Types of Radiotherapy

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External beam radiation therapy (EBRT) These modern techniques include 3-dimensional conformal radiotherapy (3D-CRT), intensity-modulated radiotherapy (IMRT), and image-guided radiotherapy (IGRT) The advantages of the newer forms of treatment are the abilities to escalate tumor dose and to minimize toxicity to normal tissue. The importance of the former attribute is enhanced disease control and the latter is improved patient compliance and satisfaction. Three-dimensional Conformal Therapy In 3-
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  External beam radiation therapy (EBRT)These modern techniques include 3-dimensional conformal radiotherapy (3D-CRT), intensity-modulated radiotherapy(IMRT), and image-guided radiotherapy (IGRT)The advantages of the newer forms of treatment are the abilities to escalate tumor dose and to minimize toxicity tonormal tissue. The importance of the former attribute is enhanced disease control and the latter is improved patientcompliance and satisfaction. Three-dimensional Conformal Therapy In 3-dimensional conformal radiotherapy (3D-CRT), the radiation beam is shaped to include a 3-dimensionalanatomic configuration of the prostate and any specified adjacent tissue. Adjacent structures include theseminal vesicles and periprostatic adventitial tissues. 3D-CRT allows for more precise delivery of therapy tothe target organ or organs.With increasing access to CT and MRI simulation equipment, as well as more powerful treatment-planningequipment, the use of 3D-CRT has markedly increased over the past decade. Indeed, 3D-CRT has essentiallyreplaced conventional external beam radiation therapy (EBRT) in the management of early-stage prostatecancer.The transition to this form of therapy has significantly reduced the number of treatment-associated toxicities.More importantly, conforming the radiation dose to a limited target has resulted in several successful doseescalation trials. The success of 3D-CRT is the result of multiple factors, including favorable dose-responserelationships, increased ability to reduce radiation to neighboring normal tissue, the relative immobility of theorgan (typically < 1 cm), and a high prevalence of disease.Inherent to the discussion of 3D-CRT is a working knowledge of the terms gross tumor volume (GTV),clinical target volume (CTV), and planning target volume (PTV). The GTV is the delineation of the visibletarget using common imaging modalities (eg, CT imaging, MRI).CTV describes the structures that may be beyond the easily visible anatomic structures delineated on CTimaging or MRI. Specifically, the CTV acknowledges the anticipated microscopic extent of tumor, as well asanticipated subclinical areas that may be at risk for disease involvement.The PTV acknowledges that daily patient positioning and setup vary and should be addressed in creatingradiation portals.Although each of these terms is readily applied to single-organ structures (eg, prostate, seminal vesicles), howwell the structures can be defined in the delineation of regional pelvic adenopathy is unclear. Indications for 3D-CRT Despite the successful completion of several prospective randomized trials in the management of prostatecancer, several issues remain unclear. Specifically, 3D-CRT is appropriate when (1) the probability that tumor remains within the anticipated target portals (ie, delineation of the GTV, CTV, and PTV for organs at risk) can be adequately determined and when (2) the importance of regional adenopathy in varying clinical settings can be delineated. Technique of 3D-CRT The process of 3D-CRT requires the acquisition of imaging data; the initial step is immobilization of the patient. Patients can be positioned in either the supine or prone position. Theoretic advantages of supineimmobilization include the ease of daily setup for the patient and staff, the ability to fuse treatment-planningimages with previously obtained diagnostic images (ie, MRI), and the relative ease of use when performingdaily setup localization with ultrasound assistance.  Many centers have adopted prone positioning. Theoretic advantages of prone positioning relate to relativesparing of small bowel from the radiation portals and reproducibility of patient positioning on daily setup.Following patient positioning, fabrication of the immobilization device is performed. This step becomesincreasingly critical as the margin around the target is decreased (eg, when a 1.5-cm margin around the prostate is decreased to a 0.5-cm margin). Numerous materials have been used to immobilize patients prior to acquiring CT imaging or MRI data for treatment planning. Commercially available products include thermoplastic casts (eg, Aquaplast), vacuum-shaping bags (eg, Vac-lock), and self-contained thermochemicals (eg, alpha cradle). Regardless of whichdevice is chosen, the goal of immobilization is to reproduce the position in which the patient is treated eachday.Upon fabrication of the device or devices, axial images of the area of interest