IAEA Training Material on Radiation Protection in Radiotherapy

Radiation Protection in
Radiotherapy

Part 5
Properties and safety of radiotherapy
sources and equipment used for external
beam radiotherapy
IAEA Safety Series 120,
Safety Fundamentals (1996)

Source: “Anything that may cause

radiation exposure… an X-ray unit may
be a source …”
External Beam Radiotherapy
Beam 2
Beam 3
Beam 1

tumour
patient

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 3

External Beam Therapy (EBT)
 Non-invasive
 Target localization important and beam
placement may be tricky
 Usually multiple beams to place target
in the focus of all beams
Multiple non-
Single beam Three coplanar beam coplanar beams

patient

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 4

External Beam Radiotherapy
 More than 90% of all radiotherapy patients
are treated using EBT
 Most of these are treated using X Rays
ranging from 20keV to 20MeV in peak-energy
 Other EBT treatment options include telecurie
units (60-Co and 137-Cs), electrons from
linear accelerators and accelerators for heavy
charged particles such as protons

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 5

Objectives
 To become familiar with different radiation
types used for external beam radiotherapy
 To understand the function of different
equipment used for EBT delivery
 To appreciate the implications of different
treatment units and their design
 To be familiar with auxiliary equipment
required and used for EBT
 To understand the measures used in this
equipment to ensure radiation safety

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 6

Contents
 Lecture 1: Radiation types and
techniques
 Lecture 2: Equipment and safe design

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 7

 IAEA Training Material on Radiation Protection in Radiotherapy

Radiation Protection in
Radiotherapy

Part 5

External Beam RT
Lecture 1: Radiation types and techniques
Objectives
 To be familiar with different radiation
types used in EBT
 To appreciate the technical needs to
make these radiation types applicable
to radiotherapy
 To understand common external beam
radiotherapy techniques

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 9

Contents
1. External Beam Radiotherapy process
2. Radiation qualities in use
3. Delivery techniques
4. Prescription and reporting
5. Special procedures

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 10

 D iag n os is
1. EBT
process A c q u is ition of p atien t d ata
S im u lator
C T s c an n er

Treatm en t p lan

C reation of treatm en t an d verific ation d ata

S im u lation (virtu al or real)

Treatm en t

V erific ation an d follow u p

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 11

EBT D iag n os is

process: A c q u is ition of p atien t d ata

S im u lator

Use of C T s c an n er

radiation Treatm en t p lan

C reation of treatm en t an d verific ation d ata

S im u lation (virtu al or real)

Treatm en t

V erific ation an d follow u p

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 12

Note on the role of diagnosis
 The responsibility of clinicians
 Without appropriate diagnosis the
justification of the treatment is doubtful
 Diagnosis is important for target design
and the dose required for cure or
palliation

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 13

Note on the role of simulation
 Simulator is often used twice in the
radiotherapy process
 Patient data acquisition - target localization,
contours, outlines
 Verification - can the plan be put into
practice? Acquisition of reference images
for verification
 Simulator may be replaced by other
diagnostic equipment or virtual
simulation

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 14

Simulator  However, some
functions can be

replaced by other
Important to mimic diagnostic X Ray units
isocentric treatment provided the location
environment of the X Ray field can
be marked on the
patient unambiguously
 Other functions
(isocentricity) can then
be mimicked on the
treatment unit

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 15

Virtual simulation
 All aspects of simulator work are
performed on a 3D data set of the
patient
 This requires high quality 3D CT data of
the patient in treatment position
 Verification can be performed using
digitally reconstructed radiographs
(DRRs)
Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 16
CT Simulation (Thanks to ADAC)
Marking the Patient already during CT

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 17

Virtual Simulation
3D Model of
the patient
and the
Treatment
Devices

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 18

Digitally Reconstructed Radiographs
as reference image for verification
View and print
DRRs for all
planned fields:
Improved
confidence for
planning and
reference for
verification

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 19

Note on the role of treatment
planning
 Links prescription to reality
 The ‘center piece’ of radiotherapy
 Becomes more and more sophisticated
and complex
 Extensive discussion in part 10

