Radiation Therapy Reviewer: • Emil Grubbe

• “Rose Lee” (1st radiation tx for

I. History breast cancer)
• Claude Regaud
A. Definition of terms: • Fractionation (Important
• Radiation principle in radiation therapy).
– emission and propagation of energy.
• Radiotherapy D. Limitations of Early Accelerator
• Is a clinical modality use in cancer - Inability to produce high energy
treatment. - Can’t penetrate deep seated tumors.
(Aim: deliver maximum dose to
target/minimum dose to surrounding E. Brachytherapy History
healthy tissues.) When it started?
• Radiation Oncology • Pierre Curie suggested to Danlos
• Discipline of human medicine to that a radioactive source could be
treat cancer. inserted into a tumor. (Curie
a) Cancer Management Institute of Paris)
b) Ionizing Radiation • Ralston Patterson
c) Biological and Physical Basis • Director of the Holt Radium
d) Professional Training Institute.
e) Clinical & Scientific Endeavor • Herbert Parker
• Medical Physicist
B. Historical Perspective • Developed Manchester System
• 1895 – Discovery of X-rays • Dr. Harold E. Johns
• 1896 – Hand of Von Koliker • Pioneer in “Cobalt tx”
(penetration of X-ray image) • October 27, 1951 = 43 year old
• 1897 – Leopold Freund (University of cervical cancer patient tx
Vienna) 1st tx of tissue with the use of (Victoria Hospital)
X-rays. • Milestone for the fight against
• 1901 – 1st noble prize in physics cancer.
• 1899 – 1st X-ray tx of cancer
• 1906 – Vinzenz Czerny (Institute for F. LINAC History
Experimental Cancer Research) • Linear Accelerator
• 1920 – X-ray (150kV) • Megavoltage treatment
• 1930 – Rolf Wideroe (1st LINAC) • Henry Kaplan & Edward Ginzton
• 1949 – Newberry 1st LINAC for • Developed 1st Linear Accelerator
medical use (England) (Stanford University)
• 1st tx = Gordon Isaacs (2y/o) with
C. Important pioneers retinoblastoma.
• Roentgen
– Discovered X-rays G. Clinical Radiation Generators
• Henri Becquerel (Kilovoltage Units)
• Father of Radioactivity
• Marie and Pierre Curie Grenz ray Therapy < 20 kV
• Polonium and Radium Contact Therapy 40 – 50 kV

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 Superficial Therapy 50 – 150 kV • Attack the affected area with
Orthovoltage Therapy 150-500 kV higher doses of radiation.
Supervoltage Therapy 500 – 1000 kV Disadvantage
Megavoltage Therapy 1 MV or greater • Expensive
• Particles trail in a straight line.
H. Generations of Accelerators
a) Early Generations A. Components
- Hammersmith (1952) • Main Operating Components
- Large and bulky 1. Injection System
-Limited gantry motion 2. RF System
b) 2nd Generation 3. Auxiliary System
- Isocentric units (360 degrees rotation) 4. Beam Transport System
- 1962 – 1982 5. Beam Collimation and Monitoring
- Improvise precision and accuracy of dose System
delivery.
c) 3rd Generation • Injection System
- Better accelerator waveguide and bending a. Electron Gun
magnet systems. - produces electron by
- Wider range of beam energies, dose rates, thermionic emission from a heated
field size and operating modes. cathode.
- Computer driven
TYPES:
I, Radiotherapy Technological 1. Diode Type
Advancements - produces bunches of electrons rather
a) 3D Conformal Radiotherapy (1990’s) than a continuous stream.
- Attempts to deliver a tumoricidal 2. Triode Type
dose to the tumor while minimizing the - produces discrete bunches of
damage to the surrounding healthy tissues. electrons by introducing a grid.
b) Intensity Modulated Radiotherapy
(IMRT) • RF System
- Advance form of 3DCRT • Converts the high voltage pulses
c) Image Guided Radiotherapy (IGRT from the modulator into pulsed
radiofrequency energy.
1. Magnetron
- Function as a high frequency
oscillator.
IIA. The Linear Accelerator - 5 MW can be produced
2. Klystron
• LINAC - RF power amplifier
• Uses high radio frequency - Mainly use in high energy LINACs.
electromagnetic waves to
accelerate charge particles. • Beam Transport
Advantages: • Used in transporting the electron
• Able to reach very high energies beam from the accelerating
without the need for extremely waveguide to the X-ray target or
high voltage.

