Basic of radiotherapy/radiation oncology

dr. Narno Budianto, Sp. R (K) Onk. Rad

BAGIAN RADIOLOGI seksi RADIOTERAPI RSU Dr. SAIFUL ANWAR MALANG 2008
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RADIOTERAPhy
DEFINITION : - treatment - ionic rays - important therapy for cancer RADIATION ONCOLOGY : - Application of radiation therapy - single/combination treatment Ionic ray : X-ray Williem Rontgen
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Basic of radiophysical radiation: Ionic Ray : - Electromagnetic wave (photo/particle) - Ionization process 1. Electro Magnetic wave : X and Gamma E (+), Mass (-), Electricity (-) deep penetration 2. Particle : - Mass, electricity (+) - electricity (+) Proton & helium - electricity (-) Electron - without electricity Neutron
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 Proton interaction with Organic Material Electron move from Orbit Atom core excess electricity (+) Ion the process called radiation ionization. Interacts Energy transfer without transfer electron excites. ELECTRON RELEASE: - Photo Electric effect - Compton effect - Pair Production

Direct Energy Absorption Indirect Energy absorption because of E transfer from one Molecule to another Free radical formation Destructive
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IONIC RAY SOURCE : - Generator : - X-RAY - Electron - Ionic Particle - According to Energy level - Ortho Volt 50 300 kv divided : Superficial Medium Deep Mega Voltage Minimal 1 MV Output : Photon, Electron, heavy Particle produced by : Linac, Betatron, Syclotron.

Natural resources : - Radio Isotope decay

- produced : Alfa-ray Beta-ray Gamma-ray

- Radio Isotope that used : 1. Co 60 2. Cs 137 3. Iridium 192 4. Radium 255 5. J 131, J 125 - Divided into : - open sources - closed sources
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RADIO ACTIVE : - substance become another substance with release E - atomic number change - can move from room to another in periodic scale. X rays characteristic: - Deep penetration - burn film - causing Ionization effect - causing biological effect ELECTRON characteristic : - max doses 100%, 1 cm under surface - after max, doses rapidly decrease
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1. 2. 3. 4. 5.

FOTON Gel electro M Mass (-) Energy deep/ sharp PDD not rapidly decrease Low skin reaction

1. 2. 3. 4. 5.

ELECTRON Particle Mass (+) Energy absorb by bone PDD rapidly decrease High skin reaction

Roentgen equipment for Radiotherapy : resources : - natural : - Co 60 T1/2 5- 6 year - Sc T1/2 23 30 year - Radium T1/2 1550 1600 year - Iridium T1/2 72 year - Generator : - Lineac : - small Pin point , small penumbra, sharp border - higher Out put - Constant - consist of: Photon, Electron - Betatron : Photon and Electron - Cyclotron : Neutron
NB : Cobalt : larger focus, larger penumbra lower Out put
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ENERGY :
Grenz ray Therapy 10 20 Kv Contact Therapy 15 50 Kv Superficial/Low Voltage 60 - 120 Kv Deep/High Voltage/Ortho Voltage 140 400 Kv Super Voltage 400 1 Mv Mega Voltage Higher than 1 MV

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RADIO SENSITIZER Molecule consist of: - Purin BUDR increase sensitivity of tumor/healthy tissue - Electron Affini Component : increase ionization reaction - Metro - Bleo - Fluora

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RADIATION DOSES UNIT:

R = Roentgen ---- Unit of doses in air Rad = Radiation absorption dose Gy = Gray 1 Gy = 100 Rad. 1 Rad = 1 cGy RESTRICTOR OF RADIATION DOSES : - Radio Sensitizer - Purpose of Radiation - Kind of Radiation rays - Tumor stadium - soft tissue tolerance
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RADIO PROTECTOR : - I U R 1721 - Cysteamine - Glutathione - substance with OH CYTOSTATICA THAT HAVE RADIO SENSITIZER EFFECT : -5FU - Actinomycin - Bleomycin - Metotrexate - Purine/Pyrimidine
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ORTHO VOLT

MEGA VOLT

penetration Max Doses Absorption used

- low - superficial - bone - Superficial tissue

- deep - under skin tissue - bone = tissue - deep Tumor

MEGA VOLTAGE CHARACTERISTIC/MV : - Sharp - small side effect - Effect on bone = tissue - deep penetration & spin Radiation Source : - closed - open
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TUMOR MARKER Body substances ---- Quantity / Quality - Ca Mamma : Ca 125, CEA, MCA, Estrogen receptor - Ca Cervix : C E A, HCG - Ca Ovaries : AFP, Ca 125, CEA, FSH, HCG - Ca Nasopharyngeal : Titer EBV etc
Differences between tumor tissue and healthy tissue : - Reproduction capability - Mitosis - Differentiation - Repair capability - Oxygenation
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BASIC OF RADIOTHERAPY - Different radiation effect between tumor and healthy tissue - Therapeutic ratio/ T R Molecular Effect Radiation : - DNA Break : - Single/Double - Basa-basa DNA - Cross Linked DNA and chromosome Damage followed by : - Direct Effect DNA Ionization - Indirect Effect * Water Molecule Ionization * Free Radical - Reparation perfect/un perfect
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CELLULER RADIATION EFECT - Chromosomal abrasion - inhibition of Reproduction - inhibition of Proliferation cycle PROLIFERATION ON RADIATION Growth Factor : - Phase S - Phase G 2 - Phase M - Phase G 1 Active Proliferation G 2, M

