
Further Reading, 27
Band Theory of Solids, 4
Impurity Bands, 5 3 Radiation Detection and Measurement, 28
Particles in Electric and Magnetic Fields, 5 Andrew Poynter, Andrzej Kacperek, and John A. Mills
Electric Fields, 5 Introduction, 28
Magnetic Fields, 5 Radiation Detection, 28
The Lorentz Equation, 5 Gas Amplification Devices, 29
Waves, 5 Scintillation Devices, 30
Transverse and Longitudinal Waves, 5 Ideal Air Ionisation Chamber, 30
Electromagnetic Radiation, 6 Proton Beam Detection, 30
Continuous Spectra and Characteristic Radiation, 7 Measurement and Standardisation of Dose, 31
Radioactive Decay, 8 Dose Standards, 31
Stable and Unstable Isotopes, 8 Traceability of Measurement, 31
Half-life, 9 Standard Calorimeter, 32
Alpha Decay, 9 The Free Air Chamber, 33
Beta Decay, 10 The Proton Beam Dose Standard, 34
Gamma Decay, 10 Practical Ionisation Chambers, 34
Electron Capture and Internal Conversion, 11 Bragg–Gray Cavity Theory, 34
Radioactive Decay Series, 11 Dose Determination Based on Calibrated
Radionuclides of Medical Interest, 12 Instruments, 35
References, 12 Requirements for Practical Ionisation Chambers, 35
Further Reading, 12 Thimble Ionisation Chamber, 35
Physical Description, 35
2 Interactions of Ionising Radiation With Matter, 13
Measurement of Dose and Dose Rate, 36
Shakardokht Jafari and Michael Wynne-Jones
The Parallel-Plate Ionisation Chamber, 37
Introduction, 13
The Beam Monitor Chamber, 37
Charged and Uncharged Particles, 13
Intercomparisons With Secondary Standard
Excitation and Ionisation, 13
Instruments, 38
Electron Interactions, 14
Strontium Consistency Check Device, 38
Collisional and Radiative Energy Loss, 14
Ionisation Chamber Corrections, 38
X-Ray Production, 14
Ion Recombination Losses, 38
Characteristic X-Rays and Auger Electrons, 16
Correction for Atmospheric Conditions, 38
Stopping Power and Linear Energy Transfer, 16
Chamber Stem Effect, 39
Range and Path Length, 17
Polarity Effect, 39
Photon Interactions, 17
Alternative Dose Measurement Systems, 39
The Photoelectric Effect, 17
Film Dosimetry, 39
The Compton Effect, 18
Semiconductor Detectors, 40
Pair Production, 19
Thermoluminescent Dosimetry, 42
Exponential Attenuation, 19
Chemical and Biochemical Detectors, 43
Attenuation of Photon Spectra, 21
Fricke Dosimetry, 43
v
vi CONTENTS

Ceric Dosimetry, 44 Production of X-Rays for Imaging, 65

Gel Dosimetry, 44 Information From Absorption and Scattering, 66
Fricke Gels and FXG Gels, 44 Differential Attenuation in the Primary Beam, 66
Polymer Gels, 44 Contrast Media, 66
Alanine-Electron Paramagnetic Resonance Scatter as Unwanted Background, 66
Dosimetry, 44 Antiscatter Grid, 66
Biological Dosimetry, 45 Planar Imaging, 67
Biological Molecules, 45 Film and Screen Detection, 67
Genetic Structures, 45 Characteristic Curve, 68
Cells and Biological Structures, 45 Digital Computed Radiography Using
Composite Detectors and Arrays, 45 Photostimulable Phosphors, 68
Linear Detector Arrays, 45 Fluoroscopic Imaging With Image Intensifier
Area Arrays, 45 Chain, 68
Volume Detectors Arrays, 46 Digital Fluoroscopy and Radiography Using Solid
Electronic Portal Dosimetry, 46 State Detectors, 69
Alternative Systems for Proton Beams Dose Assessment of Image Quality, 69
Measurement, 46 Magnification Distortion, 69
References, 47 Resolution, Geometric Unsharpness and Movement, 69
Image Signal and Noise, 70
4 Radiation Protection, 49
Dose, 70
Mike Dunn
Tomographic Imaging, 70
Introduction, 49
Computed Tomographic Reconstruction From
Biological Effects of Radiation, 49
Projections, 70
Stochastic Hereditary Effects, 49
Practical Configurations, 70
Stochastic Somatic Effects, 50
Dedicated Radiotherapy Systems, 71
Nonstochastic Somatic Effects, 50
Simulator, 71
Dose Descriptors, 50
Computed Tomography Virtual Simulator, 71
Equivalent Dose, 50
Treatment Verification Systems, 71
Effective Dose, 50
Magnetic Resonance Imaging, 72
Background Radiation, 52
Overview of the Magnetic Resonance Imaging
Legislative Requirements, 53
Process, 72
The Ionising Radiations Regulations 2017, 53
Producing a Signal, 72
The Ionising Radiation (Medical Exposure)
Returning to Thermal Equilibrium, 72
Regulations 2017, 56
Imaging Sequences, 73
Administration of Radioactive Substances Advisory
How Contrast Is Altered in a Magnetic Resonance
Committee, 57
Image, 73
Environmental Permitting (England and Wales)
How Positional Information Is Encoded in the
Regulations 2016, 58
Signal, 73
High Activity Sealed Radioactive Sources and Orphan
Magnetic Resonance Imaging Scanners, 75
Sources Regulations 2005, 58
Spectroscopy, 76
Protective Measures, 58
Clinical Applications of Magnetic Resonance Imaging
Time, 58
in oncology, 77
Distance, 58
Brain Tumours, 77
Barriers, 58
Body Tumours, 77
Contamination, 59
Ultrasound Imaging, 77
Building Materials, 59
Overview of Ultrasound Imaging Process, 77
Monitoring of Radiation Levels, 60
Physical Characteristics of Ultrasound Waves, 77
Personal Radiation Dosimeters, 60
Interactions at Interfaces, 81
Radiation Records, 61
Attenuation and Interference, 81
Other Requirements, 61
Ultrasound Scanners, 81
References, 62
Production of Ultrasound for Imaging, 81
5 Imaging With X-Ray, Magnetic Resonance Imaging and Derivation of an Ultrasound Image, 82
Ultrasound, 64 Brightness Mode Ultrasound Imaging, 82
Andy Rogers, Carl Tiivas, and Sarah Wayte Linear Array Ultrasound Imaging, 82
Introduction, 64 Intracavitary and Endoscopic Probes, 82
X-Ray Imaging, 65 Harmonic Imaging, 82
Overview of X-Ray Imaging Process, 65 Dynamic Imaging, 82
 CONTENTS vii

Contrast and Tissue Characteristic Imaging, 83 Comforters and Carers, 108

Clinical Applications of Ultrasound Imaging, 83 Outpatient Therapies, 108
General Imaging, 83 Waste Disposal, 108
Advantages and Disadvantages, 83 References, 109
Imaging for Cancer, 84
8 Radiotherapy Devices With Kilovoltage X-Rays and
Clinical Therapeutic Ultrasound, 84
Radioisotopes, 110
References, 84
Claire Fletcher and John A. Mills
6 Imaging With Radionuclides, 85 Introduction, 110
Paul Hinton Kilovoltage X-Ray Production, 110
Introduction, 85 X-Rays From Electrons, 110
Overview of the Radionuclide Imaging Process, 85 High-Voltage Circuits, 110
Gamma Cameras, 86 Kilovoltage X-Ray Characteristics, 111
Scintillation Gamma Cameras, 86 Superficial and Deep Kilovoltage Machines, 111
Solid-State Gamma Cameras, 87 Tube Stand, 112
Image Construction, 87 Collimation, 112
Imaging Techniques, 88 Skin and Eye Shielding, 112
Positron Emission Tomography Scanners, 90 Control of Output, 113
Radiopharmaceuticals, 92 Calibration of Dose Output, 113
The Radionuclide, 92 Contact Kilovoltage Machine, 113
Type of Radiation, 92 Grenz Kilovoltage Machine, 113
Physical Half-Life, 92 Radionuclide Characteristics, 114
Specific Activity, 92 Gamma Emitters, 114
Radionuclide Purity, 92 Beta Emitters, 114
Chemical Properties, 92 Brachytherapy and Afterloading Machines, 114
The Ideal Radionuclide for Imaging, 92 The High Dose Rate Afterloading Machine, 116
Mechanisms of Localisation, 92 Implanted Kilovoltage Machine, 116
Production and Quality Control of Beta-Ray Machine, 117
Radiopharmaceuticals, 93 Gamma-Ray Machine, 117
Clinical Applications, 94 Radioisotope Source, 118
Bone Imaging, 94 Beam Collimation, 118
Tumour Imaging, 94 Design of Gamma-Ray Teletherapy Machines, 119
Imaging Thyroid Cancer, 96 Radiosurgery, 120
Cardiac Imaging, 96 Radiation Safety, 120
Kidney Imaging, 97 Commissioning and Quality Control, 120
Infection Imaging, 98 Conclusion, 120
Sentinel Node Mapping, 99 References, 121
Positron Emission Tomographic Imaging, 99
9 Beam Production: Megavoltage Accelerators, 122
Conclusions, 101
Andrzej Kacperek and John A. Mills
References, 101
Introduction, 122
7 Therapy With Unsealed Radionuclides, 102 The Medical Linear Accelerator, 122
Matthew Aldridge and Sofia Michopoulou Linear Accelerator Layout and Components, 123
Introduction, 102 X-Ray Beam, 124
Iodine-131 in the Treatment of Thyroid Disease, 103 Electron Beam, 126
Thyroid Cancer, 103 Linear Accelerator Control Systems, 127
Benign Thyroid Disease, 105 Nonstandard Linear Accelerators, 127
Palliation of Bone Pain, 105 Intensity-Modulated Radiotherapy, 127
Molecular Radiotherapy Treatment of Neuroendocrine CyberKnife, 127
Tumours, 106 Tomotherapy, 127
Selective Internal Radiation Therapy, 106 Volumetric-Modulated Arc Therapy, 127
Phosphorus-32 in the Treatment of Refractory Stereotactic Ablative Radiotherapy, 127
Myeloproliferative Disease, 107 Flattening Filter-Free Dose Delivery, 128
Intraarticular and Intracavitary Treatments, 107 Patient Alignment for X-Ray and Electron Therapy, 128
Radioimmunotherapy, 107 Radiation Safety, 131
Radiation Protection, Waste and Regulations, 108 Acceptance, Commissioning and Quality Control, 131
Hospital Requirements, 108 Treatment Room Design for X-Ray and Electron
Facilities, 108 Protection, 131
viii CONTENTS

Special Techniques With Linear Accelerators, 132
The Development of Clinical Proton and Heavier
Charged Particle Accelerators, 133
Particle Accelerator Layout and Components, 134
Basic Components of a Cyclotron, 134
Basic Theory of Classic Cyclotron
11 Radiation Treatment Planning: Beam Models, Principles
Operation, 134
and Practice, 162
Ion Source Operation, 135
Maria Mania Aspradakis
Characteristics and Limitations for Therapy, 136
Synchrocyclotrons, 136
Azimuthal Vertical Focussing or Isochronous
Cyclotrons, 136
Synchrotrons, 137
Passive-Scattered Beams and Pencil Beam Scanning
Beams, 138
Gantries, 142
Types of Proton and Ion Accelerators, 143
Clinical Proton Therapy Centres, 143
Clinical Carbon Ion Therapy Centres, 145
Noncircular Accelerators, 145
Neutron and Other Beams, 146
Fast Neutron Beam Therapy, 146
Boron Neutron Capture Therapy, 146
Proton Boron Capture Therapy, 146
Pion Therapy, 147
Antiproton Therapy Beams, 147
Laser-Induced Proton and Particle
Beams, 147
Shielding of Proton Therapy Accelerators and
Treatment Rooms, 148
Nanoparticle-Enhanced Therapy, 148
Future Design, 149
Record and Verify Systems, 149
Conclusion, 150
References, 150
10 Radiation Treatment Planning: Immobilisation,
Localisation and Verification Techniques, 152
Andrew Penny and Phil Sharpe
Introduction, 152
Patient Immobilisation, 153
Thermoplastic Shells, 153
Patient Head Shells, 154
Three Dimensional Printing, 154
Nonshell Fixation Systems, 154
Stereotactic Frames, 154
Body Immobilisation, 155
Stereotactic Ablative Body Radiation Therapy, 155
Surface-Guided Radiotherapy, 155
Volume Definitions, 155
Noncomputed Tomography Contouring
Devices, 156
Physical Simulation, 156
Computed Tomography Simulation, 157
Virtual Simulation, 157
A Typical Head and Neck Computed Tomography
Simulation Procedure, 159
Multimodality Images for Planning, 159
Portal Verification and Image-Guided
Treatments, 160
Portal Imaging, 160
Image-Guided Radiotherapy, 160
References, 161
Introduction, 162
Representation of the Patient for Treatment
Planning, 163
The Planning CT, 163
Patient Immobilisation for Treatment
Planning, 164
Motion Management in Treatment
Planning, 164
Magnetic Resonance–Based Planning, 164
Beam Modelling and Dose Calculations for External
MV Photon Beam Treatment Planning, 164
Modelling of the Source of Radiation, 165
Modelling of Dose in the Irradiated Medium, 166
Factor-Based Approaches, 169
Conclusion on Model-Based Approaches, 170
Dose Per Monitor Unit Formalism: Calculation of
Monitor Units, 170
Treatment Plan Evaluation Tools, 170
Isodose Distributions, 170
Beams Eye View, 171
Dose Volume Histograms, 171
Other Tools, 173
Treatment Planning Techniques in External MV
Photon Beam Radiotherapy, 174
Forward and Inverse Planning, 174
Forward Planning With Standard Beam
Arrangements, 174
Forward-Planned Intensity-Modulated
Radiotherapy, 180
Inverse Planning, 181
Specialised Techniques With MV Photons, 183
Electron Therapy, 185
Dose Calculations for Electron Beams, 185
Energy and Depth-Dose Characteristics, 185
Penumbra, 186
Standoff and Stand in, 186
Patient Contour Effects, 186
Heterogeneities, 187
Field Matching, 187
Specialised Techniques With Electrons, 187
Kilovoltage Photon Therapy, 188
Differences Between Kilovoltage and Electron
Therapy, 188
Proton and Heavy-Ion Therapy, 188
Quality Assurance in Treatment Planning, 189
Treatment Planning System Commissioning and
Performance Testing, 189
Plan-Specific Quality Assurance, 190
References, 191

12 Networking, Data, Image Handling and Computing
in Radiotherapy, 193
John Sage
Introduction, 193
History, 193
Benefits and Hazards of Computerisation, 193
Networking, 194
Link Layer: Physical Infrastructure, 194
Network Layer: Addressing, 194
Transport Layer: Send and Receive, 195
Application Layer: The Program, 195
Network Security, 195
DICOM, 195
DICOM Data Objects, 196
Radiotherapy Data, 197
Data Storage, 197
Image Quality, 197
Radiotherapy Data Types, 197
Data Burden, 198
Data Security, 198
Software Development, 199
Conclusion, 199
References, 199
13 Quality Control, 200
John A. Mills and Phil Sharpe
Introduction, 200
The Quality Control Required, 200
Commitment to Quality Control, 201
Safety, Position and Dose, 201
Frequency, Tolerances and Failure Trends, 201
Measurement and Uncertainty, 201
Null Hypothesis, 202
Combining Variances and Tolerances, 202
Setting a Tolerance to Achieve a Performance
Level, 202
Performance Improvement, 202
Maintenance and Catastrophes, 203
Long-Term, Short-Term and Immediate
Monitoring, 203
Immediate Monitoring, 203
Long-Term Monitoring, 203
Short-Term Monitoring, 203
The Radiotherapy Process, 203
Acquisition, 204
Analysis, 204
Delivery, 204
The Need for Patient-Specific Quality Control, 204
The Radiotherapy Technology, 204
Planning Imaging, 204
Virtual Simulation, 204
Dose Prediction, 205
Kilovoltage Machines, 205
Afterloading Brachytherapy Machines, 205
Megavoltage Machines, 205
Patient Positioning, 205
Treatment Verification, 205
CONTENTS ix
Computer Systems and Networking, 205
Measurement Equipment, 205
Practical Patient-Specific Quality Control, 206
Practical Methods, 206
Phantom-Based Measurements, 206
Dosimetric Arrays, 206
Gamma Index, 206
Independent Software Verification, 207
Secondary Treatment Planning System, 207
Patient-Specific Quality Control Implementation, 207
Getting Things in Balance, 207
Quality Control Scheduling for Megavoltage
Machines, 207
Conclusion, 208
References, 208
14 Quality Management in Radiotherapy, 209
Jill Emmerson, Karen Waite, and Helen Baines
Introduction: What is Quality?, 209
History of Quality in Radiotherapy, 210
Quality Management Systems, 210
1. Customer Focus, 210
2. Leadership, 211
3. Engagement of People, 211
4. Process Approach, 211
5. Improvement, 211
6. Evidence-Based Decision Making, 211
7. Relationship Management, 211
The ISO 9000 Standard, 212
Clause 4 Context of the Organisation, 212
Clause 5 Leadership, 213
Clause 6 Planning, 213
Clause 7 Support, 213
Clause 8 Operation, 213
Clause 9 Performance Evaluation, 214
Clause 10 Improvement, 214
The Radiotherapy Process, 214
An Integrated Approach to Quality and Other
Initiatives, 214
Quality in the National Health Service, 214
Risk Management, 214
Clinical Incidents, 216
Audit, 217
Patient-Focussed Care, 220
Implementation of New Technology and New
Techniques, 221
Conclusion, 222
References, 222
SECTION 2
15 Epidemiology of Cancer and Screening, 226
Katie Spencer, David Hole, Paul Symonds, and Eva Morris
The Cancer Problem, 226
Cancer in the United States, 226
Cancer in Europe, 227
x CONTENTS

Epidemiology of Cancer, 227 Cause of Death from Cancer, 246

Terminology, 227 Staging of Cancers, 246
Survival and Cure in Cancer, 227 TNM Classification, 246
Outcome of Palliative Care, 228 Histological Grading: Differentiation, 247
Epidemiology and The Prevention of Cancer, 228 Limitations of Grading, 248
Criteria for Causality, 228 Growth Rate of Cancers, 248
Aetiology and Screening, 228 Spontaneous Regression of Cancer, 248
Lung Cancer, 228 Classification of Neoplasms, 248
Colorectal Cancer, 230 Undifferentiated Tumours, 249
Breast, 230 Current Advances in Pathology Guiding Patient
Stomach, 232 Management, 251
Prostate, 232 Further Reading, 252
Cervix, 232
Oesophagus, 233 17 Molecular, Cellular and Tissue Effects of
Melanoma, 233 Radiotherapy, 253
Head and Neck, 233 George D.D. Jones and Paul Symonds
Lymphoma, 234 Introduction, 253
Leukaemia, 234 Ionising Radiation, Free Radical Generation,
Reducing the Risks of Developing Cancer, 235 Subcellular Radiogenic Damage, 253
Reducing Tobacco Smoking, 235 Recovery, DNA Damage Repair and Damage
Modifying Alcohol Consumption, 236 Signalling, 255
HPV Vaccination, 236 Recovery, 255
Ultraviolet Light, 236 Double-Strand Break Repair and Damage
Occupational Exposure, 236 Signalling, 255
Diet, 237 Epigenetic Radiation Signalling Mechanisms, 255
Ionising Radiation, 237 Radiation-Induced Cell Killing, 257
Pollution, 237 Tumour Hypoxia, Oxygen Effect and
Chemoprevention, 237 Reoxygenation, 257
Conclusion, 238 The Cell Cycle and Sensitivity to Irradiation, 259
Further Reading, 238 Patterns of Cell Death After Irradiation, 259
Models of Radiation Cell Survival, 260
16 Biological and Pathological Introduction, 239 Radiation Effects in Normal and Malignant
John R. Goepel and Abhik Mukherjee Tissue, 261
Introduction, 239 Acute Responses of Normal Tissue, 261
Growth: Proliferation, Differentiation and Apoptosis, Subacute Reactions of Normal Tissue, 261
239 The Effect of Radiotherapy on Tissues, 261
Growth Disorders, 239 The Tolerance of Normal Tissues, 261
Neoplasia, 240 Retreatment, 262
Benign and Malignant Neoplasms, 240 Response of Tumours to Radiation, 262
Carcinogenesis, 240 Overall Treatment Time, 262
Initiation, 240 Modification of Fractionation Patterns, 262
Promotion, 240 Other Radiation Modalities, 262
Progression, 240 Heavy Particle Radiotherapy, 262
Clinical Cancer, 241 Drug–Radiotherapy Combinations, 263
Oncogenes and Tumour Suppressor Genes, 241 Future Trends (and Pitfalls), 263
Defective apoptotic mechanisms, 241 New Technologies, 263
Blood Vessels, 241 Molecular Studies, 263
Physical Agents, 242 Further Reading, 264
Chemicals, 242
Viruses and Cancer, 243 18 Principles of Management of Patients With Cancer, 265
Immunity and Cancer, 243 Paul Symonds and Angela Duxbury
Injury and Cancer, 243 Introduction, 265
Precancerous Lesions, 243 Factors Governing Clinical Decisions, 266
Field Change, 244 Tumour Factors, 266
Natural History and Spread of Cancer, 244 Patient Factors, 267
Local Invasion, 244 Treatment Modality, 267
Metastasis, 245 Support Services, 269
Functioning Tumours, 246 Palliative Care, 270
 CONTENTS xi

