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Advanced Treatment Techniques Part 2


Dietmar Georg
Division Medical Radiation Physics
Department of Radiooncology / Medical University Vienna & AKH Wien
Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology

2016 ULG Chapter 12 - Georg 1


In addition to routine RT techniques used in standard

radiotherapy departments, several specialized techniques are
used for special procedures and treatments.
These techniques deal with specific problems that usually
require equipment modifications, special quality assurance
procedures, and heavy involvement and support from clinical
increased complexity and the relatively low number of patients

usually available only in larger, regional centers.

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Categories of specialized & precision techniques

1. Total Body Irradiation (TBI)

2. Total Skin Electron Irradiation (TSEI)
3. Endorectal irradiation
4. Intraoperative radiotherapy (IORT)
5. Stereotactic irradiation
6. Intensity Modulated Radiotherapy (IMRT)
7. Particle Beam therapy
8. Image Guided and Adaptive RT (IGART)
New developments: BioART, .

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Total Body Irradiation - TBI

Special RT technique that delivers to a patient's whole body a

dose uniform to within 10 % of the prescribed dose.
OAR: lung, kidneys, liver, heart, lens.

Target cells: are immune competent cells and bone marrow cells

...therapy of disseminated malign diseases by irreversible

elimination of malign cell clones....

TECHNICAL ASPECTS OF TBI - Large variation !

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TBI Techniques
FIGURE : Overview TBI treatment techniques.

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Clinical TBI Categories

Depending on the specific clinical situation, TBI techniques are

divided into the following four categories
1. High dose TBI with dose delivery in a single session or in up to six
fractions of 200 cGy each in three days (total dose: 1200 cGy).
2. Low dose TBI with dose delivery in 10 to 15 fractions of 10 to
15 cGy each.
3. Half body irradiation with a dose of 8 Gy delivered to the upper
or lower half body in a single session.
4. Total nodal irradiation with a typical nodal dose of 40 Gy
delivered in 20 fractions.

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TBI Techniques

Mainly four methods are in use to administer TBI with modified

conventional radiotherapy equipment:
1. Treatment at extended SSDs.
2. Treatment at standard SSDs after Co-60 collimator is
3. Treatment with a translational beam.
4. Treatment with a sweeping beam.
First 2 techniques: large stationary beams and a stationary patient;

latter 2 use moving beams produced by translating the patient

through a stationary beam or sweeping the beam over a stationary
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TBI Techniques

is used.

TBI technique where the patient is moved through a stationary

beam. During treatment a build up coverlet

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Dose Prescription in TBI

TBI dose is prescribed to a point inside

the body, usually at midpoint on the
level of umbelicus

TBI procedure must deliver the

prescribed dose to the dose
prescription point and should maintain
the dose throughout the body within
10 %.
Uniformity of dose is achieved with
the use of bolus or compensators.

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Commissioning of TBI procedure

Once a treatment machine and TBI technique have been

selected, commissioning of the proposed TBI procedure must be
carried out.
Basic dosimetric parameters for TBI are the same as those for
standard radiotherapy, including absolute beam output
calibration, percentage depth doses and beam profiles (off-axis
Parameters must be measured under the specific TBI conditions
in order to obtain reliable data for use in clinical TBI

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Commissioning of TBI procedure

Several dosimetric problems, specific to

large field dosimetry but not occurring in
standard radiotherapy, must be

Related to phantoms and ionization

chambers that are used in measurement
of dosimetric parameters.

TBI treatment chart. In the lower field dose points are

given which are used to check dose uniformity.

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Commissioning of TBI procedure

TBI phantoms are generally smaller than the actual field size.
Accuracy of the TBI dosimetric data might be adversely affected
by the relatively large portion of the ionization chamber cable
irradiated with the large TBI field as well as by chamber leakage
currents and saturation characteristics which become more
problematic at the relatively low dose rates used in the TBI.
Once the basic dosimetric data for a particular TBI technique to
be used clinically are available, several TBI irradiation dry runs
should be carried out to verify the TBI dosimetry protocol.

