Radiation Oncology
Treatment Facilities & Procedures
Brachytherapy
High Dose Rate (HDR)
From 2000, South Australians were able to access HDR brachytherapy treatments for a limited number of sites in the body instead of having to travel interstate.
Like any form of brachytherapy, the HDR Unit enables high doses of radiation to be delivered to the tumour and its immediate proximity with sparing of surrounding normal tissues. The radiation source, which is located in a thin catheter either implanted directly into the tumour or into a body cavity, delivers the radiation dose in a matter of minutes (as opposed to many hours with conventional low dose rate brachytherapy systems) with a much greater degree of accuracy and safety than before. This has been made possible by modern imaging techniques and advanced 3D treatment planning systems to optimise the positioning of the radioactive source and to determine the duration of source placement. Departmental staff were sent overseas to the USA and UK for specialist training in these techniques.
Currently, the regions being treated include the bronchus, oesophagus, extra-hepatic bile ducts, selected gynaecological and head and neck sites. HDR prostate brachytherapy has been implemented in April 2006, under the mentorship of Dr Alvaro Martinez, a world renowned specialist from the William Beaumont Hospital, USA. However, this is limited to 1 patient a month until more staff resources become available for a minimum of 2 cases a month.
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Photo Shows: Rt: Dr Raghu Gowda with a patient (seated on treatment couch) in the HDR Brachytherapy Suite.
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Low Dose Rate (LDR) Iodine Seed Prostate Brachytherapy
Funding for Prostate LDR iodine seed prostate brachytherapy has been increased to 48 public patients for 2006/2007 financial year, from 26 cases since 2004/2005. Since implementation from Sept 2004 to Dec 2006, 100 patients had benefited. With this experience and competence behind them, the brachytherapy team is confidently planning to do real-time ‘live’ procedures in April 2007. This will save the patient a visit and a second anaesthetic procedure.
ADAC Pinnacle 3-D Radiotherapy Planning System
The acquisition and commissioning of the ADAC Pinnacle 3-D Radiotherapy Planning system in 2000 has enabled the department to utilise advanced imaging information (e.g. CT and MRI Images) to localise tumours within the body along with critical organ structures and accurately plan the delivery of high dose radiation like never before.
The RAH is also now able to utilise functional imaging techniques such as PET scanning to identify metabolically active tumour and in the future also hypoxic areas within tumours not able to be detected by current (anatomical) imaging techniques such as CT and MRI scans. These PET scans are performed on-site in the Nuclear Medicine Department of the RAH (the only PET Scanner in SA) and can now be directly downloaded to the ADAC Pinnacle 3-D planning system in the Radiation Oncology Department.
The first planning system of its type in South Australia, the ADAC Pinnacle radiotherapy software enables the patient's anatomy and radiotherapy dose plan to be visualised and calculated in 3 dimensions. This allows the department's specialist staff to individually plan each patient's treatment to a high degree of precision and accuracy.
Radiotherapy treatment planning utilising the ADAC Pinnacle 3-D Radiotherapy Planning System |
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Three Dimensional Conformal Radiation Therapy
For a number of years, radiation therapy has been delivered by a linear accelerator using 2-Dimensional planning. 3-Dimensional Conformal Radiotherapy (3-D CRT) is a new technique that utilizes 3-Dimensional planning and offers the Radiation Oncologist the ability to treat a region that conforms or matches to the precise shape of the tumour volume in 3 dimensions.
Much attention has been given to the use of 3-D CRT in the treatment of a number of anatomical sites over the last ten years in particular in the United States and Western Europe. 3-D CRT has been reported to decrease toxicity in single institutional, multi-institutional randomised studies by reducing the dose delivered to adjacent normal tissues without compromising target coverage in such sites as the prostate gland, head and neck, lung, liver and pancreas. It has also been extensively utilised in the management of paediatric tumours particularly those arising in the brain and other cancers such as soft tissue sarcomas. This technique has led to radiation dose escalation studies in a number of anatomical sites such as prostate, lung and liver. Recent publications report an improvement in disease free survival for instance in prostate cancer, with follow up of around 8 years.
Under the auspices of the Radiation Oncology Department Steering Committee, this treatment technique has been introduced in the RAH. The first patients were treated in mid 2000. Multiple sites have been treated in this manner including the prostate gland, pancreas, liver, lung, head and neck, and brain (adults and children), and also rhabdomyosarcoma in children. The introduction of this technique necessitated a review of the planning system within the Radiation Oncology Department. This involved the purchasing of a new radiotherapy planning system (ADAC Pinnacle) and the addition of 2 state of the art linear accelerators, at the time not available elsewhere in Australia. Several members of the staff have and are undergoing training specific to this new technique. The Department is currently reviewing its immobilisation technique aiming to avoid both random and non-random errors. Following this review, radiation dose escalation will be considered for a limited number of tumour sites during the late 2003.