Pain Control, 270 Comparison of Outcome for Different Modalities in

Nausea and Vomiting, 271 the Treatment of Basal Cell Carcinomas, 296
Context of Care, 271 Melanoma, 296
Further Reading, 271 Aetiology, 296
Subtypes of Melanoma, 296
19 Chemotherapy and Hormones, 272
Diagnosis, 297
Anne L. Thomas
Melanoma TNM Staging, 297
Introduction, 272
Stage and Prognosis, 297
General Indications for Chemotherapy, 272
Management of Melanoma, 300
Development and Testing of Anticancer Agents, 272
Adjuvant Treatment for Melanoma, 301
Phase I Studies, 273
Management of Recurrent or Metastatic
Phase II Studies, 273
Melanoma, 301
Phase III Studies, 273
Side Effects of Immunotherapy, 302
Assessing Tumour Responses, 273
Role of Radiotherapy in Malignant Melanoma, 302
The Evaluation of Targeted Therapies, 273
Cutaneous Lymphomas, 303
Principles of Cytotoxic Therapy, 273
Merkel Cell Tumours, 303
Drug Resistance, 274
Skin Sarcoma, 303
Selection and Scheduling of Chemotherapy Agents,
Kaposi Sarcoma, 305
274
Skin Appendage Tumours, 305
High-Dose Chemotherapy, 274
Further Reading, 306
Route of Administration, 274
Side Effects of Chemotherapy, 275
21 Head and Neck Cancer—General Principles, 308
Classification of Cytotoxic Drugs, 275
Christopher D. Scrase
Alkylating Agents, 275
Introduction, 308
Antimetabolites, 275
Demographics, 308
Mitotic Inhibitors, 278
Aetiology, 308
Topoisomerase Inhibitors, 279
Prevention and Early Diagnosis, 310
Miscellaneous, 279
Tumour Types, 310
Hormones, 280
Presentation, 310
Targeted Therapies, 281
Investigation, 310
Epidermal Growth Factor Receptor, 282
Nutrition, 311
Signalling Through RAS-RAF-ERK (MAPK) and
Dentition, 311
PI3K-AKT, 282
Indications for Radiotherapy, 311
Vascular Endothelial Growth Factor Signalling
Definitive Radiotherapy, 311
Pathway, 282
Postoperative Radiotherapy, 311
Proteasome Inhibitors, 282
Palliative Radiotherapy, 311
Poly(ADP-Ribose) Polymerase Inhibitors, 282
Radiotherapy Planning, 312
CDK4/6 Inhibitors, 283
Immobilisation, 312
Immunotherapy, 283
Target Volumes, 312
Therapeutic Antibodies, 283
Definitive Radiotherapy, 312
Immune Checkpoint Inhibitors, 283
Postoperative Radiotherapy, 313
Further Reading, 284
Radiotherapy Technique, 313
20 Skin and Lip Cancer, 285 Conformal Radiotherapy, 313
Charles Kelly and Paul Symonds and Intensity Modulated and Image Guided
Cliff Lawrence Radiotherapy in Head and Neck Cancers, 313
Introduction, 285 Dose and Fractionation, 317
Keratinocyte Skin Tumours, 285 Definitive Radiotherapy, 317
Aetiology, 285 Postoperative Radiotherapy, 318
Basal Cell Carcinoma, 287 Chemotherapy in Head and Neck Cancer, 318
Squamous Cell Carcinoma of the Skin, 289 Concurrent Chemotherapy and Definitive
Cancer of the Lip, 289 Radiotherapy, 318
Keratoacanthoma, 289 Concurrent Chemotherapy and Postoperative
Treatment of Nonmelanoma Skin Cancer, 290 Radiotherapy, 318
Radiotherapy for Keratinocyte Skin Cancers, 292 Induction Chemotherapy, 318
Electron Beam Treatment, 293 Chemotherapy in the Palliative Setting, 318
Electron Backscatter, 293 Toxicity of Treatment, 319
Superficial X-Ray Treatment, 293 Acute Toxicity, 319
xii CONTENTS

Late Toxicity, 320 Signs and Symptoms, 339

Future Developments, 320 Diagnosis and Staging, 340
Immunotherapy, 320 Treatment, 340
Further Reading, 320 Radiation Technique, 340
Complications, 342
22 Sino-Nasal, Oral, Larynx and Pharynx Cancers, 322
Follow-up, 342
Christopher D. Scrase and Paul Symonds
Results, 342
Nasopharynx, 323
Larynx, 342
Anatomy, 323
Anatomy, 342
Incidence of Nasopharyngeal Tumours, 323
Incidence of Laryngeal Cancer, 343
Staging System for Nasopharyngeal Tumours, 324
Staging System for Laryngeal Cancer (TNM, 8th
Aetiology, Pathology and Lymphatic Spread, 324
Edition), 343
Signs and Symptoms, 324
Aetiology, Pathology and Lymphatic Spread, 344
Diagnosis and Staging, 324
Signs and Symptoms, 344
Treatment, 324
Diagnosis and Staging, 344
Radiation Technique, 325
Treatment, 345
Complications, 325
Glottic Cancers, 345
Follow-up, 325
Complications of Treatment for Early Laryngeal
Results, 326
Cancer, 345
Nose and Nasal Cavity, 326
Results of Treatment, 348
Anatomy, 326
Hypopharyngeal Carcinoma, 348
Incidence, 328
Anatomy, 348
Staging System, 328
Incidence of Hypopharyngeal Tumours, 348
Aetiology, Pathology and Lymphatic Spread, 328
Staging System of Hypopharyngeal Tumours
Signs and Symptoms, 328
(TNM, 8th Edition), 348
Diagnosis and Staging, 328
Aetiology, Pathology and Lymphatic Spread, 348
Treatment, 328
Signs and Symptoms, 348
Complications, 330
Diagnosis and Staging, 348
Results, 330
Treatment, 348
Paranasal Sinus Tumours, 330
Radiotherapy Technique, 348
Anatomy, 330
Complications, 351
Incidence of Paranasal Sinus Tumours, 330
Follow-up, 351
Staging System for Paranasal Sinus Tumours, 330
Results, 352
Aetiology, Pathology and Lymphatic Spread, 331
Further Reading, 352
Signs and Symptoms, 331
Diagnosis and Staging, 332 23 Thyroid Cancer, 353
Treatment, 332 Charles Kelly and Paul Symonds
Complications, 332 Introduction and Epidemiology, 353
Follow-up, 333 Anatomy, 353
Results, 333 Aetiological Factors, 353
Lip and Oral Cavity Carcinoma, 333 Presentation, Diagnosis and Patient Pathway, 354
Anatomy, 333 Differentiated Thyroid Cancer, 355
Incidence of Oral Cavity Carcinoma, 333 Management of Differentiated Thyroid
Staging System for Oral Cavity and Lip Carcinoma Cancer, 356
(TNM, 8th Edition), 333 Surgery, 356
Aetiology, Pathology and Lymphatic Spread, 334 Radioiodine Ablation, 357
Signs and Symptoms, 334 Thyroglobulin, 358
Diagnosis and Staging, 335 Management of Hypocalcaemia, 358
Treatment Lip Cancers, 336 Management of Locoregional Recurrence, 358
Radiotherapy Technique, 337 Metastatic Disease, 358
Radiotherapy Technique, 338 Medullary Thyroid Cancer, 358
Follow-up, 338 Anaplastic Thyroid Cancer, 359
Results of Treatment, 338 Thyroid Lymphoma, 359
Oropharyngeal Carcinoma, 338 Thyroid Sarcoma, 359
Anatomy, 338 Hurthle Cell Carcinoma, 359
Staging System of Oropharyngeal Tumours, 339 External Beam Radiotherapy for Thyroid
Aetiology, Pathology and Lymphatic Spread, 339 Cancer, 359
 CONTENTS xiii

As Adjuvant Treatment, 359 Radiation Therapy, 376

Palliative High Dose, 360 Principles of Radiation Delivery, 376
Low Dose Palliation, 360 Future Perspectives, 377
Radiotherapy for Thyroid Lymphoma, 362 Biliary Tract Cancers, 378
Follow-Up Policy for Thyroid Cancer Principles of Radiotherapy, 378
Patients, 363 Cancer of the Colon and Rectum, 378
Further Reading, 363 Epidemiology, 378
Aetiology, 378
24 Gastrointestinal Cancer, 364 Histopathology and Clinical Features, 379
Somnath Mukherjee and Maria Hawkins Pretreatment Staging Evaluations, 379
Cancer of the Oesophagus, 364 Staging Systems, 379
Epidemiology, 364 Colon Cancer—Treatment Principles, 380
Aetiology and Pathology, 365 Management of Advanced Colorectal
Risk Factors for Squamous Cell Carcinomas, 365 Cancer, 380
Risk Factors for Adenocarcinoma, 365 Third-Line Options, 380
Anatomy, 365 Rectal Cancer—Treatment Principles, 381
Clinical Manifestations, 365 Organs at Risk, 381
Diagnostic Evaluation, 365 Anal Cancer, 382
Therapy, 366 Epidemiology and Aetiology, 382
Radical Radiotherapy, 366 Anatomy, 382
Definitive Chemoradiation, 366 Histopathology, 382
Neoadjuvant Chemoradiation, 366 Clinical Features, 382
Adjuvant Radiation or Chemoradiation, 367 Treatment, 383
Palliative Radiotherapy, 367 References (Oesophagogastric), 386
Radiation Therapy Techniques, 367 References (Pancreas), 386
Chemotherapy, 369 References (hepato-biliary, colo-rectal and anal
Other Treatments, 369 cancer), 386
Oesophagogastric Junctional Tumours, 369
Summary, 369 25 Tumours of the Thorax, 388
Cancer of the Stomach, 369 Michael Snee
Anatomy, 369 Lung Cancer, 388
Epidemiology, 369 Pathology, 388
Aetiology, 369 Symptoms, 388
Pathology, 369 Diagnosis and Staging, 389
Clinical Features, 370 Systemic Treatment for Nonsmall Cell Lung
Staging, 370 Cancer, 394
Management, 370 Chemotherapy, 394
Radiation Techniques, 371 Targeted Therapy, 395
Palliative Treatments in Advanced/Metastatic Immune Therapy, 395
Gastric Cancer, 371 Small Cell Lung Cancer, 395
Summary, 371 Neuroendocrine Tumours, 396
Pancreas, 371 Mesothelioma, 396
Anatomy, 371 Symptoms, 397
Incidence and Epidemiology, 372 Diagnosis, 397
Pathology, 372 Pathology and Natural History, 397
Diagnostic Evaluation and Imaging, 372 Management, 397
Therapy, 372 Conclusion, 398
Hepatocellular Carcinoma, 375 Further Reading, 398
Epidemiology, 375 26 Breast Cancer, 399
Symptomatology, 375 Ian Kunkler
Diagnostics and Classification, 375 Anatomy, 400
General Management Principles, 375 Lymphatic Drainage, 400
Surgical Therapy, 375 Pathology, 400
Liver Transplantation, 375 Epidemiology, 400
Locoregional Treatments, 375 Aetiology, 400
Systemic Therapy and Molecularly Targeted Ductal and Lobular Carcinoma In Situ, 402
Agents, 376 Invasive Breast Cancer, 402
xiv CONTENTS

Molecular Classification of Breast Cancer, 402 Clinical Features, 434

Multidisciplinary Management of Breast Cancer, 402 Diagnosis, 434
Diagnosis, 403 Principles of Management, 434
Clinical Assessment, 403 Role of Surgery, 434
Breast Ultrasound, 403 Choice of Systemic Therapy, 434
Magnetic Resonance Imaging, 404 Hormonal Therapy, 435
Positron Emission Tomography, 404 Locoregional Therapy, 435
Obtaining a Histological Diagnosis, 404 Target Volume, 435
Staging, 404 Technique, 435
Staging Investigations, 405 Dosage and Fractionation (Radical), 435
Management of Ductal Carcinoma In Situ, 406 Locoregional Palliative Radiotherapy, 435
Role of Postoperative Radiotherapy for Ductal Technique, 435
Carcinoma In Situ, 407 Dose, 435
Prognostic and Predictive Factors for Invasive Breast Bone Metastases: Prevention and Treatment, 435
Cancer, 408 Palliative Radiotherapy for Bone Metastases, 436
Stage, 408 Palliative Surgery, 436
Age, 408 Principles of Management, 436
Tumour Size, 408 Medical Management of Advanced and Metastatic
Axillary Node Status, 408 Disease, 436
HER2/neu Status, 409 Menopausal Status and Hormone Receptor
Lymphovascular Invasion, 409 Status, 436
Prognostic Indices, 409 Sites of Metastases and Impact on Management, 437
Hormonal Receptor Status, 409 Cytotoxic Therapy, 437
Ki67, 409 Morbidity of Chemotherapy (Adjuvant and for
Molecular Subtype, 409 Metastatic Disease), 440
Gene Profiling, 409 Bone Marrow Involvement, 440
Endocrine Therapy, 409 Growth Factor Support, 441
Mastectomy or Breast Conservation, 410 Clinical Outcomes in Early and Advanced Metastatic
Management of the Axilla, 411 Breast Cancer, 441
Regional Nodal Irradiation, 411 Follow-Up, 441
Indications for Internal Mammary Irradiation, 413 Follow-Up After Breast-Conserving Therapy, 442
Postoperative Radiotherapy, 413 Follow-Up After Mastectomy, 442
Target Volume and Techniques for Locoregional Breast Cancer in Pregnancy, 442
Irradiation, 416 Breast Cancer in Males, 443
Computed Tomography Simulation, 416 Further Reading, 443
Intensity Modulated Radiotherapy, 416
Shoulder Field, 417 27 Gynaecological Cancer, 444
Neoadjuvant Therapy, 417 Christopher Kent and Paul Symonds
Adjuvant Hormonal and Cytotoxic Therapy, 425 Anatomy, 444
Rationale, 425 Incidence of Gynaecological Cancer, 444
Who Benefits?, 426 Carcinoma of Cervix, 444
Adjuvant Endocrine Therapy, 426 Causes of Cervical Neoplasia, 444
Adjuvant Tamoxifen, 427 Pathology of Cervical Cancer, 444
Aromatase Inhibitors, 427 Symptoms and Investigations of Cervical
Adjuvant Hormonal Therapy After 5 Years of Cancer, 445
Tamoxifen, 428 Treatment, 448
Toxicity of Tamoxifen, 429 Treatment of Stage II–IVa, 449
Tamoxifen Plus Chemotherapy, 429 Future Trends, 451
Adjuvant Ovarian Suppression, 429 Carcinoma of Endometrium, 452
Adjuvant/Neoadjuvant Combination Chemotherapy Pathology, 453
(Polychemotherapy), 429 Routes of Spread, 453
Neoadjuvant Chemotherapy, 429 Treatment, 453
Postoperative Adjuvant Chemotherapy, 430 Postoperative Radiotherapy, 453
HER2 Positive Breast Cancer, 430 Future Trends, 454
Triple Negative Breast Cancer, 434 Sarcomas of the Uterus, 454
Adjuvant Chemotherapy in Older Patients, 434 Cancer of the Ovary, 454
Management of Locally Advanced Breast Cancer, 434 Aetiology, 454
 CONTENTS xv

Pathology, 454 Penis, 476

Method of Spread, 454 Pathology, 476
Clinical Features, 454 Clinical Features, 476
Investigations and Staging, 454 Staging, 476
Treatment, 455 Treatment, 477
Chemotherapy, 455 Results of Treatment, 478
Radiotherapy, 455 Further Reading, 478
Future Trends, 456
29 Lymphoma and Disease of Bone Marrow, 479
Rare Tumours of the Ovary, 456
Matthew Ahearne and Lesley Speed
Sex-Cord Tumours, 456
Introduction, 479
Germ-Cell Tumours, 456
Aetiology and Epidemiology, 479
Tumours of the Vagina and Vulva, 456
Pathological Characteristics, 480
Further Reading, 457
Clinical Features, 481
Diagnosis and Staging, 481
28 Cancer of Kidney, Bladder, Prostate, Testis, Urethra
and Penis, 458 Clinical Prognostic Factors, 481
Treatment, 481
Aravindhan Sundaramurthy and Duncan B. McLaren
Multiple Myeloma, 483
Kidney, 458
Pathology, 483
Anatomy, 458
Clinical Features, 483
Pathology, 458
Diagnosis, 484
Clinical Features, 459
Prognostic Factors, 484
Investigation and Staging, 459
Treatment, 484
Treatment, 460
Results of Treatment, 461 Leukaemia, 484
Acute Leukaemia, 484
Bladder, 461
Chronic Myeloid Leukaemia, 485
Anatomy, 461
Chronic Lymphocytic Leukaemia, 485
Pathology, 461
Myeloproliferative Disorders, 485
Aetiology, 461
Haemopoietic Stem Cell Transplantation, 486
Epidemiology, 461
Radiotherapy Doses, Techniques and
Macroscopic Appearance, 461
Toxicities, 486
Microscopic Appearance, 461
Clinical Features, 462 Hodgkin’s Lymphoma, 486
Non-Hodgkin’s Lymphoma, 486
Investigation and Staging, 462
Treatment Techniques, 487
Treatment, 462
Extra-Nodal Sites, 487
Results of Treatment, 465
Leukaemia, 491
Prostate, 465
Myeloma, 491
Anatomy, 465
Mycosis Fungoides, 492
Pathology, 465
Chemotherapy Regimens and Toxicities, 492
Hormonal Sensitivity, 466
Prostate-Specific Antigen and Screening, 466 Hodgkin’s Lymphoma, 493
Non-Hodgkin’s Lymphoma, 493
Clinical Features, 466
Mantle Cell, 493
Diagnosis and Staging, 466
Diffuse Large B Cell, T-Cell-Rich, B Cell,
Treatment, 467
Follicular Grade 3b (and for T-Cell
Testis, 471
Lymphomas), 493
Anatomy, 471
Myeloma, 493
Pathology, 472
Acute Myeloid Leukaemia, 494
Tumour Markers, 472
Clinical Features, 472 Further Reading, 494
Diagnosis and Staging, 473 30 Tumours of the Central Nervous System, 495
Treatment, 474 Pinelopi Gkogkou, Sarah J. Jefferies, and Neil G. Burnet
Testicular Lymphoma, 476 Introduction, 496
Dose and Energy, 476 Tumour Types, 496
Results of Treatment, 476 Anatomy of the Central Nervous System, 496
Urethra, 476 Anatomy of the Brain, 496
Female Urethra, 476 Anatomy of the Cerebrospinal Fluid Pathways and
Treatment, 476 Hydrocephalus, 497
Results of Treatment, 476 Anatomy of the Skull and Meninges, 498
xvi CONTENTS

Clinical Features—Presentation of Brain Tumours, 499 Treatment, 516

Specific Focal Neurological Deficit, 499 Spinal Cord Tumours—Primary, 517
Epileptic Seizure, 499 Pathology and Clinical Features, 517
Raised Intracranial Pressure, 499 Treatment—Radical, 517
Nonspecific Symptoms, 499 Treatment—Palliative, 517
Principles of Management, 499 Cerebral Metastases, 518
Diagnosis—A Combination of History, Imaging and Clinical Features and Management Principles, 518
Pathology, 499 Patients With Multiple Brain Metastasis, 518
Performance Status in the Treatment Decision, 499 Patients With One to Three Brain Metastasis, 518
Principles of Neurosurgery, 499 Treatment, 519
Principles of Radiotherapy Planning for Central Hypofractionated Radiotherapy, 519
Nervous System Tumours, 500 Stereotactic Radiosurgery, 519
Planning Volumes, 501 Spinal Cord Compression, 519
Normal Tissue Tolerance to Radiotherapy, 501 Pathology and Clinical Features, 519
Principles of Steroid Therapy, 502 Management Principles, 519
Principles of Additional Supportive Care, 502 Steroids, 520
Driving After a Diagnosis of Central Nervous System Surgery and Radiotherapy, 520
Tumour, 502 External Beam Radiotherapy, 520
Individual Tumour Types, 502 Stereotactic Body Radiation Therapy, 520
High-Grade Gliomas, 502 Further Reading, 520
Pathology and Clinical Features, 502
31 Eye and Orbit, 524
Treatment, 503
Tom Roques and Adrian Harnett
Radical Treatment, 504
Anatomy, 524
Palliative Treatment, 505
Principles of Radiotherapy to the Eye, 524
Elderly Patients, 505
Radiation and Ocular Morbidity, 525
Low-Grade Gliomas, 506
The Lens, 525
Pathology and Clinical Features, 506
The Sclera and Retina, 525
Radical Treatment, 507
The Cornea and Lacrimal Apparatus, 525
Ependymoma (Intracranial), 507
The Optic Nerves and Chiasm, 526
Pathology and Clinical Features, 507
Benign Conditions, 526
Treatment, 508
Thyroid Eye Disease, 526
Central Nervous System Lymphoma, 508
Orbital Pseudotumour, 527
Pathology and Clinical Features, 508
Malignant Tumours, 527
Management Principles, 509
Primary Malignant Tumours, 527
Radical Treatment—Full Dose Radiotherapy, 509
Skin Cancers Involving the Eyelid, 527
Localised Unifocal Disease, 509
Lacrimal Gland and Nasolacrimal Duct
Palliative Radiotherapy, 509
Cancer, 528
Elderly Population, 509
Tumours Arising From Adjacent Structures, 528
Germinoma, 509
Lymphoma, 528
Clinical Features and Management Principles, 509
Ocular Melanoma, 529
Treatment, 510
Retinoblastoma, 530
Medulloblastoma, 510
Metastases, 531
Meningioma, 510
Further Reading, 531
Pathology and Clinical Features, 510
Treatment, 510 32 Sarcomas, 532
Pituitary Tumours and Craniopharyngioma, 512 Thankamma V. Ajithkumar
Pituitary Tumours, 512 Soft Tissue Sarcomas, 532
Pathology and Clinical Features, 512 Pathology, 532
Treatment, 512 Clinical Features, 533
Craniopharyngioma, 513 Diagnosis and Staging, 533
Pathology and Clinical Features, 513 Management, 535
Treatment, 513 Chemotherapy, 536
Vestibular Schwannoma, 514 Retroperitoneal Sarcomas, 536
Pathology and Clinical Features, 514 Radiotherapy Technique, 537
Treatment, 515 Radiotherapy Side Effects, 538
Chordomas and Low-Grade Chordosarcomas, 516 Proton Therapy, 538
Pathology and Clinical Features, 516 Results of Treatment, 539

