Stereotactic Radiosurgery

Stereotactic radiosurgery (SRS) is the use of highly focussed radiation to treat benign (non-cancerous) or malignant (cancerous) brain tumours very precisely using a 3-D reference system (‘stereotactic’) and accurate positioning and immobilization of the head.  It is a non-invasive alternative to neurosurgery for certain brain tumours. Despite the name, radiosurgery does not involve an operation and it is typically delivered as an outpatient procedure.  Although usually administered in one large radiation dose (fraction) on one day, several or many smaller doses can sometimes instead be delivered over a few days or weeks.  If more than 5 fractions are used, the procedure is called stereotactic radiotherapy (SRT).

In South Australia, linac SRS and SRT have been available solely at the RAH since 1993, with well over 300 treatments delivered by the end of 2014.  The most common tumours treated are; acoustic neuromas (benign tumours of the nerve of balance and hearing), arterio-venous malformations (benign collections of abnormal blood vessels), brain metastases (secondary cancers that have spread to the brain from a primary cancer elsewhere in the body) and meningioma’s (benign tumours arising from the coverings of the brain).  Note that there is no cost to the patient, unlike Gamma Knife treatment in Sydney, which involves a co-payment.

Delivery of SRS and SRT requires collaboration between many disciplines (neurosurgery, radiation oncology, radiation therapy, medical physics and radiation oncology nursing), with the Royal Adelaide Hospital possessing an innovative and experience specialist group.  Patients are assessed initially and followed-up after treatment, in a weekly outpatient Radiosurgery Clinic.

Stereotactic Ablative Body Radiotherapy

Stereotactic Ablative Body Radiotherapy (SABR), otherwise known as Stereotactic Body Radiotherapy (SBRT), is the delivery of one or a few very high doses of radiation to small, well defined tumours involving the body. SABR can potentially offer a safe, non-invasive alternative to surgery (in many cases with equivalent outcomes to surgery) and is indicated in various types of primary and secondary cancer.

The Royal Adelaide Hospital was one of the first centres offering SABR in Australia, and draws upon the expertise of a multidisciplinary team of clinicians, radiation therapists, physicists and nurses.

SABR is not suitable for all cancers and will depend on factors such as overall condition of the patient, stage of disease and type of cancer. Patients are assessed in clinic and if appropriate will proceed to a meticulous planning phase followed by image guided treatment in either one session or a limited number of sessions over a few days. Your radiation oncologist will discuss with you the appropriateness of SABR and the possible side effects of treatment.

Indications for SABR can include primary cancers of the lung, liver and kidney, whilst oligometastases to the lung, liver, bone and lymph nodes may also be treated. Other areas are currently being tested also.

Brachytherapy

Brachytherapy is the use of radioactive sources which are either implanted within or positioned adjacent to the tumour. The treatment maybe invasive and require an anaesthetic. Brachytherapy sometimes requires that the source be placed permanently (low dose rate) or temporarily (high dose rate) depending on the situation and can be delivered with or without conventional external beam radiotherapy. This technique is used to treat a range of cancers including those involving the prostate, cervix, uterus, lung, oesophagus, gallbladder, anal canal and skin.

Radiotherapy for children

Childhood cancers are rare. The malignancies affecting children are often of different types and involve different organs from those diagnosed in adults. Radiation therapy plays an important part in the treatment of many childhood cancers, and is often combined with surgery, chemotherapy and/or newer targeted drug therapies.

These factors, along with the potential long-term effects of radiation therapy in children, require specialised understanding and care.

The Royal Adelaide Hospital is the only facility in South Australia to accept children and adolescents of all ages for radiation therapy, according to their specific treatment needs.

We work closely with staff at the Women’s and Children’s Hospital to provide a multidisciplinary approach to diagnosis, treatment and supportive care. We strive to deliver streamlined and individualised care for children undergoing radiation therapy as part of their cancer treatment.

The Royal Adelaide Hospital is the only radiation therapy facility in South Australia fully accredited to treat children on Children’s Oncology Group (COG) trial protocols. Our staff collaborates with other Children’s Oncology centres Australia-wide and overseas to ensure a high standard of care for children undergoing radiation therapy in South Australia.

A dedicated group of paediatric radiation oncologists, radiation therapists, nurses and allied health professionals aim to meet the specific needs of children in an adult hospital environment, and regularly seek ways to improve the care provided.

We are also the only centre in Australia to provide comparative planning services for Proton beam therapy [link to new Proton page], and have a proven track record in aiding applications for the Medical Treatment Overseas Program (MTOP). Proton treatment is currently unavailable in Australia, but we are able to provide guidance in your decision making through our collaboration with Proton Therapy centres in Europe and the US.