are obtained. Consecutive CTscans or MRIs are obtained, starting from 3 cm below the prostate and extending superiorly to 3 cm above thesuperior tip of the seminal vesicles.Additional CT imaging or MRI data can be obtained above or below the areas of interest. However, thisinformation has minimal impact on patient treatment or dose computation.The targets (CTV, PTV, or both) are identified on each relevant axial CT slice. Similarly, normal structures,including the bladder wall, rectum, small bowel, bony structures, and skin surface, are outlined on eachrelevant CT slice.The target volume and normal structures are then digitally reconstructed in 3 dimensions and displayed withthe beam's eye view (BEV) technique. The adequacy of target coverage and normal tissue doses can be viewedusing dose-volume histograms (DVHs) or serial 2-dimensional images superimposed with isodose curves.Compared with conventional EBRT, 3D-CRT techniques implement a larger number of beams daily toimprove the tumor–to–normal tissue dose ratio. Implementation of 3D-CRT requires the use of newer treatment machines capable of rapidly delivering a large number of precisely shaped fields under automatedcomputer control (ie, multileaf collimators [MLCs]). (See the image below.)Conformal radiation therapy. A linear accelerator equipped with a multileaf collimator is a device that candecrease the time a patient spends in the treatment room and one that improves treatment accuracy.MLCs are capable of automatically shaping the apertures of each treatment field in rapid succession under computer control. Treatment times are shortened, individual treatment blocks do not need to be fabricated, andmore complex beam shaping can be attempted. Results of 3D-CRT The results of 3D-CRT demonstrate superior bNED (biochemical, no evidence of disease) control rates,largely because of the ability to escalate the dose with less concern over the toxicity to normal tissue. 3D-CRTallows higher doses of radiation to the prostate without significant complications to the normal tissue.Even small degrees of dose escalation have been shown to improve the biochemical outcome in patientsdiagnosed with prostate cancer. Comparison studies have shown superior outcomes with doses of 78 or 79 Gyversus 70 Gy. [7, 8] Five- and 10-year follow-up results with 3d-CRT indicate increased rates of bNED control, especially in patients with intermediate prognostic factors (ie, Gleason score of 7 and PSA level of 10-20 ng/mL). bNEDrates in patients with pretreatment PSA levels of 10-20 ng/mL are approximately 30% better than those in patients treated with conventional radiotherapy (5-y results).Patients with more favorable prognostic factors (ie, Gleason score ≤6 and PSA level ≤10 ng/mL) may not benefit from dose escalation, although this issue remains highly controversial. Similarly, the bNED rates in   patients at high risk for locally or regionally advanced disease (ie, Gleason scores of 8-10 and PSA ≥ 20ng/mL) may not markedly improve after dose escalation. This is felt to be true because this group of patients isultimately at higher risk for distant metastasis. ] Intensity-Modulated Radiation Therapy Intensity-modulated radiation therapy (IMRT) can achieve tightly conformal dose distributions with the use of nonuniform radiation beams. The intent of this form of therapy is to create highly conformal fields by treatingthe patient with multiple static portals (so-called step and shoot IMRT) or dynamic fields. In dynamic IMRT, aseries of arcs are administered through the area of interest. Multileaf collimators (MLCs) are reshaped manytimes as the machine performs a series of arc rotations around the target. (See the image below.)Multileaf intensity-modulating collimator (MIMiC) unit. This is used to deliver intensity-modulatedradiotherapy.Complex treatment-planning software algorithms allow exceedingly high doses of radiation to be delivered tothe target while significantly smaller doses of radiation are delivered to the adjacent normal tissue. In contrastto the traditional method of radiation planning, inverse treatment planning is commonly used for thecalculation of doses during IMRT.IMRT establishes a treatment plan following the establishment of acceptable doses to regional (normal)anatomy. For instance, in IMRT treatment planning, the maximum tolerable dose to be delivered to theinvolved segments of the bladder, bowel, and rectum is specified.The desired target dose is then prescribed to the PTV. The computer, through a series of complex iterations,designs a treatment that maximizes delivered dose to the target and minimized dose to adjacent normal tissue.Implicit in the name of this form of therapy is the concept that the intensity of the radiation beam changesthroughout the course of therapy.IMRT has been successfully used to treat tumors when the target area is readily identifiable at the initiation of daily treatments and the desired dose for optimum tumor control is significantly higher than the acceptabledose limits for adjacent normal tissue. Tumors of the head and neck