Sample 2021 @purchasablebooks Charles M Washington, Dennis Leaver PDF

Washington and Leaver's
Principles and Practice of

Radiation Therapy
FIFTH EDITION
Charles M. Washington, EdD, MBA,

RT(T), FASRT
Senior Director, Radiation Oncology, Memorial Sloan Kettering Cancer
Center, New York, New York
Dennis Leaver, MS, RT(R)(T), FASRT

Professor Emeritus, Department of Biology, Southern Maine Community
College, South Portland, Maine
Megan Trad, PhD, MSRS, RT(T)

Associate Professor, Radiation Therapy, Texas State University, San Marcos,
Texas
Table of Contents
Cover image
Title page
Copyright
Dedication
Contributors
Reviewers
Preface
Acknowledgments
Unit I. Introduction
1. Cancer: An Overview
Patient Perspective
Biologic Perspective
Etiology and Epidemiology
Detection and Diagnosis
Treatment Options
Prognosis
Clinical Trials
The Radiation Oncology Team
Summary
2. The Ethics and Legal Considerations of Cancer Management
The Case for Ethics in Radiation Therapy
Ethical Aspects of Cancer Management
Patient Autonomy and Informed Consent
Dying Patients and Their Families
Medical-Legal Aspects of Cancer Management
Legal Doctrines
Risk Management
Medical Records
Summary
3. Patient Assessment
Patient Assessment Defined

Interprofessional Approach to the Assessment of Cancer Patients
Summary
4. Overview of Radiobiology
Interaction of Radiation and Matter
Cellular Response to Radiation
Cell Survival Curves
Radiosensitivity
Systemic Response to Radiation
Total-Body Response to Radiation
Late Effects of Radiation
Radiation Therapy
Present Status of Radiation Therapy
Summary
5. Detection and Diagnosis
Introduction to Detection and Diagnosis
Patient Interviews as a Diagnostic Tool
Medical Record and Medical History
Physical Examination
Screening
Laboratory Studies
Medical Imaging
Cancer Diagnosis (Biopsy)
Staging Systems
Summary
6. Medical Imaging
Introduction
Historic Overview
Medical Imaging Technology Overview
X-Ray Production
X-Ray Interactions With (Body) Matter
Technical Factors and Image Characteristics
An Overview of Early Advances in Imaging Modalities
Imaging Modalities in Radiation Therapy
Nuclear Medicine Imaging
Image Quality
Intravenous Contrast Agents Used in Medical Imaging
Summary
7. Treatment Delivery Equipment

Overview of Treatment Delivery Equipment
Equipment Development
Characteristics of Kilovoltage X-Ray Equipment
Clinical Applications of Kilovoltage Equipment
Megavoltage Equipment
Summary
8. Treatment Procedures
Radiation Oncology Record
Treatment Session Preparation
The Treatment Room
The Patient
Patient Transfers
Patient Position, Isocenter, and Field Placement
Verification Imaging (Isocenter)
Beam Position and Shape
Portal Verification Imaging
Beam-Modifying Devices
Assess and Accept Treatment Parameters
Treatment Delivery
Treatment Techniques
Electron Beam
Summary
9. Infection Control in the Radiation Oncology Facilities
Infection Control in Radiation Oncology Facilities
Isolation Fundamentals
Rights of the Healthcare Worker
Role of the Central Services Department
Sterilization and Disinfection Techniques
Sterility Quality Control Measures
Summary
10. Infection Control: Health and Safety
Health and Safety
Definitions
Regulatory Agencies and Public Oversight
Infection Cycle and Disease Phases
Transmission Routes
Defense Mechanisms
Drug use and Drug-Resistant Microorganisms

Healthcare Facility Epidemiology
Personnel and Student Health Services and Pertinent Infectious

Diseases
Human Immunodeficiency Virus and Acquired Immunodeficiency

Syndrome
Summary
11. Pharmacology and Drug Administration
Drug Legislation and Standardization
Drug Nomenclature and Terminology
Pharmacologic Principles
Variables that Affect Patient Response
Professional Drug Assessment and Management
Drug Categories Relevant to Radiation Therapy
Contrast Media
Administration of Contrast Media
Routes of Drug Administration
Intravenous Administration
Legal Aspects
Summary
Unit II. Physics, Simulation, and Treatment

Planning
12. Applied Mathematics Review
Review of Mathematical Concepts
Practical Examples of Mathematics in Radiation Therapy
Summary
13. Introduction to Radiation Therapy Physics
Radiation Quantities and Units
Atomic Physics
Electromagnetic Radiation
Radioactivity
Photon Interactions
Other Particle Interactions
Summary
14. Aspects of Brachytherapy
Historic Overview
What is Brachytherapy?
Source Specification
Radioactive Decay
Temporal Considerations
Brachytherapy Applications
Exposure From A Radioactive Source
Classical Systems
Dose Calculations in Brachytherapy
Clinical Examples
Radiation Safety and Quality Assurance
Electronic Brachytherapy
Summary
15. Advanced Procedures
Introduction
Image-Guided Radiation Therapy
Respiratory Motion Management
Magnetic Resonance–Guided Radiation Therapy
Stereotactic Radiation Therapy
Heavy Charged Particle Treatment
Innovation to Practice: A Perspective of the Future
Artificial Intelligence
Summary
16. Particle Therapy
Introduction
Historic Perspective
General Particle Therapy Principles
Simulation
Treatment Planning Considerations
Treatment Delivery
Quality Assurance
Summary
17. Radiation Safety and Protection
Introduction
Units
Natural Background Radiation
Foundations
Regulators
Dose Limits
Personnel Monitoring
Radiation Measurement
Brachytherapy
Teletherapy
Shielding Design
Safety Devices
Summary
18. Culture of Safety in Radiation Oncology
Motivation
Leadership
Culture of Safety
Improvement Cycles
Summary
19. Quality Improvement in Radiation Oncology
Introduction
Evolution of Quality Improvement
Quality Improvement Models
Regulating Agencies
Definitions
Standards
Clinical Aspects of Quality Control and Improvement
Continuous Quality Improvement Implementation

Summary
20. Surface and Sectional Anatomy
Perspective
Related Imaging Modalities Used in Simulation and Tumor

Localization
Anatomic Positioning
Body Cavities
Body Habitus
Lymphatic System
Axial Skeleton: Skull, Vertebral Column, and Thorax
Surface and Sectional Anatomy and Landmarks of the Head and

Neck
Surface and Sectional Anatomy and Landmarks of the Thorax

and Breast
Surface and Sectional Anatomy and Landmarks of the Abdomen

and Pelvis
Applied Technology
Summary
21. Computed Tomography Simulation Procedures
Introduction
Historic Perspective
Simulation Procedures
Computed Tomography Simulation Procedures
Contrast Agents
Patient Positioning in the Computed Tomography Scanner
Computed Tomography Topograms
Computed Tomography Data Acquisition
Methods of Simulation With Computed Tomography Images
Patient Marking System
Documenting Data
Use of Four-Dimensional computed Tomography in Virtual

Simulation
Room Design
Quality Assurance
Summary
22. Photon Dosimetry Concepts and Calculations
Radiation Therapy Prescription
Concepts Used in Photon Beam Dose Calculations
Tissue Absorption Factors
Practical Applications of Photon Beam Dose Calculations
Source-Skin Distance (Nonisocentric) Treatment Calculations