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 20

2. External beam radiotherapy
(EBT) treatment approaches
 Superficial X Rays
 Orthovoltage X Rays
 Telecurie units
 Megavoltage X Rays
 Electrons
 Heavy charged particles
 Others

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 21

External beam radiotherapy
(EBT) treatment approaches
 Superficial X Rays  40 to 120kVp
 Orthovoltage X Rays  150 to 400kVp
 Telecurie units  137-Cs and 60-Co
 Megavoltage X Rays  Linear accelerators
 Electrons  Linear accelerators
 Heavy charged  Protons from
particles cyclotron, C, Ar, ...
 Others  Neutrons, pions

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 22

Photon percentage depth dose
comparison for photon beams

Superficial beam

Orthovoltage
beam

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 23

Superficial radiotherapy
 50 to 120kVp - similar to diagnostic X Ray
qualities
 Low penetration
 Limited to skin lesions treated with single
beam
 Typically small field sizes
 Applicators required to collimate beam on
patient’s skin
 Short distance between X Ray focus and skin
Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 24
Superficial radiotherapy

Philips RT 100

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 25

Superficial radiotherapy issues
 Due to short FSD high output and large
influence of inverse square law
 Calibration difficult (strong dose
gradient, electron contamination)
 Dose determined by a timer - on/off
effects must be considered
 Photon beams may be contaminated
with electrons from the applicator
Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 26
Orthovoltage radiotherapy
 150 - 400kVp
 Penetration sufficient for palliative
treatment of bone lesions relatively
close to the surface (ribs, spinal cord)
 Largely replaced by other treatment
modalities

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 27

Orthovoltage Equipment (150 -
400 kVp)
 Depth dose
dramatically
affected by
the FSD

FSD 6cm, FSD 30cm,

HVL 6.8mm Cu HVL 4.4mm Cu

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 28

Orthovoltage patient set-up
 Like for
superficial
irradiation units
the beam is set-
up with cones
directly on the
patient’s skin

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 29

Megavoltage radiotherapy
 60-Cobalt (energy 1.25MeV)
 Linear accelerators (4 to
25MVp)
 Skin sparing in photon
beams
 Typical focus to skin
distance 80 to 100cm
 Isocentrically mounted

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 30

Photon percentage depth dose
comparison
 PHOTONS  ELECTRONS

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 31

Typical locations of tumor and
normal tissues
 PHOTONS  ELECTRONS

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 32

Build-up
effect

Result of the
forward direction
of secondary
electrons - they
deposit energy
down stream
from the original
interaction point
Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 33
Build-up
effect

 Clinically important as all radiation beams in

external radiotherapy go through the skin
 Is reduced in large field sizes and oblique
incidence and when trays are placed in the
beam
 Can be avoided by the use of bolus on the
patient if skin or scar shall be treated
Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 34
Isocentric set-up

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 35

Isocentric set-up
 Result of the large
FSDs possible with
modern equipment
 Places the tumour in
the centre - multiple
radiation beams are
easily set-up to
deliver radiation from
Image from
VARIAN webpage
many directions to
the target

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 36

Common photon treatment
techniques
 Two parallel opposed fields
 lung
 breast
 head and neck

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 37

Common photon treatment
techniques
 Four field ‘box’
 cervix
 prostate

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 38

Isocentric or not?
 All the beam arrangements discussed
so far can be set-up with a fixed
distance (e.g. 80cm) to the patient’s
skin or isocentrically with a fixed
distance to the centre of the target.

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 39

Photon beam modification
 Blocks
 Wedges
 Compensators

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 40

 Customized

Shielding blocks
shielding
block

 Beam shaping
 Conform the high dose region to the
target
 Fixed blocks
 Customized blocks made from low melting
alloy (LMA)
 Partially replaced now by Multi Leaf
Collimator (MLC)
Siemens
MLC
Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 41
Physical wedge

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 42

Wedges
 One dimensional dose modification
 Different realizations
 Now often a dynamic wedge

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 43

Use of wedges
 Wedged pair Isodose lines
 Three field
techniques
patient

patient Typical isodose lines

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 44

Compensators
 Physical compensators
 lead sheets
 brass blocks
 customized milling
 Intensity modulation
 multiple static fields
 arcs
 dynamic MLC