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 to the exit window for electron • Mechanically movable motor
beam therapy. driven couch
• Can move horizontal, vertical as
• Modulator Cabinet well as rotational directions.
• Contains components that Hand Pendant
distribute and monitor primary • Control switches.
electrical power and high voltage • Bending Magnet
pulses to the magnetron/klystron. • Bends the electron beam through
3 Major Components a right angle.
a) Fan Control Types:
b) Auxiliary Power a) 90 degrees magnets (chromatic)
Distribution System b) 270 degrees magnets (acromatic)
c) Primary power distribution c) Slalom bend(112.5 degrees)
system
• Control Console • Scattering Foil
• Provides a central location for • Thin metal sheets
monitoring and controlling the • Expands the useful size of the
LINAC. beam
• Digital display for prescribe dose
(MU), mechanical beam particles • Monitor Chambers
such as collimator setting or • Amount of Radiation
gantry angle.
Calculation of MU for fixed SSD tx:
• Drive Stand
• Containing the apparatus that
drives the LINAC
a) Klystron/Magnetron
b) Waveguide
- Guide electromagnetic
waves from the magnetron to the Calculation of MU for fixed SAD (Isocentric)
accelerating guide. treatment
c) Circulator
- Directs the RF energy into
the waveguide.
d) Water cooling system
- allows components in the
gantry to operate at a constant
temperature.
• Gantry SSD = source to Surface Distance
• Responsible for directing the OF = Field Size
photons/electron beam at a patient PDD = Percentage Depth Dose
tumor WF = Weighting Factor
a) Electron Gun CF = Calibration Factor
b) Accelerator Structure TPR = Tissue Percentage Ratio
c) Treatment head/
• Treatment Table

Prepared by Juan Carlo C. Bentinganan, MSRT, RRT

• Interlock System - Shielding blocks
• Interlocking indicates the - Custom blocks
problem in a particular device in - Asymmetrical Jaws
the LINAC - Multileaf Collimators
2. Compensators
Safety Interlocks: 3. Beam Spoilers
a) Last Man Out Switches 4. Wedge Filters
b) Door Interlocks 5. Beam flattening filters
c) Beam on/off key 6. Bolus
7. Breast Cone
• Electronic Portal Imaging Device 8. Penumbra Trimmers
(EPID) 9. Electron Beam Modification
• Portal Images
• Real time images can be Shielding Blocks
displayed on the computer screen Aims:
before treatment. a) Protect critical organs
• Can be stored for later for viewing b) Avoid unnecessary radiation exposure
or archiving. to normal tissues.
c) Matching adjacent fields
• Ionization Chambers
Ideal Shielding Material:
• Embedded in the LINAC for dose
a) High atomic no.
monitoring for px safety.
b) High density
• LINAC for 2 separate chambers.
c) Easily available
d) Inexpensive
• Collimator
• Radiation beams are collimated • Shielding: Collimators and Blocks
by adjusting upper and lower Beam Energy Required lead
jaws. thickness
• Made of high atomic no.
(Tungsten or lead) 4 MV 6 cm

• Beam Modification 6 MV 6.5 cm

TYPES: 10 MV 7 cm
a. Shielding Cobalt 60 5cm
- To eliminate radiation dose to other (1.25MeV)
parts of the body.
b. Compensation
- Allow normal dose distribution. • Bolus
c. Wedge filter • A tissue equivalent material use to
- Special tilt in isodose curve reduce Dmax
d. Flattening • Also called “build up dose”
- Where spatial distribution of the kV Radiation: even out the
natural beam is altered. surface contours.
Types of Beam Modification Devices
1. Field of blocking and shaping