Intensity Modulated Radiotherapy and Volumetric Modulated Arc Therapy

Modern Radiation Therapy is a cancer treatment that uses state-of-the-art technology to deliver the best possible outcomes for patients,  both for cancer control and the reduction of side effects. An example of this is the use of Intensity Modulated Radiation Therapy (IMRT) and Volumetric Modulated Arc Therapy (VMAT), both of which are available at the Royal Adelaide Hospital.

Every patient’s anatomy and tumour location is unique, through using high-quality CT and  other diagnostic scans (such as PET scans and MRI scans) we are able to accurately locate both  tumour and  areas of normal tissue, where the radiation dose needs to be concentrated or minimised.  In many cases the tumours can be close to sensitive normal tissues, that require dose avoidance. IMRT and VMAT use the vastly increased computer power we now have to produce optimised plans to more effectively cover the tumour and reduce potential side effects to these normal tissue structures.

Before these techniques were available, a radiation beam had a uniform intensity across its entire area. Regions were within the beam or not, in effect making things “black or white”. Now we can vary the intensity of the dose within each treatment beam, essentially giving us “shades of grey”. This allows far greater control over where the dose is distributed, and completely individualized plans for patients receiving this form of therapy.

Total Body Irradiation

Total body irradiation (TBI) is used to treat blood related cancers, such as some types of leukaemia. This treatment is often given in conjunction with chemotherapy as part of the preparation for a blood stem cell or bone marrow transplant.

Typically, a course of TBI is delivered twice per day over 2-3 days, with each treatment being at least 6 hours apart. The purpose of TBI is to eradicate remaining cancer cells, suppress the immune system (to facilitate transplantation) and to treat areas of the body where chemotherapy is less penetrable.

Total Skin Electron Therapy

Total skin electron therapy (TSET) is used to treat mycosis fungoides, the most common type of cutaneous T-cell lymphoma. This involves treating the entire skin surface with low energy electron beams. Due to the physical properties of electrons, the radiation penetrates only the skin, thus sparing deeper tissues and organs. TSET is most often used in patients who are not responding to other treatments and is occasionally used in conjunction with other therapies.

Radiation Oncology Registrar Training Program 

The Royal Adelaide Hospital provides teaching as a fully accredited site on the Royal Australian and New Zealand College of Radiologists (RANZCR) Radiation Oncology training program. 

Radiation oncology registrars on this program rotate through the three hospitals in the South Australia Network including the Royal Adelaide Hospital, the Adelaide Radiotherapy Centre, and the Alan Walker Cancer Care Centre (Darwin, NT). 

Radiation oncology registrars on this program are exposed to an extensive range of conditions and treatment techniques, primarily due to the diverse range of patients consulted at the RAH. There is formal teaching in the form of regular tutorials and lectures, and informal teaching in the clinic and at the bedside. 

Radiation oncology registrars are fully supported to successfully complete all curriculum requirements and exams on the RANZCR training program. For further information on the RANZCR Training Programme please refer to the College website: www.ranzcr.edu.au or contact SA/NT Training Network Education Support Officer Julie Beaton on [email protected] or (08) 70740365.

Radiation Oncology SABR Fellowship Program 

The Royal Adelaide Hospital provides a fellowship program for registrars who have passed their final RANZCR specialist examinations. This provides an opportunity to hone their skills in particular subspecialty areas, and also to prepare them for their first consultant position. 

There is a focus on stereotactic ablative body radiotherapy (SABR) techniques including: 

• lung 
• spinal 
• liver 
• pancreatic 
• kidney / adrenal 
• lymph node

The fellowship is flexible, and there will be opportunities to be involved in other areas such as intracranial stereotactic radiosurgery, brachytherapy (prostate and gynaecological), paediatric radiation oncology, and specific other tumour sites. 

 The fellow will be expected to be involved in a research project of their choice during the fellowship. There will be opportunities for presentation of research projects at national / international meetings, publications, and the pursuit of a higher degree. 

Radiation Therapist Training Program 

The Royal Adelaide Hospital is involved with teaching Radiation Therapy students in collaboration with the University of South Australia on the Bachelor of Medical Radiation Science (Radiation Therapy).

Radiation Therapy students gain invaluable real-world experience on their clinical placements at the Royal Adelaide Hospital. 

Resident Education 

Radiation oncology is one of the rotations available in the Royal Adelaide Hospital residency program. Each rotation is for 3 months, which gives residents a chance to have some general experience in radiation oncology. This gives residents who later go on to have careers in other specialties a broader perspective on patients with cancer, and also allows residents who are considering a career in radiation oncology a chance to work in the specialty. 

There is the chance to look after inpatients, see patients in clinic, radiotherapy planning, and also a formal resident education program. 

Medical Student Education 

The department has an active role in training medical students from the University of Adelaide. Students have the chance to shadow radiation oncologists in clinic, in the wards, and at radiotherapy planning. There is also a formal medical student education program.