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Quality Assurance for TBI

TBI is a complex treatment modality requiring careful treatment

planning, accurate localization of organs that are to receive a
reduced dose or be shielded completely from the radiation beam,
and strict adherence to quality assurance protocols.
1. Basic QA protocols covering the performance of equipment used
for TBI treatment planning and dose delivery.

TLD used for TBI in-vivo


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Quality Assurance for TBI

2. Pre-treatment QA protocols dealing with calibration and

preparation of equipment immediately preceding the TBI
3. Treatment QA protocols that deal with the measurement of dose
delivered to the patient during the TBI procedure, e.g. in-vivo
dosimetry using diodes or TLDs.

All these QA protocols need to include tolerance and action

levels. e.g. 5 % for in-vivo dosimetry.

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Quality Assurance for TBI


For high dose TBI (12 Gy or higher) the maximum dose to the
lung must not exceed 10 Gy.
Density difference between lung and normal tissue (0.33) needs
to be considered during treatment planning.
In-vivo dosimetry is essential
TLD, diodes, MOS-FET,.

QA of in-vivo system

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TBI Treatment Planning and Lung Dose

In order to reduce the lung doe to lung transmission block made of

lead alloy are used.
Typical lead lung shields are 5-8 mm thick for adults.

As the thoracic wall is also thoracic wall

shielded these parts are normal tissue
irradiated with electron
total diameter



Lung and body dimensions to

be considered for TBI treatment
thoracic wall doral Spinal cord

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Total Skin Electron Irradiation - TSEI

TSEI is a special radiotherapeutic technique which aims to

irradiate the patient's whole skin with the prescribed irradiation
dose while sparing all other organs from any appreciable
radiation dose
treatment of cutaneouse lymphomas (Extensive lymphomas of the
skin with accumulation of lymphatic cells in skin).
Heterogeneous group of lesions, therefore it is difficult to
establish generally valid recommendations.
no controlled prospective studies on dose, fractionation, etc are

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Total Skin Electron Irradiation - TSEI

Patient population requiring TSEI is relatively small

AKH/MedUni Wien: ca. 6 per year)

In the past: superficial x-ray machines, Vande Graaff generators,

Besides electron therapy for generalized lesions using
4 - 18 MeV electron beams with a total dose between 30 - 40 Gy
given in 20 fractions photo-therapy (UVA) or conventional X-rays
for localized lesions are applied.
Conventional X-rays (20-50 kV) the fractionation scheme is as
follow: 6 - 10 x 2 Gy, 2 fractions per week.

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Total Skin Electron Irradiation - TSEI

All contemporary TSEI procedures: based on Linacs that are

used for conventional radiotherapy and modified for delivery of
the large and uniform electron fields required for TSEI
Dose rate: ~ 10 Gy/min.

Since skin is a superficial organ, the choice of low energy

electron beams for treatment of generalized skin malignancies is
Photon contamination of electron beams: potential detriment
to the patient. Therefore, its magnitude must be known
accurately for each particular TSEI technique !

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Physical and Clinical Requirements for TSEI

Three categories of specifications:

1. Physical specifications of the large stationary electron field
2. Physical specifications of the dose distribution resulting from the
superposition of multiple stationary electron fields; and
3. Clinical specifications.
Clinical specifications for treatment with TSEI:
Dose/fractionation regimen.

Actual total body photon dose received by the patient during TSEI

Prescription for boosts to underdosed areas.

Prescription for any special shielding (eyes, nails, etc.).

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Physical and Clinical Requirements for TSEI

Physical specifications of large stationary electron fields include:

Electron field size on the order of 80200 cm.

Dose uniformity at dmax in a water equivalent phantom for at least

80 % of the nominal field (typically 5 % from dose at dmax in
phantom on the central ray).
Nominal SSD: 300 to 500 cm.

