Principles of Radiation Therapy
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Principles of Radiation Therapy - Thomas J. Deeley
Principles of Radiation Therapy
THOMAS J. DEELEY, MB, ChB, FRCR, DMRT
Director, South Wales and Monmouthshire, Radiotherapy Service, South Glamorgan, Area Health Authority (Teaching) and Lecturer in The Welsh National School of Medicine
BUTTERWORTHS
Table of Contents
Cover image
Title page
Inside Front Cover
Copyright
Dedication
Preface
Chapter 1: Introduction
Publisher Summary
Chapter 2: Discoveries
Publisher Summary
THE BACKGROUND
WILHELM KONRAD ROENTGEN
THE CURIES AND RADIUM
Chapter 3: Developments
Publisher Summary
ERA OF DISCOVERY 1890-1900
DEVELOPMENT 1900-1910
TECHNICAL MACHINE DEVELOPMENT 1910-1920
OVERDOSAGE EFFECTS 1920-1930
RATIONALIZATION 1930-1940
MEGAVOLTAGE 1940-1950
DEVELOPMENT OF SUPERVOLTAGE TECHNIQUES 1950-1960
TECHNOLOGICAL ADVANCES 1960-1970
ONCOLOGY 1970-1974
CONCLUSION
Chapter 4: The Treatment of Malignant Disease
Publisher Summary
BENIGN TUMOURS
MALIGNANT TUMOURS
THE CLASSIFICATION OF TUMOURS
DIAGNOSIS
PREPARATION FOR TREATMENT
TREATMENT
PRINCIPLES OF RADIOTHERAPY
CONCLUSION
Chapter 5: Physics
Publisher Summary
ELECTROMAGNETIC RAYS
Chapter 6: The Treatment of Diseases using External Beam Therapy
Publisher Summary
EXTERNAL BEAM THERAPY MACHINES
THE ADVANTAGES OF MEGAVOLTAGE THERAPY
COMPARISON OF TREATMENT GIVEN WITH ORTHOVOLTAGE AND MEGAVOLTAGE
TREATMENT TECHNIQUES
TREATMENT PLANNING
SPECIAL FEATURES
SET-UP AND IMMOBILIZATION OF THE PATIENT
PATIENTS’ RECORDS
AN EXAMPLE OF PLANNING
Chapter 7: Radium
Publisher Summary
INTERSTITIAL
INTRACAVITARY RADIUM
SURFACE THERAPY
RADON SEEDS
REPLACEMENT OF RADIUM BY ARTIFICIAL RADIOACTIVE SOURCES
CONCLUSION
Chapter 8: Radioactive Isotopes
Publisher Summary
DIAGNOSTIC USES
THERAPEUTIC USES
Chapter 9: Radiation Protection
Publisher Summary
Chapter 10: Radiobiology
Publisher Summary
THE OXYGEN STORY
THE MODIFICATION OF RADIATION EFFECTS BY THE USE OF CHEMICALS
Chapter 11: Combined Treatments
Publisher Summary
RADIOTHERAPY AND SURGERY
RADIOTHERAPY AND CHEMOTHERAPY
Chapter 12: Radiation Effects on Normal Tissues
Publisher Summary
ACUTE REACTION
LATE FIBROSIS
RADIATION EFFECTS ON GROWING TISSUES
CARCINOGENESIS
Chapter 13: Aftercare
Publisher Summary
REHABILITATION
Chapter 14: The Organization of Radiotherapy Services
Publisher Summary
PERIPHERAL CLINICS
COMBINED CLINICS
EQUIPMENT
STAFF
ASPECTS OF WORK
Service
Research
Teaching
DISEASES TREATED
Chapter 15: Research in Radiotherapy
Publisher Summary
TREATMENT TECHNIQUES
SELECTION OF PATIENTS FOR TREATMENT
TREATMENT FOR DISSEMINATED DISEASE
NEW MODES OF TREATMENT
AFTERCARE
BASIC RESEARCH
Glossary
Bibliography
Index
Inside Front Cover
Other books on radiotherapy edited by T.J. Deeley
Carcinoma of the Bronchus
Gynaecological Cancer
Central Nervous System Tumours
Malignant Diseases in Children
Computers in Radiotherapy–Clinical Aspects
Modern Trends in Radiotherapy–1 and 2
Copyright
THE BUTTERWORTH GROUP
ENGLAND
Butterworth & Co (Publishers) Ltd
London: 88 Kingsway, WC2B 6AB
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Butterworths Pty Ltd
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Also at Melbourne, Brisbane, Adelaide and Perth
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Butterworths of New Zealand Ltd
Wellington: 26–28 Waring Taylor Street, 1
CANADA
Butterworth & Co (Canada) Ltd
Toronto: 2265 Midland Avenue, Scarborough, Ontario, M1P 4S1
USA
Butterworths (Publishers) Inc
Boston: 19 Cummings Park, Woburn, Mass. 01801
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, including photocopying and recording, without the written permission of the copyright holder, application for which should be addressed to the publisher. Such written permission must also be obtained before any part of this publication is stored in a retrieval system of any nature.