Background 

Radiotherapy plays an important part in the management of cancer in Australia., with half of all cancer patients requiring radiotherapy as part of their disease management. This is most commonly delivered with X-Rays, which have been used therapeutically since the late 19th century. X-ray beams are effective in delivering high doses to the tumour cells they target, but unfortunately also give some of the dose to all healthy tissues in their path. 

In the 1950s, proton beams emerged as a new option for radiotherapy. Protons are heavy charged particles and have a unique way of depositing their energy. Rather than causing damage through their whole path, they deposit most of their energy at a distinct depth before stopping completely. When protons are used for radiation therapy this effect allows the largest dose to be delivered where it is needed – in the tumour – with minimal dose and damage to the surrounding healthy tissues. 

Early clinical use of proton therapy has focused on paediatric tumours, where damage to healthy tissues can result in long term side effects and growth problems, and adult tumours of the head and neck and central nervous system areas, where tumours are adjacent to organs with distinct radiation tolerances. A comparison of radiotherapy treatment plans created using an X-ray volumetric arc therapy (VMAT) technique and intensity modulated proton therapy (IMPT) technique for a paediatric tumour of the brainstem is shown in Figure 1. The reduction of dose delivered to healthy tissues made possible with proton therapy is demonstrated.

RAH Project

While proton therapy has experienced expansion in the United States, Europe and Eastern Asia in the past two decades, there is no clinical facility operating in the Southern Hemisphere. RANZCR has endorsed that particle therapy must be available to patients in Australia and New Zealand, however at this point in time patients who will benefit from proton therapy have to travel overseas to gain access. Funding for Proton Therapy overseas is available through the Australian Medical Treatment Overseas Programme (MTOP), following referral from the RANZCR Particle Therapy Referral Committee. Comparative planning of proton and photon treatment will help ensure that the referral decision is evidence based and objective and is a pre-requisite for all funding applications.

The Royal Adelaide Hospital (RAH) team have been working on proton planning with multiple treatment planning systems since 2014, whilst gaining international experience through training and collaboration with experts in the field. The team is happy to be able to offer a national comparative planning service to assist in the decision making and referral of patients overseas for proton therapy treatment.

Aims

1. Produce photon and proton plans for comparative purposes, for patients where a clinical benefit may be predicted from protons.
2. Inform the decision making process for referral of patients overseas for proton therapy.
3. Provide evidence to support the application for government funding for overseas treatment.
4. Build proton planning experience among RAH team and collect local comparative data. 

Planning Process

Contact the RAH team via email to inform of incoming patient (see “Contacts”).

Request form can be downloaded below or can be emailed directly from a member of the RAH proton team.  Please return ASAP with required Patient history and relevant imaging reports, correspondence etc. (can be sent via email)

Transfer of DICOM data is to be done via secure transfer by following the steps provided:

• Request a SecureFile account from Raymond Dalfsen (an email will then be sent to you directly from SecureFile with your unique username/password).
• Encrypt the DICOMs using 7Zip (http://portableapps.com/apps/u...) and assign a password to the file. (A copy of 7Zip will be placed on the SecureFile server for you to download if required)
• Upload the encrypted file to SecureFile using the login information provided in Step 1.
• Email the password for decrypting the file to Raymond Dalfsen.

The SecureFile transfer process uses the same ports as web browsing, so it will not be blocked by local hospital network firewalls.

The standard turnaround time is 2 weeks from receipt of request form and DICOM data.  Shorter planning time can be negotiated at initial request if clinically required. To ensure a quick turnaround, we request that all relevant imaging is provided, as well as planning structures from the referring Radiation Oncologist.

The RAH will complete photon and proton plans as per request form or comparison can be made with a photon plan from the referring institution if this is the preferred option.

The Plan comparison will be returned as a PDF via email, with the following:

• Spreadsheet comparison of dose volume statistics
• Screenshots of Dosimetry, DVH and accumulated dose images
• Planning report from Radiation Oncologist

Ethics, Ownership of Data & Intellectual Property

Ethics approval for this project has been obtained from the Human Research Ethics Committee of the RAH.

The patients’ original radiotherapy planning data will remain the property of the requesting institution, however the RAH will retain de-identified copies in a database that may be used for research and publication purposes. The referring Radiation Oncologist is responsible for ensuring the patient’s consent.

The intellectual property created during the comparative planning process will be owned by the RAH and the requesting institution according to the relevant policies and/or procedures of these institutions.

Comparative plans are produced by the RAH to help guide clinical decision making by the radiation oncology staff of the referring institution. Plans are produced in a research environment and are not to be used for treatment. The RAH accepts no responsibility for clinical decisions or outcomes.

Contacts

• Radiation Oncologist: [email protected]
• Radiotherapy Planning: [email protected]