Bone Tumours, 539
Osteosarcoma (Osteogenic Sarcoma), 539
Pathology, 539
Clinical Features, 539
Diagnosis and Staging Investigations, 540
Treatment, 540
Results of Treatment, 541
Ewing Sarcoma, 541
Pathology, 541
Clinical Features, 541
Diagnosis and Staging, 541
Treatment, 541
Radiotherapy Side Effects, 543
Results of Treatment, 543
Chondrosarcoma, 543
Clinical Features, 543
Diagnosis and Investigation, 543
Treatment, 543
Radiotherapy, 543
Chemotherapy, 543
Results of Treatment, 543
Undifferentiated Pleomorphic Sarcoma of Bone, 543
Secondary Tumours in Bone, 544
Clinical Features and Investigation, 544
Treatment, 544
Pathological Fracture, 545
Further Reading, 545
33 Principles of Paediatric Oncology, 546
Roger E. Taylor
Introduction, 546
Toxicity of Radiotherapy for Children, 547
Acute Morbidity, 547
Subacute Effects, 547
Long-Term Effects, 547
Tolerance of Critical Organs to Radiotherapy, 548
Chemotherapy/Radiotherapy Interactions, 548
Radiotherapy Quality Assurance, 548
Leukaemia, 548
Total Body Irradiation, 549
Hodgkin Lymphoma, 550
Non-Hodgkin Lymphoma, 550
Neuroblastoma, 550
Metaiodobenzylguanidine Therapy for
Neuroblastoma, 551
Wilms Tumour (Nephroblastoma), 551
Rhabdomyosarcoma, 551
Ewing Sarcoma/Peripheral Primitive
Neuroectodermal Tumour, 554
Osteosarcoma, 554
Central Nervous System Tumours, 555
Long-Term Effects of Radiotherapy for Central
Nervous System Tumours, 555
Chemotherapy for Central Nervous System
Tumours, 555
Low-Grade Astrocytoma, 555
High-Grade Astrocytoma, 557
Brainstem Glioma, 557
CONTENTS xvii
Ependymoma, 558
Embryonal Tumours, 558
Intracranial Germ Cell Tumours, 559
Craniopharyngioma, 564
Proton Therapy for Paediatric Tumours, 565
Conclusions, 565
Further Reading, 565
34 Care of Patients During Radiotherapy, 566
Lorraine Webster and Angela Duxbury
Introduction, 566
Assessment of Individual Patient and Carer Needs, 566
Skin Reactions, 567
Nutrition, 568
Nausea, Vomiting and Diarrhoea, 569
Fatigue, 569
Psychosocial Issues, 569
Communication, 570
Information, 571
Consent, 572
Spiritual Needs, 572
Complementary Therapies, 572
The Impact on Staff, 573
Further Reading, 573
35 Medical Complications of Malignant Disease, 575
Robert Coleman and Harriet S. Walter
Effusions Secondary to Malignant Disease, 575
Pleural Effusions, 575
Pericardial Effusions, 576
Peritoneal Effusions (Ascites), 576
Venous Thrombosis, 576
Metabolic and Endocrine Manifestations of
Malignancy, 577
Hypercalcaemia, 577
Inappropriate Secretion of Antidiuretic Hormone,
577
Other Endocrine Manifestations of Malignancy, 577
Hyperuricaemia and Tumour Lysis Syndrome, 577
Infection, 577
Paraneoplastic Syndromes, 578
Neurological, 578
Hypertrophic Pulmonary Osteoarthropathy, 578
Other Paraneoplastic Syndromes, 578
Further Reading, 578
36 Proton Beam Therapy, 579
Jenny Gains, Laura Beaton, Richard A. Amos, and Ricky A. Sharma
Introduction, 579
Physics and Technology of Proton Beam Therapy, 579
Physical Characteristics of Proton Beams, 579
Proton Therapy Systems Overview, 580
Passively Scattered Proton Beams, 580
Active Proton Pencil Beam Scanning, 581
Sources of Physical and Biological Uncertainties, 581
Treatment Planning and Delivery, 582
Proton Beam Therapy in Children, Teenagers and
Young Adults, 582
Low-Grade Astrocytoma, 583
xviii CONTENTS

Ependymoma, 583 Central Nervous System Tumours, 586

Medulloblastoma, 583 Intraocular Melanoma, 586
Craniopharyngioma, 583 Gastrointestinal Malignancies, 586
Retinoblastoma, 583 Prostate Cancer, 586
Rhabdomyosarcoma, 584 Lung Cancer, 586
Ewing Sarcoma, 584 Other Cancers and Role of Proton Beam Therapy in
Other Paediatric Tumours, 584 Retreatment, 586
Proton Beam Therapy for Adult Cancers, 584 Conclusions and Future Directions, 586
Chordoma and Chondrosarcomas, 585 Further Reading, 587
Paraspinal Tumours and Sarcomas, 585
Nasal Cavity and Paranasal Sinuses, 586 Index, 589
 CONTRIBUTORS
The editor(s) would like to acknowledge and offer grateful thanks for the input of all previous editions’ contributors, without whom this new edition
would not have been possible.

Matthew Ahearne, MBChB, MD, MRCP, Neil G. Burnet, MA, MB BChir, MD, Pinelopi Gkogkou, MD, MSc, MA, PhD
FRCPath FRCS, FRCR Oncology Department
Department of Haematology Professor Norfolk and Norwich University Hospital,
University Hospitals of Leicester NHS Trust, Manchester Cancer Research Centre Norwich,
Leicester, University of Manchester and Christie UK
UK Hospital NHS Foundation Trust,
Manchester, John R. Goepel, MB, ChB, FRCpath
Thankamma V. Ajithkumar, MBBS, MD, UK Clinical Associate Professor and Honorary
FRCR, FRCP, MBA Consultant Histopathologist
Consultant Clinical Oncologist Robert Coleman, MD, FRCP, FRCPE University of Nottingham and Nottingham
Department of oncology Yorkshire Cancer Research Professor of University Hospitals NHS Trust,
Cambridge University Hospitals, Medical Oncology Royal Hallamshire Hospital
Cambridge, Weston Park Hospital, Sheffield,
UK Sheffield, UK
UK
Matthew Aldridge, MSc, PhD Adrian Harnett, MBBS, MRCP, FRCR
Radiotherapy Physics/Nuclear Medicine Mike Dunn, BSc, MSc Department of Clinical Oncology
University College London Hospital, Retired Head of Radiation Protection Norfolk and Norwich University Hospital,
London, Medical Physics Department Norwich,
UK University Hospitals of Leicester NHS Trust, UK
Leicester,
Richard A. Amos, BSc(Hons), MSc, UK Maria Hawkins, MD, FRCR, MRCP
CPhys, CSci, FIPEM MRC group leader
Associate Professor of Proton Therapy Angela Duxbury, FCR, TDCR, MSc Department of Oncology
Medical Physics and Biomedical Emeritus Professor of Therapeutic Oxford Institute of Radiation Oncology,
Engineering Radiography Oxford,
University College London, Sheffield Hallam University UK
London, Sheffield,
UK UK Paul Hinton, BSc, MSc, CPhys, CSci,
MInstP, MIPEM
Maria Mania Aspradakis, PhD Jill Emmerson, DCR (T), HDCR (T) Medical Physics - Nuclear Medicine
Head of Radiotherapy Physics QA Radiographer Royal Surrey County Hospital,
Department of Radiation Oncology Arden Cancer Centre Guildford,
unden,
Kantonsspital Graub€ UHCW NHS Trust, Surrey,
Chur, Coventry, UK
SWZ UK
David Hole, PhD (deceased)
Helen Baines, BSc(Hons), MSc Claire Fletcher, MSc, MIPEM Late Professor of Epidemiology and
Radiotherapy Physicist Principal Clinical Scientist, Biostatistics
Medical Physics and Engineering Radiotherapy Physics, University of Glasgow,
St James’s University Hospital, UHCW NHS Trust Glasgow,
Leeds, Coventry, Scotland
UK UK
Shakardokht Jafari, PhD
Laura Beaton, MBBS, BSc, MRCP, FRCR Jenny Gains, MBBS, MRCP, FRCR, MD Medical Physics Clinical Scientist,
Clinical Research Fellow Consultant Clinical Oncologist Associate Tutor and Visiting Reasearch
Research Department of Oncology Department of Radiotherapy Fellow,
University College London Cancer Institute, University College London Hospitals NHS University of Surrey,
London, Foundation Trust, Guildford,
UK London, UK
UK

xix
xx CONTRIBUTORS

Sarah J. Jefferies, BSc, MBBS, FRCP, Sofia Michopoulou, PhD, MIPEM Andrew Rogers, FBIR
FRCR, PhD Principal Clinical Scientist Lead Interventional Medical Physics
Oncology Department Imaging Physics Expert
Addenbrooke’s Hospital, University Hospital Southampton NHS Medical Physics & Clinical Engineering
Cambridge, Foundation Trust, Nottingham University Hospitals NHS
UK Southampton, Trust,
UK Nottingham,
George D.D. Jones, PhD, MScm, BSc UK
Professor of Cancer Radiation Research John A. Mills, PhD, MIPEM,
Leicester Cancer Research Centre CPhys Tom Roques, BM BCh, MRCP, FRCR
University of Leicester, Physicist, Department of Clinical Oncology
Leicester, MACS- Quality Control Provider, Norfolk and Norwich University Hospital,
UK James Watt House, Norwich,
Hinckley, UK
Andrzej Kacperek, BSc, PhD, FIPEM UK
Head of Eye Proton Therapy Service John Sage, BSc, MSc, PhD
The National Eye Proton Therapy Centre Eva Morris, BSc, PhD Head of Radiotherapy Physics
The Clatterbridge Cancer Centre, Professor of Cancer Epidemiology Clinical Physics and Biomedical
Bebington, Leeds Institute of Data Analytics Engineering
Merseyside, University of Leeds University Hospitals of Coventry and War-
UK Leeds, wickshire,
UK Coventry,
Charles Kelly, MBChB, MSc, FRCP, UK
FRCR Abhik Mukherjee, MBBS, DMRT, MSc,
Consultant Clinical Oncologist PhD, FRCPath Christopher D. Scrase, MA, MB, FRCP,
Northern Centre for Cancer Care Clinical Associate Professor FRCR
Freeman Hospital, Department of Histopathology, Department of Oncology
Newcastle upon Tyne, Division of Cancer and Stem Cells, Ipswich Hospital NHS Trust,
UK School of Medicine Ipswich,
University of Nottingham, UK
Christopher Kent, MBChB, MRCP, Nottingham,
MSc, FRCR UK Ricky A. Sharma, MA, MBBChir, FRCP,
Consultant Clinical Oncologist FRCR, PhD
University Hospitals of Leicester Somnath Mukherjee, FRCR, FRCP Chair of Radiation Oncology
Infirmary Square Associate Professor UCL Cancer Institute
Leicester, Department of Oncology University College London,
UK Oxford Institute of Radiation Oncology, London,
Oxford, UK
Ian Kunkler, MA, MB Chir DMRT, UK
FRCR, FRCPE Phil Sharpe, MSc, MIPEM
Elizabeth M. Parvin, BSc, PhD Principal Clinical Scientist
Professor
Honorary Associate Radiotherapy Physics
Institute of Genetic and Molecular
School of Physical Sciences UHCW NHS Trust,
Medicine
Open University, Coventry,
University of Edinburgh,
Milton Keynes, UK
Edinburgh,
England,
UK
UK Michael Snee, MBBS, FRCR, DM
Cliff Lawrence, MD, FRCP Former Consultant in Clinical Oncology
Andrew Penny, BSc, MSc, MIPEM St James’ Institute of Oncology
Consultant Dermatologist
Radiotherapy Physicist Leeds,
Royal Victoria Infirmary
GenesisCare West Yorkshire,
Newcastle upon
Birmingham, UK
Tyne,
UK
UK
Lesley Speed, MBChB, MSc, MRCP
Andrew Poynter, MSc, FIPEM, CSi Oncology Department
Duncan B. McLaren, MBBS, BSc (Hons),
Operational Lead, Proton Physics, University Hospitals of Leicester
FRCP (Ed), FRCR
Radiotherapy Physics NHS Trust,
Consultant Clinical Oncologist
UCLH, Leicester,
Edinburgh Cancer Centre
London, UK
Western General Hospital,
UK
Edinburgh,
UK
 CONTRIBUTORS xxi

Katie Spencer, MB BChir, Anne Thomas, BM, PhD, FRCP Sarah Wayte, Bsc, PhD
MA, FRCR Professor of Cancer Therapeutics Lead MR Physicist
Leeds Institute of Data Analytics Leicester Cancer Research Centre Radiology Physics
University of Leeds, University of Leicester, Department of Clinical Physics &
Leeds, Leicester, Bioengineering
UK UK University Hospitals Coventry &
Warwickshire,
Aravindhan Sundaramurthy, MBBS, Carl Tiivas, BSc, MSc Coventry,
MRCP, FRCR Lead Vascular Scientist UK
Consultant Clinical Oncologist Vascular Laboratory
Edinburgh Cancer Centre University Hospital Coventry, Lorraine Webster, BSc(Hons), DCR(T),
Western General Hospital, Coventry, DipCouns
Edinburgh, Warwickshire, Macmillan Information Support Radiogra-
UK UK pher and Counsellor
Radiotherapy Department
Paul Symonds, TD, MD, FRCP, Karen Waite, DCR(T) The Beatson West of Scotland Cancer
FRCR Advanced Practitioner Quality Centre,
Emeritus Professor of Clinical Oncology Management, Governance & Paediatrics Glasgow,
University of Leicester, The Nottingham Radiotherapy Centre UK
Leicester Nottingham University Hospitals NHS
UK; Trust, Michael Wynne-Jones, MSc, MIPEM
Honorary Consultant Oncologist Nottingham, Head of Radiation Protection and
University Hospitals of Leicester, UK Radiology Physics,
Leicester, Lincoln County Hospital
UK Harriet S. Walter, MBChB, MSc Lincoln,
Associate Professor of Medical Oncology UK
Roger E. Taylor, MA, FRCP, FRCR Leicester Cancer Research Centre
Professor University of Leicester,
Clinical Oncology Leicester,
Swansea University, UK
Swansea,
UK
This page intentionally left blank
 INTERNATIONAL SYSTEM OF UNITS
AND PREFIXES FOR PHYSICAL
QUANTITIES

There are seven international system (SI) base units: The most common multiples and submultiples

Physical quantity Unit Symbol for unit Multiple Prefix Symbol for prefix
12
length metre m 10 tera T
mass kilogram kg 109 giga G
time second s 106 mega M
electric current ampere A 103 kilo k
temperature kelvin K 100 — —
amount of substance mole mol 10
3 milli m
luminous intensity candela cd 10
6 micro μ
10
9 nano n
10
12 pico p
10
15 femto f
There is also a large number of derived units, some of which are
listed here

Quantity Derived Unit Conversion Online references : http://www.npl.co.uk/reference/measurement-units/

1
speed ms —
acceleration m s
2 —
angular frequency s
1 —
angular speed rad s
1 —
angular acceleration rad s
2 —
linear momentum kg m s
1 —
angular momentum kg m2 s
1 —
force newton (N) 1 N ¼ 1 kg m s
2
energy joule (J) 1 J ¼ 1 N m ¼ 1 kg m2 s
2
torque Nm —
power watt (W) 1 W ¼ 1 J s
1
pressure pascal (Pa) 1 Pa ¼ 1 N m
2
frequency hertz (Hz) 1 Hz ¼ 1 s
1
charge coulomb (C) 1C¼1As
potential difference volt (V) 1 V ¼ 1 J C
1
electric field N C
1 1 N C
1 ¼ 1 V m
1
radioactivity Becquerel (Bq) 1 Bq ¼ 1 s
1
resistance ohm (Ω) 1 Ω ¼ 1 V A
1
capacitance farad (F) 1 F ¼ 1 A s V
1
inductance henry (H) 1 H ¼ 1 V s A
1
magnetic field tesla (T) 1 T ¼ 1 N s m
1 C
1 ¼ 1 kg s
2 A
1
physical dose gray (Gy) see 1 Gy ¼ 1 J kg
1
Chapter 2
biological dose sievert (Sv) see 1 Sv ¼ 1 J kg
1
Chapter 4

xxiii
This page intentionally left blank

1 Atoms, Nuclei and Radioactivity
Elizabeth M. Parvin
2 Interactions of Ionising Radiation With
Matter
Shakardokht Jafari and Michael Wynne-Jones
3 Radiation Detection and Measurement
Andrew Poynter, Andrzej Kacperek, and John A. Mills
4 Radiation Protection
Mike Dunn
5 Imaging With X-Ray, Magnetic Resonance
Imaging and Ultrasound
Andy Rogers, Carl Tiivas, and Sarah Wayte
6 Imaging With Radionuclides
Paul Hinton
7 Therapy With Unsealed Radionuclides
Matthew Aldridge and Sofia Michopoulou
8 Radiotherapy Devices With Kilovoltage
X-Rays and Radioisotopes
Claire Fletcher and John A. Mills
SECTION 1
9 Beam Production: Megavoltage
Accelerators
Andrzej Kacperek and John A. Mills
10 Radiation Treatment Planning:
Immobilisation, Localisation and
Verification Techniques
Andrew Penny and Phil Sharpe
11 Radiation Treatment Planning: Beam
Models, Principles and Practice
Maria Mania Aspradakis
12 Networking, Data, Image Handling and
Computing in Radiotherapy
John Sage
13 Quality Control
John A. Mills and Phil Sharpe
14 Quality Management in Radiotherapy
Jill Emmerson, Karen Waite, and Helen Baines
1
 1
Atoms, Nuclei and Radioactivity
Elizabeth M. Parvin
CHAPTER OUTLINE
Introduction
Atomic Structure
Particles
The Atom and the Nucleus
The Forces
Electron Energy Levels
Band Theory of Solids
Impurity Bands
Particles in Electric and Magnetic Fields
Electric Fields
Magnetic Fields
The Lorentz Equation
Waves
INTRODUCTION
The aim of this first chapter is to lay some of the foundations of the
physics of radiotherapy. It starts, in the section titled Atomic Structure,
by looking at the main subatomic particles and the forces that hold
them together in the atom. This leads on to an examination of the dif-
ferent types of nuclei, with an emphasis on some of the important ones
used in medical physics. The behaviour of charged particles in electric
and magnetic fields, central to much of the physics of radiotherapy, is
covered in section titled Particles in Electric and Magnetic Fields.
Waves, including the electromagnetic spectrum, and the basics of
radioactive decay are introduced in the following sections.
For some readers, this chapter will be a reminder of previous knowl-
edge, for others it will be new territory. For the latter, the references
should provide some more in-depth material that it has not been pos-
sible to include here. For convenience, SI units are listed in the Physical
Units and Constants Section.
ATOMIC STRUCTURE
Particles
Most readers will be familiar with the idea that molecules are composed
of atoms chemically bonded together. Perhaps the most familiar exam-
ple is the water molecule, which consists of two hydrogen atoms
bonded to one oxygen atom to give the well-known molecular formula
H2O. In radiotherapy, we are often more interested in the particles that
make up the atom—these are known as subatomic particles.
Table 1.1 lists the properties of the sub-atomic particles of most rel-
evance to radiotherapy; the proton, neutron, electron, positron, neutrino
and antineutrino. Strictly, only the electron, positron and neutrinos are
2
Transverse and Longitudinal Waves
Electromagnetic Radiation
Continuous Spectra and Characteristic Radiation
Radioactive Decay
Stable and Unstable Isotopes
Half-life
Alpha Decay
Beta Decay
Gamma Decay
Electron Capture and Internal Conversion
Radioactive Decay Series
Radionuclides of Medical Interest
fundamental particles; the protons and neutrons are composed of
quarks. Charges are, as is customary in physics, given as multiples of
the electronic charge, e, which is 1.602
1019 C. The proton and pos-
itron have charges of + e and the electron has a charge of –e; all the other
particles listed are neutral. The fourth column gives the masses in kilo-
grams, but in nuclear physics, it is common practice to express the mass
of a particle not in kilograms but in terms of its rest mass energy. This is
based on Einstein’s famous equation, which gives the equivalence of
mass and energy:
E ¼ mc 2 1.1
where m is the mass of the particle, c is the speed of light in a vacuum
(2.998
108 m s1) and E is the energy. For an electron, the rest mass
energy associated with a mass of 9.109
1031 kg is 8.187
1014
joules (J). It is more convenient to express this very small magnitude
of energy in units of the electron-volt (eV), where
1 eV ¼ 1:602
1019 J 1.2
The electron volt is the amount of energy acquired by an electron when
it is accelerated through a voltage of 1 volt (see the section titled Electric
Fields), hence the name electron volt. Using this conversion, we arrive at
the values given in column 5 of Table 1.1. Note that the proton and neu-
tron (known collectively as nucleons) are very much more massive than
the electron and positron, and that the neutrino has almost zero mass—
the exact value is still the subject of experiment.
The positron is the antiparticle of the electron, having the same
mass but the opposite charge; it is emitted during β+ decay (see the sec-
tion titled Beta Decay) and is important in positron emission tomog-
raphy (PET) (see Chapter 6). Neutrinos play a role in β decay (see
 CHAPTER 1 Atoms, Nuclei and Radioactivity 3

