CETRTT-2016

Organised By
DEPARTMENT OF RADIOLOGICAL PHYSICS,
SMS MEDICAL COLLEGE, JAIPUR
In collaboration with
ASSOCIATION OF RADIATION THERAPY
TECHNOLOGISTS OF INDIA (ARTTI-NC)

2nd April 2016

e-Souvenir

CONFERENCE ON EMERGING TRENDS IN RADIATION THERAPY TECHNIQUES

ORGANISNG COMMITTEE

Chief Patron
Dr. Raja Babu Panwar

Patron
Dr. U.S.Agarwal,

Vice Chancellor,
Rajasthan University of Health Sciences, Jaipur

Principal & Controller

SMS Medical College & Hospital, Jaipur

Organizing Chairman

Prof. Arun Chougule,

PHOD, Radiological Physics

SMS Medical College & Hospital, Jaipur
Co- Patron
Dr. S.M Sharma, Addl. Principal
Dr. Deepak Mathur Addl. Principal
Dr. Man Prakash Sharma, M.S

Scientific Committee
Miss Mary Joen
Miss Rajni Verma
Mr. Gourav Kumar Jain

Mr. Bhagwan Sahai Degra

Mr.Ajay Prajapati
Miss. Soniya Hooda
Mrs. Priti Gupta
Miss Bela Arora

Organizing Secretary
Mr. Mukesh Jain

Members
Mr. K M Saini
Mr. Banwari Lal Sharma
Mr. Subodh Kumar Gupta
Mr. Md.I.Vasi.
Mr. Shrikant Sharma
Mr. Abhay Singh
Mr. S.R. Choudhary
Mr Dileep Sharma
Mr. Dhan Raj Soyal
Mr. Aakash Goyal
Mrs. Ritu Mathur

Secretary General- ARTTI- NC

Mr. Rakesh Kaul

Treasurer
Ramesh Chandra Sharma
Joint Secretary
Mr. Ananth K
Mr. Gurvinder Singh
Mr. Suresh Kumar Akula

The Organising committee is thankful to

Rajasthan University of Health Sciences, Jaipur
SMS Medical College, Jaipur
Max India, Delhi
Eckert & Ziegler BEBIG India Pvt. Ltd.
Invited Speakers
Delegates
Volunteers

Thanks to all
Organising Chairman
CETRTT-2016

Message
I am happy to know that Department of Radiological Physics,
SMS Medical College, Jaipur

is organizing a CONFERENCE ON

EMERGING TRENDS IN RADIATION THERAPY TECHNIQUES (CETRTT

2016) at S.M.S. Medical College & Hospitals, Jaipur on 2nd April,
2016
As we know the use radiation started in medical & health care
many years ago in form of diagnosis & therapy. Today Radiation therapy equipped with many advancement however every precaution
needs to be taken while handling the radiation equipment because of
their hazards. This conference will provide a platform to discuss various applications of radiation in health care as well as radiation protection aspects.
As Medical Superintendent of SMS Hospital, I welcome all the invited speakers and delegates who have gathered from all over the
globe.
I am impressed by number of invited speakers and the papers being presented and discussed during the scientific deliberation of this
conference which will help in exchanging the views in the field of Radiological Physics.
I wish the conference every success an all participants a most
memorable event and enjoyable stay in Jaipur.

Dr. Man Prakash Sharma

Medical Superintendent

Message
I am very pleased to know that Department of Radiological
Physics, SMS Medical college, Jaipur (Raj.) organizing a mega
scientific event Conference on emerging trends in Radiation

Therapy Techniques on 2nd April,2016. I congratulate the Institute & ARTTI-NC on this occasion.
Radiotherapy is an essential cancer treatment that experts
suggest. It contributes to four in ten cases where cancer is cured
It is a relatively cheap, safe, cost-effective treatment that is associated with high levels of patient satisfaction. Yet the radiotherapy
service does not get the attention it deserves and is underfunded
compared to other cancer treatments.
It is recognized that more work is needed to achieve a truly
world-class radiotherapy service across INDIA. Radiotherapy services in India remain under capacity, vary in terms of quality and
patient access, and have been slow in adopting new techniques
compared with the leading radiotherapy services internationally.
Radiotherapy capacity in India needs to increase considerably in
response to this rapidly growing disease.
I extend my warm greetings & felicitations to the organizers &
participants & the conference all success.
Shri Gopal
Chief Radiation Therapy Technologist,
AIIMS, Delhi

Message
I am privileged and delighted to welcome all the delegates of the
conference of Association of radiation therapy technologist, India Northern
chapter. It gives me to give great pleasure to congratulate department of Radiation oncology, S.M.S Medical college, Jaipur on 2nd April-2016.
Radiation therapy technologist profession in India has grown up
and the technologists are acquiring expertise in advance techniques on par
with their counterparts in developed world. The present conference is being
held in this Pink city and educational center having right kind of atmosphere for such scientific exchange.
On behalf of all the members of ARTTI-Nc , I convey my sincere thanks to
Dr. Arun Chougule, Org-chairman ,Mr. Mukesh Jain org secretary and all
members of org committees for organizing this wonderful conference
I hope all the participants will get benefit from the various scientific presentations during the conference
With Best Wishes

Thomas Ranjit Singh

Chief Radiation Therapy Technologist
Department of radiation oncology
Max super Speciality Hospital,
Patparganj,NewDelhi-92

Rakesh Kaul
Sr. Vice President (ARTTI)
Secretary General (NC-ARTTI)

MESSAGE
I am privileged and feel delighted to welcome all delegates to the 3 rd CME
Northern chapter of Association of Radiation Therapy Technologists of India (NCARTTI), hosted by SMS Medical College, Jiapur, Rajasthan.
It gives me a great pleasure to congratulate Management and Department of Radiological Physics, SMS Medical College, Jaipur, Rajasthan for organizing CME on 2 nd
April 2016.
The Radiation Therapy Technologists plays a vital role in the delivery of Radiation. The Radiation Therapy Technologists has come a long way since the Cobalt days
to the present Cyber-knife and Tomotherapy.
With the rapid Technological development it is important for Radiation Therapy
Technologists to update their Knowledge. I hope these scientific meetings give us all
the wonderful opportunity to keep abreast of the technological advancement in our
discipline, which finally contribute greatly to the better patient care outcome of treatment we offer. I hope this CME will fulfill your quench for latest aspects of growing
technologies.
I wish a grand success to this conference.

Rakesh Kaul
CHIEF RADIOTHERAPY TECHNOLOGIST

Ma Superspecialit Hospital
New Delhi7

DEPARTMENT OF RADIOLOGICAL PHYSICS

S.M.S. MEDICAL COLLEGE AND HOSPITAL, JAIPUR

Dr. Arun Chougule,

Sr. Professor & Head
Department of Radiological Physics
Dean, Faculty of Para Medical Sciences

FROM DESK OF ORGANISING CHAIRMAN

Greeting to all of you from my side and organizing committee of CETRTT2016. It gives me immense pleasure to welcome you all at SMS Medical College and Hospital, the premiere institute of Northern India and the
pink city JAIPUR on the occasion of CONFERENCE ON EMERGING TRENDS IN RADIATION THERAPY TECHNIQUES on 2nd
April 2016 at SMS Hospital, Jaipur.
I am thankful to all the invited speakers from India and overseas who
have accepted my invitation to deliver invited talks and thanks are due to all
the delegates who have made it to happen.
I have tried my level best to my capacity, ability and available resources to take care of you all and make this conference scientifically & socially successful. Despite of our efforts there may be short comings and
lapses, I hope you will excuse me and will carry home only sweet memories
of CETRTT2016.
I take this opportunity to thank all those who have directly, indirectly
supported/helped in organizing this mega event. Once again I welcome you
all and wish you all very pleasant, fruitful and memorable stay in Jaipur.

Prof Arun Chougule

Organising Chairman CETRTT-2016
President,AMPI
PHOD, Radiological Physics
SMS Medical College, Jaipur

Message
On behalf of the Organizing Committee of CETRTT-2016, it is my pride
and privilege to welcome distinguished delegates around the globe for
CONFERENCE ON EMERGING TRENDS IN RADIATION THERAPY
TECHNIQUES on 2nd April 2016 at SMS Hospital, Jaipur. to be held at Pink
City Jaipur, the city with broad avenues and spacious gardens.
Amidst the power packed scientific sessions, we, the organizing committee is committed to host a conclave conducive to plethora of knowledge sharing for professionals as it has talks by eminent speakers on wide range of topics.
It will not only explore the new ideas in the field but also fill the aspiration
among the students to indulge them into research & skill development as well as
for the vendors to put the new creations into practical life, identify the bridges
between policy makers & them.
The organizing committee extends its gratitude and thanks to invited
chair persons, speakers and delegates for their contribution towards the success
of the conference, I would like to thank our trade partners for their support to
put this theme into reality.
Last but not the least , I would like to pay my sincere regards to the man
behind our inspirationDr. Arun Chougule whose innovative thought filled us
with aspiration & work as team for the success for this event . I would also like
to thank my friend Ramesh Chand Sharma & my colleagues, members of organizing committee, students and friends for their immense contribution.
Inspite of our best efforts, there might be some lapses. I do apologize for
them & hope you will enjoy your memorable visit to Pink city Jaipur
Thank you one and all for giving us the privilege of sharing knowledge &
giving your precious time.

(Mukesh Jain)
Organising Secretary
CETRTT-2016

CONFERENCE ON
EMERG)NG TRENDS )N RAD)AT)ON T(ERAPY TEC(N)QUES CETRTT
Organized by
DEPARTMENT OF RAD)OLOG)CAL P(YS)CS, SMS MED)CAL COLLEGE, JA)PUR
)n Association with
ASSOC)AT)ON OF RAD)AT)ON T(ERAPY TEC(NOLOG)STS OF )ND)A ARTT)-NC
nd April -

Scientific Programme

Time

Title of Presentations

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)nvited Speakers

Registration
)nauguration
(igh Tea
Session )
Chairperson: Dr. Rohitashwa Dana
Mr. Thomas Ranjit Singh
Small field dosimetry: Clinical considerations

Dr. Gavin Cranmer Sargison,

Canada

Radiobiology of Radiotherapy

Dr. Arun Chougule

SMS (ospital, Jaipur

Electrons, Photons and Ions - How are they different

for uses in imaging or therapies?

Dr. Rangacharyulu Chary

Canada

Session ))
Chairperson: Dr. Usha Jaipal, Mr. Shri Gopal Sharma

Creating seamless environment of for risk adapted

-D Radio-Surgery
Role of Radiotherapy Technologist in SBRT Program.
Liver Gating with Exac-Trac

Basics and evolution of gamma knife Stereotactic

Radiosurgery
Lunch

Dr. Shankar Vangipurapu

Geetanjali Cancer Center
Udaipur, Rajasthan
Dr. R.K Munjal
Max (ospital, Delhi

Mr. Rakesh Kaul

Max (ospital Saket, Delhi
R.K. Bisht
A))MS, Delhi

Contd:-

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Nuclear Medicine in Oncology

Dr. Venkaratnam
ETC(, Jaipur

Acceptance test & Commissioning of

True Beam Linear Accelerator

Mr. Boopalan
MG (ospital, Jaipur

)GRT and its practice parameters

Mr. Debojoyti Dhar

Narayana Superspeciality
(ospital, (owrah

Conformity index analysis of conventional and advanced Radiotherapy Techniques

Mr. P.G.Prakasam
Manipal (ospitals, Jaipur

Role of Radiotherapy Technologist in emerging Technologies

Mr. Athiyaman
SPMC, Bikaner

Occupation health and safety

Administration of Radiation Oncology Technologists Perspective

RTT Perspective & Education

Tea

Mrs. Majinder Kaur

CMC, Ludhiana

Mr. Thomas Ranjit Singh,

Max (ospital New Delhi
(SCC, Delhi

Session )V
Chairperson: Dr. Mukesh Mittal, Mr. Rakesh Kaul

.
.

Session )))
Chairperson: Ms. Mary Joan, Mr. Lalit Kumar Sharma,

. PM
Onwards

Effect of interfraction and intrafraction motions in

radiotherapy challenges and measures

Frame Less Stereotactic Radio Surgery SRS/FSRS

Treatment Technique And Evaluation Of Set Up
Errors

Mrs. (emalatha
SPMC, Bikaner

Mr. Deepak
Max (ospital, Delhi

SRS/SRT Radiation Therapists perspective

Mr. Md )F. Wasi

SEAROC Cancer, Jaipur

Dosimetric characterization of OSLD in diagnostic

and therapeutic energy use

Mrs. Priti Gupta

SMS (ospital, Jaipur

Measurement of contralateral breast nipple dose

during radiotherapy treatment of breast cancer

Measurement of corneal dose during External

Beam Radiotherapy of (ead & Neck Malignancies

Ms. Soniya (ooda

SMS (ospital, Jaipur

Mr. Ajay Prajapati

SMS (ospital, Jaipur

Patient specific QA tools for Rotational Therapy

Mr Gourav Kumar Jain

SMS (ospital, Jaipur

Commissioning of Bhabhatron-))

Mr. Mukesh Jain

SMS (ospital, Jaipur

Technical advancements in newer LA machine

True Beam

Valedictory Function

Mr. Yashveer Lamba

MG (ospital, Jaipur

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ADAPTIVE RADIOTHERAPY BIOLOGICAL ASPECTS

Dr. Arun Chougule
Sr. Professor & Head
Department of Radiological Physics
SMS Medical College & Hospital, Jaipur.
Email: arunchougule11@gmail.com, arunchougle@rediffmail.com
Today cancer is a major health problem and as per WHO reports over 14 million
cancer patients detected every year and in India it is about 1 million. Radiotherapy is main
treatment modality and almost about 70% cancer patients need radiotherapy as treatment
modality during their treatment course. Radiotherapy can be used as single treatment
modality or in combination with chemotherapy or surgery. In about 118 year history of
radiotherapy, it has made tremendous progress in terms of technology, accurate dosimetry
and treatment plan verification in addition to radiobiological understanding. Radiotherapy
treatment planning has traditionally been a static process in which the plan was generated
based on a single snapshot of the particular anatomy and delivered over number of weeks. No
correction for inter or intrafraction variation in tumor size is applied. However the modern
imaging modalities like CT, MRI and PET along with 3D computerized treatment planning
systems has introduced radiotherapy techniques like CRT, IMRT SRS, SRT and ART which
has improved the conformity of radiation dose to tumor with delineation of normal tissue and
OAR with better conformity index. Thereby, providing scope to escalate the tumor dose
resulting into better tumor control probability. Recent technological developments in
treatment, imaging and tracking equipments, radiotherapy has become precise and accurate
with techniques like adaptive radiotherapy (ART). The adaptive radiotherapy is defined as
changing the radiation plan delivery to a patient during the planned course of radiotherapy
treatment so as to account for temporal changes in anatomy due to tumor shrinkage,
movement of internal organs proximal to tumor (target) and patient weight loss during the
treatment. The physical changes needs to be accounted for assessment of inter and
intrafraction variation so that OAR can be spared and radiation can be delivered to entire
target volume. To achieve this target and physical dose distribution on-board imaging
techniques, immobilization and gating techniques are practiced.
In this talk I will focus on biological parameters which are of importance and needs to
be taken into account during adaptive radiotherapy so as to better tumor control probability
(TCP) and minimum normal tissue complication probability (NTCP). With CT as only
imaging modality the CT image based anatomical plans will advocate uniform homogeneous
physical dose distribution. However, the PET imaging which gives anatomical as well as
functional imaging has shown that within the GTV there are areas which are hyper and hypo
active and needs the radiation dose accordingly. PET image based planning has shifted from
physical homogenous dose to biologically effective non-homogenous dose distribution or
dose planning. EUD is a simplified parameter designed to make comparisons among
alternative treatment plans easy when radiation dose distribution in GTV is non homogenous.
The underlying assumption is that homogenous radiation dose distribution in tumor with dose
D and non-homogenous dose distribution with EUD equal to D are equivalent in a

radiobiological sense. In order to isolate the effect of cold spot and hot spot, cell kill based
concept of equivalent dose (CEUD) introduced by Niemierko needs to be followed to account
for effect of dose variation.
Currently there is great interest in integrating biological information into treatment
planning with the aim of boosting highly proliferating high risk tumor subvolumes. And this
concept is called as selective boosting or dose painting concept synonymous to
theraganishes. Further selective boosting of tumor subvolume within the GTV can be
achieved without violating the normal tissue complication constraints using the information
from functional imaging such as PET.
The details of biological factors which need to be taken into account such as oxygen
level in tumor, stem cells, radiosensitivity within tumor during the planning. In broader
perspective the adaptive radiotherapy techniques should incorporate biological, imaging and
physical variations measured and assessed during the interfraction and intrafraction of
radiotherapy.