Linear Accelerator Nonisocentric Monitor Unit Setting
Calculations
Extended Distance Calculations With Percentage Depth Dose

and Source-Skin Distance Treatment
Source-Axis Distance (Isocentric) Calculations
Unequal Beam Weighting
Separation of Adjacent Fields
Summary
23. Photon Dose Distributions
Photon Dose Distributions
Treatment Planning Essentials
Summary
24. Electronic Charting and Image Management
Introduction
Computerization, the Early Electronic Medical Record
Radiation Oncology Electronic Medical Records
Access and Mobility
Electronic Medical Records, the Next Generation
Summary
Unit III. Practical Applications
25. Bone, Cartilage, and Soft Tissue Sarcomas
Disease Management Profile
Bone and Cartilage Tumors
Soft Tissue Sarcomas
Summary
26. Leukemias and Lymphomas
Introduction
Lymphomas
Hodgkin Lymphoma
Non-Hodgkin Lymphoma
Leukemia
Summary
27. Endocrine System Tumors
Thyroid Cancer
Adrenal Cortex Tumors
Results of Treatment
Adrenal Medulla Tumors

Role of the Radiation Therapist
Summary
28. Respiratory System Tumors
Cancer of the Respiratory System
Natural History
Epidemiology
Etiology
Anatomy and Physiology
Clinical Presentation
Pathology
Staging
Patterns of Spread
Treatment Considerations
Simulation and Treatment Planning
Summary
29. Head and Neck Cancers
Natural History
Treatment Considerations
Site-Specific Study of Cancers of the Head and Neck
Radiation Therapy for Regions of the Oral Cavity
The Pharynx Region
Radiation Therapy for Regions of the Pharynx
The Larynx Region
Radiation Therapy for Regions of the Larynx
The Salivary Glands
Radiation Therapy for Regions of the Salivary GlandS
The Paranasal Sinuses
Radiation Therapy for Regions of the Paranasal Sinuses
Management of Symptoms and Morbidity
Future Directions
Summary
30. Central Nervous System Tumors
Cancer of the Central Nervous System
Summary
31. Digestive System Tumors

Colorectal Cancer
Anal Cancer
Esophageal Cancer
Pancreatic Cancer
Summary
32. Gynecological Tumors
Anatomy
Cervical Cancer
Endometrial Cancers
Ovarian Cancer
Vulvar Cancers
Vaginal Cancer
Summary
33. Male Reproductive and Genitourinary Tumors
Prostate
Penis and Male Urethra
Urinary Bladder
Testis
Kidney
Summary
34. Breast Cancer
Epidemiology and Risk Factors
Anatomy
Pathology
Staging
Prognostic and Predictive Factors
Treatment Management
Radiation Therapy
35. Pediatric Solid Tumors
Brain Tumors
Retinoblastoma
Neuroblastoma
Wilms Tumor
Soft Tissue Sarcomas
Miscellaneous Childhood Tumors

Palliative Radiation
Summary
36. Skin Cancers and Melanoma
Skin Cancers and Melanoma
Summary
Glossary
Index
UNIT I
Introduction
OUTLINE
1. Cancer: An Overview
2. The Ethics and Legal Considerations of Cancer

Management
3. Patient Assessment
4. Overview of Radiobiology
5. Detection and Diagnosis
6. Medical Imaging
7. Treatment Delivery Equipment
8. Treatment Procedures
9. Infection Control in the Radiation Oncology

Facilities
10. Infection Control: Health and Safety

11. Pharmacology and Drug Administration
Treatment Procedures
Annette M. Coleman
Radiation Oncology Record,

Medical Record: Treatment: Rational and Response,
Image Record,
Radiation Treatment Record,
Quality Assurance: Chart Review,
Treatment Session Preparation,
Radiation Prescription,
Treatment Plan and Reference Images,
Treatment History,
Verification Image History,
The Treatment Room,
Treatment Room Preparation,
The Patient,
Patient Preparation and Communication,
Patient Identification, Time Out, 167
Patient Transfers,
Wheelchair Transfers,
Stretcher Transfers,
Patient Positioning,
Localization Landmarks,
Isocenter Alignment,
Verification Imaging (Isocenter),
Image-Guided Radiation Therapy, Online Setup
Correction,
Offline Systematic Setup Correction,
Beam Position and Shape,
Beam Shaping and Multileaf Collimators,
Portal Verification Imaging,
Beam-Modifying Devices,
Bolus,
Compensators,
Wedges,
Assess and Accept Treatment Parameters,
Patient Monitoring Systems,
Console,
Treatment Delivery,
Beam On and Beam Off,
Treatment Interruptions,
Treatment Techniques,
Multiple Fields,
Adjacent Fields,
Intensity-Modulated Radiation Therapy,
Stereotactic Radiation Therapy,
Total-Body Irradiation,
Adaptive Radiation Therapy,
Electron Beam,
Electron Collimation and Beam Shaping,
Electron Therapy Shielding: Underlying Structures,
Electron Therapy and Bolus,
Summary,
OBJECTIVES
• Construct an action plan for patient treatment setup and delivery.
• Describe the radiation therapist’s role in the quality assurance
program.
• Review the radiation treatment chart for information to decide to
treat and prepare the room for treatment.
• Given a specific situation, select and describe the safest transfer
method for the patient and the radiation therapist.
• Describe a step-by-step process to align the patient and treatment
volume with the machine isocenter and coordinate system.
• Discriminate between setup and field imaging goals.
• List and define beam-shaping and beam-modification devices.
• Compare treatment setup implications between photon and
electron beams: (1) collimation, (2) bolus, and (3) adjacent fields.
• Describe multileaf collimators and their application as both beam-
shaping and beam-modification devices in treatment delivery.
• Categorize common external beam treatment techniques
• List appropriate responses to treatment interruptions.
KEY TERMS
Beam modifiers
Beam’s eye view
Collimation
Compensators
Elapsed days
Feathering
Fiducial
Field
Fraction
Fractionation
Hinge angle
Immobilization devices
Interlocks
Interfraction
Intrafraction
Isocenter
Localization
Meterset
Method of delivery
Orthogonal
Protraction
Stereoscopic
Topographic anatomy
Treatment history record
Treatment technique
Triangulation
Verification imaging
Radiation treatment is essential to quality oncologic care and its
delivery under a radiation oncologist’s direction, which constitutes
the radiation therapist’s core professional practice. Conscientious
attention to precision in simulation and treatment delivery and to
patients’ physiologic and psychologic needs highlights the radiation
therapist’s contribution to the cancer management team. Radiation
therapists deliver radiation therapy treatments, monitor and operate
sophisticated radiation-producing equipment, and maintain detailed,
accurate treatment history records.
Consistent treatment depends on abilities and limitations imposed
by equipment, treatment beam geometry, and the patient. Quality
radiation patient care depends on the radiation therapist’s specialized
knowledge and skills in radiation treatment techniques, equipment
operation, spatial proficiency between patient anatomy and
equipment capabilities, radiation exposure response, communication,
and empathy for patients’ personal needs. Knowledge in anatomy,
oncology, treatment planning, physics, radiation biology, and legal
considerations are a prerequisite to clinical judgment formation
necessary to execute responsibilities safely and responsibly.
Well-developed organization and communication skills are called
on to execute each patient’s unique treatment plan while directing a
full and varied patient load. The action plan for each patient is unique
and complex but effectively achieves a core task set. A baseline task
analysis can provide a framework for organizing an action plan (Box
8.1). Details and alternative pathways build on this foundation,
addressing individual treatment technique complexities, specialized
equipment, and procedures. Acronyms can be powerful memory
devices, assuring critical tasks are consistently executed (Box 8.2).
Radiation Oncology Record
The patient chart is the communication nucleus for the radiation care
team. As a legal record, its completeness, organization, and accuracy
are critical. Traditionally dependent on treatment team members’
handwritten accounts, electronic medical records (EMR) are now the
routine charting medium, integrating text and image information with
radiation oncology workflow. Information centrally stored can be
presented uniquely to each treatment team member by task, and
access is limited only by the facility’s information technology network.
With electronic charting, the medium for medical charting evolves,
not the requirements. Record integrity and security remains each care
team member’s responsibility. Information access and entry is
associated with a log-in identification and is managed much more
securely than with paper. In addition to accuracy, the radiation
therapist is ethically and legally accountable to patient privacy and
confidentiality of medical records.
Medical Record: Treatment: Rational and

Response
A radiation treatment chart captures relevant patient medical history,
including diagnostic and staging results along with general medical
conditions that might impact treatment outcomes. Before receiving
treatment, patients must provide their informed consent to any
procedures. Informed consent requires the patient or their legal
guardian receives an explanation and understands his or her disease
status, treatment alternatives, and consequences associated with and
without treatment. As patient advocate, the radiation therapist verifies
patient understanding and ensures informed consent is documented
in the chart.
Patient response to treatment is monitored and recorded
throughout and following treatment completion. Radiation treatment
responses often require medication, nutrition, or psychosocial
intervention; all care activities are recorded in the chart. The entire
treatment team monitors radiation reactions through direct
observation, blood counts or other lab test reviews, and questioning
regarding nutritional intake, skin reactions, and other treatment
related symptoms. Weekly radiation oncologist on-treatment visits
document weight changes, symptom emergence and care, and other
treatment response indicators. Ancillary care team members, such as
nutritionists and social workers, may also include their assessments
and instructions in the radiation therapy chart.
BOX 8.1 Treatment Procedure Task Analysis
1. Review the chart.

