Xanit International Hospital

Presentation

• What is cancer all about?
• What is Radiotherapy about?
• How does radiotherapy work out?

What is cancer all about?

Cancer is the result deriving from two consecutive processes:

• The uncontrolled multiplication of a particular cell group.
• The consecutive development of an invasive capacity by such cells allowing their migration towards and colonization of other tissues and organs producing thus some metastasis.

All cancers do bear some specific characteristics and behaviours, which is why they actually turn into very different diseases. The latter being not only due to the type of cells originating it, but to the causes producing it too.

What is Radiotherapy about?

Radiotherapy is one of the treatments offered to fight cancer, together with chemotherapy, surgery, hormonotherapy, immunotherapy, and is often used as part of such a treatment, though it can be used too to cure some determined benign diseases.

It is used for approximately 70% of patients with Oncological processes during their evolution.

It makes use of high energy ionizing radiations produced by a device situated outside patients’ bodies that are directed onto the injured area. It is therefore both a local and a regional treatment.

The devices used in modern machines are called lineal accelerators and produce electrons and high energy photons.

How does radiotherapy work out?

Its working mechanism is meant to destroy all cell capacity to grow and multiply (as regards both direct and non direct NDA damage), by acting on the injured cells: the latter being more sensible to radiations and by acting on the sane cells by producing an increased recovery possibility as to the produced damage.

Radiotherapy is meant to administrate an appropriate dose onto injured cells while entailing the least possible damage for the sane ones (which is commonly known as therapeutic index).

The objectives of radiotherapeutical treatments can either be:

• RADICAL ONES: Aiming at the complete patient recovery.
• COMPLEMENTARY to surgery: The aim is a curative one, either in order to decrease the total tumoral volume before surgery (pre surgical) or either to destroy the residual disease after surgery (post-surgical).
• PALIATIVES ONES: the aim of which being to destroy tumour growth and control or lesser all possible symptoms: pain, bleeding.

 

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Available Technology

The XANIT INTERNATIONAL HOSPITAL Radiotherapy Oncology Service is part of our Hospital Oncology Institute. It is fitted with the most advanced technology for the ionizing radiation treatment of oncology patients.

• High dose rate field electron lineal Accelerator VARIAN CLINAC 2100 CD fitted.
• Image guided radiotherapy. (IGRT)
• Radio-surgery
• High dose rate brachytherapy. 20 channels Ir 192 VARISOURCE 200
• Prostate Radiotherapy
• 3 Dimension Planification Systems
• VARIS vision/version 7

High dose rate field electron lineal Accelerator VARIAN CLINAC 2100 CD fitted with:

• 6 to 18 MV photons.
• Electrons: 6, 9, 12, 16 and 20 MeV
• Dynamic wedges.
• Multiple Load-cell Counting scale for máximum field of MLC 120.
• Laser Guard Collision detection system.
• Automatic Field Sequency programme (AFS).
• Dynamic MLC (Sliding Windows IMRT).
• Amorphous.Silicon portal vision.

Image guided radiotherapy. (IGRT)

• Image System and dosimetric control with non silicon sensors.
• Image System with positioning control system "On Board Imaging" OBI.
• Movements controlling system for treated organs by "Cone Beam".

Radio-surgery

• "Frameless" system: non invasive method for radio surgery.
• Positioning control system with guided cameras, "Radio Cameras™ Treatment Guidance System".

High dose rate brachytherapy

• 20 channels Ir 192 VARISOURCE 2000

 

Prostate Radiotherapy with permanent I-125 implant.

• RAPID Strand Seeds.

3 Dimension Planification Systems

• External radiotherapy: “Eclipse Planning workstation”.
• Intensity-modulated radiation therapy: "Helios Planning workstation".
• High Dose Rate braquitherapy: "BrachyVision planning.
• Radiosurgery: "Fastplan Planning and InMerge Systems".
• Prostate brachytherapy with permanent implants: "3D PCRT Planning station".

VARIS vision/version 7: Computer-controlled conformal radiotherapy system.

Our team with medical and technical specialists and physicians is a highly qualified one as to that most advanced technology and helps bettering the curation index while lowering the usual side effects of conventional radiotherapy.

 

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Treatment possibilities

• TAC/TAC, CT-PET/TAC and TAC/RMN Virtual simulator
• Intensity Modulated Radiation therapy (IMRT)
• Intracranial and extra cranial Fractionated stereo tactic radio-surgery and radiotherapy with Frameless system
• Image Guided Radio Therapy (IGRT)
• Brachytherapy

TAC/TAC, CT-PET/TAC and TAC/RMN Virtual simulator

It is necessary for the TAC to be carried out, to have the patient being positioned in a determined way, which shall be the same one all over the treatment. The TAC images are computerized on an "Eclipse Planificator" PC where the areas to be treated and the affected organs are marked. With such a PC (planning station) both the radiation beams and the beam intensity can be modulated and the volumes of the marked areas can be reconstructed.

