Basic Radiation Oncology

Foreword to First Edition
Preface
Acknowledgments
Contents
Authors and Contributors
About the Authors
Contributors
Introduction and History
1: Radiation Physics
1.1 Introduction and Atom
1.2 Radiation
1.2.1 Photon
1.2.1.1 Common Features of Electromagnetic Radiation [4, 5]
1.3 Ionizing Radiation
1.3.1 Ionizing Electromagnetic Radiation
1.3.1.1 X-Rays
1.3.1.2 Gamma (γ) Rays
1.3.2 Ionizing Particulate Radiation
1.4 The Interaction of Radiation with Matter
1.4.1 Photoelectric Effect
1.4.1.1 Photoelectric Effect (Fig. 1.20)
1.4.2 Compton Effect
1.4.2.1 Compton Effect (Fig. 1.23)
1.4.3 Pair Production
1.4.3.1 Pair Production
1.4.4 Coherent Effect (= Rayleigh Scattering, = Thomson Scattering)
1.5 Specific Features of X-Rays
1.6 Specific Features of Electron Energies
1.7 Ionizing Radiation Units
1.8 Radiotherapy Generators
1.8.1 Kilovoltage Machines (<500 kV)
1.8.2 Megavoltage Therapy Machines (>1 MV)
1.8.3 Cobalt-60 Teletherapy Unit
1.8.4 Treatment Head and Collimator (Figs. 1.37 and 1.38)
1.8.5 Gantry
1.8.6 Linear Accelerator (Linac)
1.8.7 Magnetron (Fig. 1.39) [24]
1.9 Measurement of Ionizing Radiation
1.9.1 Portable Measuring Equipment
1.9.2 Ionization Chamber [25]
1.9.3 Geiger–Müller Counter (GM Counter)
1.9.4 Film Dosimeters [25]
1.9.5 Thermoluminescence Dosimeters (TLD) [25]
1.9.6 Other Measuring Equipment
1.9.6.1 Electron Spin Resonance (ESR)/Alanine Dosimeter [25]
1.10 Radiation Dosimetry
1.10.1 Phantom
1.10.2 Definition of Beam Geometry
1.10.3 Build-Up Region
1.10.4 Half-Value Layer (HVL)
1.10.5 Percentage Depth Dose (PDD)
1.10.6 Isodose Curves
1.10.7 Ionization Chamber in a Water Phantom
1.10.8 Dose Profile
1.10.8.1 General Features of a Water Phantom System
1.10.9 Penumbra
1.10.9.1 Types of Penumbra
1.10.10 Inverse Square Law
1.10.11 Backscatter Factor (BSF)
1.10.12 Tissue to Air Ratio (TAR)
1.10.13 Tissue Maximum Ratio (TMR)
1.10.14 Scatter Air Ratio (SAR)
1.10.15 Collimator Scattering Factor (S c)
1.10.16 Phantom Scattering Factor (S p)
1.10.17 Monitor Unit (MU) Calculation in a Linear Accelerator
1.10.18 Treatment Time Calculation in a Co-60 Teletherapy Unit
1.11 Beam Modifiers
1.11.1 Bolus
1.11.2 Compensating Filters
1.11.3 Wedge Filters
1.11.4 Shielding Blocks
1.11.5 Multileaf Collimator (MLC)
1.12 Pearl Boxes
References
2: Radiobiology
2.1 Cell Biology and Carcinogenesis
2.1.1 Cell Structure
2.1.2 Cell Types and Organelles
2.1.3 Cell Cycle
2.1.3.1 The Stages of Mitosis [4]
Prophase (Fig. 2.6)
Metaphase (Fig. 2.7)
Anaphase (Fig. 2.8)
Telophase (Fig. 2.9)
2.1.3.2 Interphase and Its Stages [4, 5]
2.1.4 Carcinogenesis and the Cell Cycle
2.1.4.1 Eukaryotic Cell Populations [8]
2.1.5 Features of Cancer Cells
2.1.5.1 Unique Features of Cancer Cells [9, 10]
2.2 Cellular Effects of Radiation