2. Prepare the room. Position immobilization devices on the
treatment table, and place treatment accessories within reach.
3. Greet and identify the patient.
4. Assist the patient onto the treatment table and into the
prescribed position.
5. Identify treatment site and procedure; document the Time Out.
6. Raise the couch, bringing the area to be treated to the beam area.
7. Locate surface landmarks.
8. Refine the patient position relative to the isocenter using lasers,
light field, and surface landmarks.
9. Perform setup verification procedures, imaging, etc.
10. Rotate gantry and collimator to prescribed positions.
11. Position beam-shaping accessories and visually verify using the
light field.
12. Perform portal verification procedures.
13. Position beam modifiers (wedge, compensator, and bolus).
14. Inform the patient that you are leaving, and treatment will
begin.
15. Monitor the patient.
16. Set appropriate machine controls, and review correspondence
with prescribed values in the record and verification system.
17. Initiate beam-on. Monitor patient and equipment function.
When multiple fields are to be treated, do the following:
18. Validate parameters downloaded to accelerator and enable
accelerator motion, or enter the room and check the patient,
field position, and beam modifiers.
19. Repeat steps 7 through 15 for all fields until the treatment
completion.
20. Assist the patient from the couch and room.
21. Complete the treatment record.
Image Record
As with the text chart, electronic imaging practices now predominate.
Integrated text and images present a far more robust patient story
than independently managed paper and film records. Treatment
planning and delivery communications and workflow are
dramatically improved with diagnostic and planning data readily
transferable between systems.
Verification imaging completes the treatment record, and
verification image communication between the radiation therapist and
radiation oncologist is critical to treatment accuracy. Verification
imaging documents treatment localization reproduction (hidden
anatomy identification relative to observable or palpable surface
landmarks). Images are acquired with the patient in the treatment
position, compared with reference images from the treatment plan.
This provides critical confirmation and documentation that the
planned treatment was accurately reproduced.
Radiation Treatment Record

The radiation treatment record is truly unique to the radiation
oncology EMR. The radiation prescription, treatment plan, and
treatment record are highly specialized information not applied by
other medical specialties.
BOX 8.2 Treatment Procedure Mnemonics
For PATIENT IDENTIFICATION: “CONFIRM”
• Check name, On screen, Find data, Review data with patient,

Move to sim/treatment room.
• Ask the patient for two forms of identification. Once assured this
is the correct patient, verify the patient picture on the screen and
ask the patient where they are having treatment. The patient and
treatment are reviewed; ask the patient to move to the treatment
room.
For SIMULATION and TREATMENT UNIT: “SAME”
• Straighten, Align, Move couch, and Ensure immobilization.

• Use the “SAME” standard for every patient. Straighten the
patient on the simulation or treatment couch. Align the patient to
the table for both longitudinal and lateral directions. Once
straight and aligned, move the couch/patient support assembly
(PSA) vertically, longitudinally, and laterally as needed. Then
ensure immobilization is enough to begin simulation or
treatment.
For CT SIMULATION: “SIMMED”
• Set BBs/wires, Image, Mark, Measure, Educate, and Document.

• Once the “SAME” standard and proper immobilization is
demonstrated, execute the “SIMMED” routine. Set the BBs/wires
to prepare for scout/images. Once imaged, mark the patient and
make any necessary measurements. After marking, educate the
patient on marks care and future appointments. Once the patient
leaves, document required information.
For TREATMENT UNIT:“LASER”
• Level, Align, Screen check, Exit, and Review chart,

• Once the “SAME” standard and proper immobilization is
demonstrated, perform the “LASER” routine. Level the patient to
the lateral lasers. Once level, align the patient to isocenter. After
the patient is positioned correctly, check the in-room
screen/monitor for any notes or changes that must be made
before exiting the room. Once at the console, review the chart
again.
“STEPS”
• Study plan, Think about the console, Eyes on patient, Port film
verification, and Safe to treat.
• After reviewing the chart, study the treatment plan and know
what fields are to be treated. Watch the console and the patient.
Image if necessary, check and verify, move couch accordingly.
Affirm it is safe to treat and beam on.
From RL Wegener, MS, RT(R)(T). Delgado Community College,

Radiation Therapy Technology Program. With permission.
Radiation dose and equipment settings under which it was

delivered is recorded at each treatment session. The treatment history
identifies the treatment date(s) and increments the delivered
treatment number and elapsed days (total time over which treatment
is protracted) and fractional and total dose delivered to the prescribed
volume and critical structures near or in the treatment volume.
Notations are made regarding procedures completed during a
treatment session, such as verification imaging (radiographic or
electronic treatment documentation) and addition or deletion of bolus
or other beam modifiers. All treatment record entries must identify
the treating radiation therapists. When multiple fractions are
delivered on a single day, delivery time is also required.
As accelerator capabilities and treatment plans increased in
complexity, equipment settings became too numerous to manually
set, confirm, and chart in the treatment history. Modern treatment
delivery requires verification and record (V&R) systems integration
with the radiation chart.
V&R systems send prevalidated treatment plan parameters to the
treatment machine for setup and delivery. Actual machine settings are
compared against those most recently prescribed and prevent
treatment beam initiation if settings vary outside a specified tolerance
range. On beam delivery conclusion, the machine returns data
documenting what settings were in place and meterset (monitor units
[MU]) delivered.
V&R systems can extend verification and documentation beyond
the treatment machine, from patient identification to secondary
equipment not integrated with the treatment machine itself. Field
sequences may be defined, automating selection and machine
movement to settings and beam delivery.
As with the EMR, V&R functions change the method, not the
responsibilities. Appropriate decision making for the entire care team
is dependent on accurate and complete records, and treatment history
integrity is the radiation therapist’s responsibility, not the equipment.
Data accuracy must be confirmed by the treatment team before
inclusion; observed deviations from what actually took place must be
reported and investigated.
Quality Assurance: Chart Review