The same computer programme is fitted with some reconstructed digital x-rays which are virtual ones and which reproduce the image of the treatment field that would be formed by the photon beam should a real x-ray session be done.

It is usually necessary to tattoo some reference points on patients’ skin for the daily treatment machine to be positioned most exactly the same way all over the treatment period of time.

The simulation CAT is carried out in the CT-PET, which allows us to mix up images.

Small laser-marking of skin tattoos for the daily positioning during patient treatment.

Treatment field digital imaging processing.

Intensity Modulated Radiation therapy (IMRT)

It is a new advanced and highly precise radiotherapy modality.

The irradiation field is designed to be adapted (conformed) to the three dimensional tumor shape, using a geometry modulation and the energetic intensity modulation of the radiation beam.

Such an advanced treatment modality is meant to administrate a major radiation dose in the tumor and to reduce then the irradiation of sane adjacent tissues.

The IMRT is today used in prostate, head and neck, breast, tyroid and lung cancer and in gynaecologic, liver, cerebral an sarcoma tumors.

Intracranial and extra cranial Fractionated stereo tactic radio-surgery and radiotherapy with Frameless system.

It is a most advanced system for treatment with radiation using a stereotactic device to immobilize some treatment areas.

Radio-surgery means focused radiation beams are delivered in one session to a specific area of the brain to treat a tumor or arterio-venous disorders (AVM). Though it is considered as a “surgical” technique, there is no scar and it is performed on a day hospital basis, with few complications and with the same post operatory as would entail any conventional surgery.

Radiation beams are used to erase or either stop the growth of the tumor cells. Radiation beams used for AVM cause the vessels to thicken and close off.

Radio-surgery enables to irradiate an intracranial tumor or an AVM more precisely than the conventional radiotherapy would do. Stereotactic radiotherapy is allowing the same dose of radiation (or superior one) to be administrated compared to conventional radiotherapy, but it is administrated in fractionated dose over a period of time. By fractioning the dose, sane tissues located around the tumor most especially the optic and brain stem areas, are being repaired quicker.

The most unpleasant side effect of such a treatment being patient immobilization during treatment.

A highly precise Video Guidance System is used to get the patient positioned for radio-surgery treatment tri-dimensional images to be obtained during the treatment and thus to allow any sub-millimeter correction in patient position when necessary.

Radio-surgery is appropriate for benign tumors, arterio-venous disorders, functional pathology and in some cases for malignous tumors during a complementary treatment.

Fractionated stereotactic radio-surgery is indicated for

• Spinal tumor. Metastasis. Intracranial tumors.
• Chest tumors: metastasis, recurrent tumor or small primary tumor.
• Liver: hematomas and metastasis.
• Pelvic area: recurrent prostatic tumor.
• Retroperitoneal area: suprarenal gland cancer and pancreas metastasis, para-aortic adenopathies.

Patient immobilization during fractionated stereotactic radiotherapy.

CT/MR fusion for cranial tumor treatment

Image Guided Radio Therapy (IGRT)

It is a new technique used to control radiation treatments.

The Variam Medical Systems On-Board Imagen TM (OBI) is meant to produce high quality radiographic, fluoroscopic and computerized tomography TC images, after processing X-ray images and three dimension images to reflect with an excellent contrast the tumor and the healthy adjacent tissues.

The OBI system enables us to compare minouciously the irradiation field in real time (since the patient is under treatment at that very moment) and the irradiation field designed by the computer.

The sofware can calculate how to move the patient in order both images to be superposed.

Some modifications due to deviations can thus be made immediately:

• Patient positioning.
• Due to the very movements of the organ where the tumor is located.
• Tumoral size changes due to the treatment.

The patient is installed on the examination table for a treatment controlling CAT to be done

Brachytherapy

Brachytherapy is a kind of therapy using radiation in cancer treatment. Radiotherapy usually useds an energy type called ionizing radiation to destroy all cancerous cells.

While the external beam radiotherapy (EBT) uses high dose x ray beams produced by the Electron Lineal Accelerator ELA and are pointed to the tumor from outside the body, brachytherapy is inserting a radioactive substance directly inside the very body.

