Handout rmn-lecture-application of radiation-in-medicine-and-research-30-12-2013

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Application of Radiation in Application of Radiation in Medicine and ResearchMedicine and Research

Dr.R.M.NehruDr.R.M.NehruInformation and Technical Services DivisionInformation and Technical Services Division

Atomic Energy Regulatory BoardAtomic Energy Regulatory BoardNiyamak Bhavan, Mumbai Niyamak Bhavan, Mumbai –– 400 094400 094

[email protected]: Delivered at the Department of Science & Technology (DST), Govt. of India sponsored Innovation in Scientific

Pursuit for Inspired Research (INSPIRE) Science Internship Camp on Dec.30, 2013 at KASC, Erode

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TMH AERB

Acknowledgements

Dr. N. Raman, Chairman, INSPIRE Science Camp -2013, KASC, Erode

Dr. A. K. Vidya & Dr. Deepa, and the Team Members of INSPIRE Science Camp, KASC, Erode

Google Team

IAEA, WHO, NCI, DST & AERB

& YOU

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Outline…..1.Introduction

•What is Radiation?•What is Cancer?

2. Application of Radiation in • Diagnostic Radiology

N l di i• Nuclear medicine

• Radiation Therapy

3. Research Applications4. Radiation Accidents5.Conclusion

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Pioneers

Antoine Henri Becquerel

Pierre Curie (1859-1906)Marie Curie (1867-1934)

Wilhelm Conrad Roentgen(1845-1923)

Ernest Rutherford(1871-1937)

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What is Radiation?What is Radiation?

• Radiation is a form of energy.• It is emitted by either the nucleus of an

atom or an orbital electron.It i l d i th f f• It is released in the form of electromagnetic waves or particles.

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The Electromagnetic SpectrumThe Electromagnetic SpectrumWaveform of RadiationWaveform of Radiation

NONIONIZING IONIZING

Radio

Microwaves

Infrared

Visible light

Ultraviolet

X-rays

Gamma rays

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1. How “artificial” radioisotopes are produced?

Cyclotron / Nuclear Reactors

2 Wh li th “ tifi i l” di i t ?

Important Questions

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2. Who supplies the “artificial” radioisotopes?

Board of Radiation Isotope Technology, Mumbai or Suppliers from abroad

3. Who supplies the radiation-generating equipment?

Local suppliers or Suppliers from abroad

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Ref: http://www.britatom.gov.in/images/animated_webmaster.gif

Basic Safety FactorsBasic Safety Factors

TIME DISTANCE SHIELDING

Ref: www.nrc.gov

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Ref: http://www.slideshare.net/prayarhin/cancer21919RMN, 2013RMN, 2013 2020RMN, 2013RMN, 2013

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Ref: NCI website

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Ref: NCI website

14 million cancer cases Diagnosed in 2012

8.2 million cancer deaths in 2012

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CAUTION

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Applications of Radiation in Applications of Radiation in MedicineMedicine

Diagnostic Therapy

Radiation in Medicine

Radiography Nuclear Medicine

Teletherapy Brachytherapy

Radiotherapy Nuclear Medicine

[email protected], 2013RMN, 2013

Justification of practice

Net benefit positive

Optimization of protection

ALARAALARA

Dose limitation

Never to exceed Dose Limits


Technological Challenges in Clinical Technological Challenges in Clinical management of management of tumourstumours

KEY ISSUES

Accurate diagnosis

Benign or malignant / grading

Selection of appropriate therapies

Surgical resection without compromisingthe neurological functions (gross / partial)

Tumour response to treatment

Tumour recurrence or radiation necrosis

Courtesy: Dr. Rama Jayasundar, Dept. of NMR, AIIMS, New Delhi 3636RMN, 2013RMN, 2013

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Diagnostic x-rays have been used in medicine since the late 19th century with steady and continual advances:

1895 : Discovery of x-rays (Röntgen), first clinical images

Background of Diagnostic Radiology

1920s : Barium contrast studies

1930s : Intravenous contrast media

1940s : Angiography

1950s :Fluoroscopic image intensifiers / catheterization techniques

1960s :Early work on rare-earth intensifying screens

1970s :Computed Tomography (CT)

1990s :Interventional radiological techniques;

helical and multi-slice scanners



Diagnostic RadiologyDiagnostic Radiology


Modern X-ray tube“Earlier” X-ray tube

LIGHT BEAM

COLLIMATOR

HIGH VOLTAGECABLES

X-RAY TUBE HOUSING (ASSEMBLY)

Image processingImage processingX-ray photons transmitted through the structures under examination comprise the “x-ray (or radiological) image” that must then be converted into a visual image by interaction with an appropriate detector (image receptor)

FILM IN

FILM OUT


Mobile unit

• provides static images using x-ray film and intensifying screens or digital image receptors.