the section titled Beta Decay). The photon is the particle associated with
electromagnetic radiation (see the section titled Waves).
The Atom and the Nucleus
The atom is the smallest identifiable amount of an element. Each atom
consists of a central nucleus, made up of protons and neutrons, which is
surrounded by a ‘cloud’ of electrons. The diameter of an atom and
nucleus are typically 1010 m and 1014 m, respectively. To put these
dimensions into a more accessible perspective, if the atomic nucleus is
represented by the point of a pencil (diameter approximately 0.5 mm)
held in the centre of a medium-sized room (say 5 m
5 m), then the
electron cloud surrounding the nucleus would extend to the walls of
the room.
It is the number of protons in a nucleus that determines the type of
element. Because the protons in the nucleus are positively charged and
the electrons are negatively charged, a neutral atom must contain equal
numbers of protons and electrons. It is the electrons, which surround
the nucleus and are often described as orbiting it, that interact with
electrons from other atoms, thereby determining the chemical behav-
iour of the atom.
For example, a hydrogen atom has one proton in the nucleus, helium
has two, carbon has six and so on. This number is known as the atomic
number, Z, of the element. The elements listed in order of increasing
atomic number form the periodic table of the elements [1].
As shown in Table 1.1, the neutrons in the nucleus carry no charge
but do have a similar mass to the protons. The electrons have a very
small mass, so the mass of an atom is almost entirely due to from
the mass of the protons and neutrons. The sum of the number of neu-
trons (N) and protons in a nucleus is known as the atomic mass num-
ber, A and A ¼ Z + N. Because both A and Z are needed to identify a
nucleus, the notation used is of the form
A
1.3
ZX
The symbol shown here as X is the chemical symbol for the element—H
for hydrogen, He for helium, C for carbon and so on—and A and Z
are the mass and atomic numbers. Because Z determines the chemistry
and therefore the element, strictly speaking, it is not necessary to have
the value of Z shown. For example, 12 6 C represents a carbon nucleus with
six protons and six neutrons, but it could be written simply as 12C, or even
as carbon-12 because carbon always has six protons. However, to avoid
confusion, it is often easier to include both atomic and mass numbers.
For any one element, the number of protons is always the same, but
the number of neutrons, and hence A, can vary. For example, carbon
can exist as, 11 12 13 14
6 C, 6 C, 6 C or 6 C. These have 5, 6, 7 and 8 neutrons
respectively and are known as isotopes of carbon. For many elements,
some of the isotopes are radioactive (see the section titled Radioactive
Decay) and this fact can be very useful in clinical investigations because
the chemical behaviour of all the isotopes is the same. For example,
radioactive 15
8 O is taken up by the body in the same way as the stable
(i.e. nonradioactive) isotope, 16
8 O, and can be used in PET; the radioac-
tive iodine isotope 131
58 I is taken up by the thyroid gland in the same way
as the stable isotope 127
58 I, so can be used to treat thyroid cancer.
The Forces
The next point to address is the question of what holds the atoms
together. The protons in the nucleus are positively charged, and the
electrons surrounding the nucleus are negatively charged, so there is
an attractive force between them. This electrostatic or Coulomb force
depends on the product of the charges and is inversely proportional
to the square of the distance between them. For one electron
(charge –e) and a nucleus (charge Z), the magnitude of the force
(Fel) is given by the equation
Ze 2
Fel ¼ k 1.4
r2
where k is a constant and r is the distance between the electron and the
nucleus. This inverse-square relationship is analogous to the gravita-
tional force between two masses and we could use the rules of classical
physics to calculate the orbits of the electrons around the nucleus (anal-
ogous to the orbits of the planets around the Sun). However, there is
one big difference between the planetary orbits and the orbits of the
electrons around the nucleus; in the planetary case, it is possible to have
any value of the radius (and therefore energy), whereas, in the atomic
case, quantum theory only allows certain permitted orbits. This gives
rise to electron energy levels (or shells), which are the subject of the
section titled Electron Energy Levels.
For like charges, the Coulomb force is repulsive, so, because the pro-
tons in the nucleus are all positively charged, it might be expected that
the Coulomb force would cause the nucleus to fly apart. However, there
is another force that acts on both protons and neutrons: the strong force.
This force acts on protons and neutrons and other heavy particles called
hadrons; it is independent of charge and is always attractive, but only at
very short range. Fig. 1.1 shows the way in which the energy of a proton
varies depending on how far away from the nucleus it is. As a proton
approaches the nucleus, it experiences a repulsive force but, if it has
enough energy to overcome this ‘Coulomb barrier’ and gets within

~10−15 m
TABLE 1.1 Properties of the Subatomic Coulomb Protons and neutrons
Particles of Most Relevance to Radiotherapy potential within the nucleus
barrier
Rest
Mass
Energy
Particle Symbol Charge, ea Mass (kg) (MeV) Proton
Proton p +1 1.673
1027 938 –r +r
Neutron n 0 1.675
1027 940 Energy
Electron e 1 9.109
1031 0.511
Positron e +1 9.109
1031 0.511
Neutrino νe 0 >0 >0 Fig. 1.1 Schematic illustration of the energy of a proton as a function of
Antineutrino νe 0 >0 >0 its distance, r, from the centre of the nucleus. As the proton approaches
Photon γ 0 0 the nucleus, the repulsive Coulomb force increases, but close to the
nucleus, this repulsion is overcome by the attractive strong force so
a
e is charge on an electron. the energy is reduced and the nucleons are held together in the nucleus.
4 Walter and Miller's Textbook of Radiotherapy

the range at which the strong force works, then it has a much lower the simplest element, hydrogen. No energy is lost or gained while an elec-
energy in the nucleus and stays there. An energy diagram like this is tron occupies a particular shell, and only discrete amounts of energy can
known as a potential well. be gained or lost by electrons when they move between shells. You can
see from Fig. 1.2 that the lowest energy state for hydrogen has an energy
Electron Energy Levels of –13.6 eV. Therefore the amount of energy that would be required to
As mentioned in the section titled The Forces, planetary orbits around remove this electron from the atom is 13.6 eV. This is the ionisation
the Sun and electron orbits around the nucleus differ in that, in the case energy of the hydrogen atom. The energy required to raise an electron
of the electrons, quantum theory predicts that only certain orbits are from the lowest energy state to the second lowest energy state is equal
allowed. This means that only certain orbit energies can occur—these to the difference between the energies of the two states, that is, (13.6 –
different values of energy are referred to as energy levels or shells and 3.40) ¼ 10.2 eV, and so on for all other pairs of energy levels.
were first hypothesised by Niels Bohr in 1913. Large atoms have more complicated arrangements of electron
A free electron, which is outside the nucleus, is said to have zero energy levels; the energy levels are numbered according to the principal
energy; any electrons in levels closer to the nucleus have a lower, and quantum number, n (n ¼ 1, 2, 3 etc.) and are subdivided into other
therefore negative energy. Fig. 1.2 shows the possible energy levels for energy levels, sometimes known as sub-orbitals, with more quantum
numbers relating to angular momentum and spin. These quantum
numbers also dictate the number of electrons which can be in each
Etot = 0 eV
Continuum of positive .. shell. Historically, the principal quantum number may also be repre-
.
energy states (Etot > 0) E7 = –0.28 eV sented by the letters K (n ¼ 1), L (n ¼ 2), M (n ¼ 3) etc., so the shells
E6 = –0.38 eV are often referred to as the K, L, M shells etc. If all the electrons in an
E5 = –0.54 eV atom are in the lowest possible energy states allowed by the rules, then
E4 = –0.85 eV the atom is said to be in the ground state. For example, a hydrogen atom
Excited E3 = –1.51 eV in the ground state has the electron in the state with energy 13.6 eV.
states
Band Theory of Solids
E2 = –3.40 eV In individual atoms, outer electrons occupy specific energy levels.
When atoms are brought together, as occurs in solid materials, inter-
actions between atoms broaden these specific energy levels into ‘energy
bands’. Electrons may occupy energy states only within these bands,
between which are forbidden zones that normally do not have energy
states for electrons to occupy, as illustrated in Fig. 1.3.
The outermost energy bands within the solid material are termed
the valence band and the conduction band. Electrons within the valence
band are considered as linked to the chemical bonds between individual
atoms and are therefore bound in place, although the term bound is
used loosely because at normal temperatures such bonds may be con-
tinually being broken and reformed. At an energy level slightly above
the valence band is the conduction band. Electrons within this band are
surplus to any requirements for chemical bonding. At normal temper-
atures, these electrons are not associated with specific atoms and chem-
Ground n = 1–13.6 eV, etc. ical bonds, but migrate readily through the material. In some materials,
state there are insufficient electrons to fill the available energy levels of the
valence band, so the conduction band is empty. Where a large forbidden
Fig.1.2 The possible energy levels of the electron in the hydrogen atom. zone exists, these materials are classed as nonconductors or insulators
Note that when the electron is bound in the atom, the energy is negative
(see Fig. 1.3A). Other materials may have more outer electrons than
and can only take certain values. Outside the atom, the energy of the
unbound electron is zero. The energy levels are numbered, n ¼ 1, 2
the valence band can accommodate, so that the lower levels of the con-
and so on from the inside outwards. duction band are also occupied. In these materials, the conduction band

Conduction band
Conduction band Conduction band

Conduction band
Forbidden zone

Valence band Valence band Valence band Valence band

Energy
A B C D
Fig.1.3 Simplified energy level diagram for solid materials: the shaded regions shows those levels that are nor-
mally occupied by electrons for (A) an insulator; (B) a conductor; (C) a semiconductor (undoped); (D) material with
impurity levels within the forbidden zone.

overlaps with the valence band and the forbidden zone disappears, as
shown in Fig. 1.3B. These materials will generally be good conductors
of electricity. There are some materials in which the valence band is just
filled, but the conduction band is effectively empty, and a small but sig-
nificant forbidden zone exists. These materials are classed as semiconduc-
tors, illustrated in Fig. 1.3C. Any charges injected into a semiconductor
will be free to travel through the material. It is to be stressed that this
description is overly simplistic but serves as a basis for understanding
the principles of solid-state dosimeters discussed in Chapter 3.
Impurity Bands
The introduction of impurities at low concentrations can alter the
structure of the energy bands and may create energy bands that are
located between the valence and conduction bands, within the forbid-
den zone as shown in Fig. 1.3D. The properties of the material so
formed will depend upon whether these extra bands are normally occu-
pied or empty of electrons, and their actual energy levels. The addition
of impurities is critical to the formation of active semiconductor
devices (see Chapter 3) and to the development and functioning of
both scintillator and thermoluminescent materials (see Chapter 3).
PARTICLES IN ELECTRIC AND MAGNETIC FIELDS
Electric Fields
As already explained, a single charge exerts either an attractive or a
repulsive force on another charge. A collection of charges will also exert
a force on another charged particle. This force can be written as
F ¼ qE
where F is the force on the charge q and the quantity E is known as the
electric field (caused by other charges in the vicinity). The direction of the
electric field is the direction in which a free positive charge would move; a
free negative charge would move in the opposite direction, so the force on
a particle in an electric field is always parallel or antiparallel to the field.
Magnetic Fields
The force on a charged particle in a magnetic field is more complicated.
There is no force at all if the particle is not moving; if it is moving then
the force is, like the force in an electric field, dependent on the charge, q,
but it is perpendicular to the direction of both the magnetic field, B, and
the velocity, v, of the particle and depends on the angle between them.
Fig. 1.4 shows some examples.
The largest force occurs when the velocity of the particle is perpen-
dicular to the magnetic field. As the angle θ between B and v decreases,
the force decreases; when the velocity and field are parallel θ ¼ 0 and
there is no force. In fact, the magnitude of the force is given by
F ¼ q v B sin ðθÞ
ο
So, when v and B are perpendicular, θ ¼ 90 and F ¼ q v B.
F
v v
B B
B
A B
Fig.1.4 The force on a moving charge (positive in this case) in a magnetic field depends on the relative directions
of the velocity (v) and the magnetic field (B). (a) v and B are perpendicular to each other. The force (F) is large and
perpendicular to both v and B. (b) The angle between v and B is less than 90 degrees and the force is less but still
perpendicular to both. (c) v and B are parallel: there is no force.
CHAPTER 1 Atoms, Nuclei and Radioactivity 5
The Lorentz Equation
The forces on a moving charged particle, which is subject to both an
electric and a magnetic field, are complicated and are best dealt with
using the mathematics of vectors, which is beyond the scope of this
book. However, for the simple case where the magnetic field is perpen-
dicular to the velocity of the charged particle, we can write
F ¼ ðqE + qvB Þ 1.7
The electric component of the force (qE) and the magnetic component
(qvB) are not necessarily in the same direction. This equation is known
as the Lorentz equation after the Dutch physicist Hendrik A. Lorentz,
and is an extremely important equation in many areas of physics. In
radiotherapy, it is useful when considering the behaviour of electrons
in a linear accelerator and of charged particles in a cyclotron or
synchrotron.
WAVES
Transverse and Longitudinal Waves
Energy, in the form of light, heat or sound, may be transmitted from
place to place by waves. The direction of propagation of a wave is
the direction in which the energy is transported; however, the particles
in the medium do not change their overall position; they simply vibrate
about an average position. We can distinguish two types of wave:
longitudinal and transverse.
In a transverse wave (Fig. 1.5A), the oscillations are perpendicular to
the direction of propagation of the wave. Water waves, or waves on a
1.5
string, are good examples of transverse waves.
In the case of longitudinal waves (Fig. 1.5B), the particles in the
medium move backwards and forwards in a direction parallel to the
direction of propagation, although their mean position stays the same.
A good example is a sound wave; the particles of the medium (e.g. air)
oscillate parallel to the direction of the sound wave and this gives rise to
changes in pressure along the wave.
Fig. 1.5 shows the wavelength, λ, of the wave—the distance between
two adjacent peaks (or two adjacent troughs). Another important
parameter is the frequency, f, which is the number of peaks that pass
a point per second. In all cases, the speed of the wave, c, is related to
the wavelength and frequency by the equation
c ¼fλ 1.8
This means that for a wave with constant speed, a larger wavelength
corresponds to a lower frequency and vice versa. Wavelength is mea-
sured in units of metres (m) and frequency in hertz (Hz).
Longitudinal sound waves are important in ultrasound imaging (see
Chapter 5), but for radiotherapy applications we are mostly concerned
1.6
with the transverse waves of electromagnetic radiation and these are the
subject of the next section.
F
v
C
6 Walter and Miller's Textbook of Radiotherapy

Equilibrium Amplitude

A
Transverse wave
Wavelength

Equilibrium (of first segment)

Longitudinal wave

Amplitude

B
Fig.1.5 (A) Transverse and (B) longitudinal waves. Note the wavelength is the distance between two maxima.

Direction of oscillation
of electric field vector e

Direction of
wave propagation
Direction of
oscillation of
Electric field

n
Positio magnetic field
vector B

Ma
gne
tic f
ield

Fig.1.6 The oscillations of electric and magnetic fields in an electromagnetic wave.

Electromagnetic Radiation
Electromagnetic radiation is so called because it can be described as
waves in which the quantities that oscillate are electric and magnetic
fields. Fig. 1.6 shows how the fields in these electromagnetic waves
oscillate at right angles to each other.
Because electromagnetic waves depend only on electric and mag-
netic fields, they can travel through any medium, including a vacuum.
In a vacuum, all electromagnetic waves travel at a speed of approxi-
mately 3
108 m s1 (often known rather loosely as the speed of light
in a vacuum) but the properties of the radiation vary greatly with wave-
length and frequency. Fig. 1.7 shows the vast range of the electromag-
netic spectrum; note that as the frequency increases, the wavelength
decreases, according to Equation 1.8. Radiotherapy physics is mostly
concerned with the high frequency/small wavelength end of the spec-
trum, although radio waves are important in radiotherapy as they are
used to accelerate the electron beam in a linear accelerator.
By the end of the 19th century, physicists were aware that all the
different types of radiation shown in Fig. 1.7 were electromagnetic
waves and they could be explained in terms of wave physics. However,
the beginning of the 20th century saw the development of quantum
physics. Several key experiments, including the investigation of Comp-
ton scattering, an important process in radiotherapy, described in
Chapter 2, showed that, when electromagnetic radiation interacts with
matter, wave physics does not always predict the correct result. Instead
the radiation behaves as particles known as photons. A photon is a small
‘packet’ or quantum of energy and each one has an energy given by
E ¼ hf 1.9
where E is the energy, f is the frequency of the electromagnetic wave
and h is a constant, known as Planck’s constant and equal to 6.626

1034 J s.
As with the masses in the section titled Atomic Structure it is
more usual to give these energy values in electron volts (eV) where
1 eV ¼ 1.602
1019 J. This has the advantage of allowing an easy
comparison between the energy of a photon and the mass energy of
 CHAPTER 1 Atoms, Nuclei and Radioactivity 7

a particle and is especially useful when considering the transfer of
energy between a photon and particle or the conversion of a particle
into radiation, annihilation radiation or radiation into particles, pair
production (see Chapter 2). Fig. 1.7 shows the energies in eV in addi-
tion to the wavelengths and frequencies.
Continuous Spectra and Characteristic Radiation
In the section titled Electron Energy Levels we described the way in
which the electrons in atoms can only be in specific energy states,
defined by their quantum numbers. The energies of these states are dif-
ferent for each element; for example, Fig. 1.8 shows the main energy
levels for tungsten, which is an element commonly used for the Target
in x-ray production, such as x-ray tubes (see Chapters 4 and 8), and
machines, such as linear accelerators (see Chapter 9).
As previously described, to raise an electron from one energy level to
another, the energy required is equal to the difference in energy of the
two states. If an atom is excited above its ground state by absorbing
energy from incoming particles (e.g. photons or electrons) then some
electrons can be moved up into allowable, but normally empty, energy
levels. This happens, for example, in an x-ray tube (see Chapters 5 and
8). This leaves the atom in an excited state, that is, with a higher total
energy than in the ground state. After a period of time, the atom will
return to the ground state as the excited electrons drop from the higher
levels back to vacant lower energy states. When this happens, the excess
electron energy is carried away as a photon of electromagnetic radia-
tion. Thus if we have two states with energies E1 and E2 then the energy
of the photon (Eγ) is the difference between E1 and E2. Using
Equation 1.9 to relate the energy of the photon to its frequency, we
arrive at:
E1  E2 ¼ Eγ ¼ hf 1.10
The energy of photons produced is therefore dictated by the differences
in energy between electron shells of the particular atom from which
they are emitted. The spectrum of photons produced by an element
is termed the characteristic radiation and will be different for each

Gamma-rays X-rays Ultraviolet Infrared Microwaves Radio

Wavelength (m)
10–12 10–6 1 103
V
Gamma-rays Ultraviolet i Microwave
s
i
X-rays b Infrared Radio
l
e
1020 1018 1016 1014 1012 1010 108 106
Frequency, (Hz)

4 ´ 105 4 ´ 103 4 ´ 101 4 ´ 10–1 4 ´ 10–3 4 ´ 10–5 4 ´ 10–7 4 ´ 10–9

Energy (eV)
400 nm 700 nm
Orange
Yellow
Green
Violet

Blue

Red

7.5 ´ 1014 Hz 4.3 ´ 1014 Hz

3.1 eV 1.8 eV
Fig.1.7 The different types of radiation that form the electromagnetic spectrum. The visible spectrum covers a
very small range of wavelength values and is expanded below the spectrum.
8 Walter and Miller's Textbook of Radiotherapy

element. Fig. 1.8 shows the possible electron transitions leading to the
N
production of characteristic photons for tungsten. Distinction is made
(number of neutrons)
between electron transitions originating from different shells to the
same destination shell by denoting the transition (and characteristic
photon) with the final shell letter (K, L and so on) and adding a Greek
letter suffix to indicate the originating shell, as shown in Fig. 1.8.
If the electrons in tungsten are excited, as in an x-ray tube, then the
emitted photons will be a mixture of the continuous background spec-
trum (see Chapter 2) and the characteristic radiation from the tungsten
atoms. This is shown in Fig. 1.9. The energy differences between the 126
levels in heavy elements tend to be much larger than for lighter ele-
ments: note that for tungsten (see Fig. 1.8) the photon energies of
the two main spectral lines are in the x-ray region at around 60 keV,
which is in the x-ray range. They correspond to the L to K transition
and the free electron to K transition. Contrast this with the energy
of the largest possible transition in hydrogen, which is 13.6 eV, and
in the ultraviolet region (see Fig. 1.7). 82
Type of
decay
Energy (keV) Shell
0 n=∞ b+
−0.1 n = 5 (O) 50 b–
−0.6 n = 4 (N) a
Fission
−2.8 n = 3 (M) 28 Proton
Neutron
14 Stable nuclide
−12.1 n = 2 (L)
Unknown
6

Lα, Lβ, Lγ 6 14 28 50 82 Z
−69.5 n = 1 (K) (number of protons)
Fig.1.10 A graph of neutron number (A–Z) plotted against proton number
(Z). The stable isotopes are shown in black and the solid line represents
Kα, Kβ, Kγ equal numbers of protons and neutrons.
Nucleus
Fig.1.8 Electron energy levels and transitions leading to characteristic
photons for tungsten. The main transitions into each shell are marked. neutrons (A–Z) against the number of protons (Z) for stable and unsta-
ble nuclei (Fig. 1.10). This figure shows the stable nuclei in black, which
1.2 is known as the stability line. It also shows the solid line corresponding
Relative photon fluence

1 to equal numbers of protons and neutrons. We see that for low atomic
number nuclei, an equal number of protons and neutrons is favoured,
0.8
whereas a greater proportion of neutrons to provide stability for large
0.6 nuclei. This may be explained by considering the increasing electro-
0.4 static force of repulsion between protons in the nucleus as the number
0.2 of protons is increased. For a more detailed, interactive, diagram which
allows you to look up individual nuclei [2].
0
20 40 60 80 100
Evidence suggests that protons and neutrons within a nucleus adopt
Photon energy (keV) a shell-like structure analogous to electron orbits and show particular
stability when the number of protons or neutrons, or both, corresponds
Fig.1.9 Characteristic spectral lines from tungsten superimposed on the
continuous spectrum. to a magic number (2, 8, 20, 28, 50, 82, 126). The strength of the strong
force that holds the nucleons together is associated with a nuclear bind-
ing energy that must be overcome to break the nucleus apart. Essentially
RADIOACTIVE DECAY the mass of a given nucleus is less than the sum of its constituent pro-
tons and neutrons; this is known as the mass defect. Representing this in
Stable and Unstable Isotopes terms of energy, using E ¼ mc2, gives the nuclear binding energy.
In the section titled The Atom and the Nucleus we explained that Nuclei with an even number of protons or an even number of neutrons
although the atomic number, Z, of a particular element is always the are more stable than those with an odd number of one or both.
same, atomic mass number, A, can vary so that each element can have A nucleus lying off the stability line shown in Fig. 1.10 is unstable and
several different isotopes. Some of them will be stable: that is to say they decays by rearranging its nucleon numbers. This is achieved by releasing
will not decay; others will be unstable and will undergo radioactive particles, changing a proton to a neutron or vice versa, or by absorbing
decay. It is instructive to plot a graph which shows the number of nearby particles. The activity of an unstable, or radioactive, isotope is the

rate at which its nuclei decay, expressed in Becquerels (Bq). One Becque-
rel corresponds to one decay or disintegration per second. The Becquerel
is a very small unit so the activity of sources used in medicine is generally
represented in MBq (1
106 disintegrations per second) or GBq (1

