History of radiation therapy and application

History of radiation therapy and application

1. History Radiation Oncology From Orthovoltage To Megavoltage Era Dr Kanhu Charan Patro 1 CRABECON VIRTUAL JAMMU /2020

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3. Statistics >9.7 million cases are detected each year 6.7 million people will die from cancer Every day, around 1700 Americans die of the disease 20.4 million people living with cancer in the world today 1 in 3 pe ople will be diagnosed with cancer in the UK and 1 in 4 will die from their disease 3

4. Radiotherapy X ray Surgery PET MRI Chemo ? ? 4

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8. Oncologist Diagnosis Treatment Radiologist Cytopathologist Surgeon Histopathologist Molecular Pathologist Geneticist psychiatrist Nursing And Support staff Audit 8

9. Role of radiotherapy in various cancers Needed for all most head and neck cancer Radical- Naso -pharynx, cervix,laryx,hypopharynx etc. post-op-adjuvant Rectum, cervix early, stomach, head and neck, other abdominal malignancies Palliative compression, bleeding,obstruction,pian 9

10. Radiation –Part of life 10

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12. History - radiation 1896 – Becquerel - Radioactivity 1898 – Madam Curie / Pierre Curie - Radium 1903 – Nobel Prize for Curie’s & Becquerel 1903 – First successful case of malignancy basal cell carcinoma of face 12

13. Wilhelm Conrad Rontgen 13

14. William Roentgen discovered X-Rays in 1895 while studying cathode rays in a gas discharge tube. He observed that another type of radiation was produced that could be detected outside the tube. This radiation could penetrate opaque substances,produce flourescence, blacken a photographic plate and ionize a gas. He named this new radiation as X- Rays. 14

15. He also noted that these X-rays could be used to image bones. In fact one of the first known x-ray images ever produced was of his wife Bertha’s left hand . Roentgen characterized and validated his findings in a technical report within 6 weeks. News of Roentgen’s remarkable discovery travelled rapidly around the world . In recognition of his ground-breaking research, he was awarded the first Nobel Prize in Physics in 1901. 15

16. Henri Becquerel's discovery of spontaneous radioactivity When  Henri Becquerel  investigated the newly  discovered  X-rays in 1896, it led to studies of how uranium salts are affected by light. By accident, he  discovered  that uranium salts spontaneously emit a penetrating radiation that can be registered on a photographic plate. Although it was  Henri Becquerel  that discovered the phenomenon, it was his doctoral student,  Marie Curie , who named it: radioactivity Received the 1903 Nobel Prize in Physics Antoine Henri Becquerel 16

17. Bequerel’s doctoral students Marie Curie with her husband Pierre Curie showed that Bequerel rays could be measured using ionising techniques , and radiation intensity is directly proportional to the amount of uranium in a substance. They also isolated the first known radioactive elements Polonium and Radium in 1898. Marie Curie  was a physicist, chemist and a pioneer in the study of radiation. ... She and her husband, Pierre, discovered the elements polonium and radium. They and Henri Becquerel were awarded the Nobel Prize in Physics in 1903, and  Marie  received the Nobel Prize in Chemistry in 1911 Marie Skłodowska Curie 17

18. Medical student in Chicago named ‘Emil Grubbe’ noted pealing of his hands on exposure to X- Rays. He convinced his professor and assembled his x-ray machine in Chicago in 1896 itself , and that same year, used it to treat a woman named ‘Rose Lee’ with recurrent carcinoma of the breast. By 1960, Grubbe had instructed over 7000 other doctors in the medical use of x-rays. In the course of his lifetime, he underwent more than 90 surgeries for multiple cancers caused by his intense, ongoing exposure to radiation Emil Grubbe 18

19. Claude Regaud 19

20. Henri Coutard , an early French Radiation Oncologist pioneered the use of fractionated Radiotherapy in a wide variety of tumors. He reported impressive results using this approach in patients with locally advanced laryngeal cancers in 1934 . Henri Coutard 20

