Beam Therapy Equipment I

– cobalt, kV x-rays
Jeannie Wong, PhD.
Objectives
To review physics and technology of external beam
radiotherapy equipment
To understand the design and functionality of the
equipment including auxiliary equipment
To appreciate the beam properties used for
radiotherapy treatment
History
1895 – Roentgen discovered x-ray
1896 – Becquerel discovered
radioactivity
1898 – Marie & Pierre Curie discovered
Polonium and Radium,
 coined the term “Radioactivity”
WWI - Mobile x-ray unit
History of radiation therapy
1895 - mid 1900 – used to treat
skin diseases, Finsen-Lomholt
lamp
1898 – Radium therapy
1903 – JJ Thompson – radium
bath
Other quack treatments:
Radium spa/bath
Radium blanket
Radium water
Cosmos bag

Radium water
Evolution of radiotherapy
time margin

Fixed SSD RT

reduction
Isocentric RT better set-up Computer planning

Conformal RT better targeting 3D planning

IMRT better sparing Inverse planning

Image guided better Adaptive and/or 4D

RT individualisation planning
Clinical radiation generators
Grenz-ray therapy
Contact therapy
Kilovoltage units
Superficial therapy
Orthovoltage therapy

Megavoltage therapy
Grenz ray therapy
Tube potential < 20 kV
very shallow depth
penetration– all dose
absorbed within 2 mm
depth
The use of very soft
(low energy) x-ray to
treat benign skin
disorders
Eczema, Psoriasis etc.
Grenz ray induced
skin cancer?
Contact therapy
Endocavitary contact therapy
Lesion at very short FSD (< 2cm)
40 – 50 kV, 2 mA
0.5 – 1 mm Al filtration to
absorb very soft component of
energy spectrum
Depth dose – very rapid fall off
All dose absorbed at 2 cm depth
in tissue.
Superficial and Orthovoltage
“conventional” X-ray tube with electrons
accelerated by an electric field
stationary anode (in contrast to diagnostic tubes
which have a rotating anode to allow for a smaller
focal spot)
filtration important
Superficial therapy
50 – 150 kV, 5 -8 mA
small skin lesions
maximum applicator size
typically < 7cm
typical SSD < 30cm
beam quality measured in
HVL aluminum (0.5 to 8mm)
Use

of cones essential
Large focal spot and close treatment distance
(Focus to skin distance FSD often 10cm or less)
means the beam MUST be collimated on the skin
Cones are highly suitable to do this. Additional
shielding can be achieved using lead cutouts on the
skin
Output in superficial beam depends on:
On/off effect
Strong dependence on
FSD --> applicator length
significantly affects
output
Electron contamination
from the applicator
(significant for skin dose
around 100kVp)
Inverse
Square Law
Ramping up time
2000
1800
1600
1400
1200
output

1000
800
600
400
200
0
0 5 10 15 20 25 30
time (s)
Kilovoltage Equipment (10 - 150 kVp)
Filters are used to remove unwanted low energy
X-rays (which only contribute to skin dose)

Unfiltered

4.6 mm Cu
filter

Interlocks must
ensure that the
correct filter is in
place
Kilovoltage Equipment (10 - 150 kVp)
Dose rate is approx. proportional to kVpn where
2<n<3
Dose rate is approx. proportional to electron
current (mA)
Therefore it is important that kVp and mA are
stable.
It is also obviously important that the timer is
accurate and stable - and that the on/off effect is
accounted for.
Kilovoltage Equipment (10 - 150 kVp)

Dose control is achieved by a dual timer system -

one should count time up, one should count time
down from a pre-set treatment time

Interlocks must be present to prevent incorrect

combinations of kVp, mA, and filtration
 Radiation on
Operator control indicator

kV and mA
indicator
Dual timer

Emergency
off button
Selection
of filter
Key for
lock-up
Beam Half Value Layer (HVL)
Possibly the most important test to
characterize beam quality
Checks whether there is sufficient filtration in
the x-ray beam to remove damaging low energy
radiation
Need not only a radiation detector, but also
high purity (1100 grade) aluminium - most Al
has high levels of high atomic number
impurities eg. Cu
HVL Measurement
 Be careful of beam hardening
(semi-log plot is not a Dose
straight line) 10
 The second HVL is typically
larger than the first
 Calculate HVL :