The treatment chart is both a tool and a focus for the facility’s quality
assurance (QA) program. The activities and documentation performed
to reduce errors and optimize patient care comprise the QA program.
The treatment chart must include information identifying and
supporting the treatment rationale, a detailed treatment plan
description, informed consent documentation, and detailed treatment
delivery records. Treatment must not proceed if any information is
unavailable or in question.
The radiation therapist’s primary role in the QA program is
ensuring accurate radiation delivery as prescribed by a radiation
oncologist. This requires reviewing patient records, monitoring
radiation-producing equipment functioning, maintaining accuracy in
treatment reproduction, monitoring changes in patient status, and
maintaining complete and accurate treatment records.
Examples of weekly chart reviews may include monitoring
treatment verification checks, such as source-skin distance (SSD)
records, diode measurements, verification imaging frequency and
radiation oncologist review status, fractional and cumulative tracked
dose accuracy, physics chart check completion, and charge
verification.
Chart reviews include previous entry verification. With traditional
paper records, the most common charting errors were numeric:
addition or transpositions often in the dose record. As the chart is the
primary document referenced in litigation processes, corrections
require the original entry to be apparent. Legible corrections and
reasonable explanations are required. With paper, one line is drawn
through the entry, followed by the correct value, the correcting
individual initials, and the date. Correction fluid or other methods
hiding original entries are viewed with suspicion and must be
avoided.
FIG. 8.1 Treatment chart.
Changes to treatment orders or corrections to entries must be

apparent in electronic records as with paper records. The EMR assists
chart QA with time-stamped data entries and access to detailed
change histories. The ability to selectively filter and display
information relevant to tasks or timelines can greatly streamline chart
review. Prospectively, required information and processes can be
reinforced by blocking actions when information or authorization is
not available.
Treatment Session Preparation
Before initiating treatment, review the chart’s treatment section for
completeness and accuracy. Information necessary for treatment
reproduction includes an identification image and patient confirmable
data, such as birth date, street address, or phone number. Confirm
that the radiation prescription is signed; detailed patient- and
equipment-positioning information, dosimetric plans, calculations,
and the treatment history record are complete with fractional and
cumulative doses, machine settings, verification imaging, and
prescribed changes (Fig. 8.1).
Radiation Prescription
Radiation may be delivered only under a radiation oncologist’s direct
order. As with drug and other therapies, radiation orders are written
as prescriptions that must be signed by the radiation oncologist before
radiation treatment initiation. No exceptions are allowed. The
prescription must provide specific information supporting consistent
interpretation by qualified professionals, including the radiation
therapist. Recommendations have been published by the American
Society of Therapeutic Radiation Oncology, identifying key external
beam prescription elements and sequencing. Anatomic treatment site
is identified first, followed by method of delivery (minimally,
photons, electrons, or identifying an isotope). Prescription definition
begins with (1) dose per fraction (individual dose intended for a
treatment session), followed by (2) number of fractions, and (3) total
radiation dose to be delivered. Additional prescription components,
including protraction (time over which the treatment will be given)
schedule, planning instructions, information specifying beam energy,
portal sizes and entry angles, and beam modifiers (devices that
change treatment field shape or radiation distribution at depth) may
be included in the prescription and with patient-positioning
information.1 Some guidance on treatment sites naming may be found
in reports by the American Association of Physicists in Medicine and
the American College of Surgeons.2,3
Great responsibility is accepted by the radiation therapist when
dispensing the prescription. In preparation, review the prescription
before starting the treatment course, applying knowledge on radiation
effects, tumor-lethal doses, and radiation tolerance limits for normal
tissue. Prescriptions appearing to exceed tissue limits or deviate from
standard practice must be reviewed with the physician before
delivery. Great care is taken by every team member to eliminate errors
and ensure the safest treatment delivery.
The prescription is again reviewed immediately before each
treatment fraction. Changes may be ordered at any time, and the
radiation therapist provides the “last line of defense” that changes are
implemented as ordered. The physician’s signature and date must
accompany any changes in the prescription. Common prescription
changes include fraction and total dose or changes to bolus or beam
apertures. Changes affecting dose calculation require plan review to
ensure corrections have been made before treatment delivery.
Treatment Plan and Reference Images

Treatment plan review ensures critical information is available for
treatment plan reproduction before treatment initiation. Setup
instructions, diagrams, and/or photographs illustrate patient
positioning, immobilization, and surface landmark locations
indicating the treatment isocenter position (the intersection point for
the linac’s three axes rotation [gantry, collimator, and couch base]).
Any adjustments to the original information must be clearly
identified.
One or more treatment fields compose a treatment plan. A
treatment field is the tissue volume exposed to radiation from a single
radiation beam. Treatment fields expose target volumes, maximizing
the dose delivered to the tumor while minimizing the dose to normal
structures. Each treatment field, or portal, is assigned an identifier and
name indicating the prescription site and beam direction (Fig. 8.2).
Field identifiers follow department-established protocols. In general,
some incremental format is applied to distinguish fields from distinct
projections. Subscript letters, numbers, or prime marks (‘, “) denoting
changes in the field size, shape, or isocenter from the original field are
used when the prescription volume and beam direction have not
changed. Field names further clarify beam orientation and targeted
anatomy. The complete field definition includes detailed console and
beam-shaping parameters necessary to deliver dose objectives.
FIG. 8.2 Three-dimensional beam nomenclature. Beams are named

referencing the patient coordinate system. (A) The A30S beam is 30
degrees superior from the anterior axis. (B) The A60L30S beam is 60
degrees left from the anterior axis and 30 degrees superior. (C) The
P20R40I beam is 20 degrees right from the posterior axis and 40
degrees inferior.
From Bourland D. Radiation oncology physics. In: Gunderson LL,
Tepper JE, eds. Clinical Radiation Oncology. 2nd ed. Philadelphia, PA:
Churchill Livingstone; 2007.
Treatment field dimensions are stated width by length in centimeters.

International Commission on Radiation Units and Measurements
Reports 50 and 62 define treatment volumes to be used for
prescribing and reporting radiation doses.
Dose distributions and meterset calculations, typically prepared by

the medical dosimetrist,4 are reviewed and signed by at least two
treatment-planning team members before being made available for
treatment. Before treatment, radiation therapists independently
review the treatment plan for calculation factor faithfulness against
treatment parameters. Field sizes, beam modifiers, and treatment
depths used in calculations must be consistent with those identified in
the treatment setup instructions. Results may be further verified by
direct dose measurements at treatment course start using electronic
diodes or other dosimeters placed on the patient in the treatment field
during treatment. The value of these checks cannot be overstated;
therapists are the last defensive line in the collective review series
performed to eliminate errors. Radiation therapists are consistently
reported as discovering the most errors or near-miss incidents to a US
national incident learning system.5
Medical images further illustrate treatment plans. Planning images
are the standard images which on-treatment images are compared in
order to verify treatment position and to document treated volumes.
Planar radiographs from simulation procedures or digital
reconstructed radiographs from computed tomography (CT) data by
treatment planning or virtual simulation systems may serve as
treatment field or isocenter reference images. Treatment field
reference images show the beam’s eye view (BEV) area to be
irradiated and the beam shape and direction as it passes through the
patient and surrounding radiopaque references, such as bones or
implantable fiducials (placed object used as a point reference).
Isocenter reference images may additionally be required if field image
projections are insufficient, or the planning CT itself may be used with
advanced in-room imaging systems.
Treatment History
At treatment record review, therapists evaluate completeness and
accuracy to date and determine actions to be taken at the treatment
session about to commence. Questions may include the following:
• “When was the patient’s last treatment?”
• “Have any changes to the prescription or treatment plan been
ordered? Is current information sufficient to execute those
changes?”
• “How far along is the patient in his or her treatment course?”
• “What treatment site and fields are intended for today’s
treatment session?’
• “Has the weekly on-treatment visit schedule been met? Are
any changes to the patient’s physical or emotional state
identified?”
Attention to the dose delivered informs expectations for the

patient’s physical reactions to the treatment. As the treatment team
member seeing patients at each treatment session, the radiation
therapist is key to treatment response monitoring. Understanding
radiation reactions and management methods informs the decision to
proceed or withhold treatment pending radiation oncologist
consultation.
Verification Image History

Before treatment, review the historic images, implement and
document any related treatment modification orders, or call
unreviewed images to the radiation oncologist’s attention.
• “Have previous images been reviewed?”