This book is sold subject to the Standard Conditions of Sale of Net Books and may not be re-sold in the UK below the net price given by the Publishers in their current price list.
First published 1976
© Butterworth & Co. (Publishers) Ltd. 1976
ISBN 0 407 00030 5
Library of Congress Cataloging in Publication Data
Deeley, Thomas J.
Principles of radiation therapy
Bibliography: p.
Includes index.
1. Radiotherapy. I. Title. [DNLM: 1. Neoplasms–Radiotherapy. 2. Radiotherapy. QZ269 D313r] RM847.D38 616.9′94′0642 75–6710 ISBN 0-407-00030-5
Typeset and Produced by Scribe Design, Medway, Kent
Printed in Great Britain by Chapel River Press, Andover, Hants.
Dedication
To my parent
JAMES and LOIS
Preface
Radiotherapy is a specialized branch of medicine involved with the treatment of malignant disease. It is essentially a postgraduate study and consequently few medical students have experience of its applications, its limitations, the techniques used, the results of treatment and possible complications. Some medical schools have now included a few lectures and demonstrations on the wider applications of this therapy but these provide little more than a cursory introduction. Whilst there are many excellent books written for the established radiotherapist they inevitably assume that the reader already has a working knowledge of the subject. Medicine is becoming increasingly complex and future progress demands understanding and co-operation between members of those disciplines concerned with the treatment of a particular disease; this is particularly true of malignant disease which is rapidly assuming a major role in health care. With this in mind this short elementary book is presented, written to assist the non-radiotherapist to understand a little of the practice of radiotherapy. It has been simplified, I trust not over-simplified, in the hope that it will also be of help to nurses, physiotherapists and other workers who care for the patient with malignant disease and would like to understand something of this speciality. It is concerned mainly with general principles of treatment and details of special techniques used for diseases at certain anatomical sites are not discussed in detail.
I am grateful to many people for their help in the preparation of this Monograph–to Dr. D. K. L. Davies for the radiographs, Mrs. T. C. Edwards for the isodose distributions, Mr. W. H. Sutherland and Mr. C. W. Smith for their help, Mr. R. Toogood for many of the photographs, Miss J. Williams and Miss S. Edwards for secretarial assistance and to the Tenovus Charities who have generously supported with secretarial help.
I am most grateful to the authors and publishers of two excellent books, The Treatment of Malignant Disease by Radium and X-Rays (1948) by Ralston Paterson published by Arnold, London, and A Concise Text-book of Radiotherapy (1972) by Dr. F. A. Barnes and Dr. D. J. Rees published by Faber & Faber, London, who have given permission to reproduce certain diagrams. In addition it is a pleasure to acknowledge the help of three industrial organizations who have given their permission to reproduce photographs of their machines: Siemens Aktiengesellschaft, Sierex Limited and Radiation Dynamics Limited; in particular I would like to thank Dr. R. Radakovic, Mr. W. P. Wilson and Mr. T. Chippendale respectively of these three firms. Reference has been made in the text in the appropriate places.
The preparation of any publication needs considerable time not allowed for in the organization of a busy service department; I am therefore grateful to my wife, Della, and my children, Owen and Rosemary, for their forbearance.
Finally it is a pleasure to thank the staff of Butterworths for their willing assistance. A tremendous effort has been necessary to convert my very rough diagrams into the artistic figures presented here; the editorial staff have had considerable problems but have expertly overcome them as usual.