General Radiography XGeneral Radiography X--ray facilityray facility

Chest stand

• It is commonly used for examinations of most body parts including the thorax, abdomen, pelvis, skull, spine, extremities, etc.

Mobile unit


FluoroscopyFluoroscopy• provides dynamic (real-time) images using electronic or

digital imaging. It is used for the dynamic evaluation of functional disorders, guidance during biopsies, surgical procedures, etc.


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CR- Computed Radiography

DR- Digital Radiography

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• cardiovascular and endovascular radiology

• neuroradiology

Interventional radiology is a procedure in which fluoroscopic x-ray imaging guides the radiologist (or other specialist medical practitioner) during medical or therapeutic treatments such as:

Fluoroscopy for interventional radiologyFluoroscopy for interventional radiology

(biopsies, embolization, etc.)• percutaneous gastrointestinal

interventions; and • genitourinary radiology (biopsies,

tumor ablation, stent placement, etc.)


•Mammography is the most reliable method by which to detect lesions in the breast. This x-ray technique can detect small tumors before clear clinical symptoms appears.

MammographyMammography

• Breast examinations are carried out either by individual medical referral, or as part of a screening p gprogram.

• Mammography x-ray systems use dedicated equipment (low potential generators, special anode x-ray tube and filtration, etc.)

IMAGE RECEPTOR

COMPRESSION PLATE

X-RAY TUBE ASSEMBLY

OPERATOR’SPROTECTIVE

SCREEN


Computed Tomography (CT)Computed Tomography (CT)

The early “translate-rotate” scanner developed into “rotate-rotate” technology where both the x-ray tube and radiation detectors rotate around the patient. A thin (~1-10 mm) fan-shaped x-ray beam produce images as “slices” through the patient’s body.


2.Technological advances

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Multi-slice Spiral CT

2.Technological advances

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Nuclear Nuclear MedicineMedicineMedicineMedicine


What is Nuclear Medicine?What is Nuclear Medicine?

• uses radioactive materials for both diagnosis and treatment

• imaging documents organ function and structure• uses relatively small amounts of radioactive materials

(radiopharmaceuticals) to diagnose and treat disease• radiopharmaceuticals are substances that are localized

in specific organs, bones, or tissues• radiopharmaceuticals can be detected externally by

special types of cameras: gamma or PET cameras.• cameras work in conjunction with computers

to form images that provide data and information about the area of body being imaged


What is Nuclear Medicine?What is Nuclear Medicine?

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Radiopharmaceuticals Most Commonly Used Radiopharmaceuticals Most Commonly Used

• The primary radionuclide used for diagnostic Nuclear Medicine procedures is technetium-99m (99mTc). Others are I-131 &Th-2013 & 0

• The primary radionuclide used for therapeutic Nuclear Medicine procedures is Iodine-131 (131I). Others are Sr-89, Sm-153 and Rh-186.


TechnetiumTechnetium--99m99m• In short, 99mTcO4

- is added to a vial containing a chemical compound that will bind to the radionuclide and the result is a radiopharmaceutical which, after administration, will localize in the desired patient organ to later be studied/imaged with a gamma camera.to ate be stud ed/ aged t a ga a ca e a


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IodineIodine--131131

• Can be administered in capsule or liquidsolution form.

• Special precautions must be implementedwhen administering this radionuclide.


Scintillation CamerasScintillation Cameras• Commonly known as

a “Gamma Cameras”• Are used to show how the

radiopharmaceutical administered to a patient pdistributes itself throughout the body or in specifically targeted organs.


SPECT CamerasSPECT Cameras• Single Photon Emission

Computed Tomography (SPECT)

• The SPECT camera looks at a patient from different at a patient from different angles and is able to demonstrate very precise detail within the patient.


RESEARCH APPLICATIONS

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RadiotherapyRadiotherapypypy


The Science of Radiation TherapyThe Science of Radiation Therapy

• What does ionising radiation do?– Ionizing radiation deposits energy that

injures or destroys cells by damaging their genetic material (DNA) making it impossiblegenetic material (DNA), making it impossible for these cells to continue to grow.


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Radiation damages normal cells too! Radiation damages normal cells too! Then what is the rationale for its Then what is the rationale for its

use?use?• Radiation damages both cancer cells

and normal cells, however the latter are able to repair themselves and function properlyproperly.