Beam energy at waveguide exit window: 6 to 10 MeV.

Beam energy on phantom surface: 4 to 7 MeV.

Dose rate on beam central ray at dmax in water-equivalent

Photon contamination of the electron beam.

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Physical and Clinical Requirements for TSEI

Physical specifications of the dose distribution from

superposition of multiple stationary electron fields:
Dose rate at dmax on central ray (usually on skin surface)

Bremsstrahlung contamination rate at the patient's mid-separaton

at the level of umbilicus

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Current TSEI Techniques

Translational techniques: patient is translated on a stretcher through

an electron beam of sufficient width to cover the patient's dimensions.
Large electron field techniques: standing stationary patient treated at
large SSD with a single large beam or a combination of large beams.
Rotational techniques: patient is standing on a rotating platform in a
large electron field.

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Current TSEI Techniques

In many TSEI irradiation techniques lucite scatterer are used.

Distance of the lucite plate from the focus is ~ 360 cm, the
distance of the patient from the lucite plate is ~ 20 cm.

TSEI technique FPD: 360cm
using stationary
beams. Gantry angle: 97

6 MeV
electron beam
Gantry angle: 71

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Stanford technique for TSEI
Treatment cycle consists of 2 days: day 1: irradiation from ventral plus two
oblique fields, day 2: irradiation from dorsal plus two oblique fields.
About 1350 MU per field to achieve 2Gy per cycle for 6 MeV electron beams.

Cycle 1

270 (left) 90 (right)

Cycle 2

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Commissioning, QA and calibration

Once an institution decides to provide the TSEI treatment modality, an

adequate TSEI technique must be chosen and commissioned, and QA
procedures for clinical use of TSEI must be developed.
Output of the large TSEI radiation field is specified at the dose
calibration point which is found on the electron beam central ray at
dmax in a tissue-equivalent phantom.
Complete set of relevant dosimetric data must be collected;
large stationary electron field
actual dose delivery with the multiple beams or the rotational beam.

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Total Skin Electron Irradiation

Phantom measurements for

commissioning an TSEI technique

(a) Beam output calibration,

(b) Dose homogeneity

Beam output as well as flatness & homogeneity are monitored during treatment
directly on-line with two ionization chambers, one placed on the beam central axis
to monitor the beam output and the other placed off-axis to monitor the flatness.

Additionally in-vivo dosimetry using TLD can be used.

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Total Skin Electron Irradiation

Pat. nn Ganzhautelektronenbestrahlung
Gesamtauswertung Grtel

Results of in-vivo procedures during TSEI. 13.12.1999 bis 17.2.2000 ( 18 Fraktionen)

(a) angular distribution, 288 28,4456

(b) total dose, (c) dose to organs at risk. 216 31,5702

144 30,5668
28,2945 Dosis Gy
72 27,3843

(b) total dose


0 34,6751

0,0 5,0 10,0 15,0 20,0 25,0 30,0 35,0 40,0

(a) angular distribution

Pat nn 27./28.12.1999

Pat. nn Ganzhautelektronenbestrahlung (c) dose to re Auge

Gesamtauswertung Grtel
13.12.1999 bis 17.2.2000 ( 18 Fraktionen) organs at li Auge

re Rist

0 risk li Rist

re Hoden
324 30,0 36
li Hoden
20,0 re Oberschenkel innen
288 10,0 72 Dosis Gy li Oberschenkel innen

0,0 Solldosis Hinterhaupt

Dosis Gy
252 108

0,0 0,50 1,0 1,50 2,0

216 144


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Skin dose and Basic Dosimetric Parameters

TSEI dose is prescribed on the patient's skin surface at the level

of umibilicus (dose prescription point) that usually is on the axial
slice containing the central ray.
Dose rate at the dose prescription point is the skin dose rate
resulting from the particular TSEI technique used in treatment
(e.g. multiple stationary electron beams or with a rotational beam)
The skin dose rate is related to the beam output at the dose
calibration point, but the actual relationship for a particular
technique must be determined experimentally.