Brachytherpy is often called internal radiation therapy and allows the specialist to use a higher dose to treat a smaller area in a lesser time than is usually necessary with the external radiation treatment.

The objective being the same: to conform the radiation dose to tumor volumes and to limit the side effects since no adjacent healthy tissues are damaged. "Brachytherapy has been fully successful for prostate, gynecolocic, breast and many other types of cancers.

Brachytherapy is used to treat all types of cancer including those located in:

• Prostate
• Cervix
• Head and neck
• Ovary
• Breast
• Gall blader
• Uterus
• Vagina

Brachytherapy can either be temporal or permanent:

Temporal brachytherapy is using radioactive material inside or around a tumor for a particular laps of time and then is stopped.

Permanent brachytherapy is often called seeds implantation, because radioactive seeds are implanted permanently inside or around the very tumour, their radioactivity disappearing progressively. The seeds stay inside the body without any other effects on patients' health.

TEMPORAL BRACHYTHERAPY

High dose brachytherapy is administrating high density radiation directly onto malignous tumors by means of very thin needles inserted with the help of computer control afterloading equipments that move, according to a previously established treatment plan, the radiation source in a cable present inside the needle. The total dose is administrated during various injections or treatment sessions. We usually use for cervix and endometrial cancer smaller titanium loaders easier to visualize on magnetic resonance processed and CT images during the installation and treatment process, and are furthermore, more confortable for the patient during therapy duration.

PERMANENT BRACHYTHERAPY

The use of such a technique either alone or combined with radiotherapy external beams is growing quite fast since more than 60.000 patients are using it every year in the United States, a third of them diagnosticated with prostate cancer.

What is Prostatic Brachytherapy?

It is a therapeutical procedure implanting radioactive isotopes inside the prostate area only (target tumoral volume) and meant to administrate a high dose radiation in a concrete or very delimitated and previously defined with x-rays volume, allowing a anti-tumor dose to be injected against the prostate and protecting the immediately adjacent structures (rectum and bladder) from dispersed damaging radiation.

The prescribed dose, defined as therapeutical dose, is referred to as an isodose line linking the criteria englobing the wholeprostatic target tumoral volume and avoiding unacceptable non homogeneous distribution of such dosis inside it, while considering the maximum acceptable dose the most important radio sensitive adjacent structures can and must receive (ureter, rectum and bladder). Such a procedure stage is a simulation and dosification one and is realized by using a complex and sophisticated computerized system, with the help of a specialized radio physician, radiotheraperapy and urology specialists, acting as key assets for the implant collocation and the definite success of the treatment.

Prostatic brachytherapy is a kind of local radiotherapy which allows the dosis administration at a short distance by means of radioactive material (iodine -125) sources (seeds) collocation and insertion which are permanently installed in the tumoral prostate with the help of previously charged radioactive isotope needles inserted through the perinal skin, under radiologic control (transrectal prostatic echography) under regional anesthesia procedure. It is an alternative treatment to the prostatic radical surgery (Radical Prostatectomy).

Radical Prostatectomy is the excision procedure of the prostate and part of the tissues around it (seminal vesicules and regional ganglions). It can only be carried out when cancer has not yet extended to other tissues around it (T1 and T2 stages). The principal side effects of such a prostatic excision being impotence (incapacity to have or to maintain the erectile function) and the urinary incontinence (ureter urine escapes while doing some efforts). Such complications are to be taken into account since prostatic carcinoma is more and more diagnosticated and operated amoung young patients with a life expectancy of 15 years or more, meaning thus an important deterioration of their quality of life.

The Biomedical Business International Newsletter, American Cáncer Society and Godsey & Associates, declared that in 1995, in the EEUU, more than 6.000 patients were treated with brachytherapy which is more than 4% of the prostatic localized carcinomas. In 2000, the treatement number ascended to 40.000, and in 2005 to 110.000 which means 36% of the newly diagnosticated intra-prostatic localized cases.

The increase of brachytherapy acceptation is due to:

• The experience developed and the good results obtained during almost 15 years, together with the development of the transrectal echography and the incorporation of new and sophisticated computer systems and dosimetry programs bettering the implantation technique and the irradiation doses distribution (of which we shall speak later on).
• It is only necessary to be taken as an in patient for 24 hours, the patient recovery being quite rapid and a minimum immediate and late mortality (due to seeds implantation) being observed. One cannot forget that the prevalent treatment up to the present date which was the radical surgert entails major complication risks (impotence and incontinence) and the hospital stay is usually longer.

The only disadvantage being that of no precise histological information being recollected to corroborate the exact pathological situation (anathomical study) which is sometimes different from the previously established staging. Such an information obtained with surgery (radical prostatectomy with regional lymphadectomy) allows to establish a more precise prognostic.