• Cancer cells are more sensitive to radiation than normal cells and will, therefore, be destroyed at a greater rate

• The radiation is confined, as much as possible, to the cancer


Radiation Facilities in India Radiation Facilities in India (2011(2011--20122012))

Teletherapy Centres : 319Teletherapy Facilities

Co-60 Units : 237Linear Accelerators : 232Gamma Knife : 7Tomotherapy /Cyberknife : 3+2Tomotherapy /Cyberknife : 3+2

Brachytherapy FacilitiesRemote Afterloading Units (HDR/LDR) : 200/14Manual Afterloading kits (Cs-137) : 61Manual Afterloding Interstitial Applications (Ir-192): 20Opthalmic Applicator : 42


Kilovoltage Equipment (150 Kilovoltage Equipment (150 -- 400 400 kVp)kVp)

• Typical “deep x-ray unit”


Tele Tele --GammatherapyGammatherapy equipmentequipment

The Greek word “tele”means “far away”

Movement


GammaGamma--ray equipmentray equipment

• Cobalt 60– Very popular

• Cesium 137– Not popular

• Principles are the same


Bhabhatron Co-60 Teletherapy Machine

Tele = Distance•Indigenously developed in India•Typical source activity used = 370 TBq (200 RMM)

Front view

Side [email protected]

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Growth Rate of Radiation Therapy Growth Rate of Radiation Therapy Facilities in Facilities in India : India : 1990 1990 -- 20122012

1990 2000 2006 2012Type of UnitTeletherapy 170 267 378 484py(Co-60+LAs)RAL Brachy 31 66 119 214(LDR & HDR)MIC Brachy 30 77 89 61MIS Brachy 10 29 34 20


Electron AcceleratorsElectron Accelerators

• Modern accelerators have a lot of treatment options, for example– X-rays or electrons

(dual mode)( )– multiple energies

• 3 X-ray energies• 5 or more

electron energies


Medical Linear Accelerator


Radiation TherapyRadiation Therapy


Ref: http://www.slideshare.net/santam/new-techniques-in-radiotherapy

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Radiotherapy Radiotherapy pypySimulatorSimulator


Ref: http://www.slideshare.net/santam/new-techniques-in-radiotherapy

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Gamma Stereotactic RadiosurgeryGamma Stereotactic Radiosurgery“Gamma Knife”“Gamma Knife”

• Uses numerous high-activity Cobalt-60 sealed sources whereby the radiation beams converge at a specified point of treatment.

• Used for Cerebral Tumors


Brachytherapy

Radionuclide Half-life Photon Energy (MeV) Half-value Layer (mm lead) 226Ra 1600 years 0.047 - 2.45 (0.83 ave) 8.0 222Rn 3.83 days 0.047 - 2.45 (0.83 ave) 8.0 60Co 5.26 years 1.17, 1.33 11.0 137Cs 30 0 years 0 662 5 5

The Greek word “brachy”means “short”


Cs 30.0 years 0.662 5.5192Ir 74.2 days 0.136 - 1.06 (0.38 ave) 2.5

198Au 2.7 days 0.412 2.5 125I 60.2 days 0.028 ave 0.025

103Pd 17.0 days 0.021 ave 0.008

Brachytherapy ApplicationsBrachytherapy Applications

• Surface Mould• Intracavitary• Interstitial


High Dose Rate BrachytherapyBrachy = Short

Co-60

Dose rate >12 Gy/hr

Ir-192(370 GBq)


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Endovascular BrachytherapyEndovascular Brachytherapy• uses radioactive catheters, pellets,

and stents to treat coronary and peripheral vascular problems.

• radiation can be ion implanted, plated, or encapsulated in a sealed source device attached to a guidesource device attached to a guide wire used in the angioplasty procedure.

• radioactive device can be either permanently implanted or removed via the guide wire following treatment of the effected vessel wall


Isotopes for Isotopes for endovascular endovascular brachytherapybrachytherapy

• Gamma sources: 192-Ir• Beta sources: 32-P, 90-Sr/Y, 188-Rh

(Rhenium)

Dose calculation

February 1998 August 1998

Pre-PTCA

Post-PTCA

6 Months Later


Advanced M di l LiPhasing outCs-137/Co-60

TELETHERAPY • Head complexity to handlmultiple energies and multiple modalities– different flattening

filters and scatterinfoils on a ‘carousel’