21. Despite their promise, an important limitation of the early x-ray machines was their inability to produce high energy, deeply penetrating beams. It was thus difficult to treat deep-seated tumors without excessive skin reactions. Drawbacks of orthovoltage 21

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23. In 1949, Dr. Harold E. Johns , a Canadian medical physicist sent a request to the National Research Council(NRC) asking them to produce Cobalt-60 isotopes for use in a cobalt therapy unit prototype. On October 27, 1951, the world’s first cancer treatment with COBALT 60 radiation took place at Victoria Hospital for a 43 year old cervical cancer patient. This marked an important milestone for the fight against cancer. Dr. Harold E. Johns 23

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25. Despite advances made in radiation therapy technology, the Cobalt-60 unit remains the world’s main radiotherapy machine. Due to its cost effectiveness, reliability and ease of use, it is prevalent in developing countries. Cobalt-60 technology is currently used to treat roughly 70 per cent of the world’s cancer cases treated by radiation. 25

26. An exciting development was the introduction of high energy (megavoltage) treatment machines, known as LINEAR ACCELERATORS OR LINACS . Such machines were capable of producing high energy, deeply penetrating beams, allowing for the very first time treatment of tumors deep inside the body without excessive damage to the overlying skin and other normal tissues. LINEAR ACCELERATORS 26

27. Dr. Henry Kaplan and physicist Edward Ginzton developed the first medical linear accelerator at Stanford University, San Francisco in 1956. First linear accelerator 27

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29. The first patient to be treated using this machine was a 2 year old child named ‘Gordon Isaacs’ with retinoblastoma. Treatment was highly successful . For more than 40 years later, this patient remained free of disease with good vision. Gordon Isaacs 29

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34. With the advent of computers, of newer technological advances , the radiotherapy planning systems underwent a drastic makeover. In subsequent years, the field of Radiation Oncology experienced multiple technologic revolutions Computers 34

35. It was in 1990’s that 3-D Conformal Radiotherapy , a form of radiation therapy where the fields used are designed such that the radiation dose is mostly delivered to the tumor, while the surrounding tissues receive little to no radiation dose. This attempts to deliver a tumoricidal dose to the tumor while minimizing the damage to the surrounding healthy tissues. 3-dimensional information about the patient's body is supplied by the CT- simulations process. 3-D Conformal Radiotherapy 35

36. Intensity-modulated radiation therapy (IMRT) is an advanced form of three-dimensiona l conformal radiotherapy(3DCRT). It uses sophisticated software and hardware to vary the shape and intensity of radiation delivered to different parts of the treatment area. 36 Intensity Modulated Radiotherapy

37. Today, Radiation Therapy is in the midst of yet another important technologic revolution, namely (IGRT). While not truly new, IGRT is rapidly growing in popularity primarily due to the widespread adoption of new linear accelerators which function both as treatment and imaging machines. Image-Guided Radiation Therapy 37

38. Thus we have seen that over a period of just 120 years , the modality of radiotherapy has evo l ved ra p i d ly f r om some anonymous rays to the present scenario where radiotherapy is almost indispensible when it comes to the cure of cancer. Growth means change and change involves risk, stepping from the known to the unknown. 38

39. GOALS High dose to tumor tissue-Tumor control Normal tissue sparing Minimize long and short term toxicities Better Quality of life 39

40. Treatment Delivered 5 days per week over 6-8 weeks Typical treatment takes around 5 minutes Treatment is painless --like having an X-ray taken No radioactive substances involved ; beam goes on/off Side effects usually temporary ; controlled with medication/diet Covered by Medicare and many other insurance companies 40

41. Types of radiotherapy 41 TELETHERAPY BRACHYTHERAPY

42. IMAGE GUIDED RADIATION THERAPY 42 EQUIPMENT REQUIRED CT-SCAN MRI PET-CT

43. Cobalt machine 43

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45. Plaster of Paris Mould-older method 45