• “Are setup changes ordered?”
• “Which setup verification method is required today?”
• “Are treatment field images needed today?”
The Treatment Room
The organization and maintenance of the treatment room is the
radiation therapist’s responsibility. Ergonomic movement, lighting,
orderliness, and infection precautions are emphasized, enhancing
safety for patients and therapists. In addition to monitoring treatment
unit performance, inspect treatment accessories regularly for wear or
damage, and assure proper lighting levels are maintained. Enough
shelf and cabinet space must be available to securely store equipment
off the floor. Treatment accessories and positioning or immobilization
devices touching patients must be cleaned and disinfected after each
use. Isolate custom devices, avoiding cross contamination between
patients. Sustain nonreusable or disposable items, such as tape,
laundry, and bolus materials. Report and correct any unsafe
conditions.
Treatment room design may be viewed as radiating outward from
the isocenter. The isocenter is the intersection point for three machine
rotation axes (gantry, collimator, and couch base), allowing beam
redirection without repositioning the patient. A well-planned
treatment room encourages efficient movement around this focal
point. Shelves and storage cabinets form the perimeter, leaving the
area around the treatment unit clear. Treatment accessory and device
storage is generally concealed and organized at heights not requiring
stepstools or ladders for retrieval.
Universal precautions are infection control methods in which any

human blood or body fluid is treated as if it were known to be
infectious.
Maintain vigilance in infection control. Remember that

undiagnosed infections may be present in any individual, and handle
all blood and body fluids as if they were infectious. Remember the
often immunodeficient oncology patient state, and take responsibility
for preventing disease transmission. Clean treatment table and
positioning accessories with disinfectant cleaners after each use.
Replace linens after each patient, covering the treatment table and
keeping the treatment window clear. Apply universal precautions
with all patients. Remember, the most important practice toward
preventing infection transmission is thorough handwashing after
patient contact.
Isocentric linear accelerator mounting facilitates complex treatment
plan reproducibility. These versatile units accommodate exquisitely
complex field arrangements. Treatment setup seeks coincidence
between the treatment unit isocenter and treatment plan isocenter.
Yet, because both are effectively hidden from view, alignment
requires spatial awareness and visual assistance.
Laser systems installed at the treatment room perimeter generate
points or lines intersecting at the treatment machine isocenter. Three
or four sources project from the walls and from the ceiling (or
opposite the gantry), providing visual references to the machine
isocenter location. Using vertical and horizontal planes, the light
effectively references a location obscured within a patient (Fig. 8.3).
Thus, laser alignment with external patient landmarks directs
positioning the accelerator’s isocenter to its planned position within
the patient. A second laser set may be available at a position lower
and outside the gantry’s rotation arc. This set allows patient leveling
at an ergonomic table height for the therapists. Lasers are highly
focused light. Red or green helium neon lasers are generally used.
Green lasers project more sharply than red, with their shorter
wavelength scattering less at the skin surface. In-room lasers are not
harmful to skin but do have the ability to damage vision. The laser
source must not be looked directly into—this precaution applies to
everyone entering the treatment room and must be communicated to
patients.
FIG. 8.3 Horizontal and perpendicular lasers intersect at the
isocenter.
Treatment rooms require both standard and dim lighting. Full,

standard lighting provides safety for patients and therapists entering
and exiting the room and assists when locating accessory equipment.
Reducing the light in the treatment room adds clarity to lasers and
field light, thus assisting the patient positioning and treatment setup
process. While treatment is in progress, full lights are on, aiding
patient observation.
Treatment Room Preparation

Room preparation begins before the patient arrives. Treatment setup
dimensions, field size, gantry, collimator, and table positions are
reviewed. A beam aperture is set and the gantry positioned so that
lasers are visible at the isocenter and the field light crosshairs project
in a vertical or horizontal direction. The treatment table (couch) is
raised or lowered appropriate to the patient’s transportation method.
Position the table window where treatment fields will reach the
patient without intercepting the couch. Mylar covers the table
windows, supporting the patient without attenuating the treatment
beam. Support may be enhanced by carbon fiber supports beneath the
Mylar. The primary window is open across the table and supported
by side bars, meeting most field arrangement needs. For oblique or
rotational field arrangements that might pass through the side rails,
an alternative configuration supports the table center with windows
on either side.
Comfort affects the patient’s ability to maintain a treatment
position; therefore, care is taken at simulation to define a reproducible
and sustainable position. Improvements in treatment planning and
image evaluation methods are supporting increasingly narrow
margins on normal tissue, demanding increased immobilization for all
treatment sites. Complexity varies depending on anatomic site
mobility. Considerations at the time of simulation include general
patient condition (e.g., age, disability, pain), normal structure location,
treatment area skin folds, ability to treat all fields in one position, and
minimizing normal tissue exposure. Positioning and immobilization
devices, such as sponges, casts, masks, and/or bite blocks, support the
elected position. Matching devices are oriented on the treatment table
relative to the expected patient orientation and location. Interfraction
setup variation may be further minimized using indexing systems
where immobilization devices are aligned or fitted to incremented
positions on the treatment table.
Treatment accessories, such as electron cone, wedges, and bolus, are
placed in a readily accessible location away from initial setup activity.
The Patient
Patient Preparation and Communication
From first introductions, initiate and take responsibility for the
rapport characterizing the radiation therapist-patient relationship.
Seek to establish a relationship that encourages confidence and
cooperation. Patients entrust the radiation therapist with their care,
and your relationship will typically extend over a period ranging from
2 to 8 weeks. Over this period, the radiation therapist is a patient
resource, and this relationship’s caliber directly affects the patient’s
care quality perception. Anticipate questions and concerns associated
with radiation treatment, and create an environment sensitive to
patient needs. With daily contact, the radiation therapist acts as a
liaison, directing the patient to resources designed to meet his or her
physical and psychosocial needs. Developing a constructive patient-
professional relationship may provide insight into the individual’s
experience and coping mechanisms, and observations may reveal
social service needs or changes in disease state. Notify the physician
when changes are observed.
Understanding expectations during treatment empowers patients
and fosters cooperation through mutual respect. Provide clear
directions at a level the patient understands. Prioritize cultural
sensitivity and linguistic competency. Consider age, mental status,
and native language. Use questioning techniques to discover acute
radiation reaction onset and severity. Use open-ended questioning,
starting with who, what, when, and why questions not answerable
with a simple yes or no to encourage dialogue. Avoid closed
questioning: “are, do, is, will, can, should,” and so on. Brief answers
may be followed with gently probing questions to ensure the patient’s
treatment reactions are understood.
When starting treatment, extend every effort to help patients feel
safe. Explain reasons for requiring inconvenient or uncomfortable
procedures, such as removing restrictive clothing that may alter skin
marks and inhibit treatment position reproduction. Where department
practice requires undressing before entering the treatment room,
guide them through the gown and robing location and any secure
places provided for belongings. Demonstrate audio and visual
monitoring systems. Prepare them for gantry proximity, machine
motion, and treatment sounds. Offer assurance that their privacy and
contact will be maintained always, even as the radiation therapists
observe from outside the treatment room.
Through the treatment course, provide counseling in proper skin
mark maintenance, general skin care, and nutritional guidelines.
Recognize scope of practice boundaries, and demonstrate appropriate
decision-making when referrals become necessary. Assess verbal and
observable responses (e.g., skin reactions, weight change, changes in
demeanor), evaluating whether treatment should continue or be
withheld until the patient may be seen by the physician.
Patient Identification, Time Out