109 disintegrations per second). (You may also occasionally come across
the old unit of activity, the curie (Ci); 1 Ci ¼ 37 000 MBq.) Nuclei that
undergo radioactive decay are known as radionuclides.
In the construction of practical radioactive sources, we are also
interested in the amount of material that is needed to manufacture a
source with a required activity, determined by the specific activity,
the activity per unit mass (MBq kg1).
Half-life
Radionuclides decay at very different rates so it is important to have some
way of quantifying the rate of decay. If we have a collection of identical
nuclei, it is impossible to know exactly which one will decay next; one can
only predict the probability of decay. The number of nuclei, dN, which
decay in a short time dt will depend on two factors: the decay constant, λ,
which is essentially the probability of decay, and N, the number of nuclei
present at the start. This is expressed by the equation
dN ¼ λNdt 1.11
This equation can be rearranged and integrated to give
N ðt Þ ¼ No e λt 1.12
where No is the number of nuclei present at t ¼ 0 and N(t) is the number
of nuclei present at time t. e is the exponential function. A graph of N(t)
plotted against time gives an exponential decay curve similar to that
shown in Fig. 1.11.
The interesting thing about an exponential decay is that the length
of time it takes for the number of undecayed nuclei to halve is always
the same. In Fig. 1.11, this time is shown as 2 (arbitrary) time units. This
time is known as the half-life, T½, and it is related to the decay constant,
λ, by the equation
ln2 0:693
T1=2 ¼ ¼ (1.13)
λ λ
The term ln where the term ln represents the logarithm to base e; if
y ¼ ex then x ¼ ln y.
10
7
Relative activity
0
0 1 2 3 4 5
Time (arbitrary units)
Fig.1.11 Exponential decay of radioactivity with time. Note that the half-life is the time taken to drop to one-half
of the original value and is the same as the time taken to halve again to one-fourth and again to one-eighth.
CHAPTER 1 Atoms, Nuclei and Radioactivity 9
Half-lives can vary enormously—for example, the half-life of
uranium-238 (not used for medical purposes!) is approximately the
same as the age of the Earth, 4.5 billion years; the half-life of
krypton-81, used in nuclear medicine, is 13s, and others are even
shorter. The length of the half-life is an important consideration when
choosing a radionuclide for medical use; if the half-life is too long, then
the patient may be radioactive for the rest of their life; if it is too short
then the activity will decay too fast for it to be useful.
When radioactivity was first discovered at the end of the 19th cen-
tury, three different types of emitted particle were identified and were
labelled alpha (α), beta (β) and gamma (γ) radiation. These names have
remained, although there are now a few variants of them; the next four
sections will cover these different types of decay.
Alpha Decay
Alpha (α) decay occurs most often from the unstable nuclei of heavy
elements, such as uranium, radium or plutonium. The nucleus emits
an alpha particle, which is actually a nucleus of helium, 42He. Having
an equal number of protons and neutrons (both of which are magic
numbers) the helium nucleus is very stable. The parent nucleus (X)
decreases its atomic number by 2 and its mass number by 4 so the gen-
eral equation is:
Z X !Z 2 1.14
A A4
Y +42 He
where Y is the daughter nucleus. For example, radium (22688 Ra) decays to
radon (222
86 Rn) and an alpha particle. Energy must be conserved in the
transformation, so any difference, Q between the nuclear binding
energies of the parent and daughter nuclei is shared between the
emitted alpha particle, in the form of kinetic energy and any photons
that are produced (see the section titled Gamma Decay). Alpha
particles are typically emitted with kinetic energies of the order of
several MeV.
Being relatively heavy (approximately 4
the mass of a proton) and
highly charged (containing two protons), α particles are readily stopped
in matter. For example, the 4.79 MeV α particle emitted from radium
has a range of less than 4 cm in air, or less than 0.04 mm in tissue. This
means that alpha particles can be very useful for radiotherapy, but only
6 7 8 9 10
10 Walter and Miller's Textbook of Radiotherapy
if they can be released very close to the tumour tissue. Radium-226 was
used in some very early external radiotherapy treatments but has the
big disadvantage that the daughter product, radon, is a radioactive
gas. More recently, Radium-223 is being trialled as an unsealed source
of treatment for bone metastases.
Beta Decay
There are now known to be two types of beta decay. Beta minus (β)
decay occurs frequently in naturally occurring radionuclides and
involves the emission of an electron; beta plus (β+) decay occurs mainly
in artificially produced radionuclides and the particle emitted is a
positron.
A nucleus lying above the stability line in Fig. 1.10, is neutron-rich
and, by emitting an electron, can convert a neutron to a proton, thereby
approaching the stability line. An example is iodine-131, which
undergoes beta minus decay to become xenon-131:
53 I ! 54 1.15
131 131
Xe
Note that, because the total number of nucleons has not changed, the
mass number stays the same, but because a neutron has been converted
into a proton, the atomic number increases by one. The emitted β par-
ticle is a high-energy electron from the nucleus, not to be confused with
the orbiting electrons in the atom.
By contrast, a nucleus lying below the stability line of Fig. 1.10, is
proton-rich and therefore decays by converting a proton into a neu-
tron. As with β decay the mass number does not change, but in this
case, since a proton is converted into a neutron, the atomic number
decreases by one. The emitted β+ particle is a positron, the antimatter
equivalent of the electron. A good example, which is widely used in PET
imaging, is fluorine-18:
9F ! 8 1.16
18 18
O
Observation that the β particles produced display a spectrum of kinetic
energies, rather than the discrete energy difference between parent and
daughter nuclei, indicates that a further particle must be involved. For
β+ decay, this particle is the neutrino, νe; for β decay, it is its antipar-
ticle, νe . The processes for iodine-131 and fluorine-18 are therefore:
53 I ! 54 Xe +10 β + ν
131 131
and
9F ! 8 O + +10 β + ν 1.17
18 18
The energy arising from the difference in masses of the initial and final
particles is carried away as kinetic energy of beta particle and the
neutrino.
The range of a β particle is larger than that of an α particle as it is
much lighter. However, whereas the heavy alpha particles will travel
along a straight path, the beta particles will follow a much more erratic
path as they interact with atomic electrons. The range of a beta particle
in tissue is only of the order of a few millimetres and will depend on the
energy with which it was emitted.
An emitted positron (β+) travels through matter, rapidly losing
kinetic energy through interactions with atomic electrons. When it col-
lides with an electron, its antiparticle, both particles are annihilated and
their energy converted into electromagnetic radiation. Using Einstein’s
mass-energy equivalence equation, E ¼ mc2, the total energy of the radi-
ation must be 2
0.511 MeV (see Table 1.1). Conservation of momen-
tum demands that two photons, each with energy 0.511 MeV are
produced in opposite directions. This is the basis of PET (see Chapter 6).
Depending on its energy, a positron will be stopped within a very
short distance of the site of emission in tissue. The annihilation
photons, on the other hand, at 0.511 MeV, each can pass relatively
easily through tissue. Detection of these coincident photons following
administration of a positron-emitting radionuclide, such as fluorine-
18 to a patient, therefore reveals where the annihilation event
occurred and hence where the radionuclide was taken up within
the body.
Gamma Decay
In the section titled Electron Energy Levels we showed that the elec-
trons in atoms could only occupy certain allowed energy levels. In
an analogous way, each nucleus can only have certain discrete energies
and transitions between two levels involve the emission or absorption
of photons of electromagnetic radiation. As with electron transitions,
the energy values of the levels are different for different elements; how-
ever, in the nuclear case, the differences are much larger so the photons
produced are generally of much higher energy. Following an α or
β decay, the daughter nucleus is often left in an excited state. It will then
reach its ground state by emitting a photon with an energy correspond-
ing to the difference between the two energy levels. These photons
are known as gamma (γ) rays. Fig. 1.12 shows the decay scheme for
cobalt-60, which is an isotope formerly widely used for external beam
therapy and now used in the Gamma Knife (see Chapter 8).
In most cases, the emission of gamma rays occurs immediately
after the alpha or beta decay, however occasionally, the nucleus
remains in an excited state and decays with a measurable half-life.
Such an excited state is known as a metastable energy state and is
denoted by the addition of an ‘m’ to the mass number. There is no
change in Z or A during the transition from the excited state of the
metastable nucleus to the ground state, so this is known as an isomeric
transition. One important example, widely used in nuclear medicine,
is technetium-99m (Fig. 1.13). This is a useful radionuclide because it
produces only gamma rays, with an energy of 140 keV, which can be
used for imaging, and no short range α or β particles, which would
only damage tissue.
Note that both γ rays and x-rays are electromagnetic radiation at the
top end of the spectrum (see Fig. 1.7); the energy ranges overlap and
indeed both are used in radiotherapy. They are only distinguished by
their origin: gamma rays coming from the nucleus and x-rays from
the atomic electrons (see Chapter 2).
Co
60
27
5.272 years 0.31 MeV b − 99.88%
0.12%
1.48 MeV b − 1.1732 MeV g
1.3325 MeV g
Ni
60
28
Fig.1.12 Cobalt-60 decays via beta decay to give nickel-60. The nickel
nucleus is in an excited state and decays via the scheme shown, giving
gamma rays with energies 1.1732 and 1.3325 MeV.
 CHAPTER 1 Atoms, Nuclei and Radioactivity 11

Fig.1.13 Technetium-99m is produced from molybdenum-99 by beta
decay and then decays to the ground state (Tc-99g) via an isomeric tran-
sition with a half-life of 6 hours. The ground state technetium eventually
decays to stable ruthenium-99 but with an extremely long half-life and
therefore very low activity.
Electron Capture and Internal Conversion
As an alternative to positron emission (β+ decay), the nucleus of a
proton-rich atom may capture one of its own inner shell electrons,
via electron capture (EC). The captured electron combines with a pro-
ton in the nucleus to produce a neutron and neutrino, the latter being
emitted from the nucleus carrying kinetic energy equal to the difference
in nuclear binding energy between the parent and daughter nuclei. As
with β+ decay, the mass number does not change but the atomic num-
ber decreases by 1. Nuclei that decay by this method can be useful
because there is no particulate emission. An example of a nuclide that
decays by EC is iodine-125; it emits gamma rays of up to 35 keV, which
can be used for brachytherapy (see Chapter 8).
Another possible mode of decay is internal conversion (IC). An
excited nucleus may de-excite by emitting a single photon, which inter-
acts with the inner shell electron so that the electron is ejected from the
atom. In contrast to beta decay, the emitted electron will have a single
kinetic energy equal to the excitation energy of the nucleus minus the
electron binding energy. The vacancy in the atomic shells left by
the emitted electron will be filled by outer electrons, giving rise to char-
acteristic radiation (see the section titled Continuous Spectra and
Characteristic Radiation).
Radioactive Decay Series
There are many cases of radioactive nuclei that decay to give daughter
nuclei, which are themselves radioactive and so on. This gives rise to
a decay series. Fig. 1.14 shows the decay series of uranium-238, a nat-
urally occurring radionuclide. At each stage, the α or β decay leads
to a new nucleus which itself decays, the final product in this case
being a stable isotope of lead. At each decay, the rate of growth of
the activity of the daughter nuclide depends on the relative values
of the decay constants (λ) of the parent and the daughter. Another

α
238 U
92

109y
β β
γ
234 T 234 234 U
90 91Pa 92
γ γ
24d 7h 105y α

230 T
90 γ
γ
226 104y α
88R

222 103y α
86R
α
218 P
84
4d α

3m

β β
γ
γ 214 Pb
82
214 Bi
83
214 P
84

27m α 20m 10-4s α

β β
γ
210 Tl 210 Pb 210 Bi 210 P
81 82 83 84
γ
1m 22y β 5d 140d α

206 Pb
82

Fig.1.14 Decay series for 238

92 U. Half-lives are indicated in seconds (s), minutes (m), hours (h) and years (y).
12 Walter and Miller's Textbook of Radiotherapy

example, of much more clinical importance, is the decay of TABLE 1.2 Characteristics of Some
molybdenum-99 (see Fig. 1.13) to technetium-99m, which is widely
Radionuclides Used in Radiotherapy as Either
used for imaging.
If we assume that there is no daughter present at time t¼ 0, and that
Unsealed Sources or Sealed Sources
all the disintegrations of the parent lead to the required daughter prod- Decay
uct, then the activity of the daughter at time t, A2(t) is given by: Isotope Mechanism Half-Life Clinical Application
λ2
Unsealed Sources
A2 ðt Þ ¼ A1 ð0Þ eλ1 t  eλ2 t (1.18) 11
C β+ (2.0 MeV) 20 m PET imaging
λ2  λ1 13
N β+ (2.2 MeV) 10 m PET imaging
where A1(0) is the initial activity of the parent at time t ¼0 and are the 15
O β+ (2.8 MeV) 122 s PET imaging
decay constants of parent and daughter, respectively. Equation 1.18 is 18
F β+ (1.7 MeV) 109 m PET imaging
of relevance to radionuclide generators as it allows calculation of the 32
P β (695 keV) 14.3 d Polycythaemia vera
optimum time between elutions of the daughter radionuclide. 89
Sr β (500 keV) 50.5 d Bone metastases (palliation)
If the decay of the parent is much slower than that of the daughter, 99m
Tc γ (143 keV) 6.0 h Gamma camera imaging
that is, if λ2 >> λ1 then Equation 1.17 reduces to 90
Y β (923 keV) 2.7 d Radiosynovectomy

131
I β (264 keV) 8.1 d Thyrotoxicosis and thyroid
A2 ðt Þ ¼ A1 ð0Þ e λ1 t  e λ2 t (1.19) γ (364 keV) cancer
223
Ra α (5.7 MeV) 11.4 d Prostate cancer
This is the situation for ionisation chamber consistency check devices
containing a strontium-90 source. Strontium-90 undergoes beta decay Sealed Sources
with a half-life of 28.7 years to yttrium-90, which itself decays via beta 60
Co β, γ (1.17, 5.26 y External beam units and
decay with a half-life of 64 hours. The activity of the long-lived stron- 1.33) MeV) gamma knife
tium parent determines and maintains the activity of the short-lived 103
Pd EC, γ (21 keV) 17 d Brachytherapy (seeds)
yttrium daughter. 125
I EC, γ (27– 60 d Brachytherapy (seeds)
36 keV)
Radionuclides of Medical Interest 137
Cs β, γ (662 keV) 30 y Brachytherapy (pellets)
Table 1.2 lists some common isotopes applied to radiotherapy and
192
Ir β, γ (300–400) 74 d Brachytherapy (wire)
nuclear medicine. The choice of isotope for a particular application keV)
is based on decay product type (γ, β (+ or ) or α), product energy/
ies, half-life, specific activity (activity per unit mass) and availability.
The α particles (heavy helium nuclei) have a very short range in tissue
so will deposit energy close to the site at which a radionuclide is taken tissues in therapeutic applications. If greater penetration is required,
up in the body; β particles (electrons) have a slightly longer, but still of the order of centimetre for brachytherapy, or if imaging of radioac-
small, range. If the site of disease can be preferentially targeted by these tivity uptake through external detection of radiation is required, then
emissions, this leads to significant sparing of surrounding normal photons (γ) or β+ emissions will be the product of choice.

REFERENCES
[1] Interactive Periodic Table Royal Society of Chemistry, http://www.rsc.org/ [2] Interactive Segre chart. http://people.physics.anu.edu.au/ecs103/chart/
periodic-table/. (Note that this plots Z against N—the opposite of Fig. 1.9. Both versions are
commonly used).

FURTHER READING
Dendy PP, Heaton B. Physics for diagnostic radiology. 3rd ed. Baton Rouge: Grant IS, Phillips WR. The elements of physics. Oxford: Oxford University
CRC Press; 2012. Press; 2001.

Interactions of Ionising Radiation With Matter
CHAPTER OUTLINE
Introduction
Charged and Uncharged Particles
Excitation and Ionisation
Electron Interactions
Collisional and Radiative Energy Loss
X-Ray Production
Characteristic X-Rays and Auger Electrons
Stopping Power and Linear Energy Transfer
Range and Path Length
Photon Interactions
The Photoelectric Effect
The Compton Effect
Pair Production
Exponential Attenuation
INTRODUCTION
In this chapter we are mostly concerned with the interactions of elec-
trons and photons with matter, as these are the most commonly used
particles in radiotherapy (RT).
Charged and Uncharged Particles
The dominating feature of any particle is its charge. Electrons carrying a
charge of –1.6
10–19 C readily interact via the Coulomb force with
other charged particles in the matter they traverse, predominantly with
atomic electrons and, to a lesser extent, with protons in atomic nuclei.
Photons, by contrast, carrying no charge, interact relatively rarely with
matter. The use of clinical proton beams for RT is increasing as new
facilities are constructed worldwide. As charged particles, proton beams
passing through matter behave in a similar way to electrons, that is, they
readily undergo interactions with atomic electrons. The difference
between proton and electron interactions lies in the proton having a
mass of 1.67
10–27 kg, which is roughly 2000 times greater than
the electron mass of 9.11
10–31 kg. The characteristics of proton
energy loss in matter make them highly attractive for RT, offering dis-
tinct advantages over photons and electrons, as will be discussed later.
Neutron beams are less often selected as the beam of choice for RT at
the present time; however, they also offer advantages over photon
beams for some tumours because of their biological effect on tissue.
Being uncharged, neutrons interact in a similar manner to photons
and, in fact, produce very similar depth-dose characteristics.
It should be remembered that RT is not restricted to these particles
alone. Ion beams consisting of atomic nuclei stripped of their electrons
may also be used. A proton, in fact, can be thought of as a hydrogen
atom without its orbital electron. Carbon ions, in particular, have been
2
Shakardokht Jafari, Michael Wynne-Jones
Attenuation of Photon Spectra
Beam Hardening
Energy Absorption
Photo-Nuclear Interactions
Photon Depth Dose and the Build-Up Effect
Kerma and Absorbed Dose for Radiotherapy Beams
Kerma
Absorbed Dose
Units of Kerma and Dose
Heavy Charged Particle Interactions
Protons
Carbon Ions and Pions
Neutron Interactions
used to treat a number of cancers in what is, at present, a small number
of facilities worldwide, and their characteristics are being actively
researched. Negative pions (π–) were also, at one time, thought to have
great potential for RT because of the nature of their interactions and
their energy loss at the end of their range. Clinical studies on the use
of pions have not demonstrated this advantage to date.
Excitation and Ionisation
Ionising radiation, by definition, has sufficient energy to ionise matter.
That is, it has sufficient energy to overcome the binding energy of
atomic electrons. Radiation of energy below the binding energy of a
particular electron shell may still interact with an electron by raising
it to a higher, vacant shell (see Chapter 1). As a result of this interaction,
the atom has gained energy and is left in an excited state (Fig. 2.1A). It
will eventually lose this excess energy to return to its lowest energy state,
or ground state. An electron occupying an outer shell relative to the
vacancy may achieve a lower energy state by filling the vacancy (see
Fig. 2.1C). The excess energy is released as a characteristic photon
(i.e. with an energy equal to the difference in shell binding energies).
If this electron is also in an inner shell, it too will leave behind a vacancy,
which an outer electron can again occupy (see Fig. 2.1C), again losing
energy in the form of a characteristic photon. This process results in a
cascade of electrons moving between shells and a corresponding set of
characteristic photons, which eventually return the atom to its
ground state.
Even if its own kinetic energy exceeds the atomic electron’s binding
energy, an incoming electron or photon may transfer part of its kinetic
energy to an atomic electron to produce excitation. Where the incom-
ing electron or photon transfers more than the binding energy of an
atomic electron to the atom, the excited electron is ejected from the
13
14 Walter and Miller's Textbook of Radiotherapy
K
L K
M L
K ing energy through collisions with electrons in the medium. Occasionally,
L K
M L
Fig. 2.1 Excitation and ionisation for a carbon atom. (A) Excitation: an
incoming photon raises an inner shell electron to a vacant orbit; the elec-
tron has gained energy and, as a result, the atom is left in an excited state.
(B) Ionisation: an incoming photon ejects a K-shell electron from the atom;
the atom is ionised having an overall positive charge. As no scattered pho-
ton was produced, the emitted electron has acquired kinetic energy equal
to the energy of the incoming photon minus the electron’s binding
energy. (C) De-excitation: an L-shell electron drops into the vacancy in
the K-shell, emitting a characteristic photon; the L-shell vacancy is filled
by the electron involved in the original interaction. (D) De-excitation: an
L-shell electron fills the K-shell vacancy and a free electron from the
medium is captured to the L-shell.
atom, with kinetic energy equal to the total energy transferred minus
the binding energy. As a result of losing an electron, the atom has been
ionised (see Fig. 2.1B). The positive ion will seek an electron from its
surroundings to return to its uncharged state and so be chemically reac-
tive. In addition, the ejected electron will leave a vacancy behind, which
represents an excited state. The cascade process will then follow as
described earlier as de-excitation takes place (see Fig. 2.1D).
ELECTRON INTERACTIONS
Collisional and Radiative Energy Loss
The last section was concerned with the dominant interaction that a
beam of electrons undergoes when travelling through matter, that of
collisions with atomic electrons in the energy range of interest to
RT. These interactions lead to excitation and ionisation of the medium
traversed, as represented schematically in Fig. 2.2. More rarely, elec-
trons from an incident clinical beam will pass near to and interact with
the atomic nucleus, again as a result of the Coulomb force of attraction
between negatively charged electron and positively charged nucleus.
The path and momentum of the incident electron are changed under
the influence of the nucleus, resulting in a loss of electron energy. This
loss of energy is the radiative energy loss resulting in a radiated photon,
an x-ray. The term, bremsstrahlung (braking radiation), is a helpful
descriptive name given to this process, shown schematically in
Fig. 2.3. The probability of this interaction occurring is inversely pro-
portional to the square of the incident particle’s mass. As a result,
bremsstrahlung is only significant for electrons. This important process
by which x-ray photons can be produced is described in the following
section.
Fig. 2.2 Illustration of the frequent interactions, scattering, and finite
range of electrons traversing matter. A beam of 10-MeV electrons (black)
strikes a slab of water from the left. Incident electrons readily scatter, los-
energy is lost through x-ray production (bremsstrahlung, indicated by light
grey lines). Note that (A) no primary electrons escape the slab as it
exceeds the finite range of these electrons (x-ray photons and secondary
electrons generated by these photons may leave the slab, however), and
(B) the total distance travelled by an incident electron (path length) is
greater than the maximum depth reached (range).
e–
γ
e–
Fig. 2.3 Schematic representation of photon production by electrons
(bremsstrahlung). An incident electron deflected by the nuclear Coulomb
field loses energy, which appears in the form of an emitted photon.
X-Ray Production
The conversion of electron kinetic energy into photons as a beam of
electrons striking a target is decelerated in the nuclear Coulomb field
(bremsstrahlung) is the primary method for obtaining clinical photon
beams. As suggested earlier, however, for the normal range of energies
considered for diagnostic imaging and RT (20 keV to 25 MeV), elec-
trons are far more likely to interact through collisions with atomic elec-
trons. The efficiency of this process is therefore generally low. The
likelihood of bremsstrahlung depends on the atomic number of the
material traversed, Z (the total charge of the nucleus), and the energy
of the incident electron, E, according to:
Probability  ZE 2.1
The energy of the electron beam is dictated by the maximum photon
energy required. The use of high atomic number materials gives the best
yield of photons. Table 2.1 presents the proportion of electron beam
kinetic energy converted to photons for a tungsten target. The remain-
der of the incident electron’s kinetic energy is lost through collisions
with atomic electrons in the target, causing excitation and ionisation.
 CHAPTER 2 Interactions of Ionising Radiation With Matter 15