Prepared by Juan Carlo C. Bentinganan, MSRT, RRT

 mV Radiation: Primarily used to • Selection Criteria
bring up the buildup zone near the • Easily accessible lesions
skin to treat superficial lesions. • Early-stage diseases (ideal
implant < 5 cm)
• High Energy Machines • Well localized tumor to organ of
a) Van de Graff Generator origin
b) Betatron • No nodal or distant metastases
c) Cyclotron • No local infections or
d) LINAC inflammation
e) Cobalt 60 Unit • Favorable histology
• Proliferative/ulcerative lesions
• Members of the Radiotherapy Team: preferred
a) Oncology Nurse
b) Radiation Therapist A. Indications
c) Medical Physicist/ Dosimetrist
d) Radiation Oncologist A1. Radical radiation
e) Administrative Staff • Skin malignancies – BCC, SCC
• Head and Neck Cancers
III. Brachytherapy (Internal Radiation • Cervical Cancer
Therapy/Plesiotherapy
• Prostate Cancer
• Type of Radiation in which
radioactive sources are arranged A2. Boost After Extended RT
in such a fashion that radiation is
• Head and Neck Cancers
delivered to a tumor at short
• Breast cancer
distance.
• Esophagus
• Brachy (prefix) – Greek = “Short
• Anal canal
Range”
• Clinical Advantages
A3. Perioperative
a) High Biological Efficiency
b) Rapid Dose Fall-off • STS
c) High Tolerance • Cervical Cancer
d) Tolerable acute intense reaction
e) Decreased risk of tumor population A4. Post-op
f) High control rate • Endometrial Cancer
g) Better Cosmesis • Cervical Cancer
h) Minimal Radiation Morbidity • Breast Cancer
i) Day care procedure
A5. Palliative
• Disadvantages • Bronchogenic Cancer
a) Difficult for inaccessible regions • Biliary Duct Malignancy
b) Limited for small tumors • Esophageal Cancer
c) Invasive procedure • Recurrent Tumors
d) Higher dose inhomogeneity
e) Greater conformation A6. Benign
f) Radioactive hazards • Keloids
g) Costly

Prepared by Juan Carlo C. Bentinganan, MSRT, RRT

 • Predictable clinical effects
B. Brachytherapy Sources • Superior radiobiological
a. photon sources role
- emit gamma rays through • Less morbidity, control is
gamma decay and possibly best
characteristic X-ray through electron • Well-practiced since
capture and internal conversion. • Minimum intersession
e.g. Co-60, Cs-137, Ir-192, Pd-103 variability in dose
distribution.
b. beta sources HDR (High Dose Rate)
- emit electrons following beta • Short Time
source decay a. Geometry well
e.g Sr-90/Y-90 maintained
c. neutron source b. Better patient
- Emit neutrons following compliance/ comfort
spontaneous nuclear fission. c. Day care procedure
e.g. Cf-252 d. Optimization
e. No radiation hazards
C. Classification f. Small Applicator (Less
1. Source in Tumor Trauma & better packing)
- Interstitial
- Intracavitary E. After loading techniques
- Intraluminal 1. Manual After loading
- Endovascular - Avoids radiation protection issues of
2. Source in contact but superficial preloading.
-Surface brachytherapy - Better Applicator placement.
moulage - Verification prior to source
3. Duration of irradiation placement.
- Temporary (Cs-137, Ir-192, - Minimum Radiation Hazard
Co 60) 2. Remote After loading
- Permanent (I-125, Au-198) - No radiation hazard
- Accurate placement
D. Dose Rate - Geometry maintained
• Low Dose rate (LDR) - Better dose distribution
• 0.4 – 2 Gy/hr - Highly precise
• Medium Dose rate (MDR) - Short Time
• 2 -12 Gy/hr - Day Care procedure
• High Dose Rate (HDR) - Mainly use for HDR
• > 12 Gy/hr
• Roughly F. Types of Brachytherapy Implants
a) LDR – 10 Gy/day • Intracavitary
b) MDR – 10 Gy/hr – sources are placed into a
c) HDR – 10 Gy/min body cavity
• Interstitial
• Advantages • Sources are implanted into
LDR (Low Dose rate) the tumor volume.