When room preparations are complete, greet and confirm patient
identification, leading him or her to the treatment room.
Confirm patient identity using at least two methods. Many factors
contribute to potential misidentification, and consequences range
from discontent in the waiting room to treatment misadministration.
Patients may have the same or similar names, illness or anxiety may
hinder their ability to respond to their own name, and some will be
anxious enough to answer to whichever name you call. As a result, be
cautious when identifying patients, and do not become reliant on your
own recognition.
The treatment chart includes an identification image for visual
confirmation. The most important identification tool for inpatients is
their wrist bracelet, which is read before moving a patient into the
treatment room. Outpatients typically carry identification cards and
may be asked to state their own name, address, or phone number,
distinguishing them from those with the same name. Electronic
charting and patient management systems offer further security with
bar coding and biometric identity confirmation matching chart to
patient.
Globally, there is increased awareness regarding wrong site, wrong
procedure, and wrong person treatment incidents. Protocols
mandated in most countries bring attention to the 3 Rs (right) or 3Cs
(correct), patient, site, and procedure. In the United States, The Joint
Commission requires accredited organizations to comply with the
following Universal Protocol and Time Out.
6
1. Preprocedure verification (chart and room preparation): verify

procedure, patient site, identify items which must be available
for procedure, and match items to patient.
2. Mark procedure site.
3. Time out:
• standardized process within organization
• initiated by a designated team member at every
instance
• immediate team members performing the procedure
actively communicating
• correct patient confirmed using at least two methods
• correct site, markings verified
• correct procedure to be undertaken
• document, organization determines form and amount
Patient Transfers
Patients require varying assistance onto the treatment table and thus a
plan for assuring their comfort and safety. Include the patient
whenever possible in your transfer planning. He or she may be able to
move themselves or have pain they wish considered, and they have
experience informing suggestions for their safe transfer. Have the
table prepared with the correct window, and align the patient so their
treatment area will be over the window when the transfer is executed.
When planning a patient transfer, do not forget to assess your own
assistance needs.
Underestimating the need for assistance can result in injury to the

patient and the caregiver.
Many ambulatory patients require minimal assistance. However,

even ambulatory patients can find traditional treatment table height a
challenge. Extended-range treatment tables can be a great assistance;
in their absence, stepstools are routinely employed. Unstable patients,
such as those experiencing weakness or injury, may require only a
supportive arm or guidance; instruct them to lead with their strong
foot, whether stepping up or down from the stool. Still others will
arrive in a wheelchair or on a stretcher.
Evaluate transfer requirements, mindful of auxiliary medical
equipment in use. Although most extensively in place with inpatients,
outpatients also arrive with oxygen or nutritional support or even
portable medication pumps. Tubes and catheters must be recognized
and carefully handled so as not to disrupt placement or introduce
infection.
Understand and apply proper body mechanics when assisting or
transferring patients. General rules require a wide support base with
the feet apart and one foot placed slightly forward. Keep weight to be
moved close, bending at knees and hips, not waist, maintaining a flat
to normal curve in the lower back. Never twist or bend sideways
while supporting weight.
Wheelchair Transfers
For patients unable to stand unassisted, consider patient size and
general stability relative to your own abilities. A second caregiver
moving equipment and supporting the primary lifter can significantly
improve safety for everyone involved. Prepare by positioning the
wheelchair parallel to the table. If the patient has weakness or
impairment on one side, position the stronger side in the direction of
movement. Lock chair wheels. Raise footrests and stand facing the
patient. With the patient’s feet together, the assister positions their feet
on either side of the patients’ and leans forward, bending at the knees
and hips while maintaining a flat to natural lower spine curve. The
patient reaches around the lift assister’s shoulders while the lift
assister reaches under the patient’s arms, locking arms around the
patient’s back. The patient is raised to his or her feet and pivoted 90
degrees so his or her back faces the table. Next, ease the patient into a
sitting position. Once steadied, with an arm behind the patient’s
shoulders and the other behind the knees, ease the patient into the
supine position in one smooth motion.
Reverse these actions when getting the patient off the table. Give the
patient a moment to adjust after sitting up and continue supporting
them; dizziness is not unusual on such positional changes. Do not
leave the patient unaided until he or she is securely back into the
wheelchair.
FIG. 8.4 Patient transfer using a slide board.
From Ehrlich RA, Coakes C. Patient Care in Radiography. 9th ed. St
Louis, MO: Elsevier; 2017.
If, for any reason (e.g., paralysis, pain), the patient requires more
assistance onto the table, stretcher transport should be arranged. This
is a safety consideration for the patient and caregivers.
Stretcher Transfers
Stretcher transfers should be completed with no fewer than two
caregivers. The stretcher is placed alongside the treatment table with
the side rails lowered and wheels locked. The table is positioned at the
same level as the stretcher. If the patient can slide over, one lift
assistant may secure the stretcher while another stands opposite the
treatment table, providing guidance and ensuring the patient does not
fall.
Immobile patient transfer across both treatment table and stretcher
will force breaches in good body mechanics. At some point, weight
will be held away from the assisters’ own center of gravity, and
someone will push rather than pull. Extra care and concentration must
be used for these reaches. A draw sheet and slide board can assist
these transfers, reducing injury risk to the people performing the
transfer. Slide boards are relatively thin plastic sheets, large enough to
support the patient but generally used only to bridge the space
between the stretcher and treatment table so the patient may be pulled
rather than lifted from one to the other. Patients bring their hands to
their chest. The slide board is positioned by rolling the patient and
placing the board under the draw sheet. After the patient is eased
back onto the slide board, the board may be pulled to the treatment
table or the patient slid across the bridge created over the gap between
the stretcher and treatment table. The slide board must be removed if
it is in the treatment beam path or will affect the treatment position
(Fig. 8.4).
Slide boards should not be used when rolling puts the patient at
risk for injury. In this situation, several individuals are needed. The
appropriate number depends on factors such as patient size or special
considerations such as pain. Lifters position themselves to support the
patient’s head, shoulders, hips, and feet during the entire lift. Ideally,
a draw sheet is in place from the move from bed to stretcher, or the
stretcher sheet may be sufficient to avoid rolling the patient. Pull
sheets taut, rolling edges and gripping firmly. The team leader
specifies a count, so everyone lifts at the same time. The patient is
lifted just high enough to clear the treatment table and stretcher
surfaces, moved over, and eased down (Fig. 8.5). Ensure the patient is
secure and any accessory equipment, intravenous lines, catheters,
oxygen, and other tubing are cleared from treatment machine motion
from before moving the stretcher away.
Patient Position, Isocenter, and Field
Placement
Advances in imaging and treatment planning encourages continuous
precision as radiation medicine evolves. With increasing confidence,
the physician, dosimetrist, and radiation therapist focus beams to the
target while minimizing the radiation delivered to surrounding
normal tissues. V&R systems communicate detailed machine settings
to set, verify, and document treatment plan reproduction at the
treatment unit. Clinical value, however, is achieved only with beam
coincidence with the patient and his or her tumor. Surface landmark
instability and laxity in treatment position reproduction or
immobilization contribute greatly to treatment variation and thus
represent the greatest obstacle to applying advances in treatment
planning. Minimizing these factors is a primary technical challenge for
the radiation therapist.
Patient Positioning
The treatment session positioning goal is planned position
reproduction. Landmark alignment with internal targets relies on
vertical and horizontal planes; even slight body position variation can
mean large discrepancies with the internal location a surface
landmark represents (Fig. 8.6).
On arrival to the treatment room, the patient will remove artificial
devices (e.g., dentures, temporary prostheses) consistent with
simulation and planning. Prescribed shielding, such as wax/tin mouth
guard reducing scatter from fillings to the buccal mucosa, may be
positioned before settling the patient into the treatment position.
With the area to be treated over the appropriate treatment table
window, the patient is coarsely aligned straight and level. Orienting
the patient’s treatment plan isocenter as close as possible to the table
center provides maximum clearance for techniques requiring 360-
degree gantry rotation. Alternatively, treatment beams with small
gantry angles off the vertical axis, such as lung boost fields, may be
accommodated by biasing the patient toward the side that the anterior
field enters. Larger angles off the vertical axis (such as those used in
breast tangents) may be accommodated by moving the patient closer
to the treatment side.
Many opposing oblique or tangential fields may be accommodated

without treatment table rotation by making lateral patient shifts
(consequently isocenter) relative to the table surface.
Using setup instructions from the chart, the treatment position

refinement begins. Setup instructions include illustrations,
photographs, and descriptive statements, such as supine versus prone,
arm placement, and names and locations of other positioning devices.
Measurements indicating the relative anatomy position (e.g., chin to
suprasternal notch or sternal slope) may be used. The patient’s
treatment area is positioned relative to the machine isocenter where
final fine-tuning is completed.
FIG. 8.5 Patient transfer using a draw sheet.