(initial value = 9
50% of this = 4.5,
thus HVL = 2.6 mm Al)
1
0 1 2 3 4

mm Al
Orthovoltage therapy (deep therapy)
150 – 500 kV, 10 – 20 mA
Deeper skin lesions, bone
metastasis
applicators or diaphragm
FSD 30 to 60cm
beam quality in HVL copper
(0.2 to 5mm)
Kilovoltage Equipment (150 - 400 kVp)
Different applicators and filters

filters

Applicators for
different field
sizes and distances
Orthovoltage

units
Uses mostly cones
More recently also a
diaphragm with light
field has been
introduced. Care must
be taken to:
ensure correct distance
account for wide
penumbra due to large
focal spot
Kilovoltage Equipment (150 - 400 kVp)
The Inverse
Square Law is
important
Depth dose
dramatically
affected by FSD

FSD 6cm, FSD 30cm,

HVL 6.8mm Cu HVL 4.4mm Cu
Kilovoltage Equipment (150 - 400 kVp)
Control console mA and kV control

Dual timer

On and emergency
off button

Filter and kV selection

Kilovoltage Equipment (150 - 400 kVp)
It is possible to use a transmission ionization
chamber as the primary dose control system
instead of treatment time
The backup (secondary) dose control system can
be either an independent integrating dosimeter or
a timer
Alternatively, two independent timers are used -
this is the most common scenario
Clinical applications of kV therapies
Intraoperative radiotherapy – irradiation of tumor
bed or unresectable tumor tissue during surgery.
Energy ~ 50 kV
Whole skin irradiation (superficial kV beams), eg.
Mycosis fungoides, treat to d = 1 cm
Ocular treatments with superficial beams
BUT: Now electrons are commonly used to treat these
shallow and superficial lesions. Other treatment
techniques eg. Tomotherapy, brachytherapy
Problems with skin tolerance in kV therapy
Reddening & blistering of the skin (erythema , “skin
effect”) results with high radiation doses
Blistering at skin dose ~ 20 Gy in 1 fraction or 40 Gy in
4 weeks
Dose for kV treatments was usually determined by
skin tolerance
Skin sparing may be achieved by:
High beam energy
Fractionation
Multiple beams
Megavoltage therapy ( > 1 MV)
Co-60 therapy
Linear accelerator
Co-60
Radioisotope therapy
C0-60 decay produce
gamma rays with
photon energies
around 1.25MeV
2 lines at 1.17MeV and
1.33MeV
Higher energy – dose
sparing
Cobalt – 60 decay
Co-60
Photon energy
around 1.25MeV
Specific activity large
enough for FSD of
80cm or even 100cm
Therefore, isocentric
set-up possible
Evolution of radiotherapy
time margin

Fixed SSD RT

reduction
Isocentric RT better set-up Computer planning

Conformal RT better targeting 3D planning

IMRT better sparing Inverse planning

Image guided better Adaptive and/or 4D

RT individualisation planning
Isocentric set-up
Gamma-ray equipment
Isocentric set-up allows movement of all
components around the same centre

• collimator
• gantry
• couch
Control area of
a Co-60 unit
Dual timer control
Patient monitoring
lead glass
video system (CCTV)
Gamma-ray equipment
A more recent Cobalt 60 unit
Modern Cobalt 60 unit
Gamma-ray equipment
Source head and transfer mechanism
Gamma-ray equipment
Other source drawer transfer mechanisms
Moving jaws

Rotating source draw

Mercury shutter
(employed in the first
60-Co unit in 1951)
Gamma-ray

equipment
Source assembly:
The source must be
sealed so that it can
withstand
temperatures likely to
be obtained in
building fires
Dual encapsulation
is recommended to
avoid leakage
Source
assembly
Gamma-ray equipment
Limited half life: 60-
Co 5.26years
Source change
recommended every
5 years to maintain
output
Source transport
container

Treatment
unit head
Picture of a Co source change
Beam stopper

Transport
container
Radiation
survey meter

Treatment head
Gamma-ray equipment
Mechanical source position indicator

Essential to:
• indicate if source
is out of safe
• often coupled
with mechanical
device to push
source back if
stuck
Cobalt unit head for a source in a
rotating source draw

