You are on page 1of 7

Application of Gamma Rays in Medicine

RADIOTHERAPY
Introduction
Nuclear and isotope techniques are widely used in numerous areas of human
activity and for more than century have prominent application in different
areas including medicine. This paper focuses on radiotherapy which is one of
the applications of gamma rays in medicine.
To start with, a brief understanding of gamma rays should be known first,
including properties and sources of gamma rays. Without an understanding
of gamma rays, the working principle of radiotherapy could not be
demonstrated clearly.
An introduction of radiotherapy is then followed before I go into the details of
the two main approaches in radiotherapy: external beam radiation therapy
and brachytherapy.

Brief Ideas of Gamma Rays


Both gamma radiation and X-rays are highly penetrating EM waves. But
gamma radiation has higher frequencies and energy. It is more dangerous
than X-rays. Each gamma ray is a photon that is emitted from the nucleus of
an atom when the nucleus comes down from an excited state that results
from some kind of decay event. Gamma rays are similar to x-rays, in that
they are still photons, but x-rays come from a similar step down in the
electron cloud (Gilmore, 2008).

Properties of Gamma Rays


1.
2.
3.
4.

High frequency EM waves


No charge
Very weak ionizing power
Very high penetrating power, never fully absorbed, halved by 25-mm
lead
5. Range in air is over 100m
6. No defection in electric and magnetic field
7. Detectors:
a. Photographic film
b. Diffusion cloud chamber (scattered and hardly seen tracks)
c. G-M counter

Sources of Gamma Rays


Gamma rays can be sorted into two categories by their sources, namely
terrestrial gamma rays and cosmic gamma rays. The former are those
generated on Earth while the latter are those produced by nuclear fusion
reactions that occur within the core of stars, like the sun. However, we can
only observe terrestrial gamma rays here because cosmic gamma rays are
absorbed by the ozone layer before reaching the surface of Earth. The only
way to detect cosmic gamma rays is to launch a satellite-observatory into
space.

Radiotherapy
Radiation therapy is the treatment modality of malignant and benign
diseases, by means of ionizing radiation. Since a wide spectrum of ionizing
radiation is known nowadays, available technological solutions which use
these sources of radiation, are also numerous. There are two major
approaches in radiation therapy: external beam radiation therapy (also
known as teletherapy), where the ionizing radiation comes from external
source outside the body of the patient, and brachytherapy, where the source
of radiation is placed inside the patient, inside the tumor, or in its close
proximity.
The use of radionuclides in the treatment of diseases is long more than a
century, starting with observation of P. Curie that a radium source in direct
contact with skin causes burns. The first application of radium-226, as sealed
sources in radiotherapy occurred in 1915, but this method was abounded in
the middle of the twentieth century, when reactor isotopes (as cobalt)
remote manipulation became available (Magill, 2005). One of the most
important applications of radionuclides in radiotherapy is based on the use of
sealed radiation sources for external beam therapy, the use of implants for
the treatment of prostate cancer, intravascular radiotherapy and use of
radiopharmaceuticals for therapeutic purposes. In addition to these methods,
rapid development and implementation of a wide range of new and effective
techniques, such as radioimmunotherapy and ion beams is expected in near
future (John, 1983).

External Beam Radiotherapy


In external beam radiotherapy, where radiation is delivered from outside the
body, photon energies of millions of electron volts are required to penetrate
the tissue and reach the tumors inside the body. This technique has been
applied to patients just after the invention of x-rays, by kilovoltage x-ray
units (Podgorsak, 2006). Immensely rapid development of high energy gamma

and x- ray treatment started by introduction of cobalt-60 teletherapy in the


1950s and soon after with construction and development of first medical
linear accelerators. In addition to x-ray megavoltage modality, linear
accelerators are capable to provide electron beam treatments, both with a
wide range of energies (Podgorsak, 2005). In countries where facilities for the
maintenance of linear accelerators are lacking, cobalt therapy may be the
most appropriate choice for radiotherapy.
In external beam radiotherapy, the dose of ionizing radiation is provided by
radiation sources outside the body, using photons or electrons of energies of
several MeV, which is sufficient for the penetration of radiation to tumor sites
in the body. A source of radiation in external radiotherapy is mainly cobalt-60
or linear accelerators. Basic components of teletherapy machines are:
a) Gantry with stand, which houses the source of radiation and beam
collimating system;
b) Patient treatment table; and
c) Control console in the radiotherapy control room.
The therapeutic beam at cobalt machines is produced continuously, by beta
decay of radioactive source, placed in the gantry of the machine. The result
of the beta decay is excited nuclei that emits gamma rays and achieves
ground state.
Physical form of source is a metallic cylinder-shaped capsule with a length
and diameter of 2 cm. The main features of radioisotopes used for clinical
therapeutic beams are: high energy of emitted gamma radiation (energies of
1.17 MeV and 1.33 MeV), high specific activity, enabling production of small
radiation sources (specific activity of 10 15 Bq/kg or higher) and relatively
long half-life. The later property provides replacement periods of
approximately 5 years that corresponds to one half-life.
Accurate dose delivery to the target volume is of the main interest of modern
radiotherapy. During treatment, the therapeutic beam is shaped by the
collimation system, to a size of 5 cm x 5 cm up to 35 cm x 35 cm, at the
distance of 80 cm from the center of the source. Overall accuracy in tumor
dose delivery is recommended by ICRU (Bikit, 2013) and should be within
5%, based on evaluation of errors in dose delivery in a clinical environment.
To ensure quality of treatment, acceptance test, commissioning, and
calibration of a clinical beam must be performed at installation. This process
provides information on radiation output of the machine, which is a dose rate
at reference depth at certain point in a water phantom for a nominal source
to skin distance and reference conditions (reference field size, reference
temperature and air pressure, etc) (Podgorsak, 2005). Calibration of both
electron and photon beams require an accurate dosimetric system, capable