2.2.1 The Direct Effect of Radiation at the Molecular Level
2.2.2 The Indirect Effect of Radiation at the Molecular Level
2.3 Factors Modifying the Biological Effects of Ionizing Radiation
2.3.1 Characteristics of the Radiation
2.3.1.1 Linear Energy Transfer (Table 2.2) [15]
2.3.1.2 Dose Rate [20]
2.4 Target Tissue Characteristics
2.4.1 Whole Body Dose Equivalent [17]
2.4.2 Effective Dose [17]
2.4.3 Relative Biological Effect (RBE) [21, 22]
2.4.4 Overkill Effect
2.5 Target Theory
2.6 Cell Survival Curves
2.6.1 Surviving Fraction [26, 27]
2.6.2 Exponential Survival Curves
2.6.2.1 Shouldered Survival Curves with Zero Initial Slope
2.6.2.2 Shouldered Survival Curves with Nonzero Initial Slope
Components of Shouldered Survival Curves with Nonzero Initial Slope (Fig. 2.23) [16, 27, 28]
2.6.3 Linear–Quadratic Model (LQ Model)
2.6.3.1 Models Used Before the LQ Model
2.6.3.2 In Head and Neck and Lung Cancers
2.6.4 Types of Cellular Damage Due to Radiation
2.6.5 Factors Affecting the Cell Survival Curve
2.7 Tissue and Organ Response to Radiation
2.7.1 Bergonie and Tribondeau Law [40]
2.7.1.1 Michalowski Tissue Sensitivity Classification [41]
2.7.2 Factors Determining Radiation Damage According to Ancel and Vintemberger [42]
2.7.3 Rubin and Casarett Tissue Sensitivity Classification [43]
2.7.3.1 Parallel Organs [45]
2.8 Stochastic and Deterministic Effects
2.8.1 Deterministic Effect [46]
2.8.2 Stochastic Effects [46]
2.9 Tumor Response to Radiation
2.9.1 Therapeutic Index
2.9.2 Tumor Control Probability (TCP)
2.9.3 Normal Tissue Complication Probability (NTCP)
2.9.3.1 The Clinical Importance of TCP and NTCP [49–51]
2.9.3.2 Therapeutic Ratio
2.10 The Five R’s of Radiotherapy
2.10.1 Repopulation
2.10.1.1 The Consequences of Proliferation
2.10.2 Repair
2.10.3 Redistribution (= Reassortment)
2.10.4 Reoxygenation
2.10.5 Radiosensitivity (Intrinsic Radiosensitivity)
2.11 Fractionation
2.12 Radiobiology of SBRT/SABR
2.13 Radiation Protection
2.14 Pearl Boxes
2.14.1 Radiation Hormesis
2.14.2 Abscopal Effect
2.14.3 Bystander Effect
2.14.4 Avalanche Phenomenon
2.14.5 Radiation Recall Phenomenon
2.14.6 Normalized Total Dose (NTD2 Gy)
2.14.7 Normal Tissue Toxicity After Stereotactic Body Radiation (SBRT)
References
3: Clinical Radiation Oncology
3.1 Introduction and History
3.1.1 Radiotherapy Types According to Aim
3.1.2 Radiotherapy Types According to Timing
3.1.3 Radiotherapy Types According to Mode
3.2 The Radiotherapy Procedure
3.2.1 Simulation
3.2.1.1 Conventional Simulation Steps
3.2.1.2 Parameters that Should Be Written on the Simulation Film
3.2.1.3 CT Simulation (Fig. 3.10)
3.2.2 Treatment Planning
3.2.2.1 Conventional Planning
Therapies Utilizing Megavoltage Energy
Therapies Utilizing Electron Energy
3.2.2.2 Conformal Planning