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 • Surface plaque
• Sources are loaded into 2. Intrauterine tube
plaque which is brought - Made up of thin rubber (to prevent
into contact with skin excessive dilatation of the cervical canal).
surface lesion > Lengths: 2cm, 4cm, 6cm
• Intraluminal
• Source are inserted into a 3. Ovoids
lumen. - Used in pairs, one in each lateral
• Intraoperative fornix.
• Sources are brought - The shape of ovoids mimics the
surgically into or near the shape of the isodose curves around a Radiium
tumor volume. tube having “active length” of 1.5 cm.
- The ovoids were designed to be
• Intravascular
adaptable to the different vaginal capacity,
• Sources are brought
with diameter of 2cm, 2.5cm and 3 cm.
intravascularly inti a
- The largest ovoid are placed in the
lesion or near a lesion.
roomiest vagina in order to achieve the best
lateral dose throw off.
G. Dosimetry System
1. The Manchester System
4. Packing
- Oldest and extensively used systems
- Manchester applicators do not incorporate
in the world.
rectal shielding.
- Developed by Todd & Meredith in
- Hence gauze is packed firmly and carefully.
1930 & was in clinical use by 1932.
a) Behind the ovoids
- Was initially developed for radium
b) Anterior b/w the ovoids and the
tubes, but was easily adapted to
base of the bladder
different afterloading systems
c) Around the applicator tubes down
2. Paris System
to the level of the introitus
- Single Application of Radium for
- Packing helps to:
120 hours (5-6 days)
a) Keep the applicator in position.
- Almost an equal amount of Radium was
b) To reduce dose to the bladder and
used in the uterus and the vagina.
anterior rectal wall.
- Designed to deliver a dose of 7000 –
8000 mg hrs over a period of 5 days
5. Surface Moulds
(45R/hr) (5500mg/hr)
- radiation is delivered by arranging
sources over the surface of the tumor.
Most commonly used systems are:
Types:
1. Patterson-Parker (Manchester) System
a) Planar
2. Quimby (memorial) System
b) Line Source
3. Paris System
c) Cylinder
I, Intraluminal Brachytherapy
H. Brachytherapy applicators
• Radioactive source passed
1. Fletcher Applicator
through a tube and passed
- Derived from the “Manchester
into a hollow lumen.
System”
- Added internal shielding in the Sites:
1. Esophagus
colostats, afterloading ability.

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2. Bronchus: Bronchogenic carcinoma c) Introduce to the treatment
3. Biliary Duct team.
• Types of Patient data
J. Mechanical Characteristics of • Patient information
Brachytherapy Sources required for treatment
a. Needles (Cesium-137) planning varies from
b. Tubes (Cesium-137) rudimentary to very
c. Pellets (Cobalt 60 and Cesium 137) complex data acquisition:
d. Speeds (Iodine-125, Pd-103, Ir-192, Gold- a) Distances read on the
198) skin
e. Wires (Iridium-192) b) Manual determination
of contours
The sources are used as sealed sources, c) Acquisition of CT
usually doubly encapsulated in order to: information over a large
volume.
a) Provide adequate shielding against alpha d) Image fusion
and beta radiation emitted from the source e. Advance methods in
b) Contain radioactive material IGRT
c) Prevent leakage of the radioactive material • 2D Patient data
d) Provide rigidity of the source • A single patient contour,
acquired using lead wire
Common radionuclides used in remote or plaster strips, is
afterloading: transcribed onto a sheet of
a) Cobalt 60 graph paper, with
b) cesium 137 reference points
c) Iridium 192 identified.
IV. Simulation and Imaging • Radiographs taken with a
simulator can be taken for
• Treatment Simulation comparison with port
• Process by which the films during treatment.
radiation treatment fields • Radiographs are helpful
are defined, filmed and for irregular fields:
marked out on the patient o Block shaping
skin. o Positioning
• Images are then sent to the • 3D patient data
physics department where • Data are usually based on
they arrange the radiation CT images
beams and make a • Structure relevant for the
customized plan radiation treatment can
• Before Simulation now be identified on the
a) Explain the pros and cons CT Slices.
of radiation, panning and • Segmentation
treatment process • The process of
b) review the consent form distinguishing structures
and have them sign it or volumes from the

