1. Part 1 Introduction to Radiotherapy and External Beam Radiation Deepak Khuntia, MD Vice President, Medical Affairs Varian Medical Systems

2. Part 2 Proton-therapy Caterina Brusasco Compliance Manager IBA SA

3. Part 3 Internal Radiation: Brachytherapy John Christodouleas, MD, MPH VP of Medical Affairs and Clinical Research Elekta, AB

4. Role of Radiation Therapy in the Management of Cancer  In the US, about 50-60 % of cancer patients receive radiation therapy at some point during their management.

5. Direct and indirect effects Photon and charged particles

6. Radiation Treatments External PhotonProtonElectron Internal Brachytherapy Unsealed Sources

7. Radiation Work-flow ConsultationSimulationPlanningTreatment 1 to 14 days

8. Simulation PositioningImagingImmobilization

9. –uses CT and MRI-based image sets to accurately target tumors and avoid sensitive normal tissues –permits multiple different beam approaches Treatment Planning: Spares normal tissue while ensuring adequate dose to the tumor

10. Treatment Delivery  Tools at the machine to verify appropriate patient and target positioning before and during treatment –MV X-ray, U/S, MVCT, CBCT, KV X-ray, MR, fiducial markers, surface monitoring systems –Can gate the machine

11. Radiation and Imaging Workflow ConsultationSimulationPlanningTreatment

12. Adaptive Radiotherapy Khuntia 2010

13. Fraction 1 Khuntia 2010

14. Fraction 2 Khuntia 2010

15. Fraction 3 Khuntia 2010

16. Fraction 4 Khuntia 2010

17. Fraction 5 Khuntia 2010

18. Fraction 6 Khuntia 2010

19. Fraction 7 Khuntia 2010

20. Fraction 8 Khuntia 2010

21. Fraction 9 Khuntia 2010

22. Fraction 10 Khuntia 2010

23. Fraction 11 Khuntia 2010

24. Fraction 12 Khuntia 2010

25. Fraction 13 Khuntia 2010

26. Fraction 14 Khuntia 2010

27. Fraction 15 Khuntia 2010

28. Fraction 16 Khuntia 2010

29. Fraction 17 Khuntia 2010

30. Fraction 18 Khuntia 2010

31. Fraction 19 Khuntia 2010

32. Fraction 20 Khuntia 2010

33. Fraction 21 Khuntia 2010

34. Fraction 22 Khuntia 2010

35. Fraction 23 Khuntia 2010

36. Fraction 24 Khuntia 2010

37. Fraction 25 Khuntia 2010

38. Fraction 26 Khuntia 2010

39. Fraction 27 Khuntia 2010

40. Fraction 28 Khuntia 2010

41. Fraction 29 Khuntia 2010

42. Fraction 30 Khuntia 2010

43. Fraction 31 Khuntia 2010

44. Fraction 32 Khuntia 2010

45. Adaptive Radiotherapy ConsultationSimulationPlanningTreatment

46. Radiosurgery  Sub millimeter accuracy  One to 5 fractions  Cones or MLC based  Brain or outside brain  Frame or no frame

47. External Radiation: Photons, electrons, protons Caterina Brusasco, PhD Compliance Manager IBA SA

48. 3 Types of Therapeutic Radiation P e Photon Radiation (x-rays, gamma rays) Electron Radiation Particle Radiation (Proton) IonizationDNA Damage

49. Different forms of radiation interacts with tissue differently

50. Photon

51. Electron

52. Proton and Charged Particles Pediatric medulloblastoma Ref: Presentation Dr. Jay S. Loeffler, NPTC/MGH, ASTRO 2001

53. Radiation as a Treatment Modality  Linear accelerators create x-rays or electrons –Metal filament is heated to a high temperature within electric field –Electrons boil off and accelerate to metallic target –Deceleration of electrons in target emits x-rays –X-ray beam is contoured to conform to treatment needs Nucleus of atom in “ target ” e- e- electron from filament Brehmsstrahlung (braking) x-rays + -

54. Standard RT: Use mostly open fields with blocks on critical structures

55. Conformal RT: Block shaping to more precisely match the target

56. Intensity Modulated RT: Each area may have a different intensity depending on how deep, and if there are critical structures.