3.2.3 Target Volume Definitions
3.2.3.1 Volume Definitions According to ICRU 50 (Fig. 3.19) [4]
3.2.3.2 Volume Definitions According to ICRU 62 (Fig. 3.20) [5]
3.2.3.3 Uncertainties in the Volume Definitions in ICRU 62 [6]
3.2.3.4 ICRU 71[7]
3.2.3.5 ICRU 78 (Fig. 3.21) [6, 7]
3.2.4 Setup and Treatment
3.2.5 Quality Assurance
3.2.6 Treatment Fields in Radiotherapy
References
4: Central Nervous System Tumors
4.1 Introduction
4.2 Anatomy
4.2.1 Brain (Fig. 4.2) [2]
4.2.2 Brain Ventricles [2]
4.2.3 Spinal Cord (Fig. 4.4) [3]
4.3 General Presentation and Pathology
4.3.1 Spinal Cord Tumors [5]
4.3.2 Brain Tumors [1]
4.4 Staging
4.5 Diagnostic Imaging
4.6 Treatment
4.6.1 Low-Grade CNS Tumors
4.6.1.1 Radiotherapy Timing for Low-Grade CNS Tumors
4.6.1.2 Radiotherapy Dose for Low-Grade CNS Tumors
4.6.1.3 Chemotherapy for Low-Grade CNS Tumors
4.6.1.4 Chemotherapy Alone for Low-Grade CNS Tumors
4.6.2 High-Grade CNS Tumors
4.6.3 Primary CNS Lymphoma (PCNSL)
4.6.4 Meningiomas
4.6.5 Pituitary Tumors
4.6.6 Arteriovenous Malformations
4.6.7 Vestibular Schwannoma
4.6.8 Primary Medulla Spinalis Tumors
4.6.9 Medulloblastoma
4.6.10 Brain Metastasis
4.7 Radiotherapy
4.7.1 External Radiotherapy
4.7.1.1 Brain Tumors
4.7.1.2 Conformal Planning
4.7.1.3 Dose
4.7.2 Craniospinal RT
4.7.2.1 Gap Calculation
4.7.2.2 Radiotherapy in Spinal Tumors
4.7.2.3 3-Dimensional Conformal RT/IMRT (Tables 4.2, 4.3, 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, 4.10, and 4.11)
4.7.3 Symptomatic Treatments
4.7.3.1 Symptoms of Increased Intracranial Pressure and Spinal Cord Compression
4.7.3.2 Temozolomide Concurrent with RT
4.7.3.3 Temozolomide After RT (Adjuvant)
4.7.4 Side Effects of CNS Radiotherapy
4.7.4.1 Hippocampal-Sparing Whole-Brain Radiotherapy
4.8 Selected Publications
4.8.1 Low-Grade Glial Tumors
4.8.2 Radiotherapy Timing
4.8.3 Grade III Glial Tumors
4.8.4 High Grade (III–IV) Glial Tumors
4.8.5 RT Dose
4.8.6 RT Fields (Whole Brain Vs. Localized Field)
4.8.7 Fractionation
4.8.8 Temozolomide
4.9 Pearl Boxes
4.9.1 Good Prognostic Factors in Low-Grade Glial Tumors
4.9.2 Prognostic Factors in High-Grade Tumors
4.9.3 Tumors Capable of Subarachnoid Seeding via CSF
4.9.4 CNS Tumors That Can Metastasize Outside the CNS
References
5: Head and Neck Cancers
5.1 Tips for Delineating the Neck
5.2 Target Volume Determination and Delineation for the Neck
5.3 Pharyngeal Cancers
5.3.1 Nasopharyngeal Cancer
5.3.1.1 Pathology
5.3.1.2 General Presentation
5.3.1.3 Staging
5.3.1.4 Treatment Algorithm
5.3.1.5 Radiotherapy
5.3.1.6 Selected Publications
5.3.2 Oropharyngeal Cancer
5.3.2.1 Pathology
5.3.2.2 General Presentation
5.3.2.3 Staging
5.3.2.4 Treatment Algorithm
5.3.2.5 Radiotherapy
5.3.2.6 Selected Publications
5.3.3 Hypopharyngeal Cancer