We usually use the radioactive iodine -125 (125I) isotope with seeds shape and covered with a titanium capsule. Is is recommended to use 125I for either very or moderately differenced cells, with a low growth rate. The very Iodine 125 isotope characteristics make it possible for both the patients and his family to get minimum and not incapacitating at all radio protection measures. The excretions, clothes and tools used are not contaminated, not radioactive.

 

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Patient information

• How is radiotherapy administrated?
• Will I become radioactive after radiotherapy?
• Who will administrate my radiotherapy?
• Shall I get side effects with radiotherapy treatments?

How is radiotherapy administrated?

The radiotherapy treatment can be administrated either in a sole dose (one day of treatment) or in various doses (various days of treatment).

The total session number is usually in accordance with the total dose that will need be administrated according to the protocol.

Treatment duration is generally from 3 to 6 weeks long, with one session per day. Every seesion lasts between 5 to 10 minutes though it can be longer when special techniques need to be used for the treatment.

Will I become radioactive after radiotherapy?

You will not become radioactive after receiving radiotherapy, so do not bother about it; Your presence will not become dangerous for your family and friends.

Who will administrate my radiotherapy?

A coordinated team will work all together to administrate your radiotherapy. The medical staff is headed by an Oncologist Specialixed in Radiotherapy. From her onwards, we will refer to him as "your specialist".

The radiotherapy nurse is working closely with the specialist in order to give you all the attention you deserve during your treatment.

The technician is in charge of the application of the indicated treatment, and he will be able to attend you before, during and after the treatment.

The radiophysician is in charge of the necessary doses to be calculated in order to design your treatment and to control all necessary treatment units.

Shall I get side effects with radiotherapy treatments?

It all depends on the body areas onto which the treatment is being applied. Most side effects usually disappear 2 to 3 weeks after the end of the treatment.

Such effects do not necessarily arise for all patients since it depends on the administrated dose, the body area treated and physical and emotional state of the patient.

Some side effects of the treatment are:

• The skin of the treated area might become bumpy and red, mostly like a sun burnt sensation. It usually fades away alter 4 weeks of radiotherapy treatment. You shall be attended, before starting your treatment, by the nursing department and you will be given all the information as regards necessary skin care during such a treatment and as regards the most efficient creams and skin products.
• You might feel tired, more than usually tired. Try to avoid unnecessary tiredness and to get all the sleep you need. Do not over-busy yourself.
• Some swallowing uneasiness usually appears alter the first two weeks of treatment when having the neck or mouth area treated.
• You will probably feel low appetite. This a most common side effect when the abdomen or the stomach area is part of the treated area. If so, you will find it easier when getting small amounts of food during the day, instead of having three big meals. The nutritionist might be a good adviser during your treatment.
• You might loose your hair, which will occasionally only occur in the treated area.
• When getting side effects, please do inform your specialist or nurse.

Side effects mainly depend on the irradiated area location:

• Head and neck treatment:
• Red colour of the treated area
• Skin desquamation.
• Localized loss of hair or body hair.
• Mucous membrane ulcers (inner part of cheeks, tongue or gums).
• Dryness of the mouth.
• Throat irritation when having some acid, spicy or salted food.
• Swallowing uneasiness.
• Loss of taste, bad taste sensation (metallic taste in the mouth).
• Central nervous system treatment:
• Headaches
• Alopecia (Hair loss)
• Nauseas
• Vomiting.
• Dizziness
• Sleepiness, concentration problems.
• Giddiness.
• Thoracic area treatment:
• Red colour of the treated area
• Skin desquamation, irritation or sores.
• Pain while swallowing food.
• Irritative coughing.
• Abdominal Area treatment.
• Nauseas
• Vomiting
• Heartburn.
• Colics.
• Pelvis Area treatment.
• Abdominal pain (stomach cramps, spasms…)
• Diarrhoeas
• Vaginal pain.
• Pain while urinating.
• Anal pain.
• Defecation Sensation increase.

How shall I care about my skin during the radiotherapy treatment?

Keep on your skin marks till the end of the treatment. A member of the specialist team shall tell you when to get rid of them.

Rinse out the treated area with warm water but do not scrub it.

Try to avoid perfume, deodorant, alcohol, oxygenated water, antiseptic solutions, creams, lotions, etc on the treated area since they all contain substances that might react with the irradiation. Your specialist will tell you the products to be used during the treatment.