57. Proton-therapy Caterina Brusasco Compliance Manager IBA SA

58. Proton-therapy as external RT Proton- therapy (nuclei of H atoms) Photon radiotherapy (gamma, x- rays) External radiation therapy

59. The proton Bragg peak  The p dose deposition increases quadratically with penetration depth  the maximum is located at the end of the p range in matter (Bragg peak)  The p range depends on the initial p kinetic energy

60. The Spread-out Bragg Peak  The extension in depth of the tumor is covered by modulating the p energy and intensity into a Spread-out Bragg peak Tumor

61. Shaping of the dose distribution  The tumor volume is irradiated by painting it slice by slice, combining the magnetic steering of the pencil beam and the protons energy modulation

62. The accelerator  cyclotron  synchrotron  The magnetic fields guide the proton beam  The electric fields accelerate the protons to the desired energy

63. Transport of beam to the treatment room Magnetic steering of the p beam Gantry rotating around the patient Cyclotron Treatment room

64. 4 treatment rooms: 18000 ft² / 1672 m² 1 treatment room: 3600 ft² / 334 m² Examples of PT facility

65. Internal Radiation: Brachytherapy John Christodouleas, MD, MPH VP of Medical Affairs and Clinical Research Elekta, AB

66. Brachytherapy definition Placing a radiation source internally, either into or immediately next to the tumor, allowing precise radiation dose delivery 1 1. Stewart AJ & Jones B. In Devlin Brachytherapy: Applications and techniques. 2007. Brachytherapy works ‘from the inside, out’ External Beam Therapy works ‘from the outside, in’

67. Brachytherapy has a long history

68. Brachytherapy – history Brachytherapy first used to treat lupus and then malignant tumors 1,2 1901 Use of brachytherapy to treat a gynaecologic malignancy first reported 3 1903 Techniques developed to treat prostate cancer 4 1917 New radioactive sources, techniques and equipment, which prevented unnecessary radiation exposure to patients and clinicians led to a renaissance for brachytherapy 1 1950s and 1960s Brachytherapy is established as a safe and effective standard of care for many gynaecological cancers 5 1970s Brachytherapy a valued treatment option for many types of cancer, with a wealth of supporting evidence 4,5 Present day 1. Gupta VK. J Medical Physics 1995;20(2):31-5. 2. Nag S. American Brachytherapy Society. 3. Aronowitz JN, Aronowitz SV Robison RF. Brachyther 2007;6:293-7. 4. Blasko JC, Wallner K, Grimm PD et al. J Urol 1995;154:1096-9. 5. Viani GA, Manta GB, Stefano EJ et al. J Exp Clin Cancer Res 2009;28:47.

69. Three major brachytherapy methods 69 Intracavitary Interstitial Surface

70. Brachytherapy Clinical Indications

71. In some indications, it is an option. In others, it is the standard of care. Han K et al. Int J Radiat Oncol July 2013 Survival with and without BT boost in localized cervical cancer

72. Software Systems in Radiation Oncology

73. Software drives all aspects of the radiation oncology workflow ConsultationSimulationPlanningTreatment

74. Clinical Care Software Electronic medical record systems (EMRs)  Stores the patient’s medical record  Tools for charting and medical ordering

75. Radiation Treatment Planning Systems  Identify tumor and normal tissues  Define beam/implant characteristics to reach a safe/effective plan

76. Radiation Treatment Management System  Pre-treatment verification –Right patient, position, body part, treatment parameters, etc  Post-treatment record

77. Software Decision Support Tools

78. Thank you