PRINCIPLES OF

RADIOTHERAPY
E. CHISOR-WABALI
 Definition

• It is the therapeutic use of ionising

radiation in the treatment of patients
with malignant neoplasia (and
occasionally benign conditions).
TYPES OF IONISING RADIATION

Classified in terms of:

• Their nature e.g. electromagnetic or
particulate
• Linear energy transfer (LET)
• Mode of production e.g. intra or extra
nuclear production
Linear energy transfer (LET)
-Sparsely ionizing radiation e.g. X-ray,
gamma ray, Beta rays
- Intermediate ionizing radiation e.g.
Electrons
- Densely ionizing radiation e.g. alpha
particles, neutrons, negative pi
mesons
 Their nature……
• e.g. electromagnetic or particulate
radiation
-electromagnetic radiation e.g. X-rays
and gamma ray
-particulate radiations e.g. electrons,
alpha particle, neutrons, protons,
pions (pi mesons)
 Mode of production
• e.g. intra or extra nuclear production
• intra-nuclear e.g. Gamma rays, Beta
rays
• extra-nuclear e.g. X –rays, electron,
protons, neutron
 Mechanism of cell death by
radiation / Radiobiological
damage of mammalian tissue
• The specific target of radiation
damage in the mammalian cell is the
DNA molecule.
• Damage to the DNA can be by:
• 1. Direct interaction
• 2. Indirect interaction
 Direct interaction
• – direct damage to the DNA
molecule
This is true of high LET radiation
 Indirect interaction
• more important in radiotherapy and
the DNA molecular damage is by
radiation induced free radicals.
• When radiation interacts with water,
free radical ions are produced
• H20 --- H20+ + e-
• H20+ -- H+ + 0H. ( the
dot signifies an unpaired electron )
 …….continuation
• Free radicals are uncharged atoms or
molecules with unpaired electron in
the outer orbit.
• They are very reactive and result in
breaks in the chromosomes.
• The biological damage may be
repaired or result to:
• cell death
• loss of reproductive integrity
Types of Radiation Treatment/
Machine
• Teletherapy (External beam irradiation) –Megavoltage
machines-CO- 60, Linear accelerator
• Brachytherapy – Interstitial brachytherapy – radioactive
sources are inside the tumour
- Contact brachytherapy or plesiobrachytherapy:
radioactive sources are close to the tumour e.g
intracavitary,intraluminal, endovascular,
and surface brachytherapy.

• Systemic radiotherapy (Under Nuclear Medicine)- in form

of capsules or iv e.g. Iodine- 131(capsule), Strontium-
89(iv), Yttrium- 90
Oxygen Enhancement Ratio
• Is the ratio of the doses necessary to
achieve the same biological effect in
the presence or absence of oxygen.
• Oxygen enhances the sensitivity of
tumor cells to the to the killing
effects of ionising radiation.
Radiotherapy Planning
The Aim of Radiation therapy
Is to deliver a precisely measured
dose of radiation to a defined tumour
volume with as minimal damage as
possible to surrounding healthy tissue,
resulting in eradication of the tumour ,
high quality of life and prolongation of
survival at reasonable cost.
Treatment Volume
 Radiocurability
• Refers to the eradication of tumour at
the primary or regional site and reflects
the direct effect of radiation.
• Radiosensitivity
– Inversely related to cell differentiation
• Type, size, clinical staging at 1st
presentation
• General condition of the patient
• Dose-time relationship
ASSESSMENT BEFORE TREATMENT

A multidisciplinary approach is
preferred in cancer management. This
enables correct decision to be taken
especially when cure is the goal
because inappropriate initial treatment
may compromise both the quantity and
quality of survival.
 Advances in Radiotherapy
• Fractionation
• Hypofractionation
• Hyperfractionation
• Acclerated Fractionation
• CHART
• 3D Conformal RT
• Intensity Modulated RT
• Stereostatic Radiosurgery/RT
• Intravascular RT
 Clinical Assessment in
Radiotherapy

Consultant Radiotherapist and

Oncologist is a physician and a
technical specialist. Hence clinical
and technical factors must be
balanced to adequately plan RT.
 Joint Clinics
• Collaborative spirit among
specialists needed
• Timing of different modalities are
properly synchronized
• Patient have access to advise of
different specialists
• Patient is more reassured that all
treatment options have been
considered, before embarking on
the chosen course of treatment
 ..continuation
• Provide basis for audit of treatment
• Discussion about treatment is made
by specialists and the primary
physician without the patient in
attendance to prevent the patient
from being intimidated.
 RADICAL OR PALLIATIVE
TREATMENT?