5.3.3.1 Pathology
5.3.3.2 General Presentation
5.3.3.3 Staging
5.3.3.4 Treatment Algorithm for Hypopharyngeal Cancer [21]
5.3.3.5 Radiotherapy
5.3.3.6 Selected Publications
5.4 Laryngeal Cancer
5.4.1 Pathology
5.4.2 General Presentation
5.4.3 Staging
5.4.4 Treatment Algorithm
5.4.5 Radiotherapy (Figs. 5.26 and 5.27)
5.4.6 Selected Publications
5.5 Oral Cavity Cancers
5.5.1 Pathology
5.5.2 General Presentation
5.5.3 Staging (Table 5.8)
5.5.4 Treatment Algorithm [21]
5.5.5 Radiotherapy (Figs. 5.31, 5.32, 5.33, and 5.34)
5.5.6 Selected Publications
5.6 Sinonasal Cancers
5.6.1 Pathology
5.6.2 General Presentation
5.6.3 Staging
5.6.4 Treatment Algorithm
5.6.5 Radiotherapy
5.6.6 Selected Publications
5.7 Major Salivary Gland Tumors
5.7.1 Pathology
5.7.2 General Presentation
5.7.3 Staging
5.7.4 Treatment Algorithm
5.7.5 Radiotherapy (Figs. 5.43 and 5.44)
5.7.6 Selected Publications
5.8 Thyroid Cancer
5.8.1 Pathology
5.8.2 General Presentation
5.8.3 Staging
5.8.3.1 Treatment Algorithm
5.8.4 Radiotherapy
5.8.5 Selected Publications
5.9 Radiotherapy in Unknown Primary Head–Neck Cancers (Table 5.9)
5.10 Selected Publications for Head and Neck Cancers
5.11 Pearl Boxes
References
6: Lung Cancer
6.1 Introduction
6.1.1 Nonsmall Cell Lung Cancer (NSCLC)
6.1.1.1 Pathology
6.1.1.2 Major Changes in WHO 2015 Lung Cancer Classification:
6.1.1.3 General Presentation
6.1.1.4 Staging
AJCC/UICC Eighth Edition [14]
6.1.1.5 Treatment Algorithm
Stereotactic Body Radiation Therapy (SBRT)
6.1.1.6 Radiotherapy
Conventional (2D) Radiotherapy
Developmental Steps in Radiotherapy Techniques for NSCLC
Conventional Definitive RT Doses
Brachial Plexus Contouring
6.1.1.7 Selected Publications
6.2 Small Cell Lung Cancer (SCLC)
6.2.1 Pathology
6.2.2 General Presentation
6.2.3 Staging
6.2.4 Treatment Algorithm
6.2.5 Radiotherapy
6.2.6 Selected Publications
References
7: Breast Cancer
7.1 Pathology
7.2 General Presentation
7.3 Staging
7.4 Treatment Algorithm
7.5 Radiotherapy
7.6 Selected Publications
References
8: Genitourinary System Cancers
8.1 Prostate Cancer
8.1.1 Pathology
8.1.2 General Presentation
8.1.3 Staging
8.1.3.1 Histopathologic Grade (G)
8.1.3.2 Imaging
8.1.4 Treatment Algorithm
8.1.5 Radiotherapy
8.1.5.1 Relative Indications
8.1.5.2 Simulation
8.1.6 Selected Publications
8.1.6.1 PSA Relapse Definition After RT
8.1.6.2 Dose escalation
8.1.6.3 Altered Fractionation
8.1.6.4 Pelvic Field RT
8.1.6.5 Hormonal Therapy + Radiotherapy
8.1.6.6 Stereotactic Body Radiation Therapy (Ultrahypofractionation)
8.1.6.7 Prostatectomy ± RT
8.1.6.8 Adjuvant Versus Early Salvage Radiotherapy
8.1.6.9 Oligometastatic Disease
Radiotherapy to Primary
Radiotherapy to Metastases
8.1.6.10 IMRT
8.1.6.11 Surveillance vs. Prostatectomy
8.2 Testicular Cancer
8.2.1 Pathology