TABLE 2.1 Percentage of Incident Electron
Beam Energy Appearing as Bremsstrahlung for
Electrons Incident on a Tungsten Target
Electron Energy (MeV)
0.05
0.25
1 6
10
50
Data calculated using the ESTAR program [1].
A large amount of this energy is eventually released in the form of heat,
requiring the target to be cooled.
In the bremsstrahlung process, an electron may lose any amount of
energy, up to its total kinetic energy. Rather than discrete photon ener-
gies, as are observed during de-excitation of atoms, a continuous spec-
trum of photon energies is produced. An example of the photon spectra
produced when electrons are used to generate a 100 kV and 6 MV pho-
ton beam is shown in Fig. 2.4.
Photon spectra are commonly designated by kilovoltage (kV) or
Megavoltage (MV) to indicate the nominal potential used to accelerate
the electrons that created the spectrum. For example, a potential differ-
ence of 100 kV between cathode and anode in an x-ray tube will result
in electrons with an energy of 100 keV striking the target, producing a
100 kV photon spectrum. Although there is no lower limit on the
Photon Yield (%) energy of photons produced, the low-energy components of the spec-
0.5 trum are preferentially removed by photon attenuation within the tar-
2 get and other machine components, so that the peak in the spectrum
occurs at approximately one-third of the maximum photon energy.
30 For electrons striking a thin target, photons are produced in all
63 directions. The intensity (or number) in a particular direction depends
on the energy of the incident electrons, and the atomic number of the
target. For low electron energies (up to 100 keV), the intensity is almost
equal in all directions and as the electron energy increases, the photons
produced become more forward directed. This variation in photon
intensity with incident electron energy is illustrated in Fig. 2.5, where
electrons (indicated by the dashed line) are incident from the left. In
this figure, bremsstrahlung production is simulated for a number of
incident electrons, with the emitted photon energy and direction sam-
pled from known probabilities (cross sections). Some 2000 photon
tracks are represented in each figure, projected from a three-
dimensional distribution into a two-dimensional plane. The length
and shade of each photon track is representative of the individual pho-
ton energy. Note that higher energy photons (lightly shaded, long
tracks) appear predominantly in the forward direction. This is one of

1.0
Relative energy fluence

0.8

0.6

0.4

0.2

100 keV
0.0
0 20 40 60 80 100
Photon energy (keV)

1.0
Relative energy fluence

0.8

0.6 1 MeV

0.4

0.2

0.0
0 1 2 3 4 5
Photon energy (keV)
Fig. 2.4 X-ray spectra: (A) 100-kV diagnostic spectrum; bremsstrahlung
(continuous) spectrum with superimposed discrete characteristic tung-
sten x-rays and (B) 6-MV photon spectra from an Elekta SL25 linear accel-
erator. (A, from IPEM Report 78. Catalogue of diagnostic x-ray spectra and
other data. Institute of Physics and Engineering in Medicine; 1997; B,
from Baker C, Peck K. Reconstruction of 6 MV photon spectra from mea-
sured transmission including maximum energy estimation. Phys Med
Biol 1997;42:2041–2051.)
10 MeV
6 7
25 MeV
Fig. 2.5 Spatial and energy variation of bremsstrahlung produced by elec-
trons incident on a thin target. Electrons are incident from the left (dashed
line); bremsstrahlung photons energy is indicated by track length and
shade (short/dark ¼ low energy). In each case 2000 bremsstrahlung inter-
actions are simulated from known probabilities.
16 Walter and Miller's Textbook of Radiotherapy

the reasons for the average photon energy emitted from a linear accel- 8
erator target being lower at angles off the beam central axis. Collision

Stopping power (MeV cm2 g−1)

Radiative
The observed variation in spatial intensity of bremsstrahlung pho-
Total
tons affects the design of x-ray targets. At kilovoltage energies, a reflec- 6
tion target is generally used, where photons produced at right angles to
the direction of incident electrons are extracted for use. At megavoltage
energies, a transmission target is required as photons are mostly trav- 4
elling approximately parallel to the incident electron beam. This is
shown schematically in Fig. 2.6.
2

g
0
0 10 20 30 40 50
Electron energy (MeV)
e–
8
Collision

Stopping power (MeV cm2 g−1)

Radiative
Total
6

Reflection target
4
g

e–
Transmission target
Fig. 2.6 Reflection and transmission targets for the production of x-rays:
(A) represents the production of a kilovoltage therapy beam and (B) the
production of a megavoltage beam.
Characteristic X-Rays and Auger Electrons
Discrete spectral lines can be seen superimposed on the continuous
100 kV spectrum in Fig. 2.4. These are as a result of characteristic
photons being produced during de-excitation of tungsten atoms after
inner shell electrons have been excited or ejected through collisions with
the incident electron beam. The energies of these characteristic photons
correspond to the difference between the binding energies of the inner
shell vacancy and the outer shell electron that fills the vacancy. The differ-
ence between electron binding energies depends on the atomic number of
the target. For tungsten, with a K-shell binding energy of 69 keV and L-
shell binding energy of 12 keV, it follows that the minimum energy of a
characteristic photon produced by filling an electron vacancy in the K-
shell is 57 keV. The same characteristic photons are not observed in the
6-MV spectrum, as they now represent very low energies within this spec-
trum and are preferentially removed by photon attenuation.
In some instances, the characteristic x-ray does not escape the atom,
but excites an outer electron sufficiently for the electron to leave the
atom. These electrons are referred to as Auger electrons after the phys-
icist who identified the process.
Stopping Power and Linear Energy Transfer
The rate at which energy from an incident beam of charged particles is
lost as it passes through a material is described by the stopping power. If
an electron of energy, E, loses a small amount of energy, dE, in a small
thickness, dx, of material, the stopping power, S(E), is defined by:
 
S ðE Þ ¼ dE=dx MeV cm1 2.2
If the energy loss is separated into that lost in collisions, Scoll, with
atomic electrons and that lost through bremsstrahlung (or radiative
loss), Srad:
S ðE Þ ¼ S coll ðE Þ + S rad ðE Þ 2.3
2
0
0 10 20 30 40 50
Electron energy (MeV)
Fig. 2.7 Collisional, radiative, and total stopping power for electrons: (A)
in water and (B) in tungsten. Data calculated using the ESTAR program.
(From Berger M, Coursey J, Zucker A, Chang J. ESTAR, PSTAR, and
ASTAR: Computer programs for calculating stopping-power and range
tables for electrons, protons, and helium ions (version 1.2.3), Gaithers-
burg, MD: National Institute of Standards and Technology; 2005. http://
physics.nist.gov/Star.)
If energy is in MeV and distance in centimetres, stopping power has
units of MeV cm–1. Alternatively, we may express this in terms of mass
stopping power, S(E)/ρ, where ρ is the material density (g cm–3). The
magnitude of this quantity depends on both the energy of the electron
and the material involved. Fig. 2.7 shows the variation of electron mass
stopping power with energy in water and lead. Measurement of the
energy absorbed in a material is determined using stopping power
and the energy absorbed per unit mass is referred to as the absorbed
dose. Its units are J/kg, and given the special unit gray, symbol Gy.
Because stopping power reflects the difference in energy absorption
between materials, it is used in radiation dosimetry to convert mea-
sured radiation dose between materials. For example, using an air-filled
ionisation chamber surrounded by water, a direct measurement of
energy absorbed, or dose to air, Dair, can be made. The dose, Dw, that
would be absorbed if the ionisation chamber were replaced by water,
which is very close to human soft tissue, would be given by multiplying
by the ratio of mass stopping powers between water and air:
D w ¼ D air
ðS w ðE Þ=ρw Þ=ðS air ðE Þ=ρair Þ 2.4
where ρw and ρair are the densities of water and air, respectively. Strictly,
the stopping power used in equation 2.4 must be restricted to energy
absorbed within the ionisation chamber volume and must exclude
any energy that is lost from the beam but travels beyond the chamber
(site of interaction). For example, energy lost in the form of bremsstrah-
lung, or collisions in which a large amount of the incident electron’s
 CHAPTER 2 Interactions of Ionising Radiation With Matter 17

energy is transferred to an atomic electron such that it travels beyond 4–20 MeV), the range of electrons in water (or tissue) can be approx-
the chamber. imated by:
Linear energy transfer (LET) also refers to the amount of energy
deposited by ionising radiation in matter. Units are also energy per unit Electron range ðcmÞ  Beam energy ðMeVÞ=2 2.5
length, often expressed in keV μm–1. The LET is commonly used to dis- An indication of the accuracy of the aforementioned expression can
tinguish between types of ionising radiation. Photons and electrons be made by comparison with electron csda ranges in water, given in
have a lower LET than protons and alpha particles. The term of low Table 2.2.
and high LET is often used in radiobiological descriptions. The smaller
length units (μm) for LET reflect its application to energy deposition
over subcellular dimensions. A schematic comparison between energy TABLE 2.2 Electron Continuous Slowing
deposition for high and low LET beams is illustrated in Fig. 2.8 in rela- Down Approximation Ranges in Water
tion to radiobiology. Electron Beam Continuous Slowing Down
Energy (MeV) Approximation Range (cm)
0.1 0.01
1 Gy of e- or γ 1 Gy heavy ions 0.25 0.06
0.5 0.18
1 0.44
5 2.55
10 4.98
25 11.3
50 19.8

Evaluated using the ESTAR program [1].

Low LET High LET

Fig. 2.8 Comparison of dose deposition and biological effect for low and 120
high linear energy transfer (LET) beams. Circles refer to ionising events.
Relative dose (%)
100
The increased track density of ionisation events occurring for the higher
80
LET beam leads to greater biological (DNA) damage. This increase in bio-
logical damage in comparison to low LET radiation (e.g. photons) can be 60
expressed as a relative biological effectiveness (RBE), defined as the ratio 40
of radiation doses required to produce the same degree of biological dam-
age. For example, if an RBE of 1.1 is assumed for protons, then a pre- 20
Rp
scribed proton dose of 70 Gy would achieve the same biological effect 0
as a dose of 77 Gy delivered by photons. 0 20 40 60 80
Depth in water (mm)

Range and Path Length

120
Electrons have a negative charge and a relatively small mass. As a result,
Relative dose [%]

100
electron transport through matter is characterised by a large number of
80
interactions through which generally a small amount of energy is lost in
each interaction and a high degree of scattering occurs (Fig. 2.2). 60
Because of these frequent interactions, it can often be assumed that 40
electrons lose energy continuously as they traverse matter and to a good 20
approximation the energy loss can be assumed to be at a constant rate. 0
It follows that if electrons or any other particles lose energy continu- 0 10 20 30 40 50 60 70 80 90 100
ously, then they must have a finite range. This is true of all charged par- Depth in water (mm)
ticles. Calculated ranges for charged particles can be obtained using this Fig. 2.9 Electron depth-dose distribution in water. (A) 10-MeV electron
continuous slowing down approximation (csda), resulting in the csda beam, indicating practical range, Rp. (B) Variation of depth dose with
range. If a beam of monoenergetic electrons is incident on a given mate- beam energy for (from left to right) 4-, 6-, 8-, 10-, 12-, 15- and 18-
rial and we assume continuous energy loss, then the total distance trav- MeV beams. (From the Clatterbridge Centre for Oncology NHS Founda-
elled, or path length, must be the same for all electrons in the beam. The tion Trust: Douglas Cyclotron. With permission.)
depth of penetration, or range, will vary because of the different paths
traversed by individual electrons as indicated in Fig. 2.2. This range
PHOTON INTERACTIONS
straggling leads to a slope in the measured depth-dose curve, as illus-
trated in Fig. 2.9A. The steepness of this slope decreases as electron In the photon energy range of interest for RT, there are three major
energy is increased, as shown in Fig. 2.9B. Note that the dose does interactions that can occur as a beam of photons passes through matter:
not fall to zero immediately beyond the steep region of dose fall-off, photoelectric, Compton, and pair production.
because of bremsstrahlung photons being produced. The intersection
between the slope as a result of range straggling and the bremsstrahlung The Photoelectric Effect
tail gives the practical range of the electron beam, Rp. As a guide, for This interaction, shown schematically in Fig. 2.10, occurs between an
clinical electron beams produced by linear accelerators (approximately incident photon and atomic electron, generally assumed to be an inner
18 Walter and Miller's Textbook of Radiotherapy
γ γ
K
L
γ e−
M
N
e−
Fig. 2.10 Schematic representation of the photoelectric effect. An
incoming photon transfers all its energy to an inner shell electron, ejecting
the electron with a kinetic energy equal to the photon energy minus the
electron binding energy. Electron shells K to N are indicated.
shell electron. If the photon has sufficient energy to overcome the shell
binding energy of the electron, it may disappear by transferring all its
energy to the electron. The electron is then emitted from the atom, with
kinetic energy, k.e., equal to the energy of the incident photon, Eγ ,
minus the electron binding energy, b.e.
k:e: ¼ Eᵧ  b:e: 2.6
As a consequence of this interaction, the atom is ionised and in an
excited state. De-excitation then occurs, releasing characteristic pho-
tons, in the same manner as described above under “Characteristic
X-rays and Auger Electrons” after ionisation or excitation by electron
interactions. The probability of the photoelectric effect occurring is
strongly dependent on the atomic number, Z, of the material traversed
and on the energy, E, of the incident photon:
Probability  Z 3 =E 3 2.7
This strong dependence on the atomic number is put to consider-
able use in diagnostic imaging because it provides clear differentiation
between tissues with different atomic number as well as, or in the
absence of, differences in physical density. For example, a 70-kV beam
of photons passing through a human pelvis is much more likely to
interact and be absorbed when passing through bone, with an atomic
number of approximately 13, than it is when passing through adjacent
soft tissue, with an approximate atomic number of 7. The photon inten-
sity transmitted through the patient therefore clearly distinguishes
between bone and soft tissue, providing a high-contrast x-ray image.
The Compton Effect
The Compton effect dominates in water between 100 keV and 20 MeV
and is therefore the dominant interaction in tissue throughout the RT
energy range of interest for photons. This interaction involves an inci-
dent photon interacting with an atomic electron, overcoming the elec-
tron-binding energy, and transferring some of its energy to the electron
in the form of kinetic energy and the remainder as a lower energy pho-
ton. Unlike the photoelectric effect, no resonance effect is observed, and
the interaction is likely to occur with outer shell electrons with binding
energies far lower than the energy of the incoming photon. As a result,
this interaction is often referred to as occurring with free electrons. The
interaction is shown schematically in Fig. 2.11.
The probability of the Compton interaction depends on the density
of electrons in a material, which varies as Z/A, ratio of the atomic num-
ber Z and mass number A. This ratio is almost constant for elements
above hydrogen and, as a result, the Compton effect can be considered
to be independent of the atomic number of the material the photons
γ γ ’ + e−
γ’ e−
Fig. 2.11 Schematic representation of the Compton effect. An incident
photon, γ, transfers part of its energy to an electron and a lower-energy,
scattered photon, γ0 , is produced.
pass through and is dependent only on the physical density. It is for
this reason that medical imaging with megavoltage photons leads to
poorer contrast than imaging with kilovoltage photon beams. This rep-
resents a benefit for RT to soft-tissue tumours, however, as a significant
dependence on atomic number would lead to higher absorbed dose
being delivered to bone than soft tissue.
The average proportion of the incident photon’s energy transferred
to the electron depends on the incident photon energy. For a 100 keV
incident photon, on average approximately 10% of its energy, 10 keV, is
passed to the electron, whereas the scattered photon retains 90 keV. As
the incident photon energy increases, however, a higher proportion of
its energy is transferred to the electron; a 10 MeV photon transfers an
average of approximately 70%, 7 MeV, to the electron and the scattered
photon retains 3 MeV. The variation of average energy transferred to
the electron via the Compton effect is illustrated in Fig. 2.12. These
characteristics of the Compton effect have implications for RT and
radiation dosimetry. For kilovoltage photon beams, electrons set in
motion through Compton interactions can be assumed to deposit their
energy very close to the site of interaction, whereas for megavoltage
photons, these interactions produce high-energy secondary electrons
that will travel a significant distance. The latter results in the observed
skin-sparing effect of absorbed dose deposition in tissue by megavol-
tage photon beams, as electrons set in motion near the skin surface
deposit their energy over a significant depth. For example, a 3-MeV
photon (approximately the average photon energy in a 10-MV photon
spectrum) will provide an electron with an average energy of 1.8 MeV
(60%), which will deposit energy over a distance of approximately 1 cm
0.8
energy transferred to electron
0.7
Average fraction of incident
0.6
0.5
0.4
0.3
0.2
0.1
0
0.01 0.1 1 10
Photon energy (MeV)
Fig. 2.12 Average proportion of photon energy transferred to secondary
electrons during the Compton effect. (From Attix F. Introduction to radio-
logical physics and radiation dosimetry. John Wiley & Sons Inc; 1996.)
 CHAPTER 2 Interactions of Ionising Radiation With Matter
in tissue. The angular distribution of electrons set in motion by the
Compton effect is also of interest. For kilovoltage photons, the second-
ary electrons set in motion are emitted over a wide range of angles from
the direction of the incident photon. As the incident photon energy is
increased, this distribution of electrons becomes more forward
directed.
Pair Production
Above a few Mega electron volts (MeV), photons may interact with the
nuclear Coulomb field to produce an electron–positron pair, shown
schematically in Fig. 2.13. In this interaction, the photon vanishes,
and all its energy is transferred to the rest mass and kinetic energy
of the electron, k.e.(e) and positron, k.e.(e+). For an incident photon
of energy E, conservation of energy demands that:
E ¼ 1:022 + k:e:ðe + Þ + k:e:ðe Þ½MeV
Hence the incoming photon must have a minimum energy of
1.022 MeV for the interaction to occur. The probability of a photon
being attenuated by pair production is proportional to the atomic num-
ber of the material traversed and, for the energy range of interest to RT,
increases gradually with the incoming photon’s energy.
Probability  ZE ðE > 1:022 MeVÞ
In water and soft tissue, pair production only becomes significant at
photon energies above approximately 10 MeV and so it accounts for
very little of the absorbed dose to a patient undergoing RT. With higher
atomic number materials, pair production becomes significant at lower
energies, for example, at approximately 3 MeV for lead.
The electron and positron produced will lose energy in the medium
traversed, mainly through interactions (collisions) with atomic elec-
trons, as discussed earlier. The positron eventually annihilates with a
local electron, releasing the remaining positron kinetic energy and rest
mass of the positron and electron in the form of photons. This annihi-
lation event becomes more likely as the positron slows down. If it
occurs at rest, that is, when the positron has lost all of its kinetic energy,
the energy of each photon is equal to 0.511 MeV, the electron (and pos-
itron) rest mass. To conserve momentum, these two photons must
travel in opposite directions. This feature of positron–electron annihi-
lation is the key to positron emission tomography (PET), as coincident
detection of the two photons produced reveals information about the
position of the annihilation event, see Chapter 6.
Photons may undergo a similar interaction to the nuclear pair pro-
duction interaction described earlier in the Coulomb field of an elec-
tron. However, the probability of this is very low compared with the
interaction in the nuclear Coulomb field.
γ
γ e+ + e−
e+ e−
Fig. 2.13 Schematic representation of pair production in the nuclear Cou-
lomb field. HVL, Half-value layer.
19
Exponential Attenuation
An experimental arrangement is shown in Fig. 2.14 for measuring the
number of photons that reach a detector as a filter, or attenuator, is
placed in the beam path. We are interested in measuring how many
photons arrive at the detector without undergoing any interaction in
the filter (i.e. how many photons are unattenuated). The purpose of
the collimators is to prevent any scattered photons, resulting from
an interaction in the filter, from reaching the detector and so causing
us to overestimate the number of photons that have not interacted. If
scattered photons are excluded, this arrangement is referred to as
narrow-beam geometry. The detector records N photons arriving at
the detector for a thickness, x, of filter. If the number of photons reach-
ing the detector changes by an amount, dN, when a thin (infinitely thin)
filter of thickness, dx, is placed in the beam and we represent the relative
change (dN/N) per unit thickness as μ, we have:
2.8
μdx ¼ dN=N 2.10
By integrating this expression, and applying the condition that for
zero filter thickness, N0 photons are recorded at the detector, it is
straightforward to show that the number of photons, N, transmitted
by the filter and reaching the detector when a filter of thickness x is
placed in the beam:
2.9
N ¼ N 0 eμx 2.11
Parameter, μ, is the linear attenuation coefficient (units of per unit
distance, e.g. cm–1), and its value is dependent on the filter material and
the energy of the photon beam. To compare the effect of varying atomic
number on attenuation properties, it is convenient to remove the var-
iation because of material density, ρ. This is achieved by defining the
mass attenuation coefficient, μ/ρ. If μ is expressed in units of cm–1
and density in g cm–3, the units of mass attenuation coefficient are
cm2 g–1; the corresponding thickness of filter must then be expressed
in terms of mass thickness (linear thickness
density), g cm–2.
The interactions occurring in a slab of water when irradiated with a
beam of 3 MeV photons are illustrated in Fig. 2.15. The mass attenuation
coefficient is a macroscopic quantity that, in principle, can be measured
relatively simply. It represents the total probability that a photon of a
given energy will interact with matter, regardless of the type of interac-
tion. The variation of mass attenuation coefficient with energy for water
(Z ¼ 7) and lead (Z ¼ 82) is shown in Fig. 2.16. The reason for the par-
ticular shape of the attenuation curves for water and lead is explained by
the varying probability with energy of the underlying photon interac-
tions that combine to give the total interaction probability and hence
attenuation coefficient. It can be seen that in water the attenuation coef-
ficient is seen to decrease monotonically as photon energy is increased,
up to approximately 50 MeV at which point it begins to increase.
In Fig. 2.17 the region of dominance for each interaction type
is indicated as photon energy increases from the kilovoltage to
Attenuator
X (filter)
Incident
photons
Collimator Detector
Fig. 2.14 Geometry for photon attenuation measurements. Collimators
are present to prevent scattered photons from reaching the detector.
20 Walter and Miller's Textbook of Radiotherapy