Prepared by Juan Carlo C. Bentinganan, MSRT, RRT

 background by drawing and simulating the
contours. attenuation of x-rays.
• Image registration • Advantages of DRRs
• The process of matching - anatomical
images obtained from information may be
different image devices. used directly for the
• Modern Simulators determination of
• provide the ability to treatment field
mimic many treatment parameters
geometries attainable on - - The transfer error
megavoltage treatment (patient positioned a
units, and to visualize the second time at
resulting treatment fields simulator) can be
on radiographs or under avoided.
fluoroscopic examination • Fiducial Markers/Tattoos
of the patient. - Are marks that
A. Computed Tomography-based simulation determine the
- Modern simulation systems are isocenter
based on computed tomography (CT) - The therapist, using a
or magnetic resonance (MR) imagers very small needle, will
and are referred to as CT-simulators prick just the skin
or MR-simulators. surface and insert an
extremely small
• Virtual Simulation amount of ink into this
• treatment simulation of area.
patients based solely on B. Immobilization
CT information. - the most crucial parts of radiation
• The premise of virtual therapy treatment.
simulation is that the CT - For accurate delivery of a prescribed
data can be manipulated to radiation dose to a target volume, while
render synthetic sparing surrounding normal and critical
radiographs of the patient tissues.
for arbitrary geometries
• Such radiographs are also
called: digitally • Purpose of Immobilization
reconstructed radiographs Devices:
(DRR) 1. To immobilize the patient during
• Digitally Reconstructed treatment.
Radiograph 2. Ease of use.
- produced 3. Comfort for the patient.
mathematically by 4. Minimal space requirement for
tracing ray-lines from storage.
a virtual source 5. Resistance to bending and
position through the stretching.
CT data of the patient
on a virtual film plane

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 6. Minimal perturbation of the beam - In order to represent volumetric and
so as not to produce artefacts in planar variations in absorbed dose,
image acquisition. distributions are depicted by means of
• Fundamental Role of Immobilization: ISODOSE CURVES.
- To provide reliable - Isodose curves are the lines joining
means of Reproducing the points of equal PDD. The curves
the patient position are drawn at regular intervals of
from treatment absorbed dose and expressed as a
planning and percentage of the dose at a reference
simulation to point.
treatment, and from • Percentage Depth Dose
one treatment to - the “quotient,
another. expressed as a c
• Head, Neck and Brain percentage of the
Immobilization absorbed dose at any
- Initial construction depth “d” to the
and selection of proper absorbed dose at a
immobilization for fixed reference depth
head and neck cancer “do” along the central
is one of the most axis of the beam”
important parts of - P.D.D = (Dd / Ddo ) X
ensuring proper 100
treatment of the • Isodose Charts
patient - Is consist of a family
- Most common: of isodose curve.
Thermoplastic mask • Beam Profile
• Common Chest - The dose variations
Immobilization Device across the field at a
1. Vaclok specified depth.
- custom , beanbag type • Field Size
pillows that are placed around - The lateral distance
the patients upper body between the 50%
2. Breast Board isodose lines at a
- - is used specifically for the reference depth
treatment of breast cancer.

