Radiation therapy techniques in cancer treatment
- Timur Mitin, MD, PhD
Timur Mitin, MD, PhD
- Assistant Professor
- Department of Radiation Medicine
- Oregon Health and Science University
Radiation therapy (RT) was first used to treat cancer over a century ago [1,2]. Since then enormous progress has been made to improve the effectiveness of this modality and minimize side effects.
Increasingly, RT has been used with surgery and systemic therapies in combined modality approaches for a wide range of malignancies to maximize tumor control and quality of life while minimizing toxicity and preserving the organs. The best outcomes are achieved when each patient is evaluated in a multi-disciplinary setting and the team of clinicians, including surgeons, medical oncologists, radiation oncologists, and other specialists, jointly determine the best treatment.
In various settings, RT may be the sole treatment, can be given concurrently with systemic agents, or may precede or follow surgery to minimize the chance of microscopic disease left after treatment. In addition, RT may be used palliatively when disease is incurable. The duration of treatment can range from a single treatment up to eight weeks of daily irradiation. In each clinical scenario the technique, dose, expected outcomes, and related toxicities vary depending upon the diagnosis and treatment site.
Organ preservation has become a very important component of clinical oncology patient management over the past 40 years. Randomized clinical trials have established equivalent outcomes between radical surgery and organ-preservation treatment with an RT backbone for appropriately selected patients with breast cancer, laryngeal cancer, and extremity sarcoma. Smaller trials have shown the appropriateness of organ preservation for patients with bladder cancer and early stage lung cancer. Equivalent outcomes to surgery and better quality of life with organ preservation make definitive RT a very important option for managing carefully selected patients with potentially curable solid malignancies.
In this topic, the mechanism of action of radiation will be reviewed, along with the key features of different radiation therapy modalities. The application of these treatment modalities in specific malignancies and its integration with other treatment modalities are discussed in the treatment topics for those diseases.
- Stenbeck T. Ein Fall von Hautkrebs geheilt durch Rontgenbestrahlung. Mitteil Grenzgeb Med Chir. Mitteil Grenzgeb Med Chir 1900; 6.
- Die TS. Die Rontgenbehandlung des Ulcus rodens. Fortschr Rontgenstr 1901; 5.
- Revell SH. Relationship between chromosome damage and cell death, Liss A (Ed), New York City 1983. p.113.
- Marks LB, Yorke ED, Jackson A. Use of Normal Tissue Complication Probability Models in the Clinic. International Journal of Radiation Oncology Biology Physics 2010; 76:S.
- Garden AS, Morrison WH, Wong PF, et al. Disease-control rates following intensity-modulated radiation therapy for small primary oropharyngeal carcinoma. Int J Radiat Oncol Biol Phys 2007; 67:438.
- Guerrero Urbano MT, Nutting CM. Clinical use of intensity-modulated radiotherapy: part I. Br J Radiol 2004; 77:88.
- Pow EH, Kwong DL, McMillan AS, et al. Xerostomia and quality of life after intensity-modulated radiotherapy vs. conventional radiotherapy for early-stage nasopharyngeal carcinoma: initial report on a randomized controlled clinical trial. Int J Radiat Oncol Biol Phys 2006; 66:981.
- Brahme A. Design principles and clinical possibilities with a new generation of radiation therapy equipment. A review. Acta Oncol 1987; 26:403.
- Brahme A. Optimization of stationary and moving beam radiation therapy techniques. Radiother Oncol 1988; 12:129.
- Bortfeld T, Bürkelbach J, Boesecke R, Schlegel W. Methods of image reconstruction from projections applied to conformation radiotherapy. Phys Med Biol 1990; 35:1423.
- Carol M. Integrated 3D conformal multivane intensity modulation delivery system for radiotherapy.. In: Proceedings of the XIth International Conference on the Use of Computers in Radiation Therapy, Hounsell A (Ed), Manckester, UK 1991. p.172.
- Mohan R, Wu Q, Manning M, Schmidt-Ullrich R. Radiobiological considerations in the design of fractionation strategies for intensity-modulated radiation therapy of head and neck cancers. Int J Radiat Oncol Biol Phys 2000; 46:619.
- Paganetti H. Changes in tumor cell response due to prolonged dose delivery times in fractionated radiation therapy. Int J Radiat Oncol Biol Phys 2005; 63:892.
- Schäfer M, Münter M, Sterzing F, et al. Measurements of characteristics of time pattern in dose delivery in step-and-shoot IMRT. Strahlenther Onkol 2005; 181:587.
- Sterzing F, Münter MW, Schäfer M, et al. Radiobiological investigation of dose-rate effects in intensity-modulated radiation therapy. Strahlenther Onkol 2005; 181:42.
- Kry SF, Salehpour M, Followill DS, et al. The calculated risk of fatal secondary malignancies from intensity-modulated radiation therapy. Int J Radiat Oncol Biol Phys 2005; 62:1195.
- Hall EJ. Intensity-modulated radiation therapy, protons, and the risk of second cancers. Int J Radiat Oncol Biol Phys 2006; 65:1.
- Hall EJ, Wuu CS. Radiation-induced second cancers: the impact of 3D-CRT and IMRT. Int J Radiat Oncol Biol Phys 2003; 56:83.
- Loeffler JS, Durante M. Charged particle therapy--optimization, challenges and future directions. Nat Rev Clin Oncol 2013; 10:411.