TABLE 2.3 Energy Regions of Domination

for Photoelectric, Compton and Pair
Production Interactions
Interaction Low Z (Water) High Z (Lead)
Photoelectric <30 keV <500 keV
Compton 30 keV to 25 MeV 0.5–5 MeV
Pair production >25 MeV >5 MeV

Total
1 PE
Compton

Coefficient (cm2 g−1)

Pair production

0.1

Fig. 2.15 Illustration of photon interactions. A beam of 3-MeV photons

(light grey) is incident from the left on a 25-cm thick water slab. Photons
0.01
may escape the slab without interacting, others interact in the water, gen-
erating secondary electrons (black), which cause further ionisation and
may escape the slab if they are generated close to the exit face. Photons
may be backscattered from the face of the slab, along with secondary 0.001
electrons. 0.01 0.1 1 10
Photon energy (MeV)

100.01
100 Total
PE
10.00 Lead Compton
Coefficient (cm2 g−1)

Water 10 Pair production

m/r (cm2 g–1)

1.01 1

0.10 0.1

0.01 0.01

0.001
0.00 0.01 0.1 1 10
0.01 0.10 1.00 10.00 100.00
Photon energy (MeV)
Photon energy (MeV)
Fig. 2.17 Mass attenuation coefficients, showing the relative contribu-
Fig. 2.16 Mass attenuation coefficient variation with photon energy in
tions from the photoelectric effect (PE), Compton effect, and pair produc-
water and lead. The light and dark shaded regions indicate the approxi-
tion in (A) water (effective Z ¼ 7) and (B) lead (Z ¼ 82). Note the large
mate range of photon energies commonly used for diagnostic imaging
region of dominance for the Compton effect in water, because of the
and radiotherapy, respectively. (From Hubbell JH, Seltzer SM.
lower effective atomic number Z. (From Hubbell JH, Seltzer SM.
Tables of x-ray mass attenuation coefficients and mass energy-
Tables of x-ray mass attenuation coefficients and mass energy-
absorption coefficients from 1 keV to 20 MeV for elements Z ¼ 1 to 92
absorption coefficients from 1 keV to 20 MeV for elements Z ¼ 1 to 92
and 48 additional substances of dosimetric interest. National Institute
and 48 additional substances of dosimetric interest. National Institute
of Standards and Technology; 1996. NISTIR 5632; Berger MJ, Hubbell
of Standards and Technology; 1996. NISTIR 5632; Berger MJ, Hubbell
JH, Seltzer SM, et al. XCOM: Photon cross sections database. National
JH, Seltzer SM, et al. XCOM: Photon cross sections database. National
Institute of Standards and Technology; 1998. NBSIR 87-3597.)
Institute of Standards and Technology; 1998. NBSIR 87-3597.)

megavoltage range. A summary of the energy ranges in which each

interaction dominates is shown in Table 2.3. The photoelectric effect
dominates in water, or tissue, for energies up to approximately
30 keV and, in lead, up to approximately 500 keV.
The large discontinuities observed at approximately 15 keV and
88 keV for the mass attenuation coefficient in lead, shown in
Fig. 2.17B, are a result of incident photons having sufficient energy
to overcome the binding energies of the lead L and K shells, respec-
tively. This large increase in interaction probability around an electron
binding energy suggests that a resonance effect is involved, whereby the
probability of interaction is highest when the photon energy is close to
that of the electron binding energy. This feature in the mass attenuation
coefficient curve is referred to as an absorption edge. The lack of visible
absorption edges in water (Fig. 2.17A) is caused by the lower probabil-
ity of the photoelectric effect occurring in water, relative to the Comp-
ton effect and the low binding energies of the K-shell electrons for
oxygen and hydrogen.
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crossed the mist-hung meadows a few hours earlier. It was as if there were
two realities at Pentlands—one, it might have been said, of the daylight and
the other of the darkness; as if one life—a secret, hidden one—lay beneath
the bright, pleasant surface of a world composed of green fields and trees,
the sound of barking dogs, the faint odor of coffee arising from the kitchen,
and the sound of a groom whistling while he saddled a thoroughbred. It was
a misfortune that chance had given her an insight into both the bright,
pleasant world and that other dark, nebulous one. The others, save perhaps
old John Pentland, saw only this bright, easy life that had begun to stir all
about her.
And she reflected that a stranger coming to Pentlands would find it a
pleasant, comfortable house, where the life was easy and even luxurious,
where all of them were protected by wealth. He would find them all rather
pleasant, normal, friendly people of a family respected and even
distinguished. He would say, “Here is a world that is solid and comfortable
and sound.”
Yes, it would appear thus to a stranger, so it might be that the dark,
fearful world existed only in her imagination. Perhaps she herself was ill, a
little unbalanced and morbid ... perhaps a little touched like the old woman
in the north wing.
Still, she thought, most houses, most families, must have such double
lives—one which the world saw and one which remained hidden.
As she pulled on her boots she heard the voice of Higgins, noisy and
cheerful, exchanging amorous jests with the new Irish kitchen-maid,
marking her already for his own.

She rode listlessly, allowing the mare to lead through the birch thicket
over the cool dark paths which she and Michael always followed. The
morning air did not change her spirits. There was something sad in riding
alone through the long green tunnel.
When at last she came out on the opposite side by the patch of catnip
where they had encountered Miss Peavey, she saw a Ford drawn up by the
side of the road and a man standing beside it, smoking a cigar and regarding
the engine as if he were in trouble. She saw no more than that and would
have passed him without troubling to look a second time, when she heard
herself being addressed.
 “You’re Mrs. Pentland, aren’t you?”
She drew in the mare. “Yes, I’m Mrs. Pentland.”
He was a little man, dressed rather too neatly in a suit of checkered stuff,
with a high, stiff white collar which appeared to be strangling him. He wore
nose-glasses and his face had a look of having been highly polished. As she
turned, he took off his straw hat and with a great show of manners came
forward, bowing and smiling cordially.
“Well,” he said, “I’m glad to hear that I’m right. I hoped I might meet
you here. It’s a great pleasure to know you, Mrs. Pentland. My name is
Gavin.... I’m by way of being a friend of Michael O’Hara.”
“Oh!” said Olivia. “How do you do?”
“You’re not in a great hurry, I hope?” he asked. “I’d like to have a word
or two with you.”
“No, I’m not in a great hurry.”
It was impossible to imagine what this fussy little man, standing in the
middle of the road, bowing and smiling, could have to say to her.
Still holding his hat in his hand, he tossed away the end of his cigar and
said, “It’s about a very delicate matter, Mrs. Pentland. It has to do with Mr.
O’Hara’s campaign. I suppose you know about that. You’re a friend of his, I
believe?”
“Why, yes,” she said coldly. “We ride together.”
He coughed and, clearly ill at ease, set off on a tangent from the main
subject. “You see, I’m a great friend of his. In fact, we grew up together ...
lived in the same ward and fought together as boys. You mightn’t think it to
see us together ... because he’s such a clever one. He’s made for big things
and I’m not.... I’m ... I’m just plain John Gavin. But we’re friends, all the
same, just the same as ever ... just as if he wasn’t a big man. That’s one
thing about Michael. He never goes back on his old friends, no matter how
great he gets to be.”
A light of adoration shone in the blue eyes of the little man. It was,
Olivia thought, as if he were speaking of God; only clearly he thought of
Michael O’Hara as greater than God. If Michael affected men like this, it
was easy to see why he was so successful.
The little man kept interrupting himself with apologies. “I shan’t keep
you long, Mrs. Pentland ... only a moment. You see I thought it was better if
I saw you here instead of coming to the house.” Suddenly screwing up his
shiny face, he became intensely serious. “It’s like this, Mrs. Pentland.... I
know you’re a good friend of his and you wish him well. You want to see
him get elected ... even though you people out here don’t hold much with
the Democratic party.”
“Yes,” said Olivia. “That’s true.”
“Well,” he continued with a visible effort, “Michael’s a good friend of
mine. I’m sort of a bodyguard to him. Of course, I never come out here, I
don’t belong in this world.... I’d feel sort of funny out here.”
(Olivia found herself feeling respect for the little man. He was so simple
and so honest and he so obviously worshiped Michael.)
“You see ... I know all about Michael. I’ve been through a great deal
with him ... and he’s not himself just now. There’s something wrong. He
ain’t interested in his work. He acts as if he’d be willing to chuck his whole
career overboard ... and I can’t let him do that. None of his friends ... can’t
let him do it. We can’t get him to take a proper interest in his affairs.
Usually, he manages everything ... better than any one else could.” He
became suddenly confidential, closing one eye. “D’you know what I think
is the matter? I’ve been watching him and I’ve got an idea.”
He waited until Olivia said, “No ... I haven’t the least idea.”
Cocking his head on one side and speaking with the air of having made a
great discovery, he said, “Well, I think there’s a woman mixed up in it.”
She felt the blood mounting to her head, in spite of anything she could
do. When she was able to speak, she asked, “Yes, and what am I to do?”
He moved a little nearer, still with the same air of confiding in her.
“Well, this is my idea. Now, you’re a friend of his ... you’ll understand. You
see, the trouble is that it’s some woman here in Durham ... some swell, you
see, like yourself. That’s what makes it hard. He’s had women before, but
they were women out of the ward and it didn’t make much difference. But
this is different. He’s all upset, and....” He hesitated for a moment. “Well, I
don’t like to say a thing like this about Michael, but I think his head is
turned a little. That’s a mean thing to say, but then we’re all human, aren’t
we?”
“Yes,” said Olivia softly. “Yes ... in the end, we’re all human ... even
swells like me.” There was a twinkle of humor in her eye which for a
moment disconcerted the little man.
 “Well,” he went on, “he’s all upset about her and he’s no good for
anything. Now, what I thought was this ... that you could find out who this
woman is and go to her and persuade her to lay off him for a time ... to go
away some place ... at least until the campaign is over. It’d make a
difference. D’you see?”
He looked at her boldly, as if what he had been saying was absolutely
honest and direct, as if he really had not the faintest idea who this woman
was, and beneath a sense of anger, Olivia was amused at the crude tact
which had evolved this trick.
“There’s not much that I can do,” she said. “It’s a preposterous idea ...
but I’ll do what I can. I’ll try. I can’t promise anything. It lies with Mr.
O’Hara, after all.”
“You see, Mrs. Pentland, if it ever got to be a scandal, it’d be the end of
him. A woman out of the ward doesn’t matter so much, but a woman out
here would be different. She’d get a lot of publicity from the sassiety editors
and all.... That’s what’s dangerous. He’d have the whole church against him
on the grounds of immorality.”
While he was speaking, a strange idea occurred to Olivia—that much of
what he said sounded like a strange echo of Aunt Cassie’s methods of
argument.
The horse had grown impatient and was pawing the road and tossing his
head; and Olivia was angry now, genuinely angry, so that she waited for a
time before speaking, lest she should betray herself and spoil all this little
game of pretense which Mr. Gavin had built up to keep himself in
countenance. At last she said, “I’ll do what I can, but it’s a ridiculous thing
you’re asking of me.”
The little man grinned. “I’ve been a long time in politics, Ma’am, and
I’ve seen funnier things than this....” He put on his hat, as if to signal that he
had said all he wanted to say. “But there’s one thing I’d like to ask ... and
that’s that you never let Michael know that I spoke to you about this.”
“Why should I promise ... anything?”
He moved nearer and said in a low voice, “You know Michael very well,
Mrs. Pentland.... You know Michael very well, and you know that he’s got a
bad, quick temper. If he found out that we were meddling in his affairs, he
might do anything. He might chuck the whole business and clear out
altogether. He’s never been like this about a woman before. He’d do it just
now.... That’s the way he’s feeling. You don’t want to see him ruin himself
any more than I do ... a clever man like Michael. Why, he might be
president one of these days. He can do anything he sets his will to, Ma’am,
but he is, as they say, temperamental just now.”
“I’ll not tell him,” said Olivia quietly. “And I’ll do what I can to help
you. And now I must go.” She felt suddenly friendly toward Mr. Gavin,
perhaps because what he had been telling her was exactly what she wanted
most at that moment to hear. She leaned down from her horse and held out
her hand, saying, “Good-morning, Mr. Gavin.”
Mr. Gavin removed his hat once more, revealing his round, bald, shiny
head. “Good-morning, Mrs. Pentland.”
As she rode off, the little man remained standing in the middle of the
road looking after her until she had disappeared. His eye glowed with the
light of admiration, but as Olivia turned from the road into the meadows, he
frowned and swore aloud. Until now he hadn’t understood how a good
politician like Michael could lose his head over any woman. But he had an
idea that he could trust this woman to do what she had promised. There was
a look about her ... a look which made her seem different from most
women; perhaps it was this look which had made a fool of Michael, who
usually kept women in their proper places.
Grinning and shaking his head, he got into the Ford, started it with a
great uproar, and set off in the direction of Boston. After he had gone a little
way he halted again and got out, for in his agitation he had forgotten to
close the hood.

From the moment she turned and rode away from Mr. Gavin, Olivia
gave herself over to action. She saw that there was need of more than mere
static truth to bring order out of the hazy chaos at Pentlands; there must be
action as well. And she was angry now, really angry, even at Mr. Gavin for
his impertinence, and at the unknown person who had been his informant.
The strange idea that Aunt Cassie or Anson was somehow responsible still
remained; tactics such as these were completely sympathetic to them—to
go thus in Machiavellian fashion to a man like Gavin instead of coming to
her. By using Mr. Gavin there would be no scene, no definite
unpleasantness to disturb the enchantment of Pentlands. They could go on
pretending that nothing was wrong, that nothing had happened.
 But stronger than her anger was the fear that in some way they might use
the same tactics to spoil the happiness of Sybil. They would, she was
certain, sacrifice everything to their belief in their own rightness.
She found Jean at the house when she returned, and, closing the door of
the drawing-room, she said to him, “Jean, I want to talk to you for a
moment ... alone.”
He said at once, “I know, Mrs. Pentland. It’s about Sybil.”
There was a little echo of humor in his voice that touched and disarmed
her as it always did. It struck her that he was still young enough to be
confident that everything in life would go exactly as he wished it....
“Yes,” she said, “that was it.” They sat on two of Horace Pentland’s
chairs and she continued. “I don’t believe in meddling, Jean, only now there
are circumstances ... reasons....” She made a little gesture. “I thought that if
really ... really....”
He interrupted her quickly. “I do, Mrs. Pentland. We’ve talked it all over,
Sybil and I ... and we’re agreed. We love each other. We’re going to be
married.”
Watching the young, ardent face, she thought, “It’s a nice face in which
there is nothing mean or nasty. The lips aren’t thin and tight like Anson’s,
nor the skin sickly and pallid the way Anson’s has always been. There’s life
in it, and force and charm. It’s the face of a man who would be good to a
woman ... a man not in the least cold-blooded.”
“Do you love her ... really?” she asked.
“I ... I.... It’s a thing I can’t answer because there aren’t words to describe
it.”
“Because ... well ... Jean, it’s no ordinary case of a mother and a
daughter. It’s much more than that. It means more to me than my own
happiness, my own life ... because, well, because Sybil is like a part of
myself. I want her to be happy. It’s not just a simple case of two young
people marrying. It’s much more than that.” There was a silence, and she
asked, “How do you love her?”
He sat forward on the edge of his chair, all eagerness. “Why ...” he
began, stammering a little, “I couldn’t think of living without her. It’s
different from anything I ever imagined. Why ... we’ve planned everything
... all our lives. If ever I lost her, it wouldn’t matter what happened to me
afterwards.” He grinned and added, “But you see ... people have said all
that before. There aren’t any words to explain ... to make it seem as
different from anything else as it seems to me.”
“But you’re going to take her away?”
“Yes ... she wants to go where I go.”
(“They are young,” thought Olivia. “They’ve never once thought of any
one else ... myself or Sybil’s grandfather.”)
Aloud she said, “That’s right, Jean.... I want you to take her away ... no
matter what happens, you must take her away....” (“And then I won’t even
have Sybil.”)
“We’re going to my ranch in the Argentine.”
“That’s right.... I think Sybil would like that.” She sighed, in spite of
herself, vaguely envious of these two. “But you’re so young. How can you
know for certain.”
A shadow crossed his face and he said, “I’m twenty-five, Mrs. Pentland
... but that’s not the only thing.... I was brought up, you see, among the
French ... like a Frenchman. That makes a difference.” He hesitated,
frowning for a moment. “Perhaps I oughtn’t to tell.... You mightn’t
understand. I know how things are in this part of the world.... You see, I was
brought up to look upon falling in love as something natural ... something
that was pleasant and natural and amusing. I’ve been in love before,
casually ... the way young Frenchmen are ... but in earnest, too, because a
Frenchman can’t help surrounding a thing like that with sentiment and
romance. He can’t help it. If it were just ... just something shameful and
nasty, he couldn’t endure it. They don’t have affairs in cold blood ... the
way I’ve heard men talk about such things since I’ve come here. It makes a
difference, Mrs. Pentland, if you look at the thing in the light they do. It’s
different here.... I see the difference more every day.”
He was talking earnestly, passionately, and when he paused for a
moment she remained silent, unwilling to interrupt him until he had
finished.
“What I’m trying to say is difficult, Mrs. Pentland. It’s simply this ... that
I’m twenty-five, but I’ve had experience with life. Don’t laugh! Don’t think
I’m just a college boy trying to make you think I’m a roué. Only what I say
is true. I know about such things ... and I’m glad because it makes me all
the more certain that Sybil is the only woman in the world for me ... the one
for whom I’d sacrifice everything. And I’ll know better how to make her
happy, to be gentle with her ... to understand her. I’ve learned now, and it’s
a thing which needs learning ... the most important thing in all life. The
French are right about it. They make a fine, wonderful thing of love.” He
turned away with a sudden air of sadness. “Perhaps I shouldn’t have told
you all this.... I’ve told Sybil. She understands.”
“No,” said Olivia, “I think you’re right ... perhaps.” She kept thinking of
the long tragic story of John Pentland, and of Anson, who had always been
ashamed of love and treated it as something distasteful. To them it had been
a dark, strange thing always touched by shame. She kept thinking, despite
anything she could do, of Anson’s clumsy, artificial attempts at love-
making, and she was swept suddenly by shame for him. Anson, so proud
and supercilious, was a poor thing, inferior even to his own groom.
“But why,” she asked, “didn’t you tell me about Sybil sooner? Every one
has seen it, but you never spoke to me.”
For a moment he did not answer her. An expression of pain clouded the
blue eyes, and then, looking at her directly, he said, “It’s not easy to explain
why. I was afraid to come to you for fear you mightn’t understand, and the
longer I’ve been here, the longer I’ve put it off because ... well, because
here in Durham, ancestors, family, all that, seems to be the beginning and
end of everything. It seems always to be a question of who one’s family is.
There is only the past and no future at all. And, you see, in a way ... I
haven’t any family.” He shrugged his big shoulders and repeated, “In a way,
I haven’t any family at all. You see, my mother was never married to my
father.... I’ve no blood-right to the name of de Cyon. I’m ... I’m ... well, just
a bastard, and it seemed hopeless for me even to talk to a Pentland about
Sybil.”
He saw that she was startled, disturbed, but he could not have known
that the look in her eyes had very little to do with shock at what he had told
her; rather she was thinking what a weapon the knowledge would be in the
hands of Anson and Aunt Cassie and even John Pentland himself.
He was talking again with the same passionate earnestness.
“I shan’t let it make any difference, so long as Sybil will have me, but,
you see, it’s very hard to explain, because it isn’t the way it seems. I want
you to understand that my mother is a wonderful woman.... I wouldn’t
bother to explain, to say anything ... except to Sybil and to you.”
 “Sabine has told me about her.”
“Mrs. Callendar has known her for a long time.... They’re great friends,”
said Jean. “She understands.”
“But she never told me ... that. You mean that she’s known it all along?”
“It’s not an easy thing to tell ... especially here in Durham, and I fancy
she thought it might make trouble for me ... after she saw what had
happened to Sybil and me.”
He went on quickly, telling her what he had told Sybil of his mother’s
story, trying to make her understand what he understood, and Sabine and
even his stepfather, the distinguished old de Cyon ... trying to explain a
thing which he himself knew was not to be explained. He told her that his
mother had refused to marry her lover, “because in his life outside ... the life
which had nothing to do with her ... she discovered that there were things
she couldn’t support. She saw that it was better not to marry him ... better
for herself and for him and, most of all, for me.... He did things for the sake
of success—mean, dishonorable things—which she couldn’t forgive ... and
so she wouldn’t marry him. And now, looking back, I think she was right. It
made no great difference in her life. She lived abroad ... as a widow, and
very few people—not more than two or three—ever knew the truth. He
never told because, being a politician, he was afraid of such a scandal. She
didn’t want me to be brought up under such an influence, and I think she
was right. He’s gone on doing things that were mean and dishonorable....
He’s still doing them to-day. You see he’s a politician ... a rather cheap one.
He’s a Senator now and he hasn’t changed. I could tell you his name.... I
suppose some people would think him a distinguished man ... only I
promised her never to tell it. He thinks that I’m dead.... He came to her once
and asked to see me, to have a hand in my education and my future. There
were things, he said, that he could do for me in America ... and she told him
simply that I was dead ... that I was killed in the war.” He finished in a
sudden burst of enthusiasm, his face alight with affection. “But you must
know her really to understand what I’ve been saying. Knowing her, you
understand everything, because she’s one of the great people ... the strong
people of the world. You see, it’s one of the things which it is impossible to
explain—to you or even to Sybil—impossible to explain to the others. One
must know her.”
 If she had had any doubts or fears, she knew now that it was too late to
act; she saw that it was impossible to change the wills of two such lovers as
Jean and Sybil. In a way, she came to understand the story of Jean’s mother
more from watching him than by listening to his long explanation. There
must be in her that same determination and ardor that was in her son ... a
thing in its way irresistible. And yet it was difficult; she was afraid,
somehow, of this unexpected thing, perhaps because it seemed vaguely like
the taint of Savina Pentland.
She said, “If no one knows this, there is no reason to tell it here. It would
only make unhappiness for all concerned. It is your business alone ... and
Sybil’s. The others have no right to interfere, even to know; but they will
try, Jean ... unless ... unless you both do what you want ... quickly.
Sometimes I think they might do anything.”
“You mean ...” he began impatiently.
Olivia fell back upon that vague hint which John Pentland had dropped
to her the night before. She said, “There was once an elopement in the
Pentland family.”
“You wouldn’t mind that?” he asked eagerly. “You wouldn’t be hurt ... if
we did it that way?”
“I shouldn’t know anything about it,” said Olivia quietly, “until it was
too late to do anything.”
“It’s funny,” he said; “we’d thought of that. We’ve talked of it, only
Sybil was afraid you’d want to have a big wedding and all that....”
“No, I think it would be better not to have any wedding at all ...
especially under the circumstances.”
“Mrs. Callendar suggested it as the best way out.... She offered to lend us
her motor,” he said eagerly.
“You discussed it with her and yet you didn’t speak to me?”
“Well, you see, she’s different ... she and Thérèse.... They don’t belong
here in Durham. Besides, she spoke of it first. She knew what was going on.
She always knows. I almost think that she planned the whole thing long
ago.”
Olivia, looking out of the window, saw entering the long drive the
antiquated motor with Aunt Cassie, Miss Peavey, her flying veils and her
Pekinese.
 “Mrs. Struthers is coming ...” she said. “We mustn’t make her
suspicious. And you’d best tell me nothing of your plans and then ... I
shan’t be able to interfere even if I wanted to. I might change my mind ...
one never knows.”
He stood up and, coming over to her, took her hand and kissed it.
“There’s nothing to say, Mrs. Pentland ... except that you’ll be glad for what
you’ve done. You needn’t worry about Sybil.... I shall make her happy.... I
think I know how.”
He left her, hurrying away past the ancestors in the long hall to find
Sybil, thinking all the while how odd it would seem to have a woman so
young and beautiful as Mrs. Pentland for a mother-in-law. She was a
charming woman (he thought in his enthusiasm), a great woman, but she
was so sad, as if she had never been very happy. There was always a cloud
about her.