When having treatment in the thoracic area, do not use bras with iron structures nor fillings since they tend to increase skin irritation. Avoid tight lycra, rough fabrics, nylon ones or anything that might damage your skin. Use 100% cotton made fabrics. Do not depilate your armpit on the treated side.

Do not have any heat on the treated area, nor any sun bathing on it.

When feeling your skin is itching in the treated area, do not rub it. When feeling it has become an important problem, do tell so to your specialist.

When treatment is carried out on the face or neck, do not shave such an area with a razor blade.

Use an electrical blade and do not graze your skin off. Ask your specialist or your nurse before shaving the treated area.

What shall I do when feeling tired?

It is probably the most extended effect of the radiotherapy treatments. Tiredness will not only and exclusively make you feel physically tired, but might show itself too like some concentration difficulty or like you being unable to carry out some intellectual or physical tasks you were able to do normally before.

Tiredness motives are actually quite unknown and it can be shown in very different degrees. It generally depends on such factors as age, gender, treatment duration, nutrition, etc..

The following advice will contribute to better your life when getting such a side effect:

• Have some planned diary rest.
• Try to organize your activities so that you shall carry them out when feeling more relaxed during the day, or after having some effective rest.
• Inactivity will not help you bettering your health. So try to have some moderate sport activity regularly, have, for example some swimming, or walking…

When will the side effect stop?

Side effect will gradually disappear some weeks alter the end of the treatment.

You will be able to get some information about the radiation type you will receive, including how to control side effects in your particular case, and what to do when other problems arise.

Shall I be able to get sexual relations?

You will not be radioactive in anyway. You shall be able to get sexual relations when feeling at ease with it since there is no radiation nor cancer risk for your partner.

It is of importance for you to take the necessary steps to avoid any pregnancy during such a radiation treatment. Ask your specialist before taking any hormones or contraceptives and when thinking of getting pregnant once the treatment is over.

Any other advice during my treatment?

Having some equilibrated diet. Have some food from the following groups on a daily basis:

• Bread and cereals.
• Meat, Fish, eggs and dried legumes.
• Milk or derived products.
• Vegetables and fruits.

You will need be eating enough to keep on your normal weight; your caloric needs will be higher at this particular stage, and it is thus possible that you ate more than usual. The nutritionist might be of help to plan your diet. Tell your specialist when gaining or losing more than 1 kg a week.

Have enough liquids. Try to drink at least 2 to 3 litres a day. Such liquids being either: jellies, fruit ice creams, juice, infusions, soups or milk. When noticing you are losing weight, try to have higher caloric liquids.

You can have some exercise, but do rest as much as possible. You shall be able to carry on with your normal activities providing you do not tire yourself out, and give yourself some resting time.

Your specialist will tell you the type and the amount of appropriate activity for your daily life. Try to have at least six hours sleep at night time and some rest during the day.

What shall I do about my medicine?

When taking some medicines, do tell your specialist about it.

He/she will take into account your treatment and will tell you which are the medicines you can keep on having during the therapy. When in need of other medicines, you will be told so by your specialist in due time.

Shall I need to change my life style?

The treatment you will need to undergo will not entail you to be locked in nor isolated in any way.

Our aim in the present document is to give you some advice to ease your adaptation to the new situation, however, we do relieve it to be advisable for you to change your habits and activities only when considering it to be necessary; try to carry on your usual family, social and including your professional life with the maximum normality. It will be of help to you.

Who shall I ask for when in need of additional information?

The members of our radiotherapy specialist team will be able to offer you, with your help, the best possible care. When needing to ask something about your care, please do speak with your specialist.

 

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Radiotherapy team of professionals

Radiotherapy treatment team is componed of the following experienced professionals:

• Onclogy radiotherapists: they are oncology specialized doctors in charge of both the treatment prescription, its planification and patient’s supervision and control.
• Physician specialist: He is in charge in the radiotherapy department of the estimation methods, quality control and good dosification functions of machines. He revises all complex treatments. In Spain, they are often called "Hospitalarian Radiofisicians".
• Superior Radiotherapy technician: Such persons are specialist in charge of the radiotherapeutic treatments and in machine handling. They carry on the daily prescribed treatment and take care the patient is well attended by the medical staff.
• Nurses: Their function is considered as of growing importance since there are more and more radiochemotherapy concomitant treatments, more prophylactic medications given to the patient either intravenuously, intramuscularly, subcutaneuously, etc..before the daily session. Brachytherapy is more and more linked to the localization of tumors which is why the role played by nursing in the operating theatres is essential.
• Nurse assistants, office-workers, secretaries: They are in charge of patient care during the consultation, appointments, reports, etc..

 

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