The choice will depend on

• The tumour
• The patient
• Resources
 THE TUMOUR

• Site
• Size
• Spread (loco regional/ metastatic spread)
• Operability
• Radiosensitivity/ chemosensitivity
• Histology (including differentiation)
• Clearance of surgical resection margins
 THE PATIENT

• Age and general condition (physical

and mental)
• Morbidity and mortality
• Function and cosmetics
• Reliability of follow-up after
treatment
• Preference of patient
 RESOURCES

• technical expertise
• experience and
• equipment
 Tumours where RTH is the
treatment of choice
• Oral cavity, lip, tongue, cheek
• Nasopharynx, Oropharynx, Hypopharynx
• Nasal cavity, Larynx,
• Skin cancer(except melanoma),
• Cervix, Bladder, Testis- seminoma,
• Lymphomas –(early),
• Meduloblastoma ( ffing surgical
debulking), Astrocytomas (grade 3 and4),
Retinoblastoma
Curative Radiotherapy
 PRE-OPERATIVE
RADIOTHERAPY

Pre-operative radiotherapy implies

that tumour is irradiated prior to
surgery in the same anatomic
site.

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 Advantages of Pre-op RT
• sterilizing cells at the edges of the resection,
• prevent recurrence after surgery,
• damage the reproductive capability of the
cancer cells which are likely to be disseminated
or implanted in to the wound during surgical
manipulation,
• shrink a large mass with doubtful operability or
with a high operative mortality risk,
• reducing the tumour volume sufficiently to allow
resection,
• alter the lymphatic and vascular channels of the
irradiated normal tissue so that the grafted
tumour cells will not grow and
• to down stage a tumour.

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 DISADVANTAGES
• Delay in wound healing if doses
exceed 5000cGy;
• The pathology reports are not
valuable because the destruction of
tumour prevents ascertainment of
the tumour’s biology, prognostic
indices, and initial anatomic extent;
• Absence of surgical staging; and
• Some patients who would not benefit
from pre-operative radiation are
given this treatment.
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 POST-OPERATIVE
RADIOTHERAPY

Post – operative Radiotherapy implies

that tumour bed is irradiated after
surgery.

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 ADVANTAGES
• patients who may be helped by radiation can
be defined accurately as a consequence of
the surgical exploration and pathologic
review and
• unnecessary irradiation to patients who are
not likely to benefit can be avoided;
• also the target volumes are tailored to meet
what is found at surgery.
• It is indicated where a residual tumour exist
or is suspected after surgery and
• its main aim is to sterilize the surgical bed.

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 DISADVANTAGES
• It has no effect on seeding at the
time of surgery;
• Alteration of the physiology of the
tumour left behind because of
reduction of the vascular supply
(cells that were well oxygenated may
be rendered physiologically hypoxic
and more resistant to radiation);
• Adhesions with resultant increased
radiation toxicities e.g. radiation
enteritis, intestinal perforation.
20/11/09 UDUTH SOKOTO 2005 32
INTRA-OPERATIVE RADIOTHERAPY
• Some radiation centers in
developed world are using a
single high-dose Intraoperative
electron treatment for
unresectable abdominal tumours
and also to treat the surgical bed
in patients not fit for the routine
daily fractionations.

20/11/09 UDUTH SOKOTO 2005 33

 ADVANTAGES

• The major advantage of this

technique is that a single dose is
given (once);
• radiation field is well localised and
• critical structures are moved out of
the field and thus
• toxicity is minimized.

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Radiosensitivity of Tumours

Highly Sensitive
Lymphoma
Seminoma
Myeloma
Ewing’s Sarcoma
Wilm’s Tumour
• Moderately Sensitive
Small cell lung cancer
Breast cancer
Basal cell carcinoma
Meduloblastoma
Teratoma
Ovarian cancer
Relatively Resistant

Squamous cell Ca of lung

Hypernephroma
Rectal Carcinoma
Soft tissue Sarcoma
Cervical Cancer

Highly Resistant

Melanoma
Osteosarcoma
Pancreatic carcinoma
 SIDE EFFECTS OF
RADIOTHERAPY
• Acute side effects radiation (Depend on
the area being irradiated)
• But there are some general side effects-
fatigue, malaise, anorexia, nausea and
vomiting. These may be related to
metabolic effects of tumour breakdown,
bone marrow depression and the
reaction to anxiety and stress.
 Acute Effects
• Skin desquamation- dry,wet
• Alopecia
• Mucositis,dysphagia,xerostomia
• Diarrhoea, abdominal cramps
• Dysuria
• Bone marrow depression- decrease in
red cells, platelets, and leucocytes.
 Late Effects Radiation

• -Fibrosis, atrophy- Non –

stochastic effect
• -Carcinogenesis –damage to
somatic cells
• -Genetic mutation- damage to
germ cells
Advances in radiotherapy