8.2.1.1 General Presentation
8.2.1.2 Staging
8.2.2 Treatment Algorithm
8.2.3 Radiotherapy
8.2.3.1 Selected Publications
8.3 Bladder Cancer
8.3.1 Pathology
8.3.2 General Presentation
8.3.3 Staging
8.3.4 Treatment Algorithm
8.3.5 Radiotherapy
8.3.6 Selected Publications
References
9: Gynecological Cancers
9.1 Cervical Cancer
9.1.1 Pathology
9.1.1.1 The WHO Cervical Cancer Classification [2–4]
9.1.2 General Presentation
9.1.2.1 Early Period
9.1.2.2 Late Period
9.1.3 Staging
9.1.3.1 FIGO Staging (Fig. 9.2) [6]
9.1.3.2 Lymphatics of Cervix Cancer (Fig. 9.3)
9.1.4 Treatment Algorithm
9.1.4.1 Treatment Algorithm for Cervix Cancer [7–10]
9.1.4.2 Prognostic Factors [14]
9.1.5 Radiotherapy
9.1.5.1 External Radiotherapy
External Radiotherapy Fields [15–17]
Prophylactic Para-Aortic Irradiation
9.1.5.2 Brachytherapy
Radioactive Sources Used in Brachytherapy
Source Loading Types in Brachytherapy
Two-Dimensional Point-Based Brachytherapy
Dose Prescription Points (Fig. 9.12)
Three-Dimensional Volume-Based Brachytherapy [25–27]
The Application of Intracavitary Brachytherapy
9.1.6 Selected Publications
9.2 Endometrial Cancer
9.2.1 Pathology
9.2.2 General Presentation
9.2.3 Staging
9.2.3.1 FIGO Staging for Endometrial Cancer (Fig. 9.17) [29]
9.2.3.2 Endometrial Cancer Lymphatics (Fig. 9.18)
9.2.3.3 Prognostic Factors [31, 34]
9.2.4 Treatment Algorithm for Endometrial Cancer [35]
9.2.4.1 Special Situations
9.2.5 Radiotherapy [15, 16]
9.2.5.1 Brachytherapy [37, 38]
9.2.5.2 Dose–Fractionation
9.2.6 Selected Publications
9.3 Vaginal Cancer
9.3.1 Pathology
9.3.2 General Presentation
9.3.3 Staging
9.3.3.1 FIGO Staging (Fig. 9.24) [40, 43]
9.3.3.2 Lymphatics of Vagina (Fig. 9.25)
9.3.4 Treatment Algorithm
9.3.4.1 Treatment Algorithm for Vaginal Cancer [39, 44]
9.3.5 Radiotherapy
9.3.5.1 External RT Fields [45]
9.3.5.2 Brachytherapy [45]
9.3.6 Selected Publications
9.4 Vulvar Cancer
9.4.1 Pathology
9.4.1.1 Vulvar Intraepithelial Neoplasia (VIN) [47]
9.4.2 General Presentation
9.4.3 Staging
9.4.3.1 FIGO Staging [33, 49]
9.4.3.2 Lymphatics of Vulva
9.4.4 Treatment Algorithm
9.4.4.1 Treatment Algorithm for Vulvar Cancer [50, 51]
9.5 50 Gy for cN0, 54 Gy for cN+
9.5.1 Radiotherapy
9.5.1.1 External RT Fields (Fig. 9.27) [52]
9.5.2 Selected Publications
References
10: Gastrointestinal System Cancers
10.1 Esophageal Cancer
10.1.1 Pathology
10.1.2 General Presentation
10.1.3 Staging
10.1.3.1 Esophagus Lymphatics (Fig. 10.3) [2]
10.1.3.2 Location of Primary
10.1.3.3 Importance of Pretreatment Staging in Esophageal Cancer
10.1.4 Treatment Algorithm
10.1.4.1 Surgical Treatment in Squamous Cell Esophageal Cancer
10.1.4.2 Radiotherapy in Squamous Cell Esophageal Cancer
10.1.5 Radiotherapy
10.1.5.1 Conventional RT Fields (Fig. 10.5)