- Delaney TF, Kooey HM. Protons and Charge Particle Radiotherapy, 1st, Lippincott Williams & Wilkins, Philadelphia 2008.
- Mirabell R, Lomax A, Cella L, Schneider U. Potential reduction of the incidence of radiation-induced second cancers by using proton beams in the treatment of pediatric tumors. International Journal of Radiation Oncology, Biology, Physics 2002; 54.
- St Clair WH, Adams JA, Bues M, et al. Advantage of protons compared to conventional X-ray or IMRT in the treatment of a pediatric patient with medulloblastoma. Int J Radiat Oncol Biol Phys 2004; 58:727.
- Munzenrider JE. Proton therapy for uveal melanomas and other eye lesions. Strahlenther Onkol 1999; 175 Suppl 2:68.
- Courdi A, Caujolle JP, Grange JD, et al. Results of proton therapy of uveal melanomas treated in Nice. Int J Radiat Oncol Biol Phys 1999; 45:5.
- Egger E, Zografos L, Schalenbourg A, et al. Eye retention after proton beam radiotherapy for uveal melanoma. International journal of radiation oncology, biology, physics 2003; 55.
- Terahara A, Niemierko A, Goitein M, et al. Analysis of the relationship between tumor dose inhomogeneity and local control in patients with skull base chordoma. Int J Radiat Oncol Biol Phys 1999; 45:351.
- Pai HH, Thornton A, Katznelson L, et al. Hypothalamic/pituitary function following high-dose conformal radiotherapy to the base of skull: demonstration of a dose-effect relationship using dose-volume histogram analysis. Int J Radiat Oncol Biol Phys 2001; 49:1079.
- Isacsson U, Hagberg H, Johansson KA, et al. Potential advantages of protons over conventional radiation beams for paraspinal tumours. Radiother Oncol 1997; 45:63.
- Allen AM, Pawlicki T, Dong L, et al. An evidence based review of proton beam therapy: the report of ASTRO's emerging technology committee. Radiother Oncol 2012; 103:8.
- Brenner DJ, Hall EJ. Secondary neutrons in clinical proton radiotherapy: a charged issue. Radiother Oncol 2008; 86:165.
- Chung CS, Yock TI, Nelson K, et al. Incidence of second malignancies among patients treated with proton versus photon radiation. Int J Radiat Oncol Biol Phys 2013; 87:46.
- Laramore GE, Krall JM, Griffin TW, et al. Neutron versus photon irradiation for unresectable salivary gland tumors: final report of an RTOG-MRC randomized clinical trial. Radiation Therapy Oncology Group. Medical Research Council. Int J Radiat Oncol Biol Phys 1993; 27:235.
- Douglas JG, Koh WJ, Austin-Seymour M, Laramore GE. Treatment of salivary gland neoplasms with fast neutron radiotherapy. Arch Otolaryngol Head Neck Surg 2003; 129.
- Schwartz DL, Einck J, Bellon J, Laramore GE. Fast neutron radiotherapy for soft tissue and cartilaginous sarcomas at high risk for local recurrence. Int J Radiat Oncol Biol Phys 2001; 50:449.
- MacDougall RH, Kerr GR, Duncan W. Incidence of sarcoma in patients treated with fast neutrons. Int J Radiat Oncol Biol Phys 2006; 66:842.
- Husain ZA, Mahmood U, Hanlon A, et al. Accelerated partial breast irradiation via brachytherapy: a patterns-of-care analysis with ASTRO consensus statement groupings. Brachytherapy 2011; 10:479.
- Corn BW, Hanlon AL, Pajak TF, et al. Technically accurate intracavitary insertions improve pelvic control and survival among patients with locally advanced carcinoma of the uterine cervix. Gynecol Oncol 1994; 53:294.
- Viswanathan AN, Moughan J, Small W Jr, et al. The quality of cervical cancer brachytherapy implantation and the impact on local recurrence and disease-free survival in radiation therapy oncology group prospective trials 0116 and 0128. Int J Gynecol Cancer 2012; 22:123.
- Abe M, Fukuda M, Yamano K, et al. Intra-operative irradiation in abdominal and cerebral tumours. Acta Radiol Ther Phys Biol 1971; 10:408.
- Murthy R, Nunez R, Szklaruk J, et al. Yttrium-90 microsphere therapy for hepatic malignancy: devices, indications, technical considerations, and potential complications. Radiographics 2005; 25 Suppl 1:S41.
- Suit H, Goldberg S, Niemierko A, et al. Secondary carcinogenesis in patients treated with radiation: a review of data on radiation-induced cancers in human, non-human primate, canine and rodent subjects. Radiat Res 2007; 167:12.
- Mariotto AB, Rowland JH, Ries LA. Multiple cancer prevalence: a growing challenge in long-term survivorship. Cancer Epidemiol Biomarkers Prev 2007; 16.
- MECHANISM OF ACTION
- EXTERNAL BEAM RT (EBRT)
- Linear accelerators
- Photons versus electrons
- Treatment planning
- Conformal therapy
- - Intensity-modulated radiation therapy
- - Image-guided radiation therapy
- Particle therapy
- - Proton beam
- - Other heavy particles
- Stereotactic RT techniques
- Total body irradiation
- INTRAOPERATIVE RT
- TARGETED RADIONUCLIDE THERAPY
- RADIATION SIDE-EFFECTS