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 45

Intensity modulation
 Can be shown to allow optimization of
the dose distribution
 Make dose in the target homogenous
 Minimize dose outside the target
 Different techniques
 physical compensators
 intensity modulation using multileaf
collimators

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 46

Intensity MLC pattern 1

Modulation MLC pattern 2

 Achieved using a
Multi Leaf Collimator (MLC) MLC pattern 3

 The field shape can be

altered
 either step-by-step or Intensity
map
 dynamically while dose is
delivered

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 47

Dynamic treatment techniques
 Arcs
 Dynamic wedge
patient
 Dynamic MLC

 increasing complexity with increasing

flexibility in dose delivery. Verification
becomes essential

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 48

Electron radiotherapy

 Finite range
 Rapid dose fall off

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 49

Characteristics of an electron beam
R100
100

90
Therapeutic range
80 Surface
dose
70

60
R50
50
%DD

40

30

20
x-ray component
10
dmax Rp
0
0 1 2 3 4 5 6 7 8 9 10 11 12

Depth (cm)

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 50

Electron beam isodoses (20MeV)
Watch dose increase (115%!)
Watch ‘bulging’ of
due to oblique incidence
isodoses at depth

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 51

Other issues with electron beams
Dose distribution
significantly
affected by
surface contour
changes - this
must be
considered when
using bolus to
shape dose
distribution at
depth.

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 52

Inhomogeneities affect the dose
distribution
Air cavity

Monte Carlo Calculations

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 53
Use of electrons
 Skin lesions
 Scar boosting
 Avoidance of deep lying sensitive
structures (e.g. spinal cord)

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 54

More issues with the use of
electrons for radiotherapy
 Computer prediction of dose distribution
more difficult
 Small fields difficult to predict
 Dosimetry somewhat more difficult than
in photons due to strong dose gradients
and variation of electron
energy with depth

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 55

Other radiation types
 Neutrons
 Complex radiobiology
 Complex interactions
 Potential advantages for hypoxic and
radioresistant tumors
 Not widely used
 Protons - probably the most promising
other radiation type

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 56

Comparison to other radiation types

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 57

Potential
Advantage of
Proton
radiotherapy:
dose sparing
before and
behind the
target due to
Bragg peak

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 58

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 59
X Rays
versus
protons

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 60

4. Prescription and reporting
 Prescription is the responsibility of individual
clinicians, depending on the patient’s
condition, equipment available, experience
and training.
 The prescription should follow protocols
which are established by professional
organizations and modified and adopted by
radiotherapy departments.
 The prescription must be informed - as far as
possible - by clinical evidence
Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 61
Prescription and reporting
 Prescription may vary within reason
depending on equipment available
 Reporting must be uniform - any adequately
educated person must be able to understand
what happened to the patient in case of:
 need for a different clinician to continue treatment
 re-treatment of the patient
 clinical trials
 potential litigation

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 62

Recommendations by the ICRU
 International
Commission on
Radiation Units and
Measurements
 ICRU reports provide
guidance on
prescribing, recording
and reporting

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 63

Target delineation
 ICRU
report
50

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 64

Definitions form ICRU 50
 Gross Tumour
Volume (GTV) =
clinically
demonstrated
tumour
 Clinical Target
Volume (CTV) =
GTV + area at risk
(e.g. potentially
involved lymph
nodes)
Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 65
Definitions form ICRU 50
 Planning Target
Volume (PTV) =
volume planned to
be treated = CTV +
margin for set-up
uncertainties and
potential of organ
movement

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 66

Strategies for margins
 Margins are most important for clinical
radiotherapy - they depend on:
 organ motion - internal margin
 patient set-up and beam alignment - external
margin
 Margins can be non-uniform but should be
three dimensional
 A reasonable way of thinking would be:
“Choose margins so that the target is in the
treated field at least 95% of the time”
Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 67
Definitions form ICRU 50
 Treated Volume =
volume that receives
dose considered
adequate for clinical
objective
 Irradiated volume =
dose considered not
negligible for normal
tissues