• Belly Boards • Beam Alignment

- used when the patient - The field defining
is treated prone. light is made to
- allow the small bowel coincide with the 50%
to drop below the isodose lines of the
lateral field to avoid radiation beam
severe side effects of projected on a plane
irradiation perpendicular to the
beam axis and at
V. Principles of Isodose Planning standard SSD or SAD.

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• Penumbra
- Dose transition near
the borders of the
field. The region at the
radiation beam over
which the dose rate
changes rapidly as a
function of distance
from the central axis.
• Geometric Penumbra
A. Transmission Penumbra
- variable transmission of beam
through non divergent collimator
angle.
B. Physical Penumbra
- The lateral distance between two
specified isodose curves at a specified
depth. (lateral distance between 90%
--> 10% or 80 → 20%)
• Falloff of the beam
1. By the geometric penumbra
2. By the reduced side scatter
3. Physical penumbra width
• Measurement of Isodose Curve
1. Ion Chamber
- Most reliable method
because of flat energy
response and
precision.
2. Solid State detectors
3. Radiographic films
4. Computer driven devices
• Parameters of Isodose Curves
1. beam quality
- The depth of a given isodose curve
increases with beam quality
2. Source size, SSD and SDD
- The penumbra effect
- the dose variation across the field border
is a complex function of geometric
penumbra, latera scatter and collimation.
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3. Collimator and Flattening filter
- has the greatest influence in determining
the shape of the isodose curved
4. Field Size
- One of the most important parameters in
treatment planning.
C. Wedge Filters
- Beam modifying device, which causes a
progressive decrease in intensity across the
beam, resulting in tilting the isodose curves
to thinner side.
• Material (wedge filter)
a. Tungsten
b. brass
c. Lead
d. Steel
• Wedge Systems
1. Individual wedge system
- A separate wedge for each beam
width.
- To minimize the loss of beam output
- To align the thin end of the wedge
with the border of the light field.
- Used in Co60
2. Universal wedge system
- A single wedge for all beam width
- Fixed centrally in the beam
- Used in LINAC.
• Advance Wedge Systems
1. Omni wedge (Elekta)
- There is only one universal wedge (60
degree) attached above the jaws.
- To control the wedge angle, an
appropriate combination of open and
wedged fields is used.
2. Dynamic Wedge (Varian)
 - One side of jaws move in (or close) - The maximum dos for 360-degree
while beam is on. rotation occurs at the isocenter and for
- Wedge angle is determined by partial arcs it is displaced towards the
controlling the speed of the moving irradiated sector.
jaw.
• Electrons
• Wedge Angle - Delivers a reasonably uniform dose
- The angle through which an isodose from the surface to a specific depth,
curve is titled at the central ray of a after which dose falls of rapidly,
beam at a specified depth 10cm/50% eventually to near zero value.
isodose curves.
E. Tumor Dose Specified for External
D. Combination of Radiation Fields Photon Beams
• Parallel Opposed Fields
a. Advantages
- Simplicity and reproducibility of
setup
- Homogenous dose to the tumor
- Less chances miss

b. Disadvantages
- The excessive dose to normal tissues
and critical organs above and below
the tumor.

• Multiple fields
- Using field of appropriate
size
- Increasing the number of
fields or portals
- Selecting appropriate beam
directions
- Adjusting beam weights 1. Gross Tumor Volume (GTV)
- Using appropriate beam - Is the gross demonstrable extent and
energy location of the tumor. It may be consisted
- Using beam modifiers of primary tumor, metastatic
lymphadenopathy or other metastasis.
• Rotation Therapy
- The beam moves continuously about 2. Clinical Target Volume (CTV)
the patient, or the patient is rotated - Consist of a demonstrated tumor if
while the beam is held fixed. present and any other tissue with
- For small and deep-seated tumors, not presumed tumor. It represents the true
for “large” extent and location of the tumor.
- Beam should be aimed at suitable
distance beyond the tumor area and is 3. Planning Target Volume (PTV)
call “PAST POINTING”