From Ehrlich RA, Coakes C. Patient Care in Radiography. 9th ed. St
Louis, MO: Elsevier; 2017.
FIG. 8.6 Change in patient position changes landmark location
relative to interest point.
Localization Landmarks
The treatment isocenter moves with, and is hidden within, the patient.
Because neither the machine isocenter nor its planned position in the
patient can be seen directly, treatment setup is dependent on aligning
observable references distant to the actual interest point. In
combination with topographic anatomy knowledge, localization
landmarks are reference points used to direct patient positioning
relative to the treatment machine. Landmarks include natural
anatomy or artificial fiducials (fixed reference points against which
other objects can be measured) positioned at a fixed relationship to
unseen anatomy. Fiducials may be permanent or semipermanent, at
the skin surface, internal, or fixed external to the patient.
Surface landmarks (references) include visible and palpable
anatomy (bones or other identifiable points that can be seen or felt),
tiny permanent marks created in the skin (aka tattoos), or
semipermanent ink. Permanent marks are made by a sterile dye speck
to the dermis layer, just under the skin surface, with a sterile
hypodermic needle. Permanent marks allow for normal bathing
during treatment. Very tiny, they are not obvious in public and do not
damage clothing. For treatment, tiny permanent marks offer precision
and stability without spreading or migrating. Traditionally,
permanent marks were depended on for follow-up care and as
references to avoid previous treatment area overlap. These purposes
have waned as precision and previous treatment records improve.
Drawbacks include a psychological perspective, and the term tattoo
has societal connotations to manage when communicating with the
patient. Permanent marks may be an unnecessary cancer reminder
long after they are needed. An alternative to dark ink, ultraviolet ink
offers similar effectiveness that may lessen factors contributing to
posttreatment body image.7,8 Surface-guided radiation therapy
(SGRT), systems using stereo camera, and computer systems match
and monitor the patient’s treatment area surface offering
opportunities to eliminate skin marks.
Semipermanent marks, alone or in combination with minimal
permanent marks, may enhance triangulation coordinates and
identify field corners or edges. Permanent ink markers and paint pens
easily mark skin and are difficult to remove; the varying colors can be
useful for clarity across multiple plans and against different skin
tones. Cross contamination between patients is a concern. Although
studies have shown permanent markers to have effective bactericidal
action, this lessens as the pen dries, and the immunocompromised
cancer patient is more susceptible to transmissions.9 Patient education
and cooperation is necessary as potential removal or drift exists when
refreshing over the treatment course. Clear patient-sensitive tape or
markers with adhesives designed to resist removal while remaining
gentle to sensitive skin may cover marks to aid in retention during
bathing.
Implanted fiducial markers can be used, including radiopaque gold
seeds or radiofrequency beacons, that provide internal references for
mobile soft tissue, such as the prostate. These, however, require an
invasive procedure to implant and added cost and risks to a treatment
course. The use of these should be evaluated for each patient’s
situation, and risk should be low relative to the precision gained when
used.
FIG. 8.7 Three-point positioning: tattoos (x). (A) Crosshairs. (B)
Lasers. (C) Planned location isocenter. (D) Actual isocenter location.
Thermoplastic masks or stereotactic frames provide temporary,

external fiducial references. Thermoplastic molds may be formed with
enough immobilization that marks applied to the mask remain
coincident with a treatment volume. Stereotactic frames use rigid and
a highly reproducible means to orient precise incremental references
beyond the skin surface. Head frames may be screwed directly into
the skull, rendering the head immobile for the use of treating
intracranial structures. Other variations using palate or other custom
molds enable repeated frame use for fractionated treatment while
increasing immobility over thermoplastic masks alone.
Isocenter Alignment
The treatment unit isocenter position is static. It can be located by
following the room lasers and field crosshairs to their intersection
point. Begin treatment volume alignment to the machine using
triangulation references, which are three points forming intersecting
horizontal, vertical, and transverse planes. In order to align the patient
to the isocenter, the patient will be raised on the treatment couch until
the lateral side lasers coincide with the patients marks on the right
and left side. The patient can then be moved superiorly/inferiorly to
alight the transverse position. Finally the treatment couch is moved
left to right in order to align the sagittal laser or the field crosshair.
With the patient in the approximate treatment position and the
observable landmarks identified, the treatment table is positioned to
bring the patient close to the location for treatment. While maintaining
patient dignity with drapes, locate external landmarks referenced in
the setup instructions. Dim the room lights, and refine patient position
relative to machine coordinates using lasers and the treatment field
light. Using lateral marks, straighten and level the patient. The Z
plane position may be determined from the table surface or the SSD.
Several methods may be used to determine SSD. Table height has an
advantage when the patient is lying directly on the table. There will be
less interfraction or therapist variability. When a supporting device,
such as an angle board, is in use, an optical distance indicator (ODI) or
range finder may be necessary. The ODI or range finder light projects
onto the patient’s skin and is matched at the intersecting crosshairs
that coincide with the beam’s central ray. Mechanical distance
indicators include incrementally marked rods or a measuring tape
mounted to the collimator assembly extended to touch the patient’s
surface at the central axis. Treatment position is refined, aligning three
observable landmarks on the patient with isocenter references, lasers,
and beam crosshairs; treatment position is refined.
With the patient in treatment position, the isocenter is positioned
relative to the localization landmarks. The planar intersection
identified by the three positioning points may coincide with the
treatment isocenter (Fig. 8.7); however, this is not always practical.
Anatomic references are seldom conveniently located, and many
treatment sites do not lend themselves to stable localization mark
placement. Mobile skin surfaces, such as the breast or axilla; older or
obese persons; sloping surfaces, such as those treated with tangential
fields; and irregular surfaces, and areas covered by dressings are
imprecise or inaccessible. For these situations, apply a landmark and
coordinate system (Fig. 8.8). Align stable surface landmarks with
lasers followed by table motion in the X, Y, and Z planes. Indexed
couches with digital linear position readouts contribute valuable
precision in making these adjustments.
FIG. 8.8 Landmark and coordinate method. (A) Surface landmark

(tattoo). (B) Planned isocenter location. 1, Shift to depth; 2, lateral shift.
Verification Imaging (Isocenter)
Traditional isocenter position accuracy is accomplished comparing
planar images with corresponding reference images. The exposure
projections may be a treatment portal subset or defined specifically for
setup verification.
A single planar (two-dimensional) image or opposing image pair
with coincident central ray projections, however, is insufficient to
verify point position in three-dimensional space (Fig. 8.9A,B). The
isocenter position on a planar image is distorted as all information is
when compressed into two dimensions; distance to a point from the
radiation source cannot be determined. Stereoscopic images are two
images from different angles focused on the same point.
FIG. 8.9 Geometric distortion. (A) Parallel structures offset from

central axis (B) Overlying structures along beam divergence. (C)
Orthogonal projections.
Adding a second image, rotated on the isocenter from the first,

approximates the third dimension.
The isocenter position is at the central axis’s intersection. Accuracy
for stereoscopic image review increases as beam coincidence
decreases. This occurs because the increasing angle between incident
beams reduces geometric distortion. The greatest possible
noncoincidence is two beams at 90-degree angles. Orthogonal images
are two beams perpendicular to one another with a 90-degree angle
between them (Fig. 8.9C). Accuracy for stereoscopic image review is at
its greatest with perpendicular orthogonal beam sets. Adding image
projections also improves results; cone beam CT (CBCT) perhaps
being the best illustration where accumulating multiple planar
exposures produces precise spatial results.
Classic film imaging requires skill and attention to limitations,
including beam geometry, image quality, evaluator subjectivity, and
time. Image magnification varies, and distortion is introduced by poor
cassette placement. Image quality is fixed and inferior contrast
unavoidable because of megavoltage (MV) Compton scatter obscuring
radiographic landmarks. Beam position interpretation has shown
measurable assessment variability between individuals. Also, images
evaluated after treatment (offline), even on subsequent days, offer no
opportunity to correct treatments already delivered. Even when films
are taken immediately before treatment delivery (online), patient
movement is possible while patients wait for processing and
evaluation.
The graticule (bb tray or dot tray) is a calibrated device fitting into the
collimator and projecting field information to radiographic images,
central ray, aperture size, rotation, and magnification.
Electronic imaging introduces enhanced image quality and