Electrons, Photons and Ions - How are they different for uses in imaging or
therapies?
C. Rangacharyulu, Physics and Engineering Physics, Univ. of Saskatchewan,
Saskatoon SK, S7N 5E2
Email:chary.r@usask.ca
Nuclear medicine science and technology, for both therapeutic and diagnostic purposes,
exploit the interactions of radiations with matter and its consequences. In imaging, we should know the
interactions of radiations in the patients bodies and surroundings as well as in the radiation detectors,
where as our interest for therapeutic purposes is in the physical, chemical and consequential biological
effects of radiation interactions in living organisms.
In imaging, the interest is the interaction of low energy photons, electrons and positrons. On
the other hand, therapeutic applications employ various species of radiations of wide ranges of
energies. The interaction mechanisms and resultant products vary widely. Also, the imaging
applications employ radiation doses less than 100 mSv, while the therapeutic applications may exceed
a few Grays.
In this talk, I will compare and contrast the interactions and the physical effects of radiations
of interest in medical applications.

Prospective new technologies for Nuclear Medicine

C. Rangacharyulu, Physics and Engineering Physics, Univ. of Saskatchewan, Saskatoon,
SK, S7N 5E2
Email: chary.r@usask.ca
The progress in nuclear science and technologies for instrumentations, detector
materials and radiation beam facilities has always impacted medical diagnostics and therapy.
The advent of computer technologies has revolutionized the control, monitoring and
assessment medical technologies for both hardware and software. Also, particle accelerators
of diverse species of beams and high intensities have also contributed to medical uses.
In the last few years, the Field Programmable Gate Array (FPGA) systems have
simplified the hardware for data acquisition systems. Also, research towards table top
accelerators using laser wake field and plasma based systems have made significant advances.
With high power short duration pulsed lasers becoming easily available, prospects for
affordable radiation therapy look good.
In this talk, I will give a brief overview of current status and speculate on future
prospects. A word of caution against excessive uses of these tools will also be noted

SBRT treatment technique for liver tumors by exactrac adaptive gating on Novalis tx Linear
Accelerator
Rakesk Kaul, Dr. A.K. Anand, Mr. R.K. Munjal, Dr. A.K. Bansal, Deepak Kumar.
Max super speciality hospital, Saket, New Delhi

Introduction:
A high degree of tumour control and cure can be achieved through administration of
appropriate doses of ionizing radiation. Administration of lethal dose cannot be delivered
due to the tolerance of nearby healthy tissues (which cannot be excluded adequately)
Intensity modulated radiation therapy (IMRT) in combination with Image guided radiation
therapy (IGRT) can deliver a highly conformal radiation dose to the target while avoiding
nearby critical structures. However organ motion, especially respiratory motion introduces
technical challenge to IMRT/ IGRT planning and delivery of radiation.
The movement of the target typically results in either the target receiving less than the
prescribed dose or the critical structures receiving additional dose. To answer these
challenges caused by organ motion can be classified into three categoriesA) Wait for target. B) Follow the target. C) Predict the target
There are various ways to address the moving target but in this presentation our main
focus is on Exac-trac adaptive Gating which is one of the answers to the moving targets. We
have treated few cases by SBRT with Exac-trac adaptive Gating at our centre.
SBRT delivers a much higher fractional dose than conventional treatment in only a
few fractions and is effective treatment for liver lesions. In Liver Gating Patients are treated
under free breathing conditions with SBRT require accurate and precise tumor localization
at the time of CT planning. Implanted fiducials assists us in tracking & targeting the tumor
more accurately and precisely.
Nearly all thorax and abdominal structures move during normal respiration, this poses
a significant problem for Radiation Oncologist. To overcome this challenge 5 to 6 Infra -red
(IR) markers are fixed on the patients abdomen at a suitable position to yield a good
breathing cycle during treatment delivery. We at our centre are treating moving tumors by
SBRT Adaptive Exac-Trac Gating with high dose per fraction (3 to 7 fractions) on
NOVALIS TX Linear Accelerator by 6MV photon beam.
The system which takes care of moving tumors include stereoscopic X-ray imaging
system (Exac-Trac X-ray 6D) which can locate and track moving tumors by X-ray imaging
of implanted fiducials defined by the treatment planning. The Exac-Trac Adaptive Gating
consists of motion management tools that adjust the breathing cycle and tumor movement.
The technique involves tracking the internal movement of the tumor with the help of
implanted markers as well as external respiratory motion. During treatment, patients
respiratory cycle is tracked via infra-red (IR) markers placed on patients body with the help
of IR cameras installed in the treatment room. A series of KV images are taken at different
phases of the respiratory cycle to localize the internal marker, measure the tumor movement
and finally set the BEAM-ON area as per tumor movement.

Radiation is delivered when the tumor is in pre defined target area. Intra-fraction snap
verification is done to verify patient position, internal marker and tumor movement
(Respiratory cycle) of the patient in real time.
Conclusion:
Image guided SBRT for moving tumors with EXAC-TRAC ADAPTIVE GATING is
a promising treatment technique for lung and liver lesions with excellent local control and
tolerable side effect. EXAC-TRAC makes us able to chase moving tumors and treatment is
delivered with millimeter accuracy.
Time taken to treat a patient is very long as the BEAM-ON area is totally dependent
on the breathing pattern of the patient. It is comfortable to patient as it is done in free
breathing.

Acceptance Tests and Commissioning of TrueBeam Linear Accelerator

Boopalan Balaji , M.Sc, M.R.S.O, Assistant Professor, Medical Physicist cum RSO,
Mahatma Gandhi Medical College and Hospital, RIICO Institutional Area, Sitapura, Jaipur
Abstract
A Newer Generation modern digital platform TrueBeam Linear Accelerator was
introduced by Varian Medical Systems with Flattening Filter Free (FFF) mode and advanced
On Board Imaging (OBI) System. Rajasthans first TrueBeam was installed at Mahatma
Gandhi University of Medical Sciences and Technology, Jaipur and put into clinically in the
month of November 2015. The purpose of this paper is to share the early experiences about
the acceptance tests and commissioning of the TrueBeam machine. During the
commissioning, many challenges need to be faced by medical physicist to setup the quality
with good accuracy and fine precision. Medical Physicist used to do variety of mechanical
tests methods, Beam Data generation, and Data validation while modeling the Treatment
Planning Systems (TPS). Since commissioning beam data are treated as a reference and
obviously used for the treatment.
Introduction
Acceptances tests and commissioning of the Varian TrueBeam Medical Linear
Accelerator were carried out in Mahatma Gandhi University of Medical Sciences and
Technology, Jaipur (Rajasthan). Varian has recently released a new class of linear accelerator
referred to as TrueBeam linear accelerator. This platform delivers both traditionally flattened
photon beams and flattening-filter-free (FFF) photon beams. TrueBeam is capable of
delivering photon beams of 6X, 10X, 15X, 6X FFF and 10X FFF with 600 MU/Min for
flattened beams and upto 2400 MU/Min for Flattening Filter Free beams and five electron
beams such 6,9,12,15 & 18 MeV. Maximum field size of the unit is 40x40 cm2 defined by
jaws and Millenium 120 MLC which is installed under the jaws as tertiary. TrueBeam is also
equipped with KV/MV Imaging with CBCT capability. The KV and MV imaging can be
acquired in various modes: radiographic, cine, integrated, and pared KV-MV. In CBCT, there
are two CBCT acquisition modes available: full-fan over a gantry rotation of 200o and
half-fan over a gantry rotation of 360o in acquisition.
Acceptance Tests
Acceptance tests assure that the specifications contained in the purchase order are
fulfilled and that the environment is free of radiation and electrical hazards to staff and
patients. The tests are performed in the presence of a manufacturers representative. Upon
satisfactory completion of the acceptance tests, the physicist signs a document certifying these
conditions are met. When the physicist accepts the unit, the final payment is made for the unit,
ownership of the unit is transferred to the institution, and the warranty period begins. These
conditions place a heavy responsibility on the physicist in correct performance of these tests.
Acceptance tests may be divided into three groups: (1) safety checks, (2) mechanical checks,
and (3) dosimetry measurements.
Acceptance tests begin with safety checks to assure a safe environment for staff and
public. The initial safety checks should verify that all interlocks are functioning properly.
These interlock checks should include the door interlock, all radiation beam-off interlocks, all
motion-disable interlocks, and all emergency-off interlocks. The medical physicist must verify
the proper function of all these interlocks. After completion of the interlock checks, the

medical physicist should perform a radiation survey in all areas inside and outside the
treatment room.
The mechanical checks establish the precision and accuracy of the mechanical motions
of the treatment unit and patient treatment couch. Mechanical checks includes Collimator axis
of rotation, collimator jaw motion, Congruence of light and radiation field, Gantry axis of
rotation, Patient treatment couch axis of rotation, Radiation isocentre, Optical distance
indicator, Gantry angle indicators, Collimator field size indicators, Patient treatment couch
motions etc.
Dosimetry measurements establish that the central axis percentage depth doses and off
axis characteristics of clinical beams meet the specifications. Dosimetric measurements
include Photon energy or Beam Quality, Photon Beam Uniformity (Flatness and Symmetry),
Photon Penumbra, Electron Beam Quality, Electron Beam Uniformity, Electron Penumbra,
Degree of Unflatness for Flattening Filter Free Beam etc.
Commissioning:
Commissioning of an external beam therapy includes a series of tasks that generally
should consist of the following: (1) acquiring all radiation beam data required for treatment
(2) organizing this data into a dosimetry databook (3) Configuring this data into a
computerized treatment planning system (4) developing all dosimetry, treatment planning, and
treatment procedures (5) verifying the accuracy of these procedures (6) establishing quality
control tests and procedures and (7) training all personnel.
Commissioning of TrueBeam Linear Accelerator is performed with the help of the
IBA dosimetry system in water phantom (RFA-Blue Phantom, with Omni-Pro Accept-7
software). All data collection and testing were performed in accordance with the international
practice and guidelines such as AAPM Task Group TG-142 and TG-106. FFF beam data
collection and evolution carried out as per AERB (Atomic energy regulatory board, INDIA).
A procedure such as MLC DLG (Dosimetric Leaf Gap) is carried out according to Varian
specified guidelines. The chamber used for beam data collection and dosimetric measurements
are CC013, PPC05, and FC56-G. The beam data measurement is done as per recommendation
of AAA (Anisotropic Analytical Algo rithm) for photon beam and EMC (Electron Monte
Carlo) for electron beam in order to commissioning the Ec- lipse (Version: 13.6) TPS
(Treatment Planning System). Beam data measurement ware performed for standard photon
energies 6 MV, 10 MV, 15 MV flattening filter beam and 6 MVFFF, 10 MVFFF flattening
filter free beams.
Conclusion:
Acceptance and commissioning data were analyzed and overall, excellent agreement
was observed in TrueBeam commissioning data as per the guidelines. The commissioning
data provided us valuable insights and reliable evaluations on the characteristics of the new
treatment system. The systematically measured data might be useful for future reference

Occupation health and safety

Majinder Kaur, Christian Medical College, Ludhiana
Ionizing radiation is everywhere outer space as cosmic rays, in the air as emissions
from radioactive radon and its progeny. Naturally occurring radioactive isotopes enter and
remain in all living things. It is inescapable. Indeed, all species on this planet evolved in the
presence of ionizing radiation. While humans exposed to small doses of radiation may not
immediately show any apparent biological effects, there is no doubt that ionizing radiation,
when given in sufficient amounts, can cause harm. These effects are well known both in kind
and in degree.
While ionizing radiation can cause harm, also have many beneficial uses. Radioactive
uranium generates electricity in nuclear power plants in many countries. In medicine, x rays
produce radiographs. Nuclear medicine physicians use radioactive material as tracers to form
detailed images of internal structures and to study metabolism. Therapeutic
radiopharmaceuticals are available to treat disorders such as hyperthyroidism and cancer.
Radiotherapy physicians use gamma rays, pion beams, electron beams, neutrons and other
types of radiation to treat cancer. Engineers use radioactive material in oil well logging
operations and in soil moisture density gauges. Industrial radiographers use x rays in quality
control to look at internal structures of manufactured devices. Exit signs in buildings and
aircraft contain radioactive tritium to make them glow in the dark in the event of a power
failure. Many smoke detectors in homes and commercial buildings contain radioactive
americium.
Radiation has the power to both save and harm lives. Radiologic technologists use
radiation to provide quality medical imaging, but they must be aware of potential exposure to
radiations detrimental effects. When proper time, distance, and shielding techniques are used,
dangerous exposure levels can be avoided. Protection techniques are even more important for
a pregnant radiologic technologist, who must safeguard her fetus from exposure. With an
employers cooperation and appropriate protection in place, a pregnant technologist should be
able to work in a radiology setting without harming her fetus
The use of medical imaging is rising, and approximately 3.3 billion of the 5 billion
imaging examinations performed worldwide use ionizing radiation. Thus, diagnostic imaging
contributes to the majority of artificial radiation exposure to humans. Several medical imaging
disciplines and specialties use ionizing radiation, including general diagnostic radiology,
nuclear medicine, computed tomography (CT), fluoroscopy, and interventional radiology. In
addition, specialties outside radiology such as urology, orthopedic surgery, gastroenterology,
vascular surgery, and anesthesiology often use imaging examinations involving ionizing
radiation.
Although many patients benefit from radiations ability to destroy cancer cells or
capture real-time images of the human body, radiation can harm healthy cells wherever it
enters the body. It is well documented that ionizing radiation can cause damage ranging from
uncontrollable cell replication to cell death.
Studies have shown that interventional radiology workers are more susceptible to
cataracts than control populations who do not work with radiation. A pregnant radiologic