Beam on
indicator
Gamma-ray equipment
The beam control mechanism shall be a ‘fail
to safety’ type.This means the source will
return to the Off position in the event of:
end of normal exposure
any breakdown situation
interruption of the force holding the beam control
mechanism in the On position, for example failure
of electrical power or compressed air supply
Gamma-ray equipment
Geometric
penumbra
typically wide
because source
diameter is large
(>2cm)
Gamma-ray equipment
Penumbra
trimmer bars may
be employed to
reduce penumbra
width
 Gamma-ray equipment
Gantry rotation There should be
two independent
read-outs for all
mechanical
movements:
1. Electronic at
console and or
monitor in the
treatment room
2. Mechanical

Second non-
isocentrical rotational
axis for the 60-Co
source
Gamma-ray equipment
Leakage from the head with the source in the
Off position
max. 10 Gy h-1 at 1 metre from source
max. 200 Gy h-1 at 5 cm from housing
This can contribute a significant proportion of the
maximum permissible dose to staff
Gamma-ray
equipment
At commissioning, drawings of the head should
be examined to identify locations where radiation
leakage could be a problem.
Accurate ionization chamber readings should be
made at the location of any hot spots and also in
a regular pattern around the head.
Film wrap techniques can be used to identify
positions of ‘hot’ spots.
 Source Housing

Rotating wheel Hg flow Sliding drawer Moving jaws

Film wrapping technique
 Here shown with
only a single film on
a linac
 In practice film can
be wrapped around
all the treatment
head
 This technique is
useful also for other
treatment units such
as superficial and
orthovoltage. Never forget to mark and label the film
Gamma-ray equipment
Wipe tests should be carried out initially at
installation and at regular intervals to check for
surface contamination. This test need not be
carried out directly on the source surface and
can be carried out on a surface which comes
into contact with the source during normal
operation of the equipment.
Summary
While not ‘fashionable’, low to medium energy X-rays
and Cobalt-60 units have still a role to play
For kV X-rays: dosimetry tricky, patient set-up simple
For Co: full isocentric set-up, wide penumbra, reliable
Modern Co-60 uses
For calibration (Accredited Dosimetry Calibration
Laboratory)
Imaged guided RT when used in combination with
MRI (ViewRay)
Leksell Gamma Knife SRS
Co-60 Tomotherapy (Cadman & Bzdusek, MP vol
38, 2011)
Gamma knife head applicator
MR-Guided Cobalt Tomotherapy
Electromagnets 0.2 T ±
15 ppm over 40 cm
Image during
treatment ?
Beam Gating ?
Future MRS ?

Kron et al
J Med Phys (India)
References
IAEA Training Material on Radiation Protection in Radiotherapy,
Part 5 External Beam Radiotherapy Lecture 2: Equipment and
safe design
Khan, F. M. (2003). The Physics of Radiation Therapy.
Philadelphia, Lippincott Williams & Wilkins.
Metcalfe, P., Kron, T. and Hoban, P. (2007). The Physics of
Radiotherapy X-Rays and Electrons. Madison, Wisconsin,
Medical Physics Publishing.
Johns, H. E. and Cunningham, J. R. (1983). The Physics of
Radiology. Springfield, Charles C Thomas.
Morris, S. (2001). Radiotherapy physics and equipment. London,
Churchill Livingstone.
Stereotactic radiosurgery of large uveal melanomas with the gamma-knife
Ophthalmology 107, 2000, 1381–1387
View of the Leksell Gamma-
knife shortly before treatment
begins. The patient is
positioned on a hydraulically
movable table with his head
fixed in the stereotactic frame
within the collimator helmet.
For treatment, the table slides
through the then-open doors of
the radiation unit shown in the
background.
Stereotactic magnetic resonance image of the left eye with an 8.2-mm high uveal
melanoma. In the T1 sequence (A), the tumor cannot be clearly defined because of an
adjacent exudative retinal detachment. In the T2 sequence (B) of the same eye, the tumor
is clearly defined. The bottom row (C, T1 sequence; D, T2 sequence) demonstrates the
treatment plan: two focuses are chosen (red crosses) and the isodoses are set such that the
tumor is entirely encircled by the 50% isodose (yellow circle).
Find out more:
1. How do we get the Co-60 source?
2. What is the invention story of the clinical
Cobalt teletherapy unit?
3. How many Cobalt teletherapy
manufacturers are there today?
4. How does Cobalt compared with linac? In
terms of physical characteristics, treatment
efficacy, performance, etc.
Further Reading
The Uses of a Cobalt Unit for Radiotherapy
Paul Strickland Postgrad Med J 1958 34: 419-423
Cobalt60 as a source for Radiotherapy Editorial.
Radiology 1952 58(1): 113-