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 -Volume which includes CTV with an - Cancer that spread beyond the
IM as well as a set up margin (SM) for basement membrane and is growing
patient movement and set-up into surrounding healthy tissues.
uncertainties - It usually divided into 4 stages.
- TNM (T: tumor Size, L: Lymph node
4. Maximum target dose Status and M: Metastasis) Is used for
- The highest dose in the target area. breast cancer
• Cancer Screening
5. Minimum Target Dose - Screening is testing asymptomatic
- Is the lowest absorbed dose in the target women for the detection of
area. precancerous/early invasive cancer
- Screening tests should be non-
6. Mean target Dose invasive, cheap and effective in
- If the dose is calculated at large detecting precancerous lesions.
number of discrete points uniformly - Screening is effective in reducing
distributed in the target area, the mean mortality due to the cervical (pap
target dose is the mean of the smear) and breast cancer
absorbed dose values at these points. (mammography).
• Screening for Breast Cancer
7. Median Target Dose 1. Breast Self-Examination
- Is simply the value between the maximum 2. Mammography
and the minimum absorbed dose values
within the target. • Staging
- Means assessment of the extent of
8. Modal Target Dose the spread of cancer inside and
- Is the absorbed dose that occurs most beyond its site of origin.
frequently within the target area
• Local Disease
9. Hotspot - Cancer limited to its primary site
- An area outside the target that receives a
higher dose than the specified target dose • Regional Disease
- Cancer is spreading to regional lymph
Vi. Staging of Cancer nodes
• Cancer
- Uncontrolled Cellular proliferation • Distant Disease
- Local Invasion - Cancer spreading to the systemic
- Distant Metastasis organs like bone, brain, lung and liver

• In situ Cancer
- early cancer that has not invaded the A. Staging of Cancer
base membrane of tissue in which it
developed Invasive cancer is divided into 4 stages:
Stage 1: Mobile Primary
• Invasive Cancer Stage 2: Mobile Primary and Secondary
(LN)
Stage 3: Fixed primary and/or secondary

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Stage 4: Distant metastasis

• Why do we stage cancer?

- To choose the best method of
treatment e.g. early cancers are
surgically resect able (operable)
- Late cancers are too advanced to be
resected, chemotherapy and
radiotherapy may be used
- To assess the prognosis of cancer
e.g. the 5 year survival for stage 1 is
over 90% and for stage 4 is below
10%

• Methods of Staging Cancer

1. Clinical Methods
Examination of the cancer bearing
site for:
- Size (T): largest diameter of cancer
- Mobility: Mobile or immobile (fixed)
cancers
- Skin overlying cancer: intact,
edematous, ulcerated.

Examination of draining Lymph

Nodes (N): enlarged, mobile, fixed,
matted together

Examination of distant organs for

metastasis into bones, brain, lung
and liver

2. Pathological Methods
- The final diagnosis of cancer is
based upon histo-pathological
examination
- Fine needle aspiration cytology or
true-cut tissue biopsy can diagnose
invasive cancer
- Resected tumors and lymph nodes
must be subjected to histo-
pathological examination.

3. Radiological Methods

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VII. Principles in the Management of Malignancies

• Roles of Various Multidisciplinary Team members

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 - Pain: simple analgesics, narcotics,
• Medical Therapies including parenteral narcotics
chemotherapy, biological therapy - Nausea: metoclopramide, 5HT3
and hormones antagonist, steroids
Loss of appetite: steroids
CURATIVE: - Cough/SOB: codeine, narcotics,
e.g. Leukemia, lymphoma, germ cell nebulizers.
tumors, choriocarcinoma, Ewing - Depression: control symptoms,
Sarcoma/osteosarcoma correct causes, counselling,
Adjuvant antidepressants family support, aids,
e.g. Breast, colon, ovarian, sarcoma home visis, physiotherapy, nutrition,
Concurrent with radiation therapy (as occupational therapy, social work
radio sensitisers)
e.g. Head and neck, cervical, lung • Surgery
Palliative: - performed for cure by removing the
e.g. Metastatic Cancers primary cancer and lymph nodes and
for palliation by removing the mass
• Radiation Therapy causing symptoms in selected cases.
In some cases, removing solitary or
CURATIVE limited metastasis could achieve cure.
e.g. head & neck, cervical, lung, prostate,
sarcoma A. Overall Approach to Cancer Management