technologist or radiologist assistant also can put her fetus at risk if it is exposed to excessive
amounts of radiation. For these reasons, all medical imaging technologists and radiation
therapists need to be aware of radiations potential to damage their own health. This is
particularly important for radiologic technologists and radiologist assistants who work in
fluoroscopy suites where medical personnel stand close to the x-ray source
These many uses of ionizing radiation and radioactive materials enhance the quality of
life and help society in many ways. The benefits of each use must always be compared with
the risks. The risks may be to workers directly involved in applying the radiation or
radioactive material, to the public, to future generations and to the environment or to any
combination of these. Beyond political and economic considerations, benefits must always
outweigh risks when ionizing radiation is involved.
Brief Introduction on ionizing radiation. The International Commission on Radiation
Units and Measurements (ICRU) develops internationally accepted formal definitions of
quantities and units of radiation and radioactivity. The International Commission on
Radiological Protection (ICRP) also sets standards for definition and use of various quantities
and units used in radiation safety. A description of some quantities, units and definitions
commonly used in radiation safety follows. Discuss biological effects and radiation biology
and nature & mechanism of biological effects of Radiation
In 2007 the ICRP recommended that medical workers receive a maximum radiation
effective dose of 20 mSv per year, averaged over 5 years, with no more than 50 mSv in 1
year. In addition, 500 mSv each is the annual equivalent dose radiation limit to the skin,
hands, and feet. For the lens of the eye, the equivalent dose limit was initially 150 mSv, but in
2011 the ICRP reduced this to 20 mSv per year, averaged over 5 years, with no single year
exceeding 50 mSv.
Acute injuries of the types that were prevalent in pioneer radiation workers and early
radiotherapy patients have been largely eliminated by improvements in safety precautions and
treatment methods. Nevertheless, most patients treated with radiation today still experience
some injury of the normal tissue that is irradiated. In addition, serious radiation accidents
continue to occur. For example, some 285 nuclear reactor accidents (excluding the Chernobyl
accident) were reported in various countries between 1945 and 1987, irradiating more than
1,350 persons, 33 of them fatally (Lushbaugh, Fry and Ricks 1987). The Chernobyl accident
alone released enough radioactive material to require the evacuation of tens of thousands of
people and farm animals from the surrounding area, and it caused radiation sickness and burns
in more than 200 emergency personnel and fire-fighters, injuring 31 fatally (UNSCEAR
1988). The long-term health effects of the radioactive material released cannot be predicted
with certainty, but estimates of the resulting risks of carcinogenic effects, based on no
threshold dose-incidence models (discussed below), imply that up to 30,000 additional cancer
deaths may occur in the population of the northern hemisphere during the next 70 years as a
result of the accident, although the additional cancers in any given country are likely to be too
few to be detectable epidemiologically (USDOE 1987).

There are three primary sources of radiation exposures to humans around the world.
Primordial, Cosmogenic and human produced. Of all of the natural background radiation
(including cosmogenic), Rn-222 is by far the most significant in terms of radiation dose and
health consequences to people. The decay products of Rn-222, once inhaled, dose the lung
and have been linked to lung cancer at high exposures. Cosmic radiation interacts with our
atmosphere to produce cosmogenic radionuclides. It also is responsible for whole body doses.
For that we need to know the quantities and Units. The absorbed dose is the basic physical
dosimetric quantity of the Standards stochastic and deterministic risk along with a discussion
of the ALARA principle. Radiation protection sets examples for other safety disciplines in
two unique respects First, there is the assumption that any increased level of radiation above
natural background will carry some risk of harm to health. Second, it aims to protect future
generations from activities conducted today.
In the United States, the organization which reviews ICRP recommendations and
issues its own national recommendations is the National Council on Radiation Protection and
Measurements (NCRP).
Categories of Exposure are occupational, public and medical exposure. Principles
protection are justification, optimization and dose limits. Significance of different levels
radiation exposure (high dose levels), time course of manifestation of different types
damage induced by radiations. Last cover the personnel monitoring including detailed
TLD.

of
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IGRT and its practice parameters

Debojoyti Dhar,SumanMallik,JyotirupGoswami,Bipasha Pal,Suresh Das, Sayan Das, Arijit Sen,
SaikatSeeth, SouraPalit, SarbariMitra, TarakNath Roy, Somenath Pal, Mouli Chakraborty, Sonai Dutta

Narayana Superspeciality Hospital, Howrah

Introduction:
Image-guided radiation therapy (IGRT) is radiation therapy that employs imaging to
maximize accuracy and precision throughout its entire process. This process includes target
and normal tissue delineation, radiation delivery, and adaptation of therapy to anatomic and
biological changes over time .This talk will focus on image-guidance at the time of radiation
delivery to ensure its adherence to the planned treatment, referred to as in-room IGRT.
Thus IGRT is particularly applicable to highly conformal treatment modalities such as
3-D conformal radiation therapy (3-D CRT), intensity-modulated radiation therapy (IMRT) or
proton/hadrons therapy. In the case of stereotactic body radiation therapy (SBRT) or
stereotactic radiosurgery/stereotactic radiation therapy (SRS/SRT), IGRT is considered a
necessary and integral component of the entire procedure. Nevertheless, accurate radiation
therapy is important even for simple treatments.
Practice Parameters:
A)

Qualifications and responsibilities of personnel

If the certification did not include IGRT, then specific training in IGRT should be obtained
performing any stereotactic procedures. The responsibilities of the Radiation Oncologist,
Medical Physicist and Radiation Therapy technologist should be clearly defined.
Radiation Oncologist:The radiation oncologist will manage the overall disease-specific
treatment regimen, recommend and approve a proper patient positioning method; also approve
a procedure to account for the intra-treatment motion/variation, (eg. breathing movement) for
targets that are significantly influenced by such motion. He will contour the outline of the
targets and as well as Organ at Risk(OAR). He will convey case-specific prescription of the
radiation dose to the target volume and set limits on dose to adjacent normal tissue. After
obtaining informed consent for the treatment, he will oversee the actual treatment process. He
will participate in the quality assurance (QA) processes, such as approval of IGRT
assessments.
Medical Physicist: Acceptance testing and commissioning of the IGRT system, thereby
assuring its mechanical, software, and Geometric precision and accuracy, as well as image
quality verification and documentation.
Implementation and management of a QA program for the IGRT system to monitor and
assure each of the following:
a. The geometric relationship between the image guidance system and the treatment delivery
system.
b. The proper functioning of the registration software that compares planning image datasets
to IGRT Datasets.

Radiation Therapy Technologist:

1. Understanding the proper use of the patient immobilization/repositioning system and
fabricating and understanding the proper use of devices for IGRT
2. Performing initial (planning) simulation of the patient and generating the medical imaging
data appropriate for the TPS
3. Implementing the IGRT treatment plan
4. Acquiring verification images for review by the radiation oncologist
5. Performing evaluation of the stability and ongoing reproducibility of the
immobilization/repositioning system and reporting inconsistencies immediately to the
radiation oncologist and the medical physicist
B)

Clinical IGRT implementation

Introducing IGRT in clinical application includes comprehensive device operation

evaluation, acceptance/commissioning, establishment of routine QA procedures, identification
of appropriate disease sites, and creation of disease site and/or technique specific
policies/procedures. Sufficient and staff training is essential for a safe and efficient IGRT
program for targeting and reduction in margin.
It is the responsibility of all staff to keep an up-to-date knowledge on the technology and
operational details of newly introduced IGRT devices, eg, MRI guidance, fiducial markers
with electromagnetic localization and dose tracking, and better imaging techniques with CT,
ultrasound and/or camera-based systems.
The commissioning/acceptance for these IGRT systems should follow technical
recommendations from professional organizations. IGRT has been routinely implemented for
various disease sites, such as: brain; head and neck; lung/thorax; breast; liver; prostate;
gynecologic tumors; spine; and for techniques such as IMRT and SBRT/SRS. The frequency
of IGRT usage should be carefully balanced between the needs of the disease, imaging dose
and resource requirements.
C)

Documentation:

Successful IGRT implementation includes specification of the type of imaging

modality used, its frequency, and the anatomical or fiducially targets employed. As noted
above, various verification methodologies of IGRT implementation are in current use, and one
or more appropriate methodologies should be incorporated into the patients record, as part of
documentation of treatment parameters.
D)

Quality control and improvement:

Examinations should be systematically reviewed and evaluated. Monitoring should

include evaluation of the accuracy of interpretation as well as appropriateness of the
examination. Complication and adverse events or activities should be monitored, analyzed and
reported as required and periodically reviewed in order to identify opportunities to improve
patient care.

E)

Safety and patient education:

Each facility should have in place policies and procedures to provide for the safety of patients
and personnel. These should include attention to the physical environment; the proper use,
storage, and disposal of medications and hazardous materials and their attendant equipment;
and methods for addressing medical and other emergencies.
Each facility should have in place policies and procedures for educating and informing
patients about procedures and/or interventions to be performed and facility processes for the
same. This should include appropriate instructions for patient preparation and aftercare, if any.
Summary:
Use of IGRT systems is essential to treatment of any site where setup deviations and
organ motion are anticipated. Additional gains are monitoring of treatment response, weight
changes, and organ filling on day-to-day basis. With improved precision of planning systems,
use of SRS or SRT, and high dose hypo fractionated regimens, the chances of small deviations
leading to significant errors in treatment delivery are much higher, and the use of IGRT is far
more critical in these situations. Integration of LINACs with MR-based soft tissue imaging
and PET-based biological imaging may help even further improve targeting accuracy in the
future. However, it is mandatory to ensure proper training of staff and QA at all steps for
optimum use of such technology and its integration into routine use.

Administration of Radiation Oncology Department-RTTs Perspective

Thomas Ranjit singh, Chief Radiation Therapy Technologist
Max Super speciality Hospital, Patparganj
New Delhi.
Radiation Therapy Technologists form the core of Radiation Oncology Department
and play a critical role in radiation treatment delivery. Their role in administration of the
department has increased over the years and clear perspective on their role play need to be
understood.
Their role is multifold within the department, from handling of sick patients, their
attendants to handling of equipments worth millions of dollars. RTTs handle simulation and
treatment activities. They need to understand functioning of the machines, their QA and their
Standard Operating Procedures (SOPs). In case of need, they are the 1st point of contact
between machines, physicists, oncologists and engineers.
RTT also need to understand taking stock of essential items (masks, accessories,
contrast etc.) required to run the department, their issuance and consumption, inventory
control as such. RTTs got to assure delivery of treatment as per prescriptions and improvise
on treatment delivery in case of special cases.
RTT must possess good communication skills to interact with patient, attendants,
physicists, oncologists and people at upper level in hierarchy. RTT is the one who receives the
patient on daily basis for 4-8 weeks and takes the patient on treatment machine. A strong hand
in documentation skills help in preparation of patients document, charts, review and research
papers.
RTTs skills need to be updated with time, with regular training, participation in workshops
and seminars.

Conformity index analysis of conventional and advanced radiotherapy techniques

P. Gnana Prakasam, Chief Medical Physicist, Department of Radiation Oncology, Manipal
Hospitals, Jaipur
Three-dimensional conformal radiation therapy (3DCRT) is a high-precision type of
radiotherapy, regarding volumes definition (target and organs at risks), patient
immobilization, and treatment delivery.
The use of multileaf collimator (MLC) gives a possibility of shaping the isodose
surfaces around volume of interest. The conformity index was first proposed in 1993 by the
Radiation Therapy Oncology Group (RTOG) and described in Report 62 of the International
Commission on Radiation Units and Measurements (ICRU). It is presented as a relation
between the volume of the reference dose (VRI) and the target volume (TV). The conformity
index (CI) was also calculated and can be defined as the degree of conformity of the plans,
which is a ratio of the PTV receiving 95% of the prescribed dose divided by the volume of the
PTV. Conformity index RTOG =VRI/TV
According to the RTOG guidelines, ranges of conformity index values have been
defined to determine the quality of conformation. If the conformity index is situated between
1 and 2, the treatment is considered to comply with the treatment plan; an index between 2
and 2.5, or 0.9 and 1, is considered to be a minor violation, and when the index value is less
than 0.9 or exceeds 2.5, the protocol violation is considered to be major, but may nevertheless
be considered to be acceptable.CI=1 is an ideal, theoretical value but even if it is areal one, it
doesnt mean that high level of conformity is achieved. Volume of reference dose could be
shifted out of target volume with perfect mathematical corresponding. Obviously to be able to
assess conformity in daily practice, additional parameters as minimal isodose surrounded
target volume, or maximal dose and mean dose into target volume, must be determined. This
presentation aims the basic understanding and analysis of conventional and conformal
radiotherapy techniques like 3D-CRT/IMRT etc.

Role of Radiotherapy Technologists in advanced treatment techniques

Athiyaman, S.P. Medical College, Bikaner
Introduction:
Radiation therapy technologists are health care professionals skilled in the art and
science of medical radiation treatment delivery. The major focus areas of the profession are
the primary care of patients, simulation, treatment, planning, and delivery of treatments
utilizing linear accelerator produced radiation and radio-isotopes. The delivery of higher end
treatment technologies such as IMRT, Arc Therapy, and SRS & SRT relies mainly on the RT
technologist who sustains and monitors the setup accuracy, positioning of the patient,
monitoring & safe delivery of the treatment.
Patient support is an integral aspect of a radiation therapy technologist's duties. The
technologist may help alleviate the patient's fears, anxieties and distress about their cancer and
treatment, and they often work closely with nurses and social workers to minimize the
emotional impact.
Scope of practice of Radiation Technologists:
In a well equipped radiotherapy department the scope of the RT Technologists can be
classified as below.
Providing radiation therapy services by contributing as an essential member of the
radiation oncology treatment team
2.
Evaluating and assessing treatment delivery components.
3.
Providing radiation therapy treatment delivery services to cure or improve the quality
of life of patients by accurately delivering a prescribed course of treatment
4.
Evaluating and assessing daily, the physiological and psychological responsiveness of
each patient to treatment delivery.
5.
Maintaining values congruent with the professions code of ethics and scope of practice
as well as adhering to national, institutional and/or departmental standards, policies and
procedures regarding treatment delivery and patient care
1.

Conclusion:
As the technological advancement in radiotherapy and in radio diagnostic facilities is
wide spreading more skilful and equipped RT technologists are required. Having skilled RT
technologist team will enhance the quality of patient care and treatment delivery. The
technologists contribution for a good radiotherapy outcome is immense and it can be stressed
that no accurate treatment is possible without the support of RT technologist.

Effect of Inter fraction Intra fraction motion in Radiotherapy-Challenges and

measures
Hemlata Athiyaman, S.P. Medical College, Bikaner
Introduction:
The goal of radiotherapy is to irradiate malignant tumors with a lethal dose while
limiting the radiation received by the normal tissue that surrounds the tumor. To date,
increasing numbers of tumors have been treated with higher radiation doses while limiting
high doses to critical structures. The latest developments in radiotherapy (3DCRT, IMRT,
SBRT) have allowed surgical precision of radiation dose distributions with the intent to cure
the patient without damaging healthy tissue. However; these new treatment techniques
introduce an enormous inherent risk, to quote J. Rosenman: We are at increased risk of
missing very precisely.Yet, the current positioning techniques do not match the accuracy
needed to perform CRT|IMRT adequately.

