Radiation Therapy Machines

TAWEAP SANGHANGTHUM, PhD

Medical Physicist
Chulalongkorn University!
 Objectives

l  To become familiar with different radiation

types used for external beam radiotherapy
l  To understand the basic principle of
teletherapy machines and support equipment
used for EBT delivery
l  To describe the methods of brachytherapy
 Aim of Radiotherapy

l  One
of the main treatment
modalities for cancer (often in
combination with chemotherapy
and surgery)

l  Minor role in other diseases

 Radiotherapy

Teletherapy Brachytherapy
S. far from TM S. near by TM
External Beam Radiotherapy Process

Simulation! Tx Planning! Planning Veri.! Tx Field Veri.! Tx Delivery!

86.60cm
100 cm

2.85 cm inherent buildup

(equivalent to 3.28g/cm 2)
Chamber holder
Acrylic insertion
Diode detector

Treatment Couch

5!
 1. Conventional Simulator
-  Diagnostic X-ray replaced Megavoltage
-  High contrast image

-  Less destructive

-  Fluoroscopic imaging for real time display of

organ motion and beam placement/adjustment
-  High efficiency

!
 1. Conventional Simulator
Rotating
Diagnostic
gantry
X-ray tube

Radiation beam
defining system

Imager
Simulator exact
Rotating couch couch
1. Conventional Simulator
Limitation

2D image
 1. Conventional Simulator
Planning with Acuity cone-beam CT imaging

Option for 3D
as Sim-CT

-not good image

quality
 2. CT simulator
A CT-simulator
consists of a CT-scanner
with a flat table top, laser
patient positioning and
marking system, CT-
simulation software, and
hardcopy output.
 Special design of CT scanner

l  Large aperture
l  Flat couch top

l  External lasers

l  Virtual simulation
software
 DRR image

CTsim. System can generate Digitally Reconstructed

Radiograph (DRR) from CT slices
Virtual Simulation
 CT-Sim Advantages
CT image is the gold standard for treatment planning
- Electron density information
- standard dose calculation
- Good bone definition
- Accurate geometry
- Improved target definition for some cases (e.g.lung)
- Established motion management technique (4DCT)
- Fast scan & low cost (compared with MRI)
Electron density Information
 Limitation of CT
Brain tumor

Brain stem? Lesion?

3. MRI simulator
Advantages of a MRI-based treatment process

l  Excellent soft tissue contrast (many sequences selection)

- accurate target definition
l  Use of non-ionizing radiation
 3. MRI simulator
•  GE Signa HDxt 1.5T with oncology package
Open Bore
 MRI-based patient simulation
Consideration
l  MRI bore size
- image patient in treatment position with immobilization devices

l  MRI-compatible immobilization devices

l  Flat couch top similar to treatment couch
l  Image distortions
l  No electron density relationship
 CT/MR Registration

=
+
Good for plan
CT MR
• Good bone definition • Good lesion definition
• Standard for Dose Calulation • Nerves and misc. info
• Accurate geometry • No density Information
• Distorsion Issues
 4. PET-CT simulator

imaging of glucose
metabolism using
18F-FDG as a
radiopharmaceutical
 Immobilization
l  Used to reduce the patient
setup uncertainty

HipFix System
External Beam Radiotherapy Process

Simulation! Tx Planning! Planning Veri.! Tx Field Veri.! Tx Delivery!

86.60cm
100 cm

2.85 cm inherent buildup

(equivalent to 3.28g/cm 2)
Chamber holder
Acrylic insertion
Diode detector

Treatment Couch

24!
 Treatment & Planning Techniques!

l  2D (conventional radiotherapy)
l  3D-CRT (conformal radiation therapy)

l  Advanced Technique
•  Dynamic Arc!
•  4D (3D+time)
•  IMRT (Intensity Modulated Radiation Therapy)
•  VMAT (Volumetric Modulated Arc Therapy)!
External Beam Radiotherapy Process

Simulation! Tx Planning! Planning Veri.! Tx Field Veri.! Tx Delivery!

86.60cm
100 cm

2.85 cm inherent buildup

(equivalent to 3.28g/cm 2)
Chamber holder
Acrylic insertion
Diode detector

Treatment Couch

26!
 Simulation to Treatment

Patient Planning treatment

-Determination of interest
simulation: volumes: GTV, CTV, PTV, OR Treatment
CT, MR… -Conformation-beams

Differences in
target position
 Image Guided Radiation Therapy

l  How can we know the position of the target?

IGRT

■  What is IGRT for field verification?

IGRT is the use of the image in the actual treatment
room as a tool for tracing and verification of the tumor
volume immediately before or during treatment.
 Why do we neeed IGRT ?

Complex region & High dose gradients

Why do we neeed IGRT ?
Daily set up variation

DRR (Ref) IGRT (kV)

 Why do we neeed IGRT ?

Cancer of the cervix

with effect of
bladder & rectum
filling

Sagittal images

Chan, Dinniwell, et al,

Why do we neeed IGRT ?
Pt Weight Loss
Why do we neeed IGRT ?
Tumor shrinkage

•  14 cervical cancer patients

•  MRI prior to RT and after 30 Gy
•  GTV decreased (on average) by 46%
Many different systems
available... IGRT

Ionizing rad. Non-Ionizing rad.