J. Deeply Thomas
ONE
Introduction
Publisher Summary
This chapter focuses on the treatment of malignant disease. Benign tumors grow slowly and never metastasize or invade the adjacent tissues but may produce symptoms by their expansion. On the other hand, malignant tumors run a more serious course and will inevitably result in death if not removed or controlled. On the whole, they tend to grow more rapidly than benign tumors, and they may contain numerous mitoses, many of which may be abnormal. Malignant tumors may spread out into the adjacent normal tissues by arm-like processes that grow more rapidly in loose tissues and are held up by more solid tissues such as bone or cartilage. Malignant tumors have the power to disseminate and affect the prognosis. The treatment of malignant disease may be surgery, radiotherapy, chemotherapy or a combination of two or all of these. However, if cure and control are not feasible and if there are no distressing symptoms to palliate, no active treatment is given.
While the general public are normally aware of most hospital specialities, some confusion often exists about the work of the diagnostic radiologist, the radiotherapist and the radiographer. A diagnostic radiologist uses ionizing radiation, usually x-rays, to help in the diagnosis of certain diseases, by providing photographic records of parts of the body or of certain functions carried out by the body; certain contrast media may help to define certain structures and he is an expert in inserting such substances in the most inaccessible parts of the body. A radiotherapist uses ionizing radiation, mainly x-rays and gamma-rays to treat certain diseases, the majority being malignant. He is a clinician responsible for the full care of the patients in his wards or those having treatment in the department. A radiographer can work either in a diagnostic department or a therapeutic department and is responsible for taking films or for giving treatment under medical direction.
The study of radiology is not yet 80 years old and is still in a state of development. At one time it was possible to specialize in both diagnosis and therapy, but the increasing complexities of both branches now make it impossible for one man to have an overall experience of both. In this country the two have been separate for many years and sub-specialities have grown up within each branch-for example, neuroradiology, gastrointestinal diseases, paediatric radiology in diagnosis; therapists may specialize in the treatment of certain tumours, reticuloses, central nervous system, bronchus and so on.
The radiotherapist, according to Professor Franz Buschke of the Tumor Institute, Swedish Hospital, Seattle, Washington, U.S.A., should have a fundamental knowledge in gross and microscopic pathology and of diagnostic techniques for cancer in all locations; judgement as to the indication for and knowledge of the pharmacology and techniques of application of chemotherapeutic agents; a comprehensive understanding of physics, the clinical indication for and the application of techniques of treatment by x-rays, radium and radioactive isotopes plus a knowledge of the general care and psychological management of the patient with malignant disease.
To these requirements must be added a wide knowledge of malignant disease at all sites, its incidence, aetiological factors, symptomatology, methods of diagnosis, other treatment techniques, aftercare and palliation. In recent years we have adopted the term ‘oncology’ to cover the study of all aspects of malignant disease. The radiotherapist must of necessity be an oncologist; in fact, he has practised as such for many years. Oncology is not a medical speciality but a concept; no one person is able to cover with expert knowledge the whole field of this study. He may be concerned with a specific aspect, as an epidemiologist, a surgeon, a pathologist and so on but whatever his particular interests are he will benefit from at least an elementary knowledge or familiarity with the other specialities. A radiotherapist perhaps covers more of the whole oncological concept than any other clinician. He needs to know of the surgical possibilities in a particular disease even though he does not carry out surgical procedures; if the results are better with surgery than with radiotherapy then that is the treatment of choice; if radiotherapy is unsuccessful the possibility of further treatment by surgical or other methods must be considered. The radiotherapist needs to know the pathological characteristics of a tumour because these frequently have bearing on the treatment, the search for possible metastases and the frequency of follow-up examinations. Thus we can go on detailing the experience needed by the radiotherapist so that he can function fully as a clinical oncologist. While consultants in other specialities are concerned with aspects of the study of malignant disease within their speciality few limit their activities to cancer as does the radiotherapist. In addition to his own clinical responsibilities the radiotherapist must seek co-operation with many other workers, in such specialities as surgery, gynaecology, haematology, ear, nose and throat diseases, holding joint consultative clinics whenever possible.
It would be wrong to give the impression that the radiotherapist is a scientist dealing with complex high-powered machines; that he is solely concerned with complicated mathematical calculations of dosimetry requiring a slide rule, calculating machine or computer; or involved in radiobiology so that he can assess the effects of radiation on animal and vegetable organisms. He is not a scientist but a clinician concerned with the treatment aspects of malignant disease in patients and continually striving to improve the