Effect of Intra and inter fraction organ motion during Radiotherapy:

With the development of IMRT in the 1990, radiation therapy entered a new era. By
optimally modulating the incident beam fluencies, exquisite dose distribution can be planned
and delivered. IMRT offers a valuable tool for dose escalation and/or radiation toxicity
reduction and shows significant potential to improve therapeutic ratio. In reality however, a
highly conformal dose distribution is not enough; the dose should also be delivered to the
right place at the right time .Indeed IMRT alone does not completely solve the problem of
beam targeting in RT. The patient anatomy changes from day to day (intra fractional organ
motion) and even during the dose delivery process (intrafractional organ motion) due to
patient setup inaccuracy and voluntary or involuntary physiologic process of the patient. For
example, organ motion happens involuntarily for structures that are part of or adjacent to the
digestive or urinary systems. Changes in the patients condition, such as weight gain or loss,
can also affect the relative position of the critical target volume (CTV).
The adverse effects of inter and intra fractional organ motion have been studied
extensively in the literature. Because of the anatomy change, the actual received dose
distribution may well differ from the planned one. The two scenario of relevance are
insufficient dose coverage of the tumor volume and over dosage of normal tissues. To account
for the uncertainties caused by patient setup inaccuracy and organ motion and avoid potential
geographic miss of tumor target, a population based safety margin encompassing the tumor

target was introduced. Similar strategy applies to the sensitive organs to ensure sparing of the
structures.
New technology has arisen for decreasing treatment errors arising from tumor
delineation, organ motion, and daily patient positioning so that therapy can be delivered
safely, accurately, and with fewer time-consuming steps. This includes sequential CT
acquisitions, portal image acquisitions, MRI, ultrasound (US) and fluoroscopy based fiducial
marker-guided radiation therapy.
Techniques for decreasing treatment geometrical errors have been implemented widely
for many years, with experiences varying according to strategies used. These procedures
include variables such as patient immobilization style, treatment position, rectum or bladder
filling, and the use of gold standard images or newer imaging systems at the time of
simulation or during treatment fractions Accounting for treatment errors including random
error (variation of a landmarks position about its mean value), systematic error (average
displacement of a landmarks position relative to its position at simulation), and volume
changes (time trends) is an increasingly important part of the clinical radiation therapy
process.
Conclusion:
Therefore, the knowledge of treatment errors, their characteristics and possible
techniques for reducing the need to be prioritized when modeling the radiation therapy
process.

Frameless Stereotactic Radio Surgery (SRS/FSRS) treatment technique and

evaluation of set up errors
Deepak Kumar* , Rakesh Kaul*, Dr A K Anand $ , R K Munjal#
( RADIATION THERAPIST $ RADIATION ONCOLOGIST # MEDICAL PHYSICIST)
*

Department of Radiation Oncology, MAX HEALTH CARE, Max super speciality hospital,
Saket, New Delhi-17
Stereotactic Radio-surgery (SRS & FSRS) are specialized treatment techniques in
Radiotherapy and is used to deliver higher ablative dose of radiation in a single session for
(SRS) and in a limited number of fractions for FSRS. High dose delivery forces us to keep
margin of errors for both these Stereotactic techniques significantly smaller than the
conventional Radiotherapy. Even small inaccuracy can lead to under treatment of tumor or
severe over dose to adjacent normal tissues. To ensure accurate and quality treatment it is
important to assess the accuracy of the treatment delivery by designated team of Radiation
Oncologist, Medical Physicist and Radiation Therapist. To achieve the objective patient is
immobilized using frameless head mask along with mask fixation system (BRAIN LAB TM)
for treating brain lesions by SRS and FSRS.
In order to achieve treatment accuracy we at our centre use X-ray verification by ExacTrac imaging modality by applying 6D shifts followed by cone beam computed tomography
(CBCT) imaging which is most commonly used modality as image guidance tool for accurate
treatment.
In this paper we have discussed Stereotactic radiation techniques and set up errors. So
our emphasis was on proper immobilization as per CT Simulator set up instruction card used
during CT acquisition on CT SIMULATOR (Siemens Somatom Sensation Open) and on all
treatment days on Novalis Tx linear Accelerator. Images are acquired before and during
treatment delivery and the required shifts are applied so as to achieve treatment accuracy less
than 2mm.
Further to reduce setup errors during treatment we at our centre are performing QA of
the Novalis Tx linear Accelerator on regular basis which includes WINSON LUTZ test
hidden target and OBI cube test phantom to ensure the mechanical and radiation Iso-centre
and Image Guidance within the accuracy of +_ 1mm.

SRS/SRT-RTTS PERSPECTIVE
Md. Iftekhar Wasi, Dinesh Mangal, Aseem Rai, Sonal Varshney, Raymond Ravi,
Sudhanshu, Sahabuzzama
Linear accelerator center, SMS Hospital, Jaipur
INTRODUCTION:
Stereotactic radiosurgery/SRT is a highly precise form of radiation therapy initially developed
to treat small brain tumors and functional abnormalities of the brain. This treatment is only possible
due to the development of highly advanced radiation technologies that permit maximum dose delivery
within the target while minimizing dose to the surrounding healthy tissue. The goal is deliver doses
that will destroy the tumor and achieve permanent local control.
SRS/SRT RELY ON SEVERAL TECHNOLOGIESI.
II.
III.
IV.

Three dimensional imaging and localization techniques that determines the exact coordinates
of the target with in the body.
Systems to immobilize and carefully position the patient and maintain the patient position
during therapy.
Highly focused gamma ray or X-ray beams that converge on a tumor or abnormality.
Image guided radiation therapy which uses medical imaging to conform the location of a
tumor immediately before, and in some cases, during the delivery of radiation. IGRT improves
the precision and accuracy of the treatment.

EQUIPMENT USED:
GAMMA KNIFE:
The gamma knife is a radiosurgical device that has been associated with, and dedicated to,
radiosurgery. The unit incorporates 201 Co-60 sources housed in the central body of the unit. The
main components of the gamma unit are:

A radiation unit with a upper hemispherical shield and a central body.

An operating table and sliding cradle.

A set of four collimator helmets providing circular beams with diameters of 4,8,14 and 18mm
at the isocentre.

A control unit.
LINAC BASED RADIOSURGERY/SRT:
Linac based radiosurgery/SRT uses a standard Isocentric linac with tight mechanical and
electrical tolerances, modified for radiosurgery. The modifications are relatively simple and consist of:

Supplementary collimation either in the form of set of collimators to define small diameter
circular radiosurgical beams or a micro multileaf collimator to define small area irregular fields.

A remotely controlled motorized table or treatment chair rotation.

Table brackets or a floor stand for immobilizing the Stereotactic frame during treatment.

Interlocked readouts for angular and height position of the table.

Special brakes to immobilize the vertical, longitudinal, and vertical table motions during
treatment.

COMMISSIONING OF RADIOSURGICAL EQUIPMENT:

The basic principles involved in the commissioning of radiosurgical devices are very similar
for all such devices, despite the large variations in dose delivery techniques that they entail. The
following issues should be considered before embarking on a clinical radiosurgical service:

The properties of radiation beams must be measured to ensure radiation safety of the patient
and accurate treatment planning.

The mechanical integrity of the radiosurgical device must be within acceptable tolerances to
provide reliable and accurate delivery of the prescribed dose.

All steps involved in the radiosurgical procedures, from the target localization, through
treatment planning to dose delivery, must be verified experimentally to ensure reliable and accurate
performance of the hardware and software used in the radiosurgical procedure.
QUALITY ASSURANCE IN RADIOSURGERY/SRT:
Stereotactic radiosurgery/SRT is a very complex treatment modality requiring not only close
collaboration among the members of the radiosurgical team but also careful target localization and
treatment planning, as well as strict adherence to stringent quality assurance protocols. The quality
assurance protocols for radiosurgery/SRT fall into three categories:

The basic quality assurance protocols covering the performance of all equipment used for
target localization, 3-D treatment planning and radiosurgical dose delivery.

The treatment quality assurance protocols dealing with the calibration and preparation of
equipment immediately preceding the radiosurgical treatment.

Treatment quality assurance during the radiosurgical procedure on a patient.

Measurement of dose to contralateral breast at the level of nipple during

radiotherapy treatment of breast cancer
Soniya Hooda, Dr. Arun Chougule, S.M.S. Medical College, Jaipur (Raj.)
Email: soniyahooda28@gmail.com
External beam radiotherapy is being used to treat the breast malignancy. It is most
commonly used postoperatively to treat breast malignancy as postoperative radiotherapy
significantly reduces the risk of loco-regional failure and improves disease-free survival. With
the advancement of technology, the radiotherapy treatment techniques evolved from
conventional technique to advanced treatment techniques of radiotherapy such as threedimensional conformal radiotherapy (3DCRT) and intensity modulated radiotherapy (IMRT),
resulting in an improvement in the dose conformity to target volume and sparing normal
tissue. Regardless of the advancement in treatment techniques, the peripheral dose to the
contralateral breast is inevitable. The possibility of the peripheral dose inducing contralateral
breast cancer (CBC) has re-attracted the interest. Thus the present study aims to compare the
contralateral breast dose from the ipsilateral breast irradiation using two radiotherapy
treatment techniques.
The goal of this investigation was to quantify the radiation dose to the contralateral
breast after radiotherapy treatment for primary breast cancer. In present study contralateral
breast dose was measured in fifty breast cancer patients who underwent external beam therapy
on cobalt-60 teletherapy machine and linear accelerator machine. The study was performed on
breast cancer patients treated after modified radical mastectomy. The optically stimulated
luminescence dosimeter (OSLD) was placed at the level of contralateral breast nipple before
starting the treatment. Post-operative radiotherapy was delivered by medial and lateral
tangential fields daily to patients treated on linear accelerator while for the treatment on
cobalt-60 teletherapy machine medial and lateral tangential fields were treated on alternate
days. The total dose delivered was 50Gy in 25 fractions with 2Gy per fraction. The dose
contribution was measured for tangential fields only.
The beam modification was achieved with asymmetric jaw in the cobalt-60 teletherapy
machine while in linear accelerator the beam modification was achieved with the help of
multileaf collimator. The dose measured at the contralateral breast nipple for patients treated
on telecobalt machine was observed between 114.25 to 193.12 cGy for total primary breast
dose of 5000cGy in 25 equal fractions which accounted to be 2.28-3.86% of total dose to
ipsilateral breast while for the patients treated on linear accelerator the dose measured at the
contralateral breast nipple was observed between 73.75-171.00cGy for total primary breast
dose of 5000cGy in 25 equal fractions which accounted to be 1.47-3.42% of total dose to
ipsilateral breast. Further it was observed that the maximum contribution of contralateral
breast dose was due to medial tangential fields.

Dosimetric characterization of OSLD in diagnostic and therapeutic energy range

Priti Gupta, Gourav Jain, Dr. Arun Chougule
SMS Medical College and Hospitals, Jaipur
Email:-pritiguptakota@gmail.com
Optically stimulated luminescence (OSL) was studied using a commercial OSL
dosimetry system developed by Landauer (Landauer Inc., USA) to analyses the possibility of
using OSL dosimetry for external beam radiotherapy planning checks and in-vivo dosimetry.
OSL dosimetry provides a new degree of sensitivity by giving an accurate reading.InLight
nanoDot dosimeters are designed for use in single point radiation assessment applications,
and are engineered to be read out by the smallest InLight reader availablethe
microStar.OSLD is used mainly for in-vivo dosimetry and personal dosimetry. Before using
it in-vivo dosimetry, the characterization is necessary. The aim of study is characterization of
optically stimulated luminescence dosimeters for diagnostic and therapeutic energy use. The
dosimetry characteristics of OSLDs and associated readers should be optimal if OSLD is to be
suitable for radiation dosimetry, including: sensitivity, reproducibility, dose response
characteristic, dose response dependence on the signal, energy dependence, and angular
dependence. In energy response check in diagnostic at 70 kVp the response was higher 3 to 4
times than 80 kVp and after 125 kVp the response was 8 to 9 times low. The dosimeters are
calibrated at 80 kVp in diagnostic energy range, so there is need a separate calibration factor
when using OSLDs at different kVp. The linearity check in diagnostic showed that as the mAs
increased net PMT counts were increased in linearity and in therapeutic energy range first it
increased at dose range to 250 cGy and above 250 cGy it showed supralinearity. With the
field size increase absorbed dose increased at a certain field size and then decreased for
diagnostic and in therapeutic energy the variation observed in OSLD response was 3.5%.
The variation observed in OSLD response with depth was 5% in therapeutic energy range.
OSL nanoDot dosimeters show small angular dependence with different angles in
diagnostic so there is need of separate calibration factor.The purpose of this study focused on
testing specifically the Al2O3:C based OSL system in terms of evaluating its dosimetric
characteristics and performance with diagnostic beams and megavoltage beams and to assess
its suitability for use in diagnostic and radiotherapy.

Basics and evolution of Gamma Knife Stereotactic Radiosurgery

R K Bisht, Department of Neurosurgery and Gamma Knife,
All India Institute of Medical Sciences, New Delhi -110029, India
Email:raaj_bisht@rediffmail.com

Radiation therapy is the medical use of high energy ionizing radiation in the treatment
of benign and/or malignant tumors in the body. Radiotherapy remains the most effective nonsurgical treatment modality for treating cancer and contributes a significant proportion of
available treatment alternative to cure various clinical indications for long term survival.
Various modern techniques like three dimensional conformal radiotherapy, intensity
modulated radiotherapy, image guided radiotherapy, stereotactic radiotherapy/ radiosurgery,
stereotactic body radiotherapy and etc, are popular among oncologist, medical physicist and
technologist to deliver radiation dose to the tumor volume precisely. A prescribed dose of
radiation destroys the ability of cancer cells to repopulate which results in the removal of
these cells from body biologically.
Stereotactic radiosurgery (SRS) is a form of modern radiation therapy technique,
where instance and highly focused radiation is used to inactivate small target(s) volume of the
body. Proton stereotactic machines, Gamma knife, modified linear accelerators / cyber knife
and etc are various stereotactic radiosurgery are commercially available to treat targets with
improved accuracy. First Gamma knife machine was available for SRS treatments in the year
of 1968. Gamma knife Perfexion (introduced in 2006) has automated collimator system with
patient positioning system, which reduces the labour in treatment position settings and
comprehensive treatment time considerably. Gamma knife radiosurgery is a dedicated system
to treat tumors and other clinical indications in the brain. A MR compatible aluminium frame
with 3 or 4 pins around patient head is fixed for head immobilization and a stereotactic
imaging with MR/CT indicator is utilized to define target coordinate system. A state of art
treatment planning system is used to perform dosimetric calculations for treating target lesion
with higher accuracy. A precise treatment plan could be evaluated with accepted quality
indices like tumor coverage, selectivity, gradient index, conformity index and dose to the
surrounding organs. It was observed that the dose gradient within the tumor volume gives
better clinical results to the neurological benign indications with steep dose fall off outside the
target margins.
In SRS, the dose delivery with higher accuracy is foremost to deposit theoretical mean
of methodology adopted. Such higher degree of accuracy and reliability in dose delivery
required frequent mechanical, electrical and radiological quality assurance programmes. The
performance of Gamma knife with commanding accuracy and minimal quality checks make
the system highly accepted in SRS community.