and tumors of the breast are clinical siteswhere this treatment has been successfully used.IMRT is no longer considered an investigational technique in the management of prostate cancer. Rather, ithas rapidly become a highly precise method of delivering increasing doses of radiotherapy to the prostate andimmediate periprostatic tissues.However, no multicenter, phase III, prospective, randomized trial has been performed to address thesuperiority of this form of therapy over well-designed 3D-CRT. Data from the Memorial Sloan KetteringCancer Center have demonstrated the safe delivery of doses of more than 80 Gy using this technique. Thevalue of dose escalation when additional adjuvant treatments are being considered (eg, hormonal blockade,chemotherapy) remains unclear.IMRT in the treatment of prostate cancer continues to evolve; however, reproducible identification of thetarget (on daily treatments) remains challenging. The use of implantable fiducial markers and sonographiclocalization devices has become increasingly popular. Both techniques allow the treating therapists to identifythe desired target immediately prior to each day's treatment. Without such specificity, the logic of using IMRTis questionable. Image-Guided Radiotherapy  Image-guided radiotherapy (IGRT) refers to the use of additional verification tools in an attempt to ensure proper target localization during the course of radiotherapy. The term IGRT has been widely used to refer toimaging techniques as simple as daily port films to those as complicated as computer-assisted patientrepositioning devices. Regardless, as highly conformal radiotherapy is administered with increasing frequency(eg, IMRT), accurate target localization becomes mandatory.Historically, attempts to identify the target’s position have focused on imaging performed prior to each dailytreatment, or fraction. Recent efforts have attempted to address the significance of organ movement during thedaily treatment fraction. [9] Interfractional assessment (static) As radiotherapy for prostate cancer has become increasingly conformal, dose escalation has become astandard approach to the management of early-stage disease, [10] and accurate target and normal tissuelocalization has become increasingly important. Proper target identification becomes necessary in 3 distinct phases of treatment planning and treatment execution. When patients are selected for primary radiotherapytreatment, simulation is performed. CT-based imaging is most commonly used; however, some centers prefer MRI technology. [11] Accurate delineation of normal tissues in relation to the prostatic target is equally important in this phase of  patient care. Physician review of axial CT images allows delineation of the prostate. As most radiationoncologists lack formal training in the interpretation of radiographic imaging, review with a diagnosticradiologist or extensive clinical experience is advised.Following identification of the prostatic target (GTV), a clinical target volume and planning target volume arecreated. Although this phase of treatment planning allows for accurate target localization based on the gland’slocation at the time of CT imaging, it does not address organ motion subsequent to that date. Portal imaging Early attempts to identify the location of the prostate prior to each daily treatment resulted in suboptimal targetidentification. A commonly used approach has included the performance of daily port films prior to therapy.This strategy provides limited value to the image guidance process.Megavoltage imaging (portal imaging) of pelvic anatomy provides reasonable confidence that the patient’sfixed pelvic structures (bones) are in the same position as observed during CT simulation; however, it does not provide information regarding the prostate’s position in reference to these bony structures. Nevertheless, itremains an accepted method for approximating target localization in the absence of more sophisticatedimaging.An evolution from this simple form of therapy occurred with the placement of fiducial markers into the prostatic target. Using a series of implanted radio-opaque markers, a soft tissue target can be localized using portal imaging technology. Imaging of the implanted fiducial markers can be obtained with either megavoltage imaging (ie, port films) or with kilovoltage imaging. In the latter setting, low-energy x-rayequipment and detectors are mounted on the treatment machine. Ultrasonography Transabdominal ultrasonography is an accepted noninvasive method for obtaining detailed imaging of pelviccontents. It is regularly used by gynecologists and urologists in the daily assessment of their patients. Thistechnology has been adapted for use in the management of target localization for patients undergoingradiation-based treatments.In an attempt to displace normal tissue(s) from the radiation treatment portals and to facilitate theimmobilization of the gland, patients are asked to undergo their daily treatments with a full urinary bladder 
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