10.1.5.2 Conformal RT/IMRT Volumes (Fig. 10.6) [7]
10.1.6 Selected Publications
10.2 Gastric Cancer
10.2.1 Pathology
10.2.2 General Presentation
10.2.3 Staging
10.2.3.1 Gastric Lymphatics (Fig. 10.9)
10.2.4 Treatment Algorithm
10.2.4.1 Diagnostic Studies Before Treatment
10.2.5 Radiotherapy
10.2.5.1 2D Conventional Radiotherapy
10.2.5.2 3D Conformal RT/IMRT (Fig. 10.11)
10.2.6 Selected Publications
10.3 Pancreatic Cancer
10.3.1 Pathology
10.3.2 General Presentation
10.3.3 Staging
10.3.4 Treatment Algorithm
10.3.5 Radiotherapy
10.3.5.1 2D Conventional Radiotherapy
10.3.5.2 3D Conformal RT/IMRT (Fig. 10.16)
10.3.6 Selected Publications
10.4 Rectal Cancer
10.4.1 Pathology
10.4.1.1 Colorectal Cancers According to the WHO Classification
10.4.2 General Presentation
10.4.2.1 Change in Defecation Habits
10.4.3 Staging (Table 10.5)
10.4.4 Treatment Algorithm
10.4.5 Radiotherapy
10.4.6 Selected Publications
10.5 Anal Cancer
10.5.1 Pathology
10.5.2 General Presentation
10.5.3 Staging (Table 10.6)
10.5.4 Treatment Algorithm
10.5.4.1 T1 Tumor (Small and Well Differentiated) [57]
10.5.5 Radiotherapy
10.5.5.1 Conventional RT Fields in Anal Cancer (Fig. 10.27)
10.5.5.2 Conformal RT Volumes [51]
10.5.6 Selected Publications
References
11: Soft Tissue Sarcoma
11.1 Introduction
11.2 Pathology
11.3 General Presentation
11.4 Staging
11.5 Treatment
11.6 Radiotherapy
11.6.1 Three-Dimensional Conformal/IMRT
11.6.1.1 Simulation
11.6.1.2 Contouring
References
12: Non-melanoma Skin Cancers
12.1 Introduction
12.2 Pathology
12.3 General Presentation
12.4 Staging
12.5 Treatment
12.6 Radiotherapy
12.6.1 2D Conventional Radiotherapy
References
13: Lymphomas and Total Body Irradiation
13.1 Hodgkin’s Lymphoma
13.1.1 Pathology/General Presentation
13.1.2 Clinical Signs
13.1.3 Staging
13.1.4 Treatment Algorithm
13.1.5 Radiotherapy
13.2 Selected Publications
13.2.1 Early-Stage HL
13.2.2 Advanced-Stage HL
13.2.3 Ongoing Trials
13.2.4 Nodular Lymphocyte-Predominant HL
13.3 Non-Hodgkin’s Lymphoma
13.3.1 Pathology/General Presentation
13.3.2 Staging
13.3.2.1 Prognostic Factors in Non-Hodgkin’s Lymphoma [13]
13.3.3 Treatment Algorithm
13.3.4 Radiotherapy
13.3.5 Selected Publications
13.3.5.1 Low-Grade Lymphoma
13.3.5.2 Limited Stage Intermediate-Grade Lymphoma
13.3.5.3 Advanced-Stage Intermediate-Grade Lymphoma
13.4 Cutaneous Lymphoma
13.4.1 Treatment Algorithm [1]
13.4.2 Total Skin Irradiation (TSI)
13.4.3 Selected Publications
13.4.3.1 Multifocal Cutaneous Lymphoma
13.4.3.2 Primary Cutaneous Diffuse B Cell Lymphoma
13.4.3.3 Primary Cutaneous T-Cell Lymphoma
13.4.3.4 Cutaneous Lymphoma Staging (Review)
13.4.3.5 Total Skin Irradiation
13.5 Total Body Irradiation (TBI)
13.5.1 Selected Publications
13.5.1.1 TBI (Randomized Trials)
13.5.1.2 TBI (meta-analyses)
References
Index