Measurement of corneal dose during External Beam Radiotherapy of head and

neck malignancies
Ajay Prajapati, Dr. Arun Chougule, S.M.S. Medical College, Jaipur (Raj.)
Email: rttajay@gmail.com
Introduction: Cancer is the one of most common diagnosed disease. Treatment of cancer can be
done with surgery, radiotherapy (RT), chemotherapy and hormonal therapy. However 90 % of
head and neck cancer patients are treated with RT. During the RT treatment, some of critical
organs such as cornea, gonads, breast, thyroid, red bone marrow are highly radiosensitive organs
which need to be spared. If cornea receives 2 Gy radiation dose in a single fraction and 4-6 Gy
dose in fractionation then it will induce cataractogenesis. After a latent period patient will loss his
vision due to appearance of cataract.
Aim: The aim of this study was to measure the contribution of scattered radiation dose to the
cornea during the EBRT of head and neck malignancies using two different RT treatment
modalities.
Material and methods: In this study the corneal dose measurement was done on 80 patients who
had head and neck malignancies, in which 40 patients were treated on cobalt unit and remaining
40 patients on linear accelerator (linac) unit. The patient was positioned properly with appropriate
immobilization device on the treatment couch of cobalt and linear accelerator unit. Two optically
stimulated luminescence dosimeters (OSLD) were placed on the right and left eyelids respectively
before starting the treatment which were obtained from Department of Radiological Physics,
Sawai Man Singh Medical College & Hospital, Jaipur. The patient was treated with right and left
lateral fields alternately for 30 treatments days, for a total dose of 6000 cGy with a dose delivery
of 200 cGy/fraction on cobalt unit and on the linac unit, patient was treated bilaterally for 35
treatments days, for a total dose of 7000 Gy with a dose delivery of 200 cGy/fraction.
Results: During the treatment on telecobalt machine we measured maximum radiation dose to the
cornea was 14.97 cGy, i.e., 7.48 % of the tumor dose in case of G.B.M. malignancy and minimum
corneal dose was 5.66 cGy, i.e. 2.83 % of the tumor dose in case of Ca. vocal cord. While for the
patients treated on linear accelerator, we measured maximum radiation dose to the cornea was
12.44 cGy i.e. 6.22% of the tumor dose in case of Ca. maxilla and minimum corneal dose was
0.62 cGy, i.e.0.31% of the tumor dose in case of Ca. larynx. Result and discussions showed that
patient treatment planning, immobilization, beam shaping devices or plan execution play an
important role during the RT treatment of head and neck cancers.

Patient specific Quality Assurance tools for Rotational Therapy

Gourav Kumar Jain,
Department of Radiological Physics, SMS Medical College and Hospital, Jaipur
Radiotherapy plays an important role in management of cancer, almost 70% of cancer
cases require radiotherapy. External beam radiotherapy (EBRT) plays a vital role in
management of cancer especially when the spread of disease is loco-regional or in advanced
stages for palliative care. External beam radiotherapy also called Teletherapy in which the
radiation source is at a certain distance away from the patient and the target within the patient
is irradiated with an external radiation beam. Apart from conventional 3DCRT, several new
external beam radiotherapy treatment delivery techniques evolved in past few decades
including intensity modulated radiotherapy (IMRT), volumetric modulated arc therapy
(VMAT)and dynamic conformal arc therapy. These newer EBRT techniques has been
succeeded to achieve the common goal of radiotherapy by sparing normal tissue significantly
due to tight margins of target but there are some disadvantages associated with them too. They
have added the complexity in each step of treatment planning, calculation and delivery as
compared to 3DCRT.
As treatment delivery becomes more complex, there is a pressing need for robust
quality assurance tools to improve efficiency and comprehensiveness whilst maintaining high
accuracy and sensitivity. In order to prevent errors that can adversely affect the patient
resulting in radiation incident, Complex treatments in radiotherapy require patient-specific
quality control and the patient specific quality assurance (QA) becomes an important part of
QA program. Clinics are generally dependent on third-party vendors for patient specific
quality assurance (QA) tools.
Quality control (QC) check points which can effectively prevent errors are the
inspection of treatment plans (secondary plan checks) and measurement of treatment plans
on a phantom with a simple geometry pretreatment. In the present era, solid water made
round, oval, slab, antromorphic phantoms of different size used for this purpose and most of
the patient specific QA tools use vented or liquid ionization chamber in cylindrical or parallel
plate geometry, diode as detector in form of a single detector or an array of detectors or both.
Ionization chambers are the preferred choice of detector for absolute 1 dimensional (1D) point
dose measurements. Planner detector arrays or films are used for 2D measurements. 3D dose
is generally reconstructed with the help of multiple planner 2D arrays or a cylinder-shaped
phantom having a number of detectors measurements, electronic portal imaging device
(EPID) measurements. Other 3D dose measurement dosimeters are Polymerizing gels and
Fricke dosimeters.
The absolute point dose measurements performed using ionization chamber as per the
recommendation in AAPM TG-119 and generally, pin point chambers are preferred.2D
measurement can beperformed using films (radiochromic/ radiographic), diode detector array
Sun Nuclear MapCheck, vented ionization chamber (IC) detector array PTW Seven29,
parallel plate (PP) liquid filled detector array PTW 1000SRS, vented ionization chamber
detector array IBA IMatrixX. Available tools in market for 3D measurements are diode

detectors based Sun Nuclear ArcCheck, vented IC or PP liquid filled PTW Octavius4D,
diode detector based Scandidos Delta4,IBA Compass. Other solutions for 3D
measurements are MathResolutions Dosimetry Check and using 2D measurements of EPID.
Almost all the detector arrays experience angular dependence. Vendors are using
different solutions to overcome this specific problem with the use of inclinometer and internal
angular dependence corrections, always irradiate detector array perpendicular to incident
radiation. Detector size is a key parameter for resolution. Films have the highest resolution of
about 0.35 mm per pixel but the films are passive dosimeter and require time consuming
laborious process for results. Diodes also have the better resolution as compared to ionization
chambers. Unlike ionization chamber, diodes experience energy dependence. Separate
calibration files used to overcome this energy dependency.
Ionization chambers and films are gold standards. Electronic 2D detector arrays suffer
from limited spatial resolution and angular dependence. Intensive QA require 3D dosimetry.
Rigorous QA check use Ion chamber array in 2 planes. But, effective & efficient QA
measurements with ion chamber/ion chamber array in 1 plane.
There are limitations to the manual review of treatment plans as it is time consuming
and potentially error-prone. Moreover, the measurement of a plan (pretreatment) has
significant limits to its effectiveness in detecting certain types of errors. However, in vivo
electronic portal imaging device (EPID)-based verification may be more effective than other
QC checks already in widespread use. Complementary to EPID dosimetry is a software-based
system that can aid the plan review process. The presence of a fluorescent screen in EPID
leads to an over-response of the detectors to low doses and EPID requires a number of
correction factors to generate dose fluence. But, the use of EPIDs for transit dosimetry
continues to be an important research topic with the potential for providing important realtime information. Other future tools for patient specific QA providing real-time information
are dose reconstruction using CBCT data and MLC DynaLog files are area of research
interest.

Technical advancements in newer LA machine (TrueBeam)

*a radiation therapist perspective *
Yashveer, Chief Radiation Therapist, Mahatma Gandhi Hospital, Sitapura, Jaipur
Aim & Objective- To elaborate the upgraded technical features of newer LA like Truebeam,
to share the knowledge & The impact of these benefits in radiotherapist's workflow.
Discussion- Radiotherapy is an enormously growing field of medical science and physics.
Over short time duration numerous technologies and machines have come in this field. So we
have to keep ourselves updated with these new technologies and machines. Thats why, here a
short discussion about this newer linear accelerator is being provided. TrueBeam accelerates
treatment by intelligent automation, imaging, positioning and reduction of the number of
steps needed for treatment up to 5 folds. It offers more convenience for the patient by
shortening treatment time with a dose rate of up to 2400 MU/minute with FFF (Flattening
Filter Free) mode. A Standard IMRT treatment that lasts 10-15 minute normally can be
completed in a time shorter than two minutes. It provides treatment processes with a higher
performance by giving a higher dose in a shorter time. It enables increase in hitting the target
by giving less time for tumor movement during dose delivery that is performed in a very short
time: sensitivity of TrueBeam system is less than 1 millimeter. This accuracy is provided by
the sophisticated structure of the system which forms a new synchronization level among
technologies of imaging, positioning, management of movement, shaping of irradiation and
dose delivery and performs accuracy control every 10 milliseconds throughout treatment.
With automated CBCT its quiet easy and safe taking cbct with lesser exposure to patient and
no need to change FAN for pelvic and H&N cases. Despite being so sensitive & accurate, this
newer system is very user friendly & convenient for Radiotherapist's to operate this system.
ConclusionThe newer linear accelerators like TrueBeam are capable of treatment with increased
precision & accuracy, with more user friendly interface & convenience.

COMMISSIONING & QUALITY ASSURANCE TEST OF TELEGAMMA

UNIT
Mukesh Jain, Ananth.K, Ramesh Chand Sharma, Prof. Arun Chougule,
Introduction:
Cancer is the second most common disease in India responsible for maximum mortality with
about 0.6 million deaths per year in India. Regardless of prognosis, the initial diagnosis of cancer is
still perceived by many patients as a life-threatening event. There are around 400 teletherapy units in
India as against a requirement of around 1200 as per UICC (International Union against Cancer),
IAEA,WHO guidelines which stats the equipment of one cobalt unit is required for treatment of cancer
patients for one million populations in the developing countries.
The clinical scientific evidence regarding tumor control and overall cancer survival for most
tumor sites are generally inconclusive at this time while using advanced radiation treatment
techniques. The need for these advancements is based on the underlying assumption that the new,
complex technologies will improve loco-regional control of cancer and therefore cure more patients
.the new technology can produce new ways for errors to occur, necessitating ongoing evaluation of QA
for radiation therapy.
As cobalt-60 could possibly be used for about 30-40% of all patients treated with radiation
therapy with a corresponding reduction in overall operating costs and to ensure quality treatment with
grater reproducibility, A comprehensive quality assurance test & commissioning is required which can
serve as a baseline protocol for the machine as well as operating procedure before the machine is
practically used for patient treatment and also to verify certain documents from the Manufacturer
usually accompany the delivery of the machine and its ancillary accessories to the end users.
In our present work we conducted the quality assurance test and commissioning of the
Bhabhatron-II-TAW teletherapy unit so as to ensure the consistency and accuracy in dose delivery of
prescribed dose, minimal radiation dose to normal tissue, and minimal exposure to occupational
radiation workers, adequate patient monitoring and mechanical/electrical safety.
Materials and Methods
The Bhabhatron-II Telecobalt machine considered in this study is a new telecobalt product in
the market, manufactured in India. We need to verify its dosimetric parameters and some of the values
supplied by the manufacturer. These tests were carried out as per requirements of AERB standards and
acceptance criteria mentioned in safety code AERB/RF-MED/SC-1 (Rev.1) &RPAD/Telecobalt/QA
,These test are carried out by using ionization chamber, Electrometer, 30 X 30 X 30 cm cubic water
phantom, Survey meter, Radiographic Film and Laser Alignment Test Tool.

Summary
The safety checks like interlocks, warning signs, mechanical checks like ODI, Field Size,
Gantry rotation, Isocenter, couch indexing verification, Alignment of optical field and radiation field
and radiation checks like PDD verification, output, linearity, wedge-tray ,collimator transmission
factor measurement, Source ON-OFF position leakage are performed , The radioactive source installed
in Bhabhatron-II unit was found to be 168 RMM , the radiation leakage through the collimator of
Bhabhatron-II, especially the X-jaws, was found to be less than the leakages recoded in the earlier
model of the unit- Bhabhatron-I, The measurement performed for wedge filters have values that are
similar to the manufacturers stated values and within the acceptable 2% deviation and the
transmission factors obtained for plain tray, being conventional, is used to standardized values
obtained for other tray patterns. The transmission factors for trays are also measured. Beside these test
a radiation protection survey was conducted. The results obtained thereof are in coherence with the
AERB recommendation and other international regulations.
Conclusions
Bhabhatron II mainly differs from other conventional Telecobalt Machine as it is a computer
controlled one. Ensuring Radiation Safety is the primary aim involved in the commissioning process.
All the Quality Assurances were under the recommended Tolerance limit. Bhabhatron-II being a
computer controlled machine satisfies the necessary and basic safety requirements for Clinical usage
the plan parameters such as Field size, Collimator, Gantry and Couch parameters can be loaded for
individual patients along with the Treatment Time.
Configuring this machine with the T.P.S and executing the Treatment through 3-D Planning
will give a huge benefit to the patient. Implementation of Multi leaf collimator in this advanced
machine is expected. Even though the Telecobalt Machines has disadvantages of Penumbra, Periodic
reduction of Dose Rate etc., implementation of computer controlled Treatment Delivery, Asymmetric
Jaws, motorized wedge, Record of Patient History, Battery backup of six hours etc. has remarkably
enhanced the Quality of treatment in the field of Radiotherapy.
It is stated that all the radiation leakage/transmission parameters are within the tolerance limit
specified by the relevant IEC standard, and AERB Safety code (SC/MED/01R). Overall the
commissioning was successful.

Patient Dose with Quality Image under Diagnostic Reference levels

Suresh Kumar Akula, Gurvinder Singh, Prof. Arun Chougule
SMS Medical College and Hospital, Jaipur
Email:suresh.suryas@gmail.com
Aim and Objectives:
i) To set Diagnostic Reference Level (DRL) for locations of all diagnostic equipments in the
local hospitals as compared to National standards.
ii) To review the local DRLs and compare with national or referenced averages. If any
significant variations found, evaluate and rectify the practices.
iii) To survey and asses radiation doses to patient and reduce the redundancy in patient
imaging to maintain DRLs.
Materials and Methods: The Dose Area Product (DAP) values to the patient and cumulative
doses (CD) were recorded and compared with the values of Multimeter (PTW-NOMEX
software) readings. The effective dose from DAP for each examination site for 15 patients
(Live data) and WHOLE BODY (Humanshaped) phantom values are compared under
standard imaging parameters. Reducing the redundancy of patient imaging the patient organ
site dose was simultaneously compared with Multimeter data. The observed readings are
within limits as compared to the values of National Radiological Protection Board (NRPB) in
UK.
Results & Discussion: The difference between the organ site doses measured by DAP meter
and Multimeter (NOMEX) software were within tolerance limits. Some organ sites (Cervix
and Head and Neck) measurements are higher than the DRL values that mentioned in NRPB.
The DAP measured for each organ site compared with multimeter readings and values of
NDRL and found to be comparable with NDRLs as mentioned by NRPB in UK.
Conclusion: Although the DRL project for defining conventional diagnostic X-ray
examinations has been completed the results have not been published yet. So our observations
are compared with values reported by NRPB for UK. DAP and Multimeter (NOMEX
software) can be used as the dose indicator to calculate the organ site dose. This method can
provide important information of patient absorbed dose and enhance the radiation protection
of patient in radiological procedures. This will also help to reduce the redundancy of patient
imaging by making standard imaging protocols.