Dedicated Panning CT Simulator
A large bore CT scanner was commissioned into clinical use in October 2002. This enables previously inaccessible sites such as the breast to be planned to a higher degree of precision and accuracy on the ADAC Pinnacle 3-D Radiotherapy Planning System and for 3D-CRT to be implemented. The department has been one of the first in Australia to implement 3-D CRT of breast cancer. This should lead to better patient outcomes through more accurate placement of radiation beams to the tumour bearing breast whilst reducing the amount of lung and particularly the heart within the path of the radiation beam fields by the Linear Accelerator.
Digital Image Processing
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Rt: Ms Judith Matthewson processing a digital image of a patient’s treatment area, acquired on the Linear Accelerator, to check accurate placement of the radiation field. Digital image processing, implemented in Oct 2004, after its integration into the Varis Vision 8, enables the processed image to be checked against the planned image through the computer network. The improved streamlining, better image quality and software to detect treatment set-up variations has provided staff with the capacity to make decisions about accurate field placement more confidently and expeditiously. An electronic copy of the image and record of any adjustments is kept for statistical analysis and reflects the inexorable progress towards paperless/electronic records. |
Radiosurgery Unit
Radiosurgery is the treatment of small benign and malignant tumours using highly focused radiation localized by stereotactic technology. There are currently 9 linear accelerator based units in Australia and New Zealand. The RAH system commenced operation in November 1993 and since that time 170 patients have been treated:
| Acoustic neuroma | = | 65 |
| Arterio-venous malformation | = | 60 |
| Brain metastasis | = | 23 |
| Meningioma | = | 14 |
| Others | = | 8 |
Radiosurgery is labour intensive, requiring coordinated input from multiple disciplines (neurosurgery, radiation oncology, radiology, radiation physics, radiation therapy and nursing).
Single treatments (‘stereotactic radiosurgery’) are planned and delivered during the course of one working day. Multiple or fractionated treatments (‘stereotactic radiotherapy’) require the use of a relocatable head fixation device over several days to several weeks - this was instituted at the RAH in 2001.
A review of the first 4½ years' experience at the RAH was recently published in Australasian Radiology (2000;44:185-92). This confirmed outcome at the RAH within the range reported in the world literature. Another analysis is planned during 2002.
Paediatric Radiotherapy
The Department of Radiation Oncology at the RAH takes the responsibility for treating all childhood malignancies requiring radiotherapy in South Australia. The department has a close affiliation with the Women's and Children's Hospital which includes combined oncology clinics involving Radiation Oncologists from the RAH.
The RAH prides itself on the coordination of service required to look after children with cancer. A complicating factor associated with the treatment of paediatric patients is the occasional need to anaesthetize patients on a daily basis to accurately maintain a reproducible treatment position. An information booklet has also been produced by the Department specifically for children who are to receive radiotherapy.
The need for highly accurate planning and delivery of treatment, along with issues associated with daily anesthetics and the special emotional considerations relating to childhood cancer make this highly specialized field of radiation therapy a rewarding challenge for the team at the RAH.
Clinical Outreach Activities
The Department of Radiation Oncology is very active in providing clinical outreach services both within metropolitan Adelaide and in rural and remote regions.
There is a regular RAH Radiation Oncology service at all of the major public hospitals in Adelaide along with Ashford Community Hospital, Calvary Private Hospital and Burnside Hospital. Darwin, Mt Gambier, Pt Lincoln and Broken Hill also have regular Radiation Oncology clinics to which patients can be referred for radiotherapy treatment consultation. Northern Territory patients can now benefit from having their radiotherapy planning scans done on-site in Darwin with these images being transferred electronically to the RAH in Adelaide. This unique process can save a significant amount of time for the patient and also allow the patient to stay at home and arrive in Adelaide only when their treatment is ready to start.
Quality Assurance/Patient Care
The Department of Radiation Oncology at the RAH prides itself on the quality of treatment and care delivered to each patient. Due to the technical and highly specialised nature of radiation oncology, the need to incorporate regular radiation beam testing and quality assurance procedures is vital. The RAH has a specialist physics and radiation engineering team dedicated to the assurance of high quality and safe radiotherapy.
Apart from technical quality assurance, the RAH is committed to providing the best possible patient care. The Department has a regular QA program for treatment documentation and clinical audit via a multidisciplinary chart round. Radiation Oncologists (cancer specialist doctors), Radiation Therapists (radiotherapy planning and treatment staff) and radiation therapy nurses strive to optimise not only the radiotherapy treatment but also the service and general medical care required for each individual patient.