– monitor chambers– collimators

Medical Linear accelerators /Cyberknife

systems

Phasing out to based

Teletherapy

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Advantages of MRAdvantages of MRnon-invasive biochemical characterisation

particularly useful in a sensitive organ like brain

surgical resection without compromising theneurological functions can be done usingfunctional MRI

tumour response to treatment

tumour recurrence or radiation necrosis

Courtesy: Dr. Rama Jayasundar, Dept. of NMR, AIIMS, New Delhi 8383RMN, 2013RMN, [email protected]

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Courtesy: IAEARef: http://www.cyberphysics.co.uk/topics/atomic/Accelerators/Cyclotron/Cyclotron%20.htm

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PET ScanningPET Scanning• Positron Emission Tomography (PET).• Used to study physiologic and

biochemical processes within the body.• Processes studies are blood flow,

oxygen, glucose and fatty acid t b li i id t t Hmetabolism, amino acid transport, pH

and neuroreceptor densities • PET scanning is, however, in very

limited usage because of the high cost of setting up a PET department.


Positron Emission Tomography (PET)

Courtesy: IAEA 8787RMN, 2013RMN, 2013 RMN, 2013RMN, 2013 8888

Ref: http://www.sepscience.com/images//Articles/Issues/0212/Steinbach/FIG-1.jpg

Figure 5 Treatment monitoring with fluorodeoxyglucose (FDG) PET and CT in a patient with locally advanced distal esophageal cancer (arrows)

Weber WA et al. (2008) Technology Insight: novel imaging of molecular targets is an emerging area crucial to the development of targeted drugs

Nat Clin Pract Oncol 5: 44–54 doi:10.1038/ncponc0982

Permission obtained from the American Society of Clinical Oncology © Weber WA (2006) Positron emission tomography as an imaging biomarker. J Clin Oncol 24: 3282–3292

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Ref: http://cancergrace.org/cancer-101/tag/pet-scans/

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What is 3D?

Ref: www.unmc.edu

Target delineation

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What is IMRT?

IMRT stands for “Intensity Modulated Radiation Therapy”


Comparison of Conventional and IMRT Treatment Planning


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Conventional


Proven Promises of IMRT

● Dose conformity & Dose Escalation● Ability to treat complex shaped (concave or convex) structures● Sparing of critical normal structures● Differential dose intensity delivery with altered● Differential dose intensity delivery with altered fractionation

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IMRT/IGRT FLOW CHARTIMRT/IGRT FLOW CHART

Diagnosis TreatmentPlanning

TreatmentDelivery

Images: • X-ray• CT Scanner

ImmobilizationVirtual Simulation Contouring dMLC

Simulation

• Ultrasound• MRI•PET

Optimization

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INTENSITY MODULATED RADIATION THERAPY INTENSITY MODULATED RADIATION THERAPY (IMRT)(IMRT)

• Treatment delivery step and Shoot method in Siemens ARTISTE

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EPIDEPID

• Film• Camera based EPID• aSi based EPID (kV & MV)• Orthogonal images• BEV Matching

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KV XKV X--RAY ONBOARD RAY ONBOARD IMAGINGIMAGING

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Ref: Khan: The Physics of Radiation Therapy, 4th Ed. (2009), Ch. 25

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Ref: Khan: The Physics of Radiation Therapy, 4th Ed. (2009), Ch. 25

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Dose escalation & decrease of risk of side effect

3D CRTIMRT /IGRT

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RADIATION ACCIDENTS


Ref: IAEA report on “THE RADIOLOGICAL ACCIDENT IN SAMUT PRAKARN” (2002)

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Radiological Accident at Goiania


3.Radiation Protection

ICRP 85

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QAQA frequency frequency of each testof each test

Daily or

•Probability of an error occurring.•Clinical consequences of the error.

Monthly 3 or 4-Monthly

6-Monthly

Annual

yweekly

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QA test equipments..QA test equipments..

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Research Applications

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Radioisotopes + Molecular Imaging + Nanotechnology + Research Applications

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Ref: http://www.rikenresearch.riken.jp/images/figures/hi_4501.jpg

• The invaion of Scientific technology is inevitable inmedical specialties and continues to pose many challengesand issues

• Best benefits using radiation could be derived by

CONCLUSIONS

• Understanding the strengths and limitations of systems,• Proper Training /Education• Following Stringent QA procedures• Strict adherence to the Regulatory Compliance /Safety

Culture

• Bright Future is there for Scientific areas suchas General and Applied Sciences (Radiological,Biochemical, Molecular Biology, Nanoscience ++)

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Handout rmn-lecture-application of radiation-in-medicine-and-research-30-12-2013

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