DAP meter fixed to the X-ray

Gantry Head.

Fig-1: X-ray Machine having DR and CR Facility. Fig-2:X-ray Machine connected with DAP
meter.

DAP Meter

Multimeter placed on the human body-phantom to take

readings simultaneously with DAP meter readings.

Fig-3: X-ray machine connected with DAP meter and Multimeter (NOMEX-PTW-Software)
place on the site going to view.

Fig-4: Nomex-Multimeter kept on the Human Body Phantom at Chest site the effective field
at the X-ray Gantry Isocentre.
Table-1: Standard Human Shaped Body Phantom DAP vs NOMEX-Multimeter readings:
NDRL
DAP(Gy.Cm2
NOMEX-PTW
Number of
)
Media
Multimeter Readings
Radiograph Readings
n
75th Percentile Avg-DOSE (10-3) Gy
Min Max Mean
DAP
Skull AP
15
1.14 2.768 0.13 0.1689
7.04
0.02268
Abdomen
15
0.5 1.55 1.01 1.01
2.32
3.435
AP
Cervical
15
0.03 0.23 0.11
0.1
0.22
3.102
Spine AP
Cervical
15
0.03 0.26 0.12
0.1
0.24
3.235
Spine LAT
Chest AP
15
0.01 0.56 0.18 0.11
0.18
1.875
Chest PA
15
0.01 0.8
0.06 0.08
0.16
1.902
Lumbar
15
0.3 1.69
0.9
1.2
1.62
2.12
Spine AP
Lumbar
15
0.6
2.7
1.88
1.6
2.68
2.316
Spine LAT
DAP distribution
(Gy. cm2 )

Pelvis AP
Thoracic
Spine AP
Thoracic
Spine LAT

15

0.71

3.64

2.86

1.1

2.64

3.113

15

0.2

1.2

0.6

0.5

0.97

2.04

15

0.2

1.32

1.1

0.8

2.03

2.76

Table-2: Distribution of mean Dose Area Product for Patients (adults).(25 40 yrs)
Radiograph
Abdomen
AP
Cervical
Spine AP
Cervical
Spine LAT
Chest AP
Chest PA
Lumbar
Spine AP
Lumbar
Spine LAT
Pelvis AP
Thoracic
Spine AP
Thoracic
Spine LAT

Median

NDRL DAP
(Gy.Cm2 ).
75th Percentile DAP

1.01

1.01

2.32

0.27

0.14

0.1

0.22

0.03

0.24

0.15

0.1

0.24

15

0.01

0.56

0.18

0.11

0.18

15

0.01

0.8

0.06

0.08

0.16

15

0.3

1.69

0.9

1.2

1.62

15

0.6

2.7

1.88

1.6

2.68

15

0.1

2.9

1.6

1.1

2.64

15

0.2

1.2

0.6

0.5

0.97

15

0.2

1.32

1.1

0.8

2.03

Number
of
Patients

Min

Max

Mean

15

0.5

1.55

15

0.03

15

DAP distribution(Gy cm2)

SRS, SRT and other radiotherapy techniques in CNS & brain tumors
Mary Joan, Department of Radiological Physics, SMS Medical College, Jaipur
Brain tumors can be classified into two different categories: primary or metastatic.
Primary brain tumors begin within the brain. A metastatic tumor is formed when cancer cells
located elsewhere in the body break away and travel to the brain. If a tumor is determined
malignant, the tumor cells are examined under a microscope to determine how malignant they
are. Based on this analysis, tumors aerated, or graded, by their level of malignancy from least
to most malignant.
A variety of therapies are used to treat brain tumors. The type of treatment
recommended depends on the size and type of the tumor, its growth rate, brain location, and
the general health of the patient. Treatment options include surgery, radiation therapy,
chemotherapy, targeted biological agents, or a combination of these. Surgical resection (if
safe) is generally the first treatment recommendation to reduce pressure in the brain rapidly.
Radiation therapy may be advised for tumors that are sensitive to radiation.
Conventional radiation therapy uses external beams of x-rays, gamma rays or protons aimed
at the tumor to kill cancer cells and shrink brain tumors. The therapy is usually given over a
period of several weeks. Whole brain radiation therapy is an option in the case of multiple
tumors or tumors that cannot be easily targeted with focal treatment.
Arc therapy is an advanced treatment technique that builds on the advantages of
IMRT. The potential advantages of arc therapy over IMRT have not been fully established;
this technique is not yet widely available.
Intensity-modulated radiation therapy (IMRT): an advanced mode of highprecision radiotherapy that utilizes computer-controlled x-ray accelerators to deliver precise
radiation doses to a malignant tumor or specific areas within the tumor. The radiation dose is
designed to conform to the three-dimensional (3-D) shape of the tumor by modulatingor
controllingthe intensity of the radiation beam to focus a higher radiation dose to the tumor
while minimizing radiation exposure to healthy cells.
Stereotactic radiosurgery: a highly precise form of radiation therapy that directs
narrow beams of radiation to the tumor from different angles. For this procedure, the patient
may wear a rigid head frame. Computed tomography (CT) or magnetic resonance imaging
(MRI) help the doctor identify the tumor's exact location and a computer helps the doctor
regulate the dose of radiation.

Stereotactic radiotherapy is similar physically to radiosurgery but involves

fractionation (multiple treatments). This modality would be recommended for tumors within
or close to critical structures in the brain that cannot tolerate a large single dose of radiation or
for larger tumors.
Three-dimensional conformal radiation therapy (3D-CRT): a conventional form of
radiation treatment delivery that uses a specific arrangement of x-ray beams designed to
conform to the shape of the tumor to maximize tumor dose and minimize normal surrounding
tissue dose. This form of treatment is tailored to the patient's specific anatomy and tumor
location. CT and/or MRI scan is often required for treatment planning.
Brachytherapy: the temporary placement of radioactive materials within the body usually
employed to give an extra doseor boostof radiation to the area of the excision site.
Rationale for Craniospinal irradiation (CSI) in medulloblastoma
CSF dissemination is known in 16-46% of cases. Posterior fossa, spinal cord, ventricular
walls & supratentorial region including the cribriform plate form the main sites ofrelapse.
Being radiosensitive, RT is curative in upto 70% of standard risk patients.
Target volume for CSI
Whole brain with its meninges, Spinal cord down to the caudal end of the thecal sac(usually
S2 but should be verified by saggital MRI), and primary tumour site/posterior fossa (for
boost).
Challenges in planning CSI
Challenges in CSI planning are immobilization & positioning of a large target area, large &
irregular shape of the clinical target volume (CTV), multiplicity of fields, inhomogeneity at
the junctions between the brain and spinal fields, large number of critical normal structures
having direct bearing on the late effects in these pediatric long term survivors.
Steps in planning
Positioning, Immobilization, Simulation, Verification, Treatment and Junction shift.
Positioning
PRONE: It provides direct visualization of the field junctions on the patient. Good alignment
of the spine can be achieved.
SUPINE: Comfortable. Useful in anesthesia (in < 7yr age group)
Radiotherapy Planning
Phase I: With two lateral cranial fields and 1 or 2 spinal fields
Phase II: Posterior fossa boost with two lateral cranial fields and conformal technique in low
risk cases.

Critical issues in CSI fields

Concern 1: Divergence of the upper border of the spinal field in case of single (and inter
divergence of spinal fields in case of 2 spinal fields)
Concern 2: Divergence of both cranial fields.
Techniques for matching craniospinal fields: Collimator/couch rotation, half beam block,
asymmetric jaws, penumbra generators, wedge and tissue compensator
Treatment & verification: Port films after placing radio-opaque markers on the inferior
border of cranial field can be used to verify craniospinal field matching. Electronic portal
imaging has also played important role in verification & correction of set up errors.
Junction shift: Usually shifted by 1 to 2 cm at each shift. Done every few fractions, either in
cranially or caudal direction. Cranial inferior collimator is closed & spinal superior collimator
is advanced by the same distance superiorly (if junction to be shifted cranially).Similarly,
lower border of superior spinal field &superior border of inferior spinal field are also shifted
superiorly, maintaining the calculated gap between them.
CSI results in predictable, if quantitatively variable, acute changes in the peripheral blood
counts.
Neutropenia or thrombocytopenia most often noted during or after the third week.CSI is
interrupted if, The TLC falls below 3000 per cumm, the neutrophil count falls below 1,000
cells per milliliter, platelet count falls below 80,000 per cummor any neutropenia with fever
or thrombocytopenia with bleeding manifestations. If blood counts necessitate interrupting
CSI for more than2 consecutive days, initiation of posterior fossa irradiation can be done.

Evolution of Gamma knife and workflow of treatment procedure

Gurvinder Singh, Medical Physicist, SMS Medical College and Hospital, Jaipur
Recent advancements in radiotherapy have not only raised the quality of treatment but
also improved the treatment outcomes. High precision and accuracy are two main tools that
are contributing mainly to these results. Gamma knife is among the leading advance machines
in accurate treatment delivery. It delivers the precise dose with few mm accuracy in the
targeted area.
First Gamma Knife built in 1968 under the direction of Lars Leksell in Stockholm,
Sweden. Lars Leksell was a neurosurgeon. It was a treatment unit designed specifically for
intracranial radiosurgery. It used beams of highly-focused gamma rays to treat small to
medium size lesions, usually in the brain. This was based upon the principle of converging
arcs which were focusing on a specific point known as Unit Centre Point (UCP). In early days
a prototype was developed for research purposes only. But in 1986 after 18 years of research,
first commercial unit was introduced as Gamma Knife C model. This model was semiautomatic. Soon an advanced model 4C was introduced with 201 Co60 sources. This model
was microprocessor controlled but couch movements were manual. In 2006, Gamma Knife
Perfexion model was introduced which was fully automatic model with 194 Co 60 sources. It
was introduced with Automatic Positioning System (APS) which controls the couch
movements using microprocessor.
Treatment procedure in gamma knife is a step by step process. It begins with the
stringent application of frame with skull under local anesthesia. This frame act as a coordinate system for further treatment. Images are acquired with CT, MRI or angiography
localizers and transferred to planning system. Planning is done after image definition and dose
prescription by a medical physicist. Different shots of 4, 8 and 16mm are utilized to get
conformity and uniformity. This plan is approved by radiation oncologists or neurosurgeons
for final delivery. Then plan parameters are transferred to the treatment unit. Treatment unit
have an Automatic Positioning Couch (APC) system that adjusts the positions automatically
while delivering the dose.
In this way gamma knife is a completely advance and accurate machine to deliver high
doses with greater conformity and accuracy. It is best modality for cranial treatments. But it
has a limitation that it is dedicated unit for brain treatments only.

AFOMP Newsletter

Publisher :Dr.Tae-Suk Suh

Editor

: Dr.Arun Chougule

Advisor : Dr. Yimin Hu

Dr. Howell Round

Australia

Bangladesh

China

Hong

Kong

India

Indonesia

Iran

Japan

Korea

Malaysia Mongolia Nepal New Zealand Pakistan Philippines Singapore Taiwan Thailand Vietnam*

Vol.7 No.02 Dec 2015

INSIDE STORIES

From the desk of the editor

1. Conference Report
AOCMP 2015

Wish you all very happy, healthy and

prospers New Year 2016. I am happy to put before

..Page 03
2. IMPCB Update
..Page 06
3. The Global Growth of
Medical Physics in the
Past 50 Years
..Page 10
4. Status of Medical
Physics in Nepal
..Page 12
5. Meeting Report on
IAEA RAS 6077

you the Dec 2015 AFOMP newsletter issue

During the AOCMP 2015 at Xian, China, new
office bearers of AFOMP for 2016-18 were elected. On
behalf of myself and editorial board of AFOMP newsProf. Dr. Arun Chougule
letter I take the opportunity to welcome the Prof. Tae
Suk Suh as President AFOMP, Prof. Arun Chougule
as Vice President, Assoc. Prof. Howell Round as Secretary General and Prof.
Ng Kwan Hoong as Treasurer. We wish the new team all the best for their efforts to uplift the medical physics in general and AFOMP region in particular. I
have stressed on earlier occasions and once again emphasis on close cooperation, communication between the national organisations of medical physicists in
the AFOMP region and between individual medical physicists. Continuous education and updating of recent advancements, innovations in the field are the key
to raise the standard of profession and there are number of educational resources to update yourself such as IAEA, AAPM, and ICTP, etc. The newsletter is
trying to provide the information regularly in this regards and I welcome the
readers/ agencies/ stakeholders to update us so that the information is spread.

Further, I appeal to all of you to kindly provide the information about scientific activities planned in coming years so that the information is put in newsletter /website for benefit of our members & colleagues. I know there are lots of
6. Travel Grant Report
heterogeneities in AFOMP region in terms of education standards, resources,
on 15th AOCMP 2015
..Page 16 carrier opportunities, structured academic programmes, still then with constant
cooperation and updating the gap can be bridged. In this direction the efforts of
IMPCB are remarkable. I have put the article on IMPCB for benefit of all readers.
7. BMPS
This newsletter contains an article The Global Growth of Medical Physics in the
..Page 18 past 50 years: - Dr. Slavik Tabakov, President IOMP, AFOMP travel grant report, AOCMP2015 report, and briefs about two medical physicist national organisations,
8. Calendar of Events

..Page 15

..Page 20

Once again I take this opportunity to wish you very happy New Year 2016
and all the success.
Looking forward for your feedback and inputs

Prof. Dr. Arun Chougule

AFOMP Newsletter, Vol 07 No.02 Dec 2015

AFOMP Newsletter, Vol 07 No.02 Dec 2015

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Conference Report -15th Asia-Oceania Congress of Medical Physics (AOCMP 2015)

Professor Yimin Hu-President,AFOMP
Nov. 5-8, 2015, Kempinski Hotel, Xian, China

15th Asia-Oceania Congress of Medical Physics (AOCMP2015) was held on Nov. 5-8,
2015 in the Kempinski Hotel of the historical-ancient capital Xian city of China. This
mega scientific event is co-sponsored and organized by the Chinese Society of Medical
Physics (CSMP), the Shaanxi Provincial Cancer Hospital, Shaanxi Province, China, under
the auspices of the Asia-Oceania Federation of Organizations for Medical Physics
(AFOMP), the American Association of Physicists in Medicine (AAPM) and the International
Organization for Medical Physics (IOMP). The chairman of this meeting is Professor Yimin
Hu, the president of AFOMP, and also president of CSMP.

Altogether, 285 delegates participated in this international meeting, including 203 (44 students) from China, and 82 (27 students) from other countries. 123 oral presentations and
132 poster presentations were arranged from the submitted 255 scientific abstracts.
Among them, excellent papers awards were given to 10 young medical physicists, 5 for
oral and 5 for poster presentations.

The congress was planned in three days, from November 6-8, 2015. The program included
14 talks by invited speakers in the plenary and invited sessions, TG100 and RTIS workshop, IMPCB symposium, and 20 oral sessions covering the medical physics of radiotherapy, radiology, gamma knife, nuclear medicine, radiation protection, and medical physics
education. In addition, a special session was held to celebrate the International Day of
Medical Physics (IDMP).