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 68

  The concept of
margins was
expanded on
by ICRU report
62
 Internal margin
= due to organ
motion
 Set-up margin
 The two are
often combined
as independent
uncertainties
Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 69
5. Special procedures
 Total body irradiation
 Total electron skin irradiation
 Stereotactic radiosurgery

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 70

Total body irradiation (TBI)
 Target: Bone marrow
 Different techniques available
 2 lateral fields at extended FSD
 AP and PA
 moving of patient through the beam
 Typically impossible to do a
computerized treatment plan
 Need many measurements

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 71

 TBI: one possible patient position

R ice bags
Radiation field P lace d all aro un d bo dy
to ach ie ve tw o distin ct
at >3m FSD; sep aratio ns
collimator rotated

Breast board
A ng le of brea st b oa rd
ad ju ste d for in dividu al
pa tien ts

C ouch top

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 72

Issues with TBI
 In vivo dosimetry essential
 May need low dose rate treatment
 Shielding of critical organs (e.g. lung)
and thin body parts may be required
 this can be only for parts of the treatment
to achieve the best possible dose
uniformity

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 73

Total electron skin irradiation
 Treat all skin to very shallow depth
 Different techniques available
 4 or 6 fields
 rotating patient
 Impossible to plan using a computer
 Requires many measurements for
beam characterization

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 74

Total Body Skin Irradiation
 Multiple electron
fields at extended
FSD
 Whole body skin as
target

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 75

Issues with TBSI
 Use low energy electrons (4 or 6MeV)
 Spoiler in front of patient improves dose
distribution
 in vivo dosimetry required
 shielding of nails and eyes
 boost of some areas (e.g. under arms)
may be required

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 76

Stereotactic procedures
 Target usually brain lesions
 External head frame used to ensure
accurate patient
positioning
 Invasive or
 Re-locatable

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 77

Image registration
 Variety of systems
 Many frame
attachments to
allow for different
diagnostic
modalities (MRI,
CT, angiography)

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 78

 Image registration

MRI
CT scan

Leksell fiducial markers on both

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 79

Stereotactic procedures
Both systems MedTec
 Spatial accuracy around 1mm
 High dose single fraction (e.g. for
arterio-venous malformations) =
stereotactic radiosurgery using an
invasively mounted head frame
 Multiple fractions for tumour
treatment = stereotactic
radiotherapy using a re-locatable
head immobilisation

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 80

EBT verification tools
 Correct location
 portal films
 electronic portal imaging
 Correct dose
 phantom measurements
 in vivo dosimetry

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 81

EBT verification tools
 Correct location  Part 10 with some
 portal films comments in second
 electronic portal lecture part 5 (now)
imaging
 Correct dose  Parts 2 and 10
 phantom
measurements
 in vivo dosimetry

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 82

Summary
 A wide variety of radiation qualities are
available for the optimization of radiotherapy
for individual patients
 The choice depends on patient and
availability of equipment
 Given adequate understanding of radiation
properties and patient requirements many
highly specialized procedures have been
developed to address problems in
radiotherapy

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 83

Have we achieved the objectives?

 To be familiar with different radiation types

used in EBT
 To appreciate the technical needs to make
these radiation types applicable to
radiotherapy
 To understand common external beam
radiotherapy techniques

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 84

Where to Get More
Information
 Part 10 relates directly to this part
 References:
 Karzmark, C, Nunan C and Tanabe E. Medical
electron accelerators. McGraw Hill, New York,
1993.
 Site visit of ...

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 85

Any questions?
 Question:

Please put together a table comparing electron and

X Rays produced by linear accelerators
X Rays and electrons in EBT
X Rays electrons
Used on % of 90% <10%
patients
Production Linacs Linacs
Applicators Collimators Special electron
applicators
Dosimetry Cylindrical Plane parallel
chamber chamber
Range in patients Infinite – in Finite – from 2 to
practice >10cm 7cm
…
Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 88
Acknowledgments
 John Drew, Westmead Hospital,
Sydney
 Patricia Ostwald, Newcastle Mater
Hospital

Radiation Protection in Radiotherapy Part 5, lecture 1: Radiation types and techniques 89