46. Head & Neck 46

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48. Abdomen and Pelvis 48

49. Vacuum Mould 49

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51. Evolution of Treatment Techniques 51 CUSTOMISED BLOCKS MULTILEAF COLLIMATOR BASED 3D-CRT 1990s 1980s

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53. Treating Head & Neck with Sliding Windows 53

54. IMRT Divides each treatment field into multiple segments Modulates beam intensity , giving discrete dose to each segment Uses multiple, shaped beams (~9) and thousands of segments IMRT Initiated in 1995 Reached the clinic in 2000

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59. Mesothelioma 59

60. Small Volume Adjacent to Critical Structure 60

61. 3D Dose Shaping - H&N and Brain 61 Brain Stem

62. Target Motion in Radiotherapy 62 Caveman et al Oops! The target moves! IGRT/GATED RT

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67. Radiation ECRT 67

68. RADIOTHERAPY 68

69. CONVENTIONAL 3DCRT IMRT IGRT VMAT / RAPIDARC PET /FUNCTIONAL GUIDED RADIOTHERAPY 69

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72. RADIOTHERAPY DELIVERY 72

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78. Brachytherapy is a form of radiotherapy where a sealed radiation source is placed inside or next to the area requiring treatment. Brachy is Greek for short 78

79. Many early advocates of Radiation Therapy thus relied instead on the placement of radioactive sources in close proximity or even within the tumor, a technique known as BRACHYTHERAPY . This modality dates back to when Pierre Curie suggested to Danlos that a radioactive source could be inserted into a tumour. It was found that the radiation caused the tumour to shrink. In the early twentieth century, techniques for the application of brachytherapy were pioneered at the Curie institute in Paris by Danlos. 79

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82. Ralston Patterson who was a radiologist and who had keen interest in newer advances related to the field was appointed as Director of the Holt Radium Institute in 1931, who went on to build a world recognised centre for the treatment of cancer by radiation. 82

83. Herbert Parker who was a medical physicist at the Holt Radium institute who developed the MANCHESTER SYSTEM for radium therapy along with Patterson in 1932 83

84. Following initial interest in brachytherapy in Europe and the US, its use declined in the middle of the twentieth century due to the problem of radiation exposure to operators from the manual application of the radioactive sources . However, the development of remote afterloading systems, which allow the radiation to be delivered from a shielded safe, in the 1950s and 1960s, reduced the risk of unnecessary radiation exposure to the operator and patients. 84

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92. BRACHYTHERAPY 92

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95. PROCEDURE 95

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97. ORGAN PRESERVATION HEAD AND NECK CANCERS BREAST CANCERS ESOPHAGUS CANCERS PENILE CANCER SOFT TISSUE SARCOMA BLADDER CANCERS CANAL CANCERS 97

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99. Intra- operative Brachytherapy procedure 99

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112. ICA HDR application 112

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115. ORGAN PRESERVATION FOR CANCER ANAL CANAL 115

116. ANAL CANAL BRACHYTHERAPY 116

117. ORGAN PRESERVATION FOR CANCER TONGUE 117

118. TONGUE IMPLANT IN PROGRESS 118

119. 119 ORGAN PRESERVATION FOR CANCER LIP

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123. Applicator in situ with IOP 123

124. Complete response –towards healing hypo-pigmentation 124

125. Recent 125

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127. KELOIDS 127

128. CANCER ESOPHAGUS 128

129. ESOPHAGEAL BRACHYTHERAPY 129

130. PROSTATE CANCER 130

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135. SMART THINKING 135

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137. Sharp gun-missed target 137

138. 10/20/12 01:12 PM 138 138

139. Just “Doing It” is not good enough ! You must know “what” to do and “where” to do it ! 10/20/12 01:12 PM 139 139

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