- Ultrasound
- Electromagnetic (Calypso)
2D 3D 4D - Surface imaging (AlignRT,
CRAD)
- Plain film
- CT on rail!
- EPID (MV)
- MVCT (Tomo)
- OBI/XVI
- CBCT (kV/MV)
- ExacTrac

34!
 2D Portal Radiographic Film

Limitation
l  It is not real time display
 2D MV; Electronic Portal Imaging Device

EPID
real-time
verification

- Based on bony
landmarks
- 1 isocenter

The technology can identify patient positioning errors so corrective

action can be taken before the dose of radiation is delivered.
 2D Orthogonal kV X-ray

Floor-mounted system

Ceiling-mounted system

Gantry-mounted system (OBI)

CBCT

Varian
CBCT

Elekta SynergyTM
VolumeView
 Electromagnetic (Calypso)
!
Wireless miniature
Electromagnetic Transponders ! Real Time Tracking of Target Motion

Passive
39!
Surface Imaging

IGRT Before and During

treatment

The limitation of
surface imaging is no
visualization of
internal anatomy
 Inroom-MRI
kV-CBCT 90s ViewRay MR

ViewRay system
(3Co sources + 0.35T MR scanner)
FDA approved !
External Beam Radiotherapy Process

Simulation! Tx Planning! Planning Veri.! Tx Field Veri.! Tx Delivery!

86.60cm
100 cm

2.85 cm inherent buildup

(equivalent to 3.28g/cm 2)
Chamber holder
Acrylic insertion
Diode detector

Treatment Couch

42!
 Radiation Therapy Machines!

Teletherapy machines can be divided by……

1.  Energy
- kilovoltage
- megavoltage
2.  Type of radiation!
- X-ray, γ-ray
- particle e.g. electron, neutron
 Radiation Therapy Machines!

Kilovoltage Unit
A. Grenz-Ray Therapy < 20 kV
B. Contact Therapy 40-50 kV
C. Superficial Therapy 50-150 kV
D. Orthovoltage Therapy 150-500 kV
E. Supervoltage Therapy 500-1000 kV!
 Orthovoltage x-rays

Cooling
water Target

Contact x-rays Superficial x-rays

Radiation Therapy Machines!

Megavoltage Unit
F. Van de Graff
G. Betatron
H. Microtron
I. Cyclotron!
J. Cobalt-60 Unit
K. Linear Accelerator!
Radiation Therapy Machines!

Microtron
Van de Graff
Co-60 machines!

High specific activity

and exposure rate
constant

1.  Source head

2.  Collimator

3.  Gantry

4.  Couch!
 Co-60 machines!

Source!
• The 60Co source is produced by irradiating
ordinary stable 59Co with neutrons in a reactor
• The nuclear reaction can be represented by
59Co (η,γ) 60Co
Cobalt – 60 decay
 Co-60 machines!

Source
assembly
Gamma knife head applicator

- Used for stereotactic brain irradiations

- 201 sources of Co-60 around a patients head
Patient in gamma knife collimator head
 Linear Accelerator!

The linac is a device that used high-

frequency electromagnetic waves to

accelerate charged particles to high energies

through accelerator tube

 Linac
Electron X-rays
For superficial TM For deep TM

4-25 MeV 4-18 MV

The major components of linac!
 Treatment Head!

X-RAY TARGET!

FLATTENING FILTER!
SCATTERING FOIL!

Electron mode! X-ray mode!

 Photon PDD!

PHOTONS ELECTRONS

Linac beams
 Dose Distribution!

Photon Electron
 TREATMENT HEAD!

bending
magnet!

accelerating tube!

different flattening
filters and scattering
foils on a ‘carousel’!

monitor
chambers!

collimators!
Cyber Knife Tomotherapy
Particle Therapy Treatment
 Particle Beam Radiotherapy
P from cyclotron and C from synchrotron are commonly used
187 MeV
•  Relatively low entrance
dose (plateau)
•  Maximum dose at depth
(Bragg peak)
•  Rapid distal dose fall-off
(has finite range)
•  RBE = 1 for proton
= 3 for carbon
 Medulloblastoma
PHOTONS dose bath

100%

60%

PROTONS
10%
 Brachytherapy Process

Insert X-ray with QA source Tx planning! Loading

applicator! dummy! position! source!
 Brachytherapy Types

Permanent Implants
Short half life with low energy:
- I-125 (60 days; 28 keV)
- Pd-103 (17 days; 21 keV)

Temporary Implants
Long half life with high energy
Ra-226, Cs-137, Co-60, Ir-192
 Brachytherapy Machine

Ir-192 source
γ-rays

energy 0.38 MeV

T1/2 = 74.2 days!

Small tumor
- primary
- after teletherapy
Not too close to vital structure!
Intracavitary

Most common
brachytherapy

- cervix cancer
Surface Mould
Implantation
Electronic Brachytherapy
 IORT with INTRABEAM®
Radiation Delivery to the Tumor Bed

Example: Tumor bed after X-Ray Source in

Breast tumor lesion wide local excision place for radiation
delivery
Treatment of Breast Tumors