Adjuvant (eliminate micro metastatic 1. What is the type of cancer?

disease after surgery or radiotherapy)
e.g. Breast, brain, head & neck
Palliative (improve quality of life and
prolong survival)
- Advance local diseases and metastatic
cancers
- In most cases, this requires a tissue
diagnosis. In modern oncology, it is
unusual or inappropriate to start treatment
based on clinical diagnosis alone without
tissue diagnosis. Tissue diagnosis is also
important to perform molecular studies to
select appropriate targeted therapies.

• Palliative Care 2. What is the extent of the spread of

Aim: improve quality of life by
controlling symptoms.
- If a tumor can be shrunk by
chemotherapy or radiotherapy, this
would be an efficient option for
controlling symptoms. In most cases,
concurrent use of palliative care
services and active anti-cancer
therapy are necessary to maintain
quality of life.
• Examples of Symptoms and
Management:
cancer?
- This is answered by staging scans
including CT scans, bone scans and PET
scans.
3. Is it curable or not curable?
- This depends on the type of cancer and
the presence or absence of and the extent
of metastasis.
• Incurable Metastatic Cancer
- Aim is to prolong survival and
improve quality of life.

Prepared by Juan Carlo C. Bentinganan, MSRT, RRT

 • How does treating with chemotherapy
or radiotherapy improve quality of
life?
- By shrinking the cancer mass
- By decreasing the need for the
sedative effect of analgesics
- By living longer
• Concepts of Median Survival
- Survival figures are obtained from
large data bases.
- Therefore, we can only quote median
figures rather than absolute numbers
for expected duration of survival.
- The meaning of median survival
needs to be clearly explained to
patients and families to illustrate
uncertainty.
B. Radiation Therapy Techniques in Cancer
Treatment
B1. External Beam Radiation Therapy
• Linear Accelerator
1. Conformal Therapy
a) Intensity modulated
radiation therapy
b) Image-guided radiation
therapy
• Particle therapy
a) Proton Therapy
b) Other heavy particles
• Stereotactic Radiation Therapy
Techniques
a) Total Body Irradiation
b) Gamma Knife
• Proton Therapy
- type of radiation therapy — a
treatment that uses high-powered
energy to treat cancer and some
noncancerous tumors. Radiation
therapy using X-rays has long been
used to treat these conditions. Proton
therapy is a newer type of radiation
therapy that uses energy from
positively charged particles (protons).
Prepared by Juan Carlo C. Bentinganan, MSRT, RRT
Proton Therapy is used to treat:
• Brain tumors
• Breast cancer
• Cancer in children
• Eye melanoma
• Esophageal cancer
• Head and neck cancers
• Liver cancer
• Lung cancer
• Lymphoma
• Pancreatic cancer
• Pituitary gland tumors
• Prostate cancer
• Sarcoma
• Tumors affecting the spine
• Tumors in the base of the skull
• Gamma Knife
- The procedure uses highly focused
gamma radiation beams to target
tumors, lesions, and other conditions
of the brain. Sometimes, the
procedure is used when other
treatment options have not worked
Gamma Knife Surgery may be used to treat:
• brain tumors, including malignant
and benign tumors, specifically ones
that cannot be reached with
traditional brain surgery or following
surgery
• tremors, including essential
tremor or tremor caused by
Parkinson’s disease
• acoustic neuroma, also known
as vestibular schwannomas, or
tumors that develop around the nerves
of the inner ear
• trigeminal neuralgia, a condition
that affects the nerves in the face
• vascular malformations, or tangles
of blood vessels in the brain
Prepared by Juan Carlo C. Bentinganan, MSRT, RRT