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Electron PDDs for an TSEI.

The basic dosimetric parameters of the large TSEI electron field are
influenced by the large SSD, by the scatterer and by oblique beam

Depending on beam incident angle the major contribution of dose is delivered

at depths in the range between 0 and about 14 mm.

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Basic Dosimetric Parameters
Field flatness measured at dmax in a tissue equivalent phantom and
normalized to 100% at the dose calibration point.
Electron beam output at the dose calibration point.
Percentage depth doses (PDDs) measured to a depth of 15 cm in a
tissue-equivalent phantom, normalized to 100 % at the dose
calibration point and measured on the central ray as well as on various
directions parallel to the central ray.
Physical characteristics of the clinical beam are measured with a
modular cylindrical polystyrene or water phantom
Ca. 30 cm diameter and height.
Skin dose rate homogeneity is typically measured with TL dosimetry
or film on the phantom surface.
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Quality Assurance in TSEI

TSEI is a special technique that, much like any other irradiation

procedure, requires strict adherence to quality assurance protocols.

These protocols fall into three categories:

1. Basic QA protocol dealing with the equipment used in total skin electron
2. Pre-treatment QA protocol dealing with the calibration and preparation of
equipment immediately prior to TSEI treatment
3. Treatment QA protocol which deals with measurements of the actual dose
delivered to the patient during the TSEI procedure.

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Shielding and boosting in TSEI
OAR, such as the eyes and fingernails as well as toenails need special
Eye shielding individually shaped mask are used, for fingernails and
toenails lead shields or tapes can be applied. Doses to OAR are
monitored with in vivo dosimetry
Some parts of the skin are difficult to reach.
a boost is necessary to achieve the necessary dose to control the
disease; e.g. testicles, anus, inner thigh, sole of the foot ,..

Eye shields used for

TSEI treatments.

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Shielding of OAR during TSEI treatments, eyes, finger- & toenails.

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Intraoperative Radiotherapy - IORT

IORT is a special radiotherapeutic technique which delivers in a

single session a radiation dose on the order of 10 to 20 Gy to a
surgically exposed target (internal organ, tumor, or tumor bed).

Roots of IORT go back to early 20th century when Beck and

Finsterer applied this method independently to improve
treatments for progressive gastro intestine tumors. At that time
RT was based an ortho-voltage equipment low penetration of
kV X-rays necessitated IORT to treat deep situated tumors

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Intraoperative Radiotherapy - IORT

Modern clinical applications of IORT were investigated

essentially during the last 10 years.
If IORT is used as boost modality for external beam RT the IORT
application (localization and dose) must be recorded
Full 3 D information is hardly available for IORT!
High demands on infrastructure, especially on the
interdisciplinary team and their timing as well as on the

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Physical and clinical Requirements for IORT

Time patterns of the treatment and tumor growth are also

IORT as a boost modality prior to standard RT if given adjuvant

IORT team consists of a surgeon, radiation oncologist, medical

physicist, anaesthesiologist, nurse, pathologist, and radiation
IORT requires an operating room for the surgical procedure and
a treatment room for delivery of the radiation dose
Often both rooms are merged into one

specially shielded operating suite in which a dedicated radiation

treatment unit is installed permanently

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Physical and clinical Requirements for IORT

Besides the selection of the radiation modality and location in

which the treatment unit is to be installed, an applicator system
must be chosen:

1. to define the target

2. to shield tissues outside the target area from radiation.
3. to keep sensitive tissues from falling into the target area
during irradiation.

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IORT Radiation Modalities and Techniques

There are three different radiation modalities which may be used to

deliver radiation dose intraoperatively:
1. Orthovoltage x rays;
2. MeV electron beams;
3. (HDR iridium-192 brachytherapy sources.