He did not escape quickly enough, for Aunt Cassie’s sharp eyes caught a
glimpse of him as he left the house in the direction of the stables. She met
Olivia in the doorway, kissing her and saying, “Was that Sybil’s young man
I saw leaving?”
“Yes,” said Olivia. “We’ve been talking about Sybil. I’ve been telling
him that he mustn’t think of her as some one to marry.”
The yellow face of Aunt Cassie lighted with a smile of approval. “I’m
glad, my dear, that you’re being sensible about this. I was afraid you
wouldn’t be, but I didn’t like to interfere. I never believe any good comes of
it, unless one is forced to. He’s not the person for Sybil.... Why, no one
knows anything about him. You can’t let a girl marry like that ... just any
one who comes along. Besides, Mrs. Pulsifer writes me.... You remember
her, Olivia, the Mannering boy’s aunt who used to have a house in Chestnut
Street.... Well, she lives in Paris now at the Hotel Continental, and she
writes me she’s discovered there’s some mystery about his mother. No one
seems to know much about her.”
“Why,” said Olivia, “should she write you such a thing? What made her
think you’d be interested?”
“Well, Kate Pulsifer and I went to school together and we still
correspond now and then. I just happened to mention the boy’s name when
I was writing her about Sabine. She says, by the way, that Sabine has very
queer friends in Paris and that Sabine has never so much as called on her or
asked her for tea. And there’s been some new scandal about Sabine’s
husband and an Italian woman. It happened in Venice....”
“But he’s not her husband any longer.”
The old lady seated herself and went on pouring forth the news from
Kate Pulsifer’s letter; with each word she appeared to grow stronger and
stronger, less and less yellow and worn.
(“It must be,” thought Olivia, “the effect of so many calamities
contained in one letter.”)
She saw now that she had acted only just in time and she was glad that
she had lied, so flatly, so abruptly, without thinking why she had done it.
For Mrs. Pulsifer was certain to go to the bottom of the affair, if for no other
reason than to do harm to Sabine; she had once lived in a house on Chestnut
Street with a bow-window which swept the entrance to every house. She
was one of John Pentland’s dead, who lived by watching others live.
4

From the moment she encountered Mr. Gavin on the turnpike until the
tragedy which occurred two days later, life at Pentlands appeared to lose all
reality for Olivia. When she thought of it long afterward, the hours became
a sort of nightmare in which the old enchantment snapped and gave way to
a strained sense of struggle between forces which, centering about herself,
left her in the end bruised and a little broken, but secure.
The breathless heat of the sort which from time to time enveloped that
corner of New England, leaving the very leaves of the trees hanging limp
and wilted, again settled down over the meadows and marshes, and in the
midst of the afternoon appeared the rarest of sights—the indolent Sabine
stirring in the burning sun. Olivia watched her coming across the fields,
protected from the blazing sun only by the frivolous yellow parasol. She
came slowly, indifferently, and until she entered the cool, darkened
drawing-room she appeared the familiar bored Sabine; only after she
greeted Olivia the difference appeared.
She said abruptly, “I’m leaving day after to-morrow,” and instead of
seating herself to talk, she kept wandering restlessly about the room,
examining Horace Pentland’s bibelots and turning the pages of books and
magazines without seeing them.
 “Why?” asked Olivia. “I thought you were staying until October.”
“No, I’m going away at once.” She turned and murmured, “I’ve hated
Durham always. It’s unbearable to me now. I’m bored to death. I only came,
in the first place, because I thought Thérèse ought to know her own people.
But it’s no good. She’ll have none of them. I see now how like her father
she is. They’re not her own people and never will be.... I don’t imagine
Durham will ever see either of us again.”
Olivia smiled. “I know it’s dull here.”
“Oh, I don’t mean you, Olivia dear, or even Sybil or O’Hara, but there’s
something in the air.... I’m going to Newport for two weeks and then to
Biarritz for October. Thérèse wants to go to Oxford.” She grinned
sardonically. “There’s a bit of New England in her, after all ... this education
business. I wanted a femme du monde for a daughter and God and New
England sent me a scientist who would rather wear flat heels and look
through a microscope. It’s funny how children turn out.”
(“Even Thérèse and Sabine,” thought Olivia. “Even they belong to it.”)
She watched Sabine, so worldly, so superbly dressed, so hard—such a
restless nomad; and as she watched her it occurred to her again that she was
very like Aunt Cassie—an Aunt Cassie in revolt against Aunt Cassie’s
gods, an Aunt Cassie, as John Pentland had said, “turned inside out.”
Without looking up from the pages of the Nouvelle Revue, Sabine said,
“I’m glad this thing about Sybil is settled.”
“Yes.”
“He told you about his mother?”
“Yes.”
“You didn’t let that make any difference? You didn’t tell the others?”
“No.... Anything I had to say would have made no difference.”
“You were wise.... I think Thérèse is right, perhaps ... righter than any of
us. She says that nature has a contempt for marriage certificates.
Respectability can’t turn decay into life ... and Jean is alive.... So is his
mother.”
“I know what you are driving at.”
“Certainly, my dear, you ought to know. You’ve suffered enough from it.
And knowing his mother makes a difference. She’s no ordinary light
woman, or even one who was weak enough to allow herself to be seduced.
Once in fifty years there occurs a woman who can ... how shall I say it?...
get away with a thing like that. You have to be a great woman to do it. I
don’t think it’s made much difference in her life, chiefly because she’s a
woman of discretion and excellent taste. But it might have made a
difference in Jean’s life if he had encountered a mother less wise than
yourself.”
“I don’t know whether I’m being wise or not. I believe in him and I want
Sybil to escape.”
Olivia understood that for the first time they were discussing the thing
which none of them ever mentioned, the thing which up to now Sabine had
only touched upon by insinuation. Sabine had turned away and stood
looking out of the window across the meadows where the distant trees
danced in waves of heat.
“You spoiled my summer a bit, Olivia dear, by taking away my Irish
friend from me.”
Suddenly Olivia was angry as she was angry sometimes at the meddling
of Aunt Cassie. “I didn’t take him away. I did everything possible to avoid
him ... until you came. It was you who threw us together. That’s why we’re
all in a tangle now.” And she kept thinking what a strange woman Sabine
Callendar really was, how intricate and unfathomable. She knew of no other
woman in the world who could talk thus so dispassionately, so without
emotion.
“I thought I’d have him to amuse,” she was saying, “and instead of that
he only uses me as a confidante. He comes to me for advice about another
woman. And that, as you know, isn’t very interesting....”
Olivia sat suddenly erect. “What does he say? What right has he to do
such a thing?”
“Because I’ve asked him to. When I first came here, I promised to help
him. You see, I’m very friendly with you both. I want you both to be happy
and ... besides I can think of nothing happening which could give me
greater pleasure.”
When Olivia did not answer her, she turned from the window and asked
abruptly, “What are you going to do about him?”
Again Olivia thought it best not to answer, but Sabine went on pushing
home her point relentlessly, “You must forgive me for speaking plainly, but
I have a great affection for you both ... and I ... well, I have a sense of
conscience in the affair.”
“You needn’t have. There’s nothing to have a conscience about.”
“You’re not being very honest.”
Suddenly Olivia burst out angrily, “And why should it concern you,
Sabine ... in the least? Why should I not do as I please, without
interference?”
“Because, here ... and you know this as well as I do ... here such a thing
is impossible.”
In a strange fashion she was suddenly afraid of Sabine, perhaps because
she was so bent upon pushing things to a definite solution. It seemed to
Olivia that she herself was losing all power of action, all capacity for
anything save waiting, pretending, doing nothing.
“And I’m interested,” continued Sabine slowly, “because I can’t bear the
tragic spectacle of another John Pentland and Mrs. Soames.”
“There won’t be,” said Olivia desperately. “My father-in-law is different
from Michael.”
“That’s true....”
“In a way ... a finer man.” She found herself suddenly in the amazing
position of actually defending Pentlands.
“But not,” said Sabine with a terrifying reasonableness, “so wise a one ...
or one so intelligent.”
“No. It’s impossible to say....”
“A thing like this is likely to come only once to a woman.”
(“Why does she keep repeating the very things that I’ve been fighting all
along,” thought Olivia.) Aloud she said, “Sabine, you must leave me in
peace. It’s for me alone to settle.”
“I don’t want you to do a thing you will regret the rest of your life ...
bitterly.”
“You mean....”
“Oh, I mean simply to give him up.”
Again Olivia was silent, and Sabine asked suddenly, “Have you had a
call from a Mr. Gavin? A gentleman with a bald head and a polished face?”
Olivia looked at her sharply. “How could you know that?”
 “Because I sent him, my dear ... for the same reason that I’m here now ...
because I wanted you to do something ... to act. And I’m confessing now
because I thought you ought to know the truth, since I’m going away.
Otherwise you might think Aunt Cassie or Anson had done it ... and trouble
might come of that.”
Again Olivia said nothing; she was lost in a sadness over the thought
that, after all, Sabine was no better than the others.
“It’s not easy to act in this house,” Sabine was saying. “It’s not easy to
do anything but pretend and go on and on until at last you are an old woman
and die. I did it to help you ... for your own good.”
“That’s what Aunt Cassie always says.”
The shaft went home, for it silenced Sabine, and in the moment’s pause
Sabine seemed less a woman than an amazing, disembodied, almost
malevolent force. When she answered, it was with a shrug of the shoulders
and a bitter smile which seemed doubly bitter on the frankly painted lips. “I
suppose I am like Aunt Cassie. I mightn’t have been, though.... I might have
been just a pleasant normal person ... like Higgins or one of the servants.”
The strange speech found an echo in Olivia’s heart. Lately the same
thought had come to her again and again—if only she could be simple like
Higgins or the kitchen-maid. Such a state seemed to her at the moment the
most desirable thing in the world. It was perhaps this strange desire which
led Sabine to surround herself with what Durham called “queer people,”
who were, after all, simply people like Higgins and the kitchen-maid who
happened to occupy a higher place in society.
“The air here needs clearing,” Sabine was saying. “It needs a
thunderstorm, and it can be cleared only by acting.... This affair of Jean and
Sybil will help. We are all caught up in a tangle of thoughts and ideas ...
which don’t matter.... You can do it, Olivia. You can clear the air once and
for all.”
Then for the first time Olivia thought she saw what lay behind all this
intriguing of Sabine; for a moment she fancied that she saw what it was
Sabine wanted more passionately than anything else in the world.
Aloud she said it, “I could clear the air, but it would also be the
destruction of everything.”
Sabine looked at her directly. “Well?... and would you be sorry? Would
you count it a loss? Would it make any difference?”
 Impulsively she touched Sabine’s hand. “Sabine,” she said, without
looking at her, “I’m fond of you. You know that. Please don’t talk any more
about this ... please, because I want to go on being fond of you ... and I can’t
otherwise. It’s our affair, mine and Michael’s ... and I’m going to settle it,
to-night perhaps, as soon as I can have a talk with him.... I can’t go on any
longer.”
Taking up the yellow parasol, Sabine asked, “Do you expect me for
dinner to-night?”
“Of course, more than ever to-night.... I’m sorry you’ve decided to go so
soon.... It’ll be dreary without you or Sybil.”
“You can go, too,” said Sabine quickly. “There is a way. He’d give up
everything for you ... everything. I know that.” Suddenly she gave Olivia a
sharp look. “You’re thirty-eight, aren’t you?”
“Day after to-morrow I shall be forty!”
Sabine was tracing the design of roses on Horace Pentland’s Savonnerie
carpet with the tip of her parasol. “Gather them while you may,” she said
and went out into the blazing heat to cross the meadows to Brook Cottage.
Left alone, Olivia knew she was glad that day after to-morrow Sabine
would no longer be here. She saw now what John Pentland meant when he
said, “Sabine ought never to have come back here.”
5

The heat clung on far into the evening, penetrating with the darkness
even the drawing-room where they sat—Sabine and John Pentland and old
Mrs. Soames and Olivia—playing bridge for the last time, and as the
evening wore on the game went more and more badly, with the old lady
forgetting her cards and John Pentland being patient and Sabine sitting in a
controlled and sardonic silence, with an expression on her face which said
clearly, “I can endure this for to-night because to-morrow I shall escape
again into the lively world.”
Jean and Sybil sat for a time at the piano, and then fell to watching the
bridge. No one spoke save to bid or to remind Mrs. Soames that it was time
for her shaking hands to distribute the cards about the table. Even Olivia’s
low, quiet voice sounded loud in the hot stillness of the old room.
At nine o’clock Higgins appeared with a message for Olivia—that Mr.
O’Hara was being detained in town and that if he could get away before ten
he would come down and stop at Pentlands if the lights were still burning in
the drawing-room. Otherwise he would not be down to ride in the morning.
Once during a pause in the game Sabine stirred herself to say, “I haven’t
asked about Anson’s book. He must be near to the end.”
“Very near,” said Olivia. “There’s very little more to be done. Men are
coming to-morrow to photograph the portraits. He’s using them to illustrate
the book.”
At eleven, when they came to the end of a rubber, Sabine said, “I’m
sorry, but I must stop. I must get up early to-morrow to see about the
packing.” And turning to Jean she said, “Will you drive me home? Perhaps
Sybil will ride over with us for the air. You can bring her back.”
At the sound of her voice, Olivia wanted to cry out, “No, don’t go. You
mustn’t leave me now ... alone. You mustn’t go away like this!” But she
managed to say quietly, in a voice which sounded far away, “Don’t stay too
late, Sybil,” and mechanically, without knowing what she was doing, she
began to put the cards back again in their boxes.
She saw that Sabine went out first, and then John Pentland and old Mrs.
Soames, and that Jean and Sybil remained behind until the others had gone,
until John Pentland had helped the old lady gently into his motor and driven
off with her. Then, looking up with a smile which somehow seemed to give
her pain she said, “Well?”
And Sybil, coming to her side, kissed her and said in a low voice,
“Good-by, darling, for a little while.... I love you....” And Jean kissed her in
a shy fashion on both cheeks.
She could find nothing to say. She knew Sybil would come back, but she
would be a different Sybil, a Sybil who was a woman, no longer the child
who even at eighteen sometimes had the absurd trick of sitting on her
mother’s knee. And she was taking away with her something that until now
had belonged to Olivia, something which she could never again claim. She
could find nothing to say. She could only follow them to the door, from
where she saw Sabine already sitting in the motor as if nothing in the least
unusual were happening; and all the while she wanted to go with them, to
run away anywhere at all.
Through a mist she saw them turning to wave to her as the motor drove
off, to wave gaily and happily because they were at the beginning of life....
She stood in the doorway to watch the motor-lights slipping away in silence
down the lane and over the bridge through the blackness to the door of
Brook Cottage. There was something about Brook Cottage ... something
that was lacking from the air of Pentlands: it was where Toby Cane and
Savina Pentland had had their wanton meetings.
In the still heat the sound of the distant surf came to her dimly across the
marshes, and into her mind came absurdly words she had forgotten for
years.... “The breaking waves dashed high on the stern and rockbound
coast.” Against the accompaniment of the surf, the crickets and katydids
(harbingers of autumn) kept up a fiddling and singing; and far away in the
direction of Marblehead she watched the eye of a lighthouse winking and
winking. She was aware of every sight and sound and odor of the breathless
night. It might storm, she thought, before they got into Connecticut. They
would be motoring all the night....
The lights of Sabine’s motor were moving again now, away from Brook
Cottage, through O’Hara’s land, on and on in the direction of the turnpike.
In the deep hollow by the river they disappeared for a moment and then
were to be seen once more against the black mass of the hill crowned by the
town burial-ground. And then abruptly they were gone, leaving only the
sound of the surf and the music of the crickets and the distant, ironically
winking lighthouse.
She kept seeing them, side by side in the motor racing through the
darkness, oblivious to all else in the world save their own happiness. Yes,
something had gone away from her forever.... She felt a terrible, passionate
envy that was like a physical pain, and all at once she knew that she was
terribly alone standing in the darkness before the door of the old house.

She was roused by the sound of Anson’s voice asking, “Is that you,
Olivia?”
“Yes.”
“What are you doing out there?”
“I came out for some air.”
“Where’s Sybil?”
For a moment she did not answer, and then quite boldly she said, “She’s
ridden over with Jean to take Sabine home.”
 “You know I don’t approve of that.” He had come through the hall now
and was standing near her.
“It can’t do any harm.”
“That’s been said before....”
“Why are you so suspicious, Anson, of your own child?” She had no
desire to argue with him. She wanted only to be left in peace, to go away to
her room and lie there alone in the darkness, for she knew now that Michael
was not coming.
“Olivia,” Anson was saying, “come inside for a moment. I want to talk
to you.”
“Very well ... but please don’t be disagreeable. I’m very tired.”
“I shan’t be disagreeable.... I only want to settle something.”
She knew then that he meant to be very disagreeable, and she told
herself that she would not listen to him; she would think of something else
while he was speaking—a trick she had learned long ago. In the drawing-
room she sat quietly and waited for him to begin. Standing by the
mantelpiece, he appeared more tired and yellow than usual. She knew that
he had worked on his book; she knew that he had poured all his vitality, all
his being, into it; but as she watched him her imagination again played her
the old trick of showing her Michael standing there in his place ... defiant, a
little sulky, and filled with a slow, steady, inexhaustible force.
“It’s chiefly about Sybil,” he said. “I want her to give up seeing this
boy.”
“Don’t be a martinet, Anson. Nothing was ever gained by it.”
(She thought, “They must be almost to Salem by now.”) And aloud she
added, “You’re her father, Anson; why don’t you speak?”
“It’s better for you. I’ve no influence with her.”
“I have spoken,” she said, thinking bitterly that he could never guess
what she meant.
“And what’s the result? Look at her, going off at this hour of the
night....”
She shrugged her shoulders, filled with a warm sense of having
outwitted the enemy, for at the moment Anson seemed to her an enemy not
only of herself, but of Jean and Sybil, of all that was young and alive in the
world.