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FACTORS THAT INFLUENCE: RADIATION RESPON : - Oxygenation - Proliferation - Heat - Radio Sensitizer FRACTINATION ON RADIATION ( DIVIDED DOSES) ; - Characteristic 4 R : - Reparation - Reoxygenation - Redistribution - Repopulation
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RADIOTHERAPY : - Definitive - Exact Doses - Combination 1. surgery : - Radiation before surgery - Radiation During surgery - Radiation after surgery 2. Cytostatica : - before Radiation - during Radiation - after Radiation 3. Immunology in research
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RADIATION THERAPEUTIC GOAL : - Curative - Palliative

RADIATION : 1. External Radiation (Tele far) 2. Brachy therapy (short) : - Implants/ Interstitial - Intra Caviter - Contac Recent Brachytherapy after Loading technique 3. Radio Farmaka
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FACTOR THAT INFLUENCE RADIATION OUTPUT : 1. Patient condition 2. Continuities 3. Unprecise calculation (ketidak tepatan penentuan) 4. Stage of disease 5. Biological characteristic EFFORT TO REINFORCE RADIATION EFECT : - Radio Sensitizer - Hyperthermia, Hyperbaric - Depend on cell tumor characteristic
RADIATION SIDE EFECT : - Acute - Chronic
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FACTORS THAT MUST BE UNDERSTOOD IN RADIOTHERAPY

Radiation type (high voltage X ray, uranium, radium, Co 60 etc.) Cell type Bergonie Tribondeau law Cell environment Tumor vasculature Radiation weight
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PLANNING OF RADIOTHERAPY

Decide tumor place and wide Illumination technique and dosage distribution Tissue toleration

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SOMATIC EFFECT AND IONIZED RADIATION

Skin Acute dermatitis Level I : erithematosa dermatitis Level II : bullosa dermatitis Level III : eschariotic dermatitis Chronic dermatitis Late effect of acute dermatitis Eyes Konjungtivitis and keratitis Eyes lens is very sensitive, 400 500 rad cataract
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 Internal genitalia Dosage 600 rad sterility ( testis is more sensitive than ovum) Gravid dead infant, anomaly Gen mutation Lungs Cough, hypoxia, chest pain, fibrosis Bone Disturbance of bone development, osteoporosis

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 Neurotic system Myelitis, neuron tissue degeneration Radiation disease Fever, anorexia, headache, nausea, vomiting, weakness, diarrhea Genetic effect Gene mutation

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STOCHASTIC EFFECT
Low dosage radiation illumination Somatic Genetic Dosage 0.25 until 1000 Sv 4 characteristic of stochastic effect There is no threshold dosage Appear after passing delayed time Morbidity radiation dosage There is no automatically healing
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DETERMINISTIC EFFECT
High dosage radiation illumination Fit with threshold dosage Time : view minutes after radiation There is automatically healing Morbidity level is fit with dosage Ex : - anorexia - vomiting, nausea, weakness shock dead
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DETERMINISTIC EFFECT HAPPEN IN :

Dosage > 100 Sv damaged central nervous system Dosage 10 50 Sv Damaged GIT Dosage 3 5 Sv Damaged bone marrow Dosage 3 Sv Women infertility Dosage 2 Sv Permanent infertility of men Dosage 2 -5 Sv cataract Dosage 1 -2 Sv (whole body) nausea
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 radiasi

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Energi radiasi
Radiasi mempunyai energi Max Planck (1900) pertukaran energi antara radiasi & materi tidak terjadi secara kontinyu, tapi melalui satuan energi kwantum E=hxf E (erg) = energi radiasi dalam erg h = konstanta Planck = 6,62 x 10-27 erg
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f = frekuensi radiasi Dan f = C C = kecepatan gelombang elektromagnetik = 3 x 1010 cm/detik = panjang gelombang, maka E=hxC
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 Karena h dan C konstan, energi radiasi berbanding terbalik dengan panjang gelombang.

