PRINCIPLES OF

RADIATION
ONCOLOGY
PRINCIPLES OF RADIATION
ONCOLOGY
 Ionizing radiation has been used in cancer
therapy since 1896 and currently plays a role in
the management of almost all types of cancer.
 Nearly 60% of all cancer patients undergo
radiation therapy sometime during the course
of their disease (50% for cure and 50% for
palliation)
 Radiotherapy is one of the two main methods
for the locoregional treatment of cancer.(the
other is surgery)
 The use of ionizing radiation implies the
understanding of some basic problems;
radiation physics; the radiation biology; the
relation with the tumor biology; clinical
consideration linked to planning of radiotherapy.
PRINCIPLES OF RADIATION
ONCOLOGY
 Radiation oncology is the clinical and
scientific discipline devoted to management
of patients with cancer (and other diseases)
with ionizing radiation (alone or combined
with other modalities) The aim of radiation
therapy is to deliver a precisely measured
dose of irradiation to a defined tumor volume
with minimal damage to surrounding healthy
tissue.This results in eradication of tumor,
high quality of life,prolongation of survival at
competitive cost, and allows for effective
palliation or prevention of symptoms of
cancer, including pain, restoring luminal
patency, skeletal integrity, organ function,
with minimal morbidity.
PRINCIPLES OF RADIATION
ONCOLOGY
 A cm3 tumor contains 10 million viable cells.
To eradicate such a tumor each cell must be
made incapable of reproduction (sterilized).
 THE GOAL of therapy should be defined at
the onset of therapeutic intervention;
CURATIVE- there is a probability of long-term
survival after adequate therapy; the goal is
to sterilize a targeted tumor completely while
preserving the integrity of surrounding
normal structures.
PRINCIPLES OF RADIATION
ONCOLOGY

PALLIATIVE; there is no hope of survival for

extended periods. Symptoms producing
discomfort require treatment. No major
iatrogenic conditions should be seen.
PRINCIPLES OF RADIATION
ONCOLOGY
 Methods of administering radiation;
Teletherapy (external beam radiotherapy)-from
sources at distance from the body;
Brachyterapy (the source of radiation is placed
adjacent to or within the tumor itself)
Nonsealed radionuclide therapy-systemic
irradiation from radioactive isotopes
administrated intravenously or via the
digestive tube.
TELETHERAPY
COBALT UNIT
LINEAR ACCELERATOR