Apart conventional linacs, dedicated mobile linacs (robotic linacs),

which can be used in an operation theater, are well established

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Intraoperative Brachytherapy
The patient undergoes surgery, where a bolus material (~ 1 cm thickness )
with BT afterloading applicators is located close to the tumor bed or the
residual tumor mass, then the surgical cut is sterilize bandaged.

Next step: patient (in anastasia) is

brought to RT department, and a
treatment plan is made, based on
the anatomical specification of
the surgeon
After treatment delivery: patient
is transferred back to the OP
theatre, bolus removed, surgical
intervention finished.

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Linac based IORT can be applied in a dedicated operation theater (OP)

using a modified linac.
linac cannot be used with its full degrees
of freedom due to restricted geometrical
options for IORT.
linac inefficiently
financial aspects

IORT treatment using a dedicated

IORT linac.

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ALTERNATIVE: patient is transferred

to RT department after surgical
risk of infections.
first aid in case of an emergency,
linac rooms in an RT department
are not equipped like an OP.
linac (mobile linacs),.
literature data are scarce on the used of
mobile linacs,
standard for IORT (?)

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Mobile Linacs for IORT

Mobile linacs are almost as expensive as a standard linac for RT

purchasing such a device may be difficult.
warm up and QA
trained personnel.


Dedicated mobile IORT linac Novac 7 in two typical IORT applications.

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Mobile Linacs for IORT

Special waveguide enables compact system compared
to standard electron linacs used in RT
Maximum dose rate of 10 Gy/min
Internal shielding and integrated beam stopper to shield
primary beam makes it suitable for OP theatres,
Available electron energies are 4, 6, 9 or 12 MeV with
dose rates of 250 or 1000 cGy/min
Available FS: from 3 cm to 10 cm (circular )
Dose homogeneity is about +/- 5% .

Dedicated mobile IORT linac MOBETRON.

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Mobile Linacs for IORT

The NOVAC 7 linac consists of a linac mounted on a robotic arm.

Main advantage: degrees of freedom concerning irradiation geometry.
Disadvantage: shielding for the application room.
In Italy movable radiation protection shield-walls are used. Such
devices are, however, not allowed by Austrian regulatory bodies.

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Electron-applicator DOCKING:

Electron-applicator tube: positioned during surgery and must not be

moved after it is placed.
Small movements or a
tilt can results in a
different positioning
or may even harm the
Before treatment delivery
the central axis of the linac
must be correctly aligned
Electron applicator positioning and
with the axis of the applicator. applicator docking for IORT.

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Commissioning an IORT programme

Radiation beam parameters must be measured and dosimetry

data summarized so that it may be readily used.
Dosimetry measurements which may be necessary, depending
upon the IORT modality used
absolute dose output at the end of treatment applicators; central
axis depth dose data; surface dose and buildup; bremsstrahlung
contamination for electron beams; and dose distribution data.
Transition between the surgical procedure and irradiation must
be carefully planned and all steps involved properly worked out
practiced as part of the commissioning procedure.

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Special features of IORT

Effect of oblique electron applicator position on isodose distributions.

If the IORT electron applicator is not perpendicular to surface or not

well adjusted during surgery the isodoses are shifted !!!

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Quality Assurance in IORT

QA of IORT treatments is in some respects even more important than

that for standard radiotherapy.
IORT treatments are almost always given in a single session, making it
essentially impossible to correct a misadministration of dose.
QA in IORT consists of three components:
1. Basic quality assurance dealing with all IORT equipment.
2. Pre-treatment QA dealing with equipment preparation and
verification immediately prior to IORT treatment.
3. Treatment QA during the IORT dose delivery to the patient

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Endocavitray Rectal Irradiation

In recent years increasing efforts have been directed toward the
development of organ-saving therapeutic approaches for
malignant neoplasms that were traditionally treated by radical

For malignancies of the rectum and anal canal, sphincter-saving

procedures are successful in achieving not only a high
probability of local control but also an improved quality of life by
avoiding the permanent colostomy and male impotence that
may result from abdomino-perineal resection

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Endocavitray Rectal Irradiation
Endocavitary rectal (endorectal) irradiation is a sphincter-saving
procedure used in treatment of certain rectal carcinomas with
superficial x rays.
introduced in the 1930s by Chaoul and subsequently developed
and practiced by several workers most notably Papillon.