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Besaran dan satuan dasar dosimetri

Dosimetri : kegiatan pengukuran dosis radiasi dengan tehnik pengukuran didasarkan pada pengukuran ionisasi yang disebabkan oleh radiasi dalam gas (udara). Radiasi mempunyai besaran = besaran fisika lain Dosis radiasi yang diterima/ diberikan bila medium terkena radiasi.
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Dosis serap
Radiasi ionisasi pada jaringan / medium yang dilalui Dosis serap D : besarnya energi radiasi yang diserap tiap satuan massa bahan yang menerima radiasi. D = dE / dm dE = energi yang diserap oleh medium bermassa dm Dalam sistem SI = joule /kg atau Gray (Gy)
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Sebelumnya digunakan satuan : erg / gr atau rad (radiation absorbed dose) 1 rad = 100 erg / gr 1 rad = 10-2 J /kg 1 Gy = 100 rad Laju dosis serap : turunan dari dosis serap terhadap waktu Adalah = dD / dt
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Dosis ekuivalen
Ditinjau dari sudut efek biologi yang ditimbulkan : efek yang timbul pada suatu jaringan akibat penyinaran bermacammacam radiasi pengion tidak sama dosis radiasi sama, jenis radiasi berbeda. Digunakan dosis ekuivalen (HT.R) Menunjukkan kualitas radiasi dalam kaitannya dengan akibat biologi yang ditimbulkan.
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 International Commission on Radiological Protection (ICRP) memperkenalkan faktor bobot radiasi (WR) HT.R = WR . DT,R DT,R : dosis serap yang dirata-ratakan organ / jaringan yang menerima radiasi. Faktor bobot tidak berdemensi , satuan dosis ekuivalen = satuan dosis serap = J/kg Satuan khusus = Sievert (Sv)
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 Sebelum digunakan satuan SI :digunakan satuan REM ( Roentgent equivalent man / mammal ) : 1 Sv = 100 Rem

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Faktor bobot radiasi

Jenis dan rentang energi radiasi Foton semua energi (gamma,sinar X) Elektron, semua energi Neutron dengan energi En En <- 10 keV 10keV < En <- 100 keV 100keV <En<-2MeV 20 2MeV < En <-20 MeV En> 20 MeV 5 WR 1 2

5 10 10

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 Proton energi > 2 MeV Partikel alfa

5 20

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 Faktor bobot radiasi WR : dosis serap 1 Gy partikel alfa memberi efek biologi 20x lebih besar dari pada dosis serap 1Gy sinar gamma / sinar X Radiasi gamma , dosis 1 Sv memberikan efek biologi yang nilai kerugiannya sama besar dengan yang ditimbulkan oleh 1 Sv radiasi alfa atau 1 Sv radiasi beta /1 Sv radiasi lain.
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Dosis efektif
Keefektifan radiasi dalam menimbulkan efek tertentu pada suatu organ (HE) Hubungan antara peluang timbulnya efek biologi tertentu akibat penerimaan dosis ekuivalen pada suatu jaringan tergantung pada organ / jaringan yang tersinar. Digunakan bobot jaringan (WT) HE = WT . H T
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Faktor bobot jaringan untuk berbagai organ tubuh

Jenis jaringan /organ Gonad Sumsum tulang merah 0,12 Usus besar ,paru,lambung Bladder, payudara,hati 0,05 Oesophagus,thyroid Kulit,permukaan tulang 0,01 Adrenal,otak,colon prox,usus kecil, Ren, otot,pancreas,spleen,thymus, Uterus. WT 0,20 0,12 0,05

0,05

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Paparan
Besaran intensitas menyatakan intensitas sinar X menghasilkan ionisasi diudara jumlah tertentu X = dQ / dm dQ : jumlah muatan elektron akibat interaksi antara foton dengan atom atom udara dalam volume udara bermassa dm Satuan : Roentgen
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 1 Rontgen = kuantitas radiasi sinar X / gamma yang menghasilkan 1 e.s.u ion positif atau negatif didalam 1 cm3 (NTP) 1 R = 1 esu / cm3 (NTP) Ion bermuatan = 4,8 x 10-10 esu 1cm3 udara = 0,001293 gr Nilai penyerapan energi = 87,7 erg 1 gram udara = 87,7 erg/gr 1 rad = 100 erg/gr udara
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1 erg / gr udara = 0,01 rad 1 R = 0,877 rad

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Efek Stokastik
Paparan radiasi dosis rendah Somatik Genetik Dosis 0,25 s/d 1000 Sv 4 ciri efek stokastik tidak ada dosis ambang Timbul setelah melewati masa tunda Keparahan # dosis radiasi Tidak terjadi penyembuhan spontan
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Efek Deterministik
Paparan radiasi dosis tinggi Sesuai dosis ambang Waktu : beberapa saat setelah terjadi radiasi Terjadi penyembuhan spontan Tingkat keparahan sesuai besarnya dosis Misal : - nafsu makan kurang - mual, lesu, lemah syok kematian.
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 Lokal : eritema, pedih, gatal Limfosit menurun parameter tinggi rendahnya dosis

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Efek Deterministik terjadi :

Dosis > 100 Sv kerusakan susunan saraf pusat Dosis 10 50 Sv kerusakan GIT Dosis 3 5Sv kerusakan sumsum tulang Dosis 3 Sv kemandulan pada wanita Dosis 2 Sv kemandulan pada laki-laki (permanen) Dosis 2 5 Sv katarak Dosis 1 2 Sv (seluruh tubuh) mual
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 3. Tahap biokimia - secara : ekstra seluler intra seluler - terjadi beberapa detik - Hasil reaksi berinteraksi dengan molekul organik radikal bebas oksidator molekul kompleks bahan dasar (menempel atom, merubah ikatan molekul).
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