Aplicatorul pentru
electroni
•PRINCIPLES OF RADITION
ONCOLOGY
Ionizing radiation is a form of electromagnetic or particulate
energy that during absorption causes ionization. Ionisation is
distributed through tissue.
Stages of radiation action are physical, (activated/excited or
ionizing molecules); physico-chemical stage (free radicals,
free atoms are produced by the interactions of secondary
electrons with water);chemical stage (free radical each other
and with the milieu).
Direct damage (of the excited or ionizing molecules) accounts
for 20-30% of radiation damage and indirect effect 70-80%
(produced by the free radicals)
Damages are mainly on DNA.
Biological stage represents the sequential response of the
organism to the irradiation. Radiation generates highly
reactive free radical molecules that irreparably alter the
cell’s DNA structure, thereby rendering the cell incapable of
proliferation
PRINCIPLES OF RADIATION
ONCOLOGY
 CLINICAL RESPONSE
A cell that has been sterilized by radiation may
appear to be histologically normal and
remain physiologically active but be unable
to reproduce. Actual cell death may not occur
until the time of cell division, when the cells
attempts to replicate faulty DNA. Therefore,
the time course of clinical response in any
tissue, normal or malignant, is determined by
rate of tissue turnover.
PRINCIPLES OF RADIATION
ONCOLOGY
 CLINICAL RESPONSE Rapidly proliferating
normal tissues (bone marrow and
gastrointestinal mucosa) and neoplasms
(small cell lung cancer and lymphoma)
generally exhibit cell loss within days or
weeks after the first dose of radiation;
however, normal tissues (nerves and
hepatocytes) and tumors with slow turnover
rates (well-dfferentiated prostatic carcinoma)
may not manifest cell loss for months to
years. The rate of response is characteristic
of the cell population.
PRINCIPLES OF RADIATION
ONCOLOGY
 Radiosensitivity and radioresistance-
 Radiosensitivity is the susceptibility of
tumoral cells to the lethal action of the
ionizing radiation.
A unit dose of ionizing radiation causes a
simillar degree of DNA damage in most cell
types.No tissue is intrinsically resistant to
radiation injury. The goal is to deliver enough
radiation to sterilize EVERY malignant cell.
With few exceptions, the number of
malignant cells is the major factor in
successful tumor control.
PRINCIPLES OF RADIATION
ONCOLOGY
 Modification of responses to
irradiation;extrinsec factors can modify the
degree of cellular radiosensitivity;oxygen,
radiosensitizers, radioprotectors,cytotoxic
chemotherapy.
PRINCIPLES OF RADIATION
ONCOLOGY
Probability of tumor control
Higher doses of irradiation produce
better tumor control. Numerous dose
response curves for a variety of
tumors have been published
Various levels of irradiation yield
different probabilities of tumor control,
depending on the histology and
number of clonogenic cells present
PRINCIPLES OF RADIATION
ONCOLOGY
Basis for prescription of irradiation -1-
 Evaluation of tumor extent.
 Knowledge of pathologic characteristic of the disease.
 Definition of goal of therapy (cure or palliation).
 Selection of appropriate treament modalities
(irradiation alone or combined with surgery,
chemotherapy, or both.
 Determination of optimal dose of irradiation and
volume to be treated, according to anatomic location,
histologic type, stage, potential regional nodal
involvement (and other tumor characteristics), and
normal stuctures in the region.
 Evaluation of patient’s general condition, plus periodic
assessement of tolerance to treatement, tumor
response,and status of normal tissue treated.
PRINCIPLES OF RADIATION
ONCOLOGY
Basis for prescription of irradiation-2-
 Radiation oncologist must work closely with physics,
treatment planning and dosimetry staffs to ensure
greatest accuracy, practicality and cost benefit in
design of treatment plans.
 Ultimate responsibility for treatment decisions,
technical execution of therapy and consequences of
therapy always rests with the radiation oncologist.
PRINCIPLES OF RADIATION
ONCOLOGY
Irradiation treatment planning
 Different irradiation doses are required for given
probabilities of tumor control, depending on tumor
type and the initial number of clonogenic cells
present. Varying radiation doses can be delivered to
specific portions of the tumor (periphery versus
central portion) or to the tumor bed in cases in which
all gross tumor has been surgically removed.
 International Commission on Radiation Units and
Measurements Reports Nos. 50 and 62 define the
following treatment planning volumes;
PRINCIPLES OF RADIATION
ONCOLOGY
 GTV Gross tumor volume; all known gross
disease
 CTV Clinical target volume; encompasses GTV
plus regions considered to harbor potential
microscopic disease.
 PTV Planning target volume; provides margin
around CTV to allow for internal target motion,
other anatomic motion during treatment (e.g.
respiration) and variations in treatment setup.
Treatment portals must adequately cover all
treatment volumes plus a margin to account for
beam physical characteristics, such as
penumbra.
PRINCIPLES OF RADIATION
ONCOLOGY COMBINATION OF THERAPEUTIC
MODALITIES

Combination of therapeutic modalities

Preoperative radiation therapy; rationale;
preoperative radiation therapy potentially
eradicates subclinical or microscopic disease
beyond the margins of surgical resection,
diminishes tumor implantation by decreasing
the number of viable cells within the
operative field, sterilizes lymph node
metastases outside the operative field,
decreases potential for dissemination of
clonogenic tumor cells that might produce
distant metastases, increase the possibility of
resectability.
Disadvantages; may interfere with normal
healing of tissues
PRINCIPLES OF RADIATION
ONCOLOGY
 Postoperative irradiation; may
eliminate residual tumor in the
operative field by destroing subclinical
foci of tumor cells after surgerycancer
 Disadvantages; delay in initiation of
irradiation until wound healing is
completed; vascular changes produced
in tumor bed by surgery may impair
radiation effect.
PRINCIPLES OF RADIATION
ONCOLOGY
Irradiation and chemotherapy
Enhancement is any increase in effect on
tumor or normal tissues greater than
observed with either modality alone