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Physical & Clinical Requirements

Main physical requirements for the technique to be successful is that
the x-ray beam have a low effective energy
Recommended PDD in tissue should have its maximum (100%) on the
surface and about 50%, 30%, and 10% at depths of 5, 10, and 25 mm,
x-ray tube potential of ~50 kVp and a short SSD
Clinical selection criteria for endocavitary rectal irradiation:
1. biopsy-proven well or moderately well differentiated rectal
2. mobile lesion with a maximum diameter of 3 cm
3. location of lesion with 10 cm from the anal canal
4. no evidence of lymph node or distant metastases

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Endocavitary Rectal Irradiation

X-ray tube for the short SSD technique for endorectal treatments.

Two techniques have been used for endorectal treatments:

(1) short SSD technique with SSD on the order of 4 cm and the x-ray
tube inserted into the proctoscopic cone

(2) long SSD technique with SSD on the order of 20 cm and the x-ray
tube coupled to the cone externally

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Endocavitary Rectal Irradiation

Most of the published accounts of endorectal

irradiation deal with the short SSD technique
Papillon technique
Both the proctoscopic cone and the inserted x-ray
tube are handheld during the treatment
Radiation protection point of view potentially
hazardous if proper radiation safety procedures
are not followed.
x-ray tube should be handheld during the
treatment to avoid possible cone movement during
the treatment and therefore geographic miss.
FIGURE : X-ray tube for endorectal
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Endocavitary Rectal Irradiation
Long SSD technique has been developed for use of superficial x-ray
tubes, the design of which does not allow insertion into a
protoctoscopic cone
Advantages of long over short SSDs in endorectal irradiation:
x-ray tube can be connected to the ~ 20 cm long proctoscopic cone
externally, allowing the use of smaller diameter cones
x-ray tube and the proctoscope do not have to be handheld during
treatment, thereby improving positioning and treatment accuracy as well
as solving the radiation protection problem
dose uniformity over the tumor volume is improved since a change in SSD
of a few mm on an irregular tumor surface affects the surface dose
uniformity much more at an SSD of 4 cm than 20 cm

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Quality Assurance in Endocrectal Treatments

Number of fractions is relatively low and prescribed dose high.

Basic QA dealing with complete equipment: superficial x-ray
tube, treatment proctoscopic cone and obturator, visualization
device dosimetry and beam output of the x-ray tube (IC that is
suitable for calibration of superficial x rays), calibration factor
Pre-treatment QA dealing with equipment preparation
immediately prior to endocavitary treatment. Calibration of the
x-ray beam and operation of all other treatment components
should be verified.
Treatment QA during the delivery of the endorectal treatment.

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Endocavitary Rectal Irradiation Steps
1. patient is positioned onto the proctoscopic couch and the proctoscopic cone
with a plunger is inserted into the rectum
2. plunger is removed, a proctoscopic viewing device is attached to the cone,
and the cone is placed over the tumor
3. Short SSD technique: x-ray tube is then inserted into the cone, and both the
cone as well as the x-ray tube are handheld for the duration of treatment
Long SSD technique: cone is then immobilized with an adjustable hydraulic
clamp and the x-ray tube is coupled with an electromagnetic lock to the
cone and also immobilized
4. x-ray machine is turned on and the prescribed target dose delivered
5. Total tumor dose: ~ 100 Gy delivered in two or three fractions (~20 to 30
Gy/fr). Fractions are typically 2 weeks apart.

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