The invited plenary and session lectures are as follow.

1. Plenary invited

AFOMP Newsletter, Vol 07 No.02 Dec 2015

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Conference Report -15th Asia-Oceania Congress of Medical Physics (AOCMP 2015)

Professor Yimin Hu-President,AFOMP
Nov. 5-8, 2015, Kempinski Hotel, Xian, China

Speaker

Talk

Jiahong Gao

Diffusion Magnetic Resonance Imaging

Yimin Hu

LA technology improves patients care - on 6 high theory

Allen Li

MRI-guided RT

Kwan-Hoong Ng

How reliable is volumetric breast density in predicting breast cancer risk?

Jeffrey Williamson

Lei Xing
Tao Xu

From Anatomy-Based Dose-Localization to Biology-Guided Radiation

Therapy
Recent Advances in Radiation Therapy: Treatment Planning, QA and
Dose Delivery
Gamma Knife's Products and Technologies

2. Session invited
Speaker
Hasin Anupama

Talk
Determination of the reference air kerma rate for Ir-192 and Co-60 HDR

Azhari

sources using three different international protocols

Arun Chougule

Luminescence dosimetry-medical applications

Yiping Du

Recent Development in Short TE MRI

Fridtjof Nsslin
Arabinda Kumar
Rath

Preparedness for Nuclear & Radiological Emergency Challenging the

Medical Physicist
Particle Radiotherapy, an Emerging Technology for Treatment of Cancer

Yu Wen

Exploration of the precise diagnosis and treatment for Neusoft medical

Golam Abu Za-

Dosimetry of small photon fields according to the German protocol DIN

karia

6809-8 (2014) and comparison with others protocols

In summary, the conference was successful and fruitful for all the participants, including radiation scientists, medical physicists, radiation oncologists, radiologists, radiobiologists, dosimetrists, and radiation technologists, researchers & students.

AFOMP Newsletter, Vol 07 No.02 Dec 2015

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IMPCB Update
Raymond K Wu, PhD, CEO of IMPCB
One year has passed since I wrote about the International Certification Board in the
newsletter. IMPCB and its Accreditation Committee (AC) and Subcommittees had accomplished a number of projects. I am happy to make another report as requested by Professors Suh and Chougule for the readership here.
The most significant news is the agreement reached with IOMP on the relationship
between the two organizations which resulted in IOMP becoming more involved with the
affairs and future development of the organization. A joint Task Group (TG) was formed
upon request by IOMP to initiate discussions and make recommendations. The TG also
took steps to prepare for the IOMP Council's official recognition of IMPCB in Toronto.
The recommendations of the TG initiated the amendment of the IMPCB ByLaws which
were approved by the Board of Directors and by the Voting Members. The agreement is
documented in the Memorandum of Understanding (MoU) approved by IOMP and
IMPCB. The main points in the MoU include the clarification that IMPCB will focus on
the standardization and accreditation of certification programs for medical physicists,
whilst the accreditation of education and training programs is the responsibility of the
IOMP. IMPCB will adopt IOMP guidelines in the requirements for certification and accreditation of certification programs. Included in the MoU is the agreement that IOMP
will be designated the Principal Supporting Organization with three representatives on
the BOD of IMPCB.
Based on the IOMP policy statements and other published standards, the AC completed the document Requirements for Successful Completion of the Certification Process to described in more details the expectation of education pre-requisites before taking the certification examinations. The Board of Directors (BOD) approved the document,
and authorized the AC to proceed with the tasks related to accreditation of national certification boards that are adhering to the requirements. The BOD also agreed to collaborate with the IAEA to work on assisting organizations to establish their national certification, and the certification of individuals in certain countries that national boards are not
likely to be established due to the lack of resources or low number of medical physicists.
In June, the Hong Kong Institution of Physicists in Medicine (HKIPM) became the
first Supporting Organization after the ByLaws amendment and joined the other Charter
Supporting Organizations of IMPCB. At the same time the Korean Medical Physics Certification Board (KMPCB) and the HKIPM officially submitted the applications for accreditation. The AC worked diligently in subsequent months to review the applications, and
communicated with several medical physicists including some outside of the KMPCB
and HKIPM leadership. The review resulted in the recommendations to the BOD in August, 2015, and the Board voted to grant conditional approval of accreditation for both
boards pending site visits to be conducted in November.
The site review team for KMPCB consists of Tomas Kron, AC Chair, Raymond Wu,
AFOMP Newsletter, Vol 07 No.02 Dec 2015

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IMPCB Update
Raymond K Wu, PhD, CEO of IMPCB
CEO, and Colin Orton, President, with Siyong Kim, BOD member as consultant. The
contingent travelled to Seoul on Nov 2-3, immediately before the AOCMP2015, to meet
with the officials of KMPCB, the students of two training programs, and the faculty. The
team visited two of the hospitals, and met with medical physics leaders from many Korean institutions. The Presidents of the Korean Society for Radiation Oncology and the Korean Society of Nuclear Medicine joined the President of Korean Society of Medical Physics to expressed support of KMPCB. The site review team recommended to the AC for full
accreditation which was approved via email. On November 3rd, Mr Sang-Jin Shin, Korean
legislator, presented a symposium managed by KSMP at the Korean National Assembly
entitled System Renovation for Safety in the Field of Radiation Medicine. The announcement of approval of the accreditation application was made in the middle of the
symposium by President Orton. The first medical physicists to be certified by the newly
accredited KMPCB were given the certificates. After the symposium, the certified young
physicists were pictured with the KMPCB officers and the site review team (see pictures).
Immediately after the AOCMP2015, a site review was conducted in Hong Kong on November 10 and 11. The site review team consists of Carmel Caruana, AC member, Raymond Wu, and Colin Orton. The team visited the medical physicist training centre in
Hong Kong Sanatorium & Hospital (HKSH), talked to the trainees individually, met with
the faculty, and had lunch with HKSH management and administrators. In the afternoon
the team travelled to the Prince of Wales Hospital to meet with the trainers and trainees
in a group setting. In the following morning, the team met with officers of HKIPM to discuss the perceived strength and weaknesses, and made recommendations for future improvements. As in Korea, the Team recommended to AC for full accreditation which was
approved via email. Later in the evening, there was a seminar organized by HKIPM attended by medical physicists from many private and government hospitals as well as radiation oncologists, radiologists, and government regulators. In the seminar, the three
site review team members made presentations and announced the approval of the accreditation application (see pictures).
Not by coincidence, the medical physicist communities of Korea and Hong Kong were
the two earliest supporters of the international board certification initiative. They have
certification programs in practice for many years. Through the accreditation exercise,
both programs had to make significant improvements to achieve the status of accreditation. We hope the future impact in the quality of healthcare in both communities will
justify the efforts.
IMPCB is ready to accept additional national medical physics organization as Regular
Supporting Organizations. All Supporting Organizations are welcomed to request for assistance to develop their certification programs or apply for accreditation. For more details, please visit http://www.IMPCB.org.
The readership is reminded that there is an article in the December issue of the
AFOMP Newsletter, Vol 07 No.02 Dec 2015

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IMPCB Update
Raymond K Wu, PhD, CEO of IMPCB
eMPW on IMPCB written by President Colin Orton.

Fig 1. Site review meeting with faculty

of one of the training sites in Korea

Fig 2. Site review team with Korean Legislator S J Shin, KOSRO President Dr. EunKyung Choi, National Assembly Parliamentarian J K Lee, KSNM Past President Dr D H
Moon, and Korean medical physics leaders

Fig. 3 Site review team with officers of HKIPM

Fig. 4 Accreditation announcement at the Seminar

organized by HKIPM

AFOMP Newsletter, Vol 07 No.02 Dec 2015

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AFOMP Newsletter, Vol 07 No.02 Dec 2015

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The Global Growth of Medical Physics in the Past 50 years

Slavik Tabakov, PhD, FIPEM, FHEA, FIOMP, Hon. Prof. IOMP President
The history of the International Organisation for
Medical Physics (IOMP) now spans over more than
50 years. In this period of time we saw dramatic
changes in healthcare and in particular in the progress of medical technology. When at mid-1960
there were about 6000 medical physicists globally
(mainly in USA and the Western world), now in
2015 these are about 20,000 globally, with many
medical physicists in low-and-medium-income
countries.
This growth has also another specific characteristic. While at the beginning most medical physicists were working in Radiotherapy, gradually an
increasing number of colleagues were employed also in the field of Medical Imaging and related Radiation Protection. To use a technical analogy, this
growth could be compared to a system with positive
feedback, which led to acceleration of the development of various new equipment. Starting in late 1960s and early 1970s with the new Ultrasound Imaging and Computed Tomography, just after two decades all Medical Imaging equipment was moving toward digitalisation.
The new equipment applied new physical phenomena and transformed immensely
the healthcare provision. Today it is impossible to even imagine contemporary medicine
without the sophisticated Medical Imaging and Radiotherapy equipment. Due to this reason, when the high-level UNESCO World Conference Physics and Sustainable Development (Durban, South Africa, 2005) discussed the main topics of applied physics in the
21st century, one of the highlighted topics was Physics and Health (presented by IOMP).
However the positive feedback system required more and more medical physicists
initially for research and industry, but later increasingly more for supporting the clinical
application of the new equipment (related both to safety and effective use). This presented the profession with a new challenge developing new educational methods and materials, which would create a fast track from the new applied research to the teaching
desk. This is how in the mid-1990s medical physics was one of the first professions to
develop and implement its own original e-learning materials (EMERALD and EMIT).
These materials were quickly disseminated all over the world through the ICTP College
on Medical Physics (an institution under the aegis of IAEA/UNESCO). Currently elements of these e-learning materials are used in more than 70 countries. This specially
boosted the development of medical physics education and training in low-and-medium
AFOMP Newsletter, Vol 07 No.02 Dec 2015

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The Global Growth of Medical Physics in the past 50 years

Slavik Tabakov, PhD, FIPEM, FHEA, FIOMP, Hon. Prof. IOMP President
income countries. Typical example for this is Asia, where in the past decade the growth
of medical physics specialists is over 120%.
This educational development triggered increased international collaboration. In the
past two decades IOMP co-organized nearly 100 workshops, seminars and courses with
attendees from about 85 countries. Half of these events were in collaboration with the
ISEP programme of the American Association of Physicists in Medicine (AAPM). These activities naturally led to the development of a Medical Physics Dictionary, which is currently translated into 29 languages. The next development, answering the need of quick
access to new information in our dynamic profession, was the Medical Physics eEncyclopaedia. This unique searchable e-material is linked with the Dictionary and is
currently used by more than 4000 colleagues per month through the web portal
www.emitel2.eu .
e-Learning is now adopted at all levels in the profession and supports many new educational courses. This is one of the reasons for double growth of the profession in the
past two decades - about 4000 new medical physicists per decade compared with about
2000 new specialists growth during the previous three decades (1965-1995).
On this background it was natural that IOMP, IFMBE and IUPESM succeeded to negotiate with the International Labour Organisation (ILO, Geneva) the occupations of medical physicists and biomedical engineers to be explicitly included in the International
Standard Classification of Occupations (ISCO-08). Medical physicists were listed under
number 2111; biomedical engineers listed under number 2149 (published in 2012). Related to this was also the introduction of the International Day of Medical Physics (IDMP,
7 November the birthday of Maria Sklodowska Curie), which is now celebrated by all
our members all over the world.
Having seen the rapid progress of Medical Physics as a profession, we could ask ourselves - what could be expected in the next two decades? My view is that surely the
growth will continue. There is nothing more precious than health and our profession,
dealing with some of the most sophisticated equipment of our time (both in diagnostics
and therapy), will be needed more and more. Again the main focus will be in research
and clinical application, but teaching underpins both. Its beneficiaries should be not only our colleagues, but also our fellow physicians, who have to constantly adapt their
knowledge to the latest healthcare technology.
Another very important focus is to increase the visibility of our profession at all levels
- institutional, local and national - this is exactly the purpose of the International Day of
Medical Physics, and here I am using this opportunity to congratulate sincerely all colleagues in connection with our Professional Day.

AFOMP Newsletter, Vol 07 No.02 Dec 2015

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Status of Medical Physics in Nepal.

Pradumna Prasad Chaurasia

NAMP president, Assistant chief medical physicist/RSO, Assistant Prof. Medical Physics ( MDRT) , NAMS
Dept.of radiation Oncology , B.P.K.M. Cancer hospital, Bharatpur, Nepal, pradumnachaurasia@gmail.com

The need for a medical physicist post in Nepal was first identified when a decision
was made to start a radiotherapy service in 1990 at the Bir Hospital Kathmandu. Nepal
started using ionizing radiation for cancer treatment in 1991 with the installation of the
first telecobalt machine.Still personnel monitoring with TLD badges is done from BARC,
India . Once in three years radiotherapy chambers are caliberated from BARC , Mumbai
and we get Nd,w.
In 2014, about 4200 patients received radiotherapy in Nepal. According to the WHO
IARC Globocan, there is a need for 11,200 new patient treatments.
Now there are 8 medical physicists in hospitals and one in a diagnostic radiology teaching faculty. As yet, there are no female medical physicists in Nepal. Recently two M. Sc.
medical physicists have returned back from Bangladesh and are searching job opportunity here.
The Nepalese Association of Medical Physicists (NAMP) was formally registered in
2009 to promote the medical physics profession. Nepalese medical physicists have participated in many colleges on medical physics organized by the Abdus Salam International Center of Theoretical Physics in Italy. It also associates with the Association of Medical
Physics of India and the BMPS. NAMP successfully organized a Symposium on Medical
Physics on the occasion of International Day of Medical Physics in 2013. NAMP was associated organizing ICMPROI from 20-22 August 2014 in Dhaka, Bangladesh with BMPS
and AMPI.
There is a trend to appoint MSc physics or medical physics graduates and train them
to be medical physicists. It is high time to start a formal postgraduate medical physics
course or accredited residency in Nepal to meet the national demand. Professional recognition and accreditation is essential.
Justification of the uses of ionizing radiation in human health, abreast with new advanced technologies in therapeutic and diagnostic imaging clinical application are challenging in Nepal. Only doing clinical routine medical physics work will not be enough,
and research and education is also important.
The IOMP accepted the application of P. P. Chaurasia to represent Nepal in IOMP
functions in 1998. Nepal became a member of the IAEA in 2008, but still there is no regulatory body in Nepal. Self-regulation based on best practices developed internally is the
key to successful integration of technology by ensuring highest quality without compromising on safety. Radiology departments with techniques such as CT and MRI, nuclear
medicine facilities and radiology teaching departments must appoint a medical physicist.
There are four radiotherapy centers with a total 3 Tele Cobalt machines, 3 linear accelerators and 4 high dose rate brachytherapy machines for treatment of 4000 patients
AFOMP Newsletter, Vol 07 No.02 Dec 2015

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Status of Medical Physics in Nepal.