of measuring the dose deposited in a sensitive volume. The procedure for


calibration of a clinical photon beam is recommended by a number of
internationally recognized organizations as the American Association of
Physicists in Medicine (AAPM), Institution of Physics and Engineering in
Medicine and Biology (IPEMB) (UK), Deutsches Institut fr Normung (DIN)
(Germany), Nederlandse Commissie voor Stralingsdosimetrie (NCS) and
Nordic Association of Clinical Physics (NACP) (Scandinavia), or by
international bodies such as the IAEA (Bikit, 2013). This procedure ensures
accuracy and a high level of consistency in dose assessment in different
radiotherapy centers.
Accuracy in dose delivery also requires careful treatment planning. This
process is rather complex and involves numerous steps, consisting of beam
characterization, patient data acquisition, generation of a treatment plan and
transfer of the plan to the treatment machine, verification of a patient
treatment plan and careful positioning of the patient at the treatment unit,
and finally, treatment of the patient (Levitt, 2006). With modern
computerized treatment planning systems that have advanced capabilities of
beam shape generation, dose distribution calculation and minimization of
dose to normal tissues, patient anatomy is represented as a 3D model based
on CT slices generated during patient preparation. There are also other
imaging modalities used in treatment planning, for better visualization of
tumor tissues, in a process called image registration and fusion, such as MRI,
PET, ultrasound, SPECT.

Brachytherapy
Hundreds of thousands of patients each year is referred to brachytherapy
treatments (in the Greek language brachys means close). In this technique, a
sealed source of radiation is introduced into the body cavity or tissue and its
proximity to the tumor, provides the necessary dose for the tumor and
minimal dose to the surrounding healthy tissue. The radiation of
radionuclides is usually of moderate energy gamma radiation, which allows
homogeneous irradiation of the target and simultaneous protection of normal
tissue. Radiation sources usually have a high specific activity and small size.
With brachytherapy implants, it is possible to achieve successful treatment
with very low energy photons (20 keV, palladium). Common sources include
gamma-emitting radionuclides (iridium-192, cesium-137, iodine-125,
palladium-103) whose radiation has a range of the order of cm in tissues.
Shorter ranges, of order of mm, are achieved using beta-emitting
radionuclides such as strontium-90, rhenium-188 and phosphorus-32 (Magill,
2005; Martin, 2006).
The first patient treatments were performed using radium sources (Levitt,
2006; Devlin, 2007). Development of nuclear physics and radionuclide

production technology has leaded to significant increase in the number of


radionuclides with features important for brachytherapy, such as half-life and
type and energy of emitted radiation. Classification of brachytherapy
modalities can be done using different criteria, such as technique used to
load sources (manual, remote afterloading), period of implementation
(temporary or permanent) or approach used to insert the source into the
patient (interstitial, intracavitary, intraluminal or mold).
The main features of brachytherapy source are: half-life, specific activity
related to amount of radioactivity obtained for a certain mass of source and
energy and type of radiation emitted from the source (energy spectrum).
These characteristics determine the clinical application of the source.
Most of the radionuclides used in brachytherapy are of reactor origin. The
radioactive isotope 137 Cs is a fission product (Joslin, 2001). The other
isotopes are produced by neutron bombardment of stabile nuclei in a nuclear
reactor (Joslin, 2001).
The half-life of brachytherapy source ranges from few days to many years.
The length of the half-life determines the period of source replacements. Of
course, a longer half-life is more desirable, as it provides many patient
treatments and thus reduces the cost of each treatment. The half-life is also
important property for selecting the radionuclide for permanent and
temporary implants. A shorter half-life is more desirable for permanent
implants, as they remain presently in patients posing a certain risk of
radiation exposure to the public and environment. The sources used for the
permanent implantation are iodine, palladium and gold.
The strength of radioactive source used in brachytherapy is fairly limited by
a specific activity. The specific activity defines the activity contained in the
mass unit. Therefore, if the source has high specific activity, it is possible to
design a brachytherapy source of small physical size, yet to be highly
radioactive to provide efficient therapy. On the contrary, if the source has low
specific activity, its use in brachytherapy is limited by its large physical size.
The average energy of the source is directly related to the number of
photons penetrating the patient tissue. Higher energy sources allow deeper
penetration in tissue and higher dose to larger distances. However, this also
increases the shielding requirements for brachytherapy staff and
environment. Therefore, low energy sources are commonly used in
permanent implants. Due to the absorption of decay products in the patient
itself, this technique does not imply significant radiation risk to the patients
surrounding.
Cobalt and iridium are radiation sources commonly used in brachytherapy.
The iridium has a spectrum with multiple energies of gamma radiation,