Pradumna Prasad Chaurasia

NAMP president, Assistant chief medical physicist/RSO, Assistant Prof. Medical Physics ( MDRT) , NAMS
Dept.of radiation Oncology , B.P.K.M. Cancer hospital, Bharatpur, Nepal, pradumnachaurasia@gmail.com

only. BPKMCH treated 1940 patients in external beam radiotherapy with one cobalt and
two linear accelerators in 2013. There is a simulator and Eclipse treatment planning
system for three dimensional conformal planning and IMRT. External beam radiotherapy
can be delivered by Cobalt units or linear accelerators collectively known as megavoltage
machines. High income countries have 6 megavoltage machines per million population
and we have 0.2 megavoltage machines per million population. Not a single linear accelerator machine was added since 2002 in Nepal from government so there is lack of required number of machine in Nepal. It is better to replace 20 year used old machines
with new one. One new bunker for a clinical linear accelerator is built now in B.P.K.
cancer hospital Bharatpur in 2015. Unfortunately professional training for radiation oncology medical physicists (ROM P) and radiation therapy technologists (RTTs) is not
available in Nepal to lend support to any expansion in radiotherapy services in Nepal.
Although well-trained radiation oncologists are essential, the major determinant of safe
and accurate treatment depends on the RTTs and ROMPs. If the RTTs do not accurately
position a patient each day during course of treatment and the ROMPs do not ensure the
correct dose of radiation is given each day ,then it does not matter how well (or badly) the
radiation oncologists are trained.
Radiotherapy has the potential to greatly improve the outcomes of cancer patients. It
needs to be applied efficiently and safely to achieve that benefit. Quality assurance protocols such as the IAEA inter center dosimetry project help to ensure that accurate doses
are delivered. Programs are needed also to develop common evidence based protocols to
standardize patients treatment. Treatment protocols specific to local regions would give
guidance on best practice and reduce wasteful variations. Improvements will come only
with careful service planning, investment in staff, equipment and better access to information and education about cancer. Overall treatment time has been shown to impact
on survival in in patients treated with radiation therapy for cervix cancer, head and neck
cancer, and delay in starting radiation therapy worsens survival for glioblastoma. In cervix cancer the overall treatment time (from start of external beam radiation therapy to
completion of brachytherapy) should be less than 56 days. Increasing the treatment time
reduces the survival by 1 percent per extra day.
It is very difficult to know how to change this situation in a low income countries like
Nepal. Without doubt, the shortages of radiotherapy service can be overcome by investment in staff, equipment and maintenance. Advocacy is essential for increasing radiotherapy facility in all region. Adequate access to radiotherapy is a crucial component of
quality modern multidisciplinary cancer care. Public and private partnership is also essential in radiotherapy service. Two private cancer hospitals with radiotherapy facility
will start soon in Nepal. With increase in number of radiotherapy centers medical physicist number will also increase and more improvement will be there. Still there is not any
medical physics department in Nepal in any hospital.

AFOMP Newsletter, Vol 07 No.02 Dec 2015

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Status of Medical Physics in Nepal.

Pradumna Prasad Chaurasia

NAMP president, Assistant chief medical physicist/RSO, Assistant Prof. Medical Physics ( MDRT) , NAMS
Dept.of radiation Oncology , B.P.K.M. Cancer hospital, Bharatpur, Nepal, pradumnachaurasia@gmail.com

AFOMP Newsletter, Vol 07 No.02 Dec 2015

131313131313131313131313 1313

Meeting Report on IAEA RAS 6077

To Develop Guidelines for Assessment and Certification of Medical Physics Trainees,
Kathmandu, Nepal, 30 Nov - 3 Dec 2015
An IAEA technical expert mission to develop guidelines for assessment and certification of medical physics trainees in the RCA region was organized at the Top of the World.
The experts taking part in this meeting were: Mr. Brendan Healy (IAEA), Dr. Kamila Afroj
Quadir (Bangladesh), Dr. Supriyanto Ardjo Pawiro (Indonesia), Dr. Kwan Hoong Ng
(Malaysia), Dr. Muhammad BasimKakakhel (Pakistan) along with the local counterpart
Dr. Kanchan Adhikari (Nepal).The meeting was also attended by local Nepalese physicists
Mr.Shanta Lall Shrestha and Mr. BidyapatiJha. This meeting is the third of an ongoing
series of meetings on Recommendations on accreditation and certification for medical
physics education and clinical training in the RCA region.
The experts deliberated on
the criterion for entry into a
clinical training program and
recommended that the clinical training program to involve a modular/competency
based structure from a nationally adopted Clinical
Training Guide (CTG). Considerable time was spent in
formulating the process of assessment that needed to be
put in place for the certification of medical physicists.
The national mechanisms
needed, such as the establishment of an Accreditation
and
Certification
Board
(ACB), was also discussed.
The meeting was very fruitful being conducted in very pleasant cool weather with some
social-cultural-gastronomic activities to strengthen friendship amongst the experts and
the local colleagues.
The IAEA experts posing at Durbar Square: (from left) Brendan Healy, Kwan Hoong
Ng, Kanchan Adhikari, Kamila Afroj Quadir, Supriyanto Ardjo Pawiro, and Muhammad
Basim Kakakhel.

Prof Kwan-Hoong Ng, PhD, MIPEM, DABMP

Department of Biomedical Imaging & University of Malaya Research Imaging Centre
University of Malaya ,Kuala Lumpur, Malaysia
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Travel Grant Report on 15th Asia-Oceania Congress of Medical Physics (AOCMP)

Hasin Anupama Azhari
Founder President, Bangladesh Medical Physics Society (BMPS)
Chairman, Dept of Medical Physics and Biomedical Engineering (MPBME), Bangladesh
5-8 November 2015, Xian, China

15th AOCMP Congress Asia-Oceania Congress in Medical Physics was held in Xian,
Peoples Republic of China, from 5 - 8 November 2015. It was my great pleasure for being one of the awardees and also covey my heartiest thanks to organizing committee for
inviting me in the congress
The organizers had set the programme focused on research & re-cent advancement to
cover the whole spectrum of medical physics: Therapy session (total 6), Imaging session
(total 4), TG 100 Workshop, RTIS workshop, new technology/ radiobiology, gamma
knife, Nuclear medicine session, Dosimetry and Radiation Protection.
On the first day, there was AFOMP council meeting. The members countries , AFOMP
were present. The needs for development of MP are discussed according to the appeal of
different societies. A new Executive Committee formed and on behalf of BMPS we are
congratulating to the new one.
Being an academician it was very helpful for me to attend the conference. The
knowledge gained from here is transferred to the students, faculty members. Not only
knowledge also the management, set up, that means the whole procedure of conference
organizational process has been discussed to future generations for make them interested in these meetings. My university (Gono University) is the pioneer to start medical
Physics course in Bangladesh and we have now 250 students. After coming back from
AOCMP congress I have arranged a seminar for all the students and share my experiences and make them interested for attend these meetings, scientific presentations, research etc.
There are some special programs other than presentations like IDMP celebration on
November. IMPCB symposium. All representatives from IOMP, AFOMP, EFOMP,
AAPM had been elaborately and clearly defined the importance of this day. All the member countries organizations must celebrate this day for public awareness as well as for
the future positive aspects for their country.
I also mentioned that, the selection of awardees for poster presentations were done from
students. This was an encouragement for the future generations of MP for more interested towards research and scientific work.
7th

In IMPCB symposium the member of the IMPCB showed the procedure of certification. As in many countries are need of this, I must say this round table discussion was
extremely useful for us.
Lastly it was a great honour to me as well as for Bangladesh Medical Physics Society
(BMPS). Young medical physicists will be encouraged for this type of support from
AFOMP. I would like to express my sincere and outmost gratitude to the chairman of the
award committee Dr. Kin-Yin Cheung for considering me for this travel award, special
thanks to AFOMP President Prof Yimin Hu, AFOMP Secretary Prof. Howell Round and
other members for their continuous support for BMPS.

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Travel Grant Report on 15th Asia-Oceania Congress of Medical Physics (AOCMP)

Hasin Anupama Azhari
Founder President, Bangladesh Medical Physics Society (BMPS)
Chairman, Dept of Medical Physics and Biomedical Engineering (MPBME), Bangladesh
5-8 November 2015, Xian, China

"

Humility is the foundation of all the other virtues..." St.Augustine.

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Bangladesh Medical Physics Society

Safayet Zaman, Secretary
Bangladesh Medical Physics Society (BMPS)

Bangladesh Medical Physics Society (BMPS) is a scientific organization, founded in

1998. It is the core professional body of the medical physicists practicing in Bangladesh. Its objective is to promote medical physics education, training, scientific
workshops, seminars and related activities in Bangladesh. It is also dedicated to
facilitate research and development and take appropriate steps to establish academic
programs for different institutions and communicate with other medical physics organizations outside the country. BMPS is dedicated to ensure accuracy, safety and
quality in the use of radiation in medical procedures and for that it is trying to establish rules and regulations for the development of Qualified Medical Physicists (QMP).
Currently BMPS is trying to negotiate with all concerned bodies to create medical
physicist posts in government hospitals and institutions.
History of BMPS
In order to familiarize medical physics in Bangladesh, the Task Group 16 Medical
Physics in the Developing Countries of Ger a Medical Physics ociety DGMP and
Physics Department of Bangladesh University of Engineering and Technology
(BUET) jointly organized seminars and workshops each year between 1996 to
2000. In 2001 Gono Bishwabidyalay (University) opened the department of Medical
Physics and Biomedical Engineering and started M.Sc. in medical physics & biomedical engineering for the first time in Bangladesh and in 2006 it started B.Sc. program.
BMPS has collaboration with German Academic Exchange Program (DAAD)
through Gono University. Each year, through DAAD scholarships one PhD candidate
and two medical physicists working in the field of medical physics are having training
in Germany. Two M.Sc. students of Gono University are visiting Germany each year
under the current co-operation.
The members of the BMPS are medical physicists and biomedical engineers
working at different reputed hospitals and institutions, doctors, radiation oncologists, students and other professionals working in the field of medical physics and
biomedical engineering.
Achievements of BMPS
Since its inception, BMPS organizes national, international conference, seminar,
workshop each year. In the international conference held in 2011, 94 papers were
presented and 200 delegates including thirty foreign cancer specialists from 11
countries (Bangladesh, China, UK, Germany, India, Indonesia, Lebanon, Japan, Ne-

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Bangladesh Medical Physics Society

Safayet Zaman, Secretary
Bangladesh Medical Physics Society (BMPS)

In 2014 around 350 participants including 40 foreign cancer specialists (Bangladesh,

China, UK, Germany, Italy, Mexico, Austria, Sweden, Australia, Canada, India, Sri
Lanka, Indonesia, Lebanon, Japan, Nepal, Poland and Pakistan) joined the international conference that consisted 18 sessions.

Participants at the ACBMPS-2015

BMPS other Activities

e-Encyclopaedia of Medical Physics and Multilingual Dictionary Recruitment of Medical Physicist as permanent Post
Public Awareness in print and electronic media
e Newsletter: Voice of BMPS 7th November each year
Member of different national and international organizations (BPS,AFOMP Scientific
Committee etc)

AFOMP Newsletter, Vol 07 No.02 Dec 2015

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Calendar of Events 2016

JAN 2016

January 26 - 27, 2016

ICMPBB 2016 : 18th International Conference on Medical Physics, Biophysics and Biotechnology
Jeddah, Saudi Arabia
https://www.waset.org

FEB 2016

15 19 Feb 2016
ICTR-PHE: Int'l Conference on Translational Research in Radio-Oncology and Physics for
Health Geneva
Geneva, Switzerland,https://ictr-phe16.web.cern.ch/
20 24 Feb 2016
Int'l Conf. of Nuclear Sciences and Applications and the IRPA-Egypt Radiation Protection
Workshop, Hurghada, Qesm Hurghada, Red Sea Governorate, Egypt
Feb 22-23:
Workshop on Medical Physics ,
D h a k a , B a n g la d e s h , safayet3@gmail.com

MAR 2016

2 6 Mar 2016
European Congress of Radiology - Vienna
Vienna, Austria, http://www.myesr.org/
09-11 March, 2016
10th European Breast Cancer Conference, Amsterdam, The Netherlands
18 21 Mar 2016
Mexican Symposium on Medical Physics - Mexico City
Mexico City, Federal District, Mexico

APR 2016

2nd April 2016

Conference of Emerging Trends in Radiation Therapy Technology,
Department of Radiological Physics, SMS Medical College, Jaipur, Mail:- icmprpr2k15@gmail.com
April 18-19, 2016

4th International Conference on Blood Malignancies and Treatment, Dubai, UAE

April 20
Seminar on Medical Physics
D h a k a B a n g la d e s h , safayet3@gmail.com
29 April-03 May, 2016
ESTRO 35
Turin, Italy, http://www.estro.org/

MAY 2016

9 16 May 2016
Int'l Radiation Protection Association (IRPA) Congress - Cape Town
Kaapstad, Foreshore, Cape Town, 8001, South Africa
International Radiation Protection Association
http://www.irpa2016capetown.org.za/

JUNE 2016

27 30 Jun 2016
18th Int'l Conference on the Use of Computers in Radiation Therapy - London, UK
London, UK , http://www.iccr2016.org/
27-29 June, 2016
6TH WORLD CONGRESS OF BRACHYTHERAPY
San Francisco, USA

AFOMP Newsletter, Vol 07 No.02 Dec 2015

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Officers and Council of AFOMP

President :- Dr. Tae-Suk Suh

Dept. of Biomedical Eng., College of Medicine,
The Catholic University of Korea,
505 Banpo-dong, Seocho-gu, Seoul, 137040, Korea
Telephone: +82-2-2258-7232
Fax: +82-2-2258-7506
E-mail : suhsanta@catholic.ac.kr

AFOMP News letter & Event

information should be addressed to:

Dr.Arun Chougule
E-mail :arunchougule@rediffmail.com

Vice President :- Prof. Dr. Arun Chougule

Dr. Arun Chougule
Dean, Faculty of Paramedical Science,
Sr. Professor & Head, Department of Radiological Physics,
S.M.S. Medical College & Hospitals
Jaipur-302015, India
E-mail : arunchougle@rediffmail.com

Secretary General :- Dr Howell Round

Associate Professor, School of Engineering
University of Waikato, Private Bag 3105,
Hamilton 3240,
NEWZELAND
Ph +64 7 838 4173, Mobile +64 210368549
Email h.round@waikato.ac.nz

AFOMP webmaster:
Sunmi Kim
E-mail :arcmpsmk@gmail.com

Advertising requests
should be addressed to:
Dr.TaeDr.Tae-Suk Suh,
E-mail :suhsanta@catholic.ac.kr
Dr.Arun Chougule
arunchougule@rediffmail.com

AFOMP correspondence
should be addressed to:
Dr Howell Round
E-mail :h.round@waikto.ac.nz

Past President :- Dr. Yimin Hu

(1)

Chaoyang Qu Panjiayuan
Nanli No. 17,
Department of Radiation Oncology,
Cancer Institute (Hospital),
Beijing 100021, China

(2) Cancer Research Institute (Tumor

Hospital),
Chinese Academy of Medical Sciences
&
Peking Union of Medical College,
Beijing, China
Email: yiminhu888@163.com

Treasurer :- Dr. Kwan-Hoong Ng

Department of Biomedical Imaging
University of Malaya
59100 Kuala Lumpur
Malaysia
Tel: 603 7950 2088
Fax: 603 7958 1973

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