however, significant contributions to the spectrum come from photons of


energies 0.296 MeV (28.7%), 0.308 MeV (29.8%), 0.316 MeV (83.0%) and
0.468 MeV (47.7%)(Joslin, 2001).
Brachytherapy was been introduced over a hundred years ago (Joslin, 2001),
and since then, many physical quantities have been used to describe the
source quantitatively, i.e. to describe the source strength. Significant
limitation of many of these quantities is related to the fact that the strength
of source is assessed from the dose rate measurement around the
encapsulated source placed in water or air. However, the dose distribution
depends on a complex interaction processes in the source itself and its
surrounding. Eventually, common quantities used for dose assessment in
brachytherapy are:

Milligram-radium-equivalent (mgRaEq), where 1 mgRaEq of the radium


substitute (source similar to radium-226) is defined as amount of the
source that gives the same output as 1 mg radium source
encapsulated in 0.5 mm platinum in the same output measurement
geometry;
Apparent activity (Ci): 1 Ci apparent activity of encapsulated
radioactive source is defined as amount of encapsulated source that
gives the same output, or exposure in air, as an unencapsulated source
of the same isotope of 1 Ci activity;
Air-kerma strenght (Sk): defined as the dose-free air along the
transverse axis of an encapsulated source, measured at a large
distance from the source such that the source can be approximated by
a point source. Air-kerma strength has the unit of cGy cmh, and is
represented by the symbol U (A.A.P.M., 1987). This is the
internationally accepted physical quantity widely used in
brachytherapy.

For the purpose of dose assessment, it is important to consider the physical


size and shape of the radiation source. There are two approaches in which
the source is treated either as a point source or more realistically, as a
cylinder. The dose distribution around a point brachytherapy source
decreases with the square of the distance (A.A.P.M., 1987). However, clinical
sources have a finite size. The cylindrically shaped source is encapsulated in
a metal shell of stainless still, platinum or titanium. In this case, suitable,
more complex equations are used to calculate the dose around the line
source as Sievert integral (Bikit, 2013) and TG43 formalism (Bikit, 2013). The
principle of dose calculation in clinical application is based on superposition,
i.e. the final dose distribution at a certain point around the multiple of
sources lying in the brachytherapy applicator is obtained as a sum of doses
to a particular point, coming from each source (Devlin, 2007).

Although manufacturers provide the information on source strength, it is


mandatory to perform in-hospital calibration of a source and thus, verify the
source straight. The calibration should be traceable to national or
international standards. The in-hospital calibration is performed according to
internationally recommended protocols, most often with the calibrated
dosimetry system, which includes a calibrated well chamber and
electrometer (A.A.P.M., 1987).

Conclusion
Radiotherapy is an excellent example for transfer of modern technologies
and scientific knowledge in daily clinical practice. Based on various properties

of nuclei and radiation, such as the interaction of radiation with matter, radiation
detection, biological effects of radiation and static and dynamic nuclear properties
(magnetic properties, stability, radioactive decay), application of gamma rays bring
on a daily basis immense benefits in the diagnosis and treatment of disease and in
the development of medical science.

References
1) American Association of Physicist in Medicine (A.A.P.M.). (1987). Specification
of Brachytherapy Source Strength. A.A.P.M. Report 21. New York.

2) Bikit, I. (2013). Gamma Rays: Technology, Applications and Health


Implications. Nova Science Publishers, Inc..

3) Devlin, P. (ed.). (2007). Brachytherapy: Applications and Technique. Lippincott


Williams and Wilkins.

4) Gilmore, G. R. (2008). Practical gamma-ray spectrometry. (2nd ed.).


John Wiley and Sons Ltd.
5) Johns, H. and Cunningham, J. (1983). The Physics of Radiology. (4th
ed.). Springfield. Illinois
6) Joslin, C. (ed.). (2001). Principles and Practice of Brachytherapy: Using
Afterloading Systems. Hodder Arnold Publishers.

7) Levitt, S.H.; Purdy, J.A.; Perez, C.A. and Vijaykumar, S. (2006). Technical Basis
of radiation therapy. (4th ed.). Springer-Verlag. Heidelberg. Germany. p. 3
31.

8) Magill, J. and Galy, J. (2005). Radioactivity, Radionuclides, Radiation.


Springer-Verlag. Berlin Heidelberg and European Communities.

9) Martin, B. (2006). Nuclear and Particle Physics. John Wiley and Sons Ltd.
10)
Podgorsak, E. (2005). Radiation oncology physics: a Handbook for
teachers and students. I.A.E.A., Vienna.
11)
Podgorsak, E. (2006). Radiation physics for medical physicists. Springer
Verlag. Berlin. Heildelberg.

You might also like