registration tools. The phosphor plates of the computed radiography
(CR) are exposed in a similar manner as film. Electronic portal
imaging devices (EPIDs) eliminate geometric distortion from
misaligned cassettes. EPIDs capture near real-time planar images or
multiple exposures while the gantry rotates to produce a CBCT. CBCT
visualizes soft tissue with or without implanted markers and
produces three-dimensional images for the most accurate position
evaluation. Images available in moments at the treatment console
minimize time for patient movement between imaging and correction.
Enhancement algorithms produce visualization clarity, automated
image registration, and fusion, and display produce rapid, consistent
results reducing subjectivity. Electronic MV portal and kilovoltage
(kV) imaging accelerate isocenter and treatment field alignment
verification.
Image-Guided Radiation Therapy, Online

Setup Correction
Electronic imaging’s efficiency and quality make routine pretreatment
online correction viable. Online, image-guided radiation therapy
(IGRT) techniques correct interfraction setup variation or changes
occurring between treatment sessions. Image- and nonimage-based
systems are used. Precise online corrections support reduced normal
tissue in treatment volumes.
Motion observation and correction may be applied pretreatment, or
during treatment (intrafraction), ensuring moving target inclusion.
Options include radiographic systems, planar (cine) or four-
dimensional CBCT, and nonradiographic means, such as ultrasound,
SGRT, and radiofrequency tracking systems monitoring implanted
beacons. Intrafraction motion monitoring may be combined with
motion-reducing equipment and/or beam interruption (gating)
mechanisms should the target move outside the treatment beam path.
Offline Systematic Setup Correction

Online image review most effectively minimizes daily setup variation;
however, time and exposure factors may not outweigh this benefit for
all treatment protocols. Setup variation includes systematic (e.g.,
changes in equipment between simulation and treatment room) and
random components (e.g., bladder or bowel filling, organ motion),
with systematic variation the more significant source.
Systematic variation is the consistent component in daily setup
variation, primarily resulting from planned treatment setup transfer
from the simulator to the treatment unit. Systematic isocenter setup
variation may be approximated offline by determining the average
setup correction from the first few treatment sessions. This correction
may be added to setup instructions for subsequent treatment sessions.
Remaining random variation includes inherent setup and organ
motion variation that cannot be prospectively eliminated. Anticipated
random error range varies with anatomic site and must be
accommodated for in treatment planning. Random error is minimized
by immobilization and online imaging techniques.
Offline protocols determining systematic setup variation can identify

setup adjustments, producing more accurate results preimaging or
pretreatment. Judicious online and offline protocols, in combination
with trend analysis, can produce improved results for all patients.
Beam Position and Shape
Once isocenter coincidence is accepted, rotate the gantry to the
projection angle for treatment initiation. Basic linac collimation
(arrangement of shielding material designed to define the x an y
dimensions of the field) limits beam shape to rectangles. Large
blocking systems with movable, opposing “jaws” are positioned in the
treatment machine head. Field (jaw) settings define the overall
radiation field dimensions at the isocenter. Electron therapy and
stereotactic techniques add tertiary collimation systems and cones,
improving dose distribution by reducing penumbra (Fig. 8.10).
Because neither people nor tumors present in squares and
rectangles, treatment plans generally require further treatment
aperture shaping. Standard lead or spent uranium blocks were a
common, useful accessory in the treatment room. Modern radiation
therapy beam shaping requires custom shielding using low melting
point lead alloys, such as Cerrobend, or multileaf collimation (MLC).
Cerrobend’s bismuth (50%), lead (26.7%), tin (13.3%), and cadmium

(10%) composition has a 165°F (74°C) melting point. Alternative
alloys with similar characteristics and lower toxic metal
concentrations are available to further protect workers.
Beam Shaping and Multileaf Collimators

Linear accelerators equipped with MLC (Fig. 8.11) systems customize
field shapes using jaws sliced into leaf banks where opposing leaf
banks form leaf pairs. Independently positioned, leaf pairs quickly
and flexibly produce complex treatment field shapes. For additional
information on MLC configuration, see Chapter 7, Figure 7.21.
The number of leaf pairs, available leaf widths, leaf design, and
control systems vary between manufacturers, with some
manufacturers offering several models. Design considerations include
minimizing leakage between leaves with an interlocking leaf design or
by positioning the primary jaws outside the field as backup jaws
during treatment delivery. Leaf end shape optimizes a divergent field
edge and will be rounded on systems that move leaves on a single
plane. Leaf width is measured at the isocenter and impacts field edge
smoothness. Micro-MLC units with leaf widths less than 5 mm
provide greater refinement. Micro-MLC units may be removable,
offering treatment unit flexibility. Control systems may be integrated
with the accelerator console or may be separate, which has
implications for field parameter selection and MLC files as well as
backup options should network access be interrupted.
FIG. 8.10 Penumbra decreases as source to collimation distance
increases.
FIG. 8.11 Multileaf collimator.
Courtesy of Elekta Systems.
In addition to treatment volume customization, MLCs improve

safety and satisfaction. Without heavy blocks, strain injuries or
injuries caused by dropping heavy equipment is reduced for patients
and radiation therapists. MLCs repositioned from the console reduces
overall treatment session time, improving patient comfort and
department efficiency.
FIG. 8.12 Superflab bolus.
Courtesy Civco, Inc., Orange City, IA.
Portal Verification Imaging
Portal images verify the BEV path, the beam shape, and projection
using the MV treatment beam. Exit dose exposes an EPID, CR plate, or
classic radiographic film. As verification portal images are taken
before the first treatment, systematic errors may be corrected before
treatment is delivered.
Portal images use single- or double-exposure techniques. Single-
exposure images are enough when radiographic landmarks are
located within the treatment area. Classic, slow exposure rate
verification film (v-film) is an option where film is in place during the
entire treatment exposure. Double exposures include a short exposure
to the treatment area and a second exposure following field-shaping
retraction, which exposes a larger area surrounding the treatment
area. Double exposures include treatment field and surrounding
anatomy information, increasing interpretation landmarks while also
increasing normal tissue dose.
Department policy defines portal imaging frequency. Partially
based on historic studies showing a reduction in treatment errors
associated with increased portal imaging, portals at treatment course
initiation and weekly thereafter for most cases are an accepted
standard. Unstable landmarks or treatment volume proximity to
critical structures may prompt increased frequency. IGRT protocols
where daily isocenter position is verified may support reducing
individual treatment portal imaging frequency.
Beam-Modifying Devices
The primary treatment planning goal is treating a target to an even
(homogeneous) dose while minimizing the dose delivered to normal
tissue. With assurance, the radiation is directed toward the prescribed
volume; static devices or dynamic collimation systems may further
modify radiation dose distribution across the treatment field.
Bolus
In radiation therapy, bolus refers to materials whose interactions with
the radiation beam mimic tissue. Bolus comes in many forms and has
many applications. Bolus must conform to the treatment surface
without air gaps and build up or attenuate dose equivalently to tissue
to be effective. Commercially available gel sheets developed
specifically for use in radiation therapy are available in standard-
thickness sheets (Fig. 8.12). Other commercial sheet materials for
surfaces include brass mesh. Materials for custom bolus shapes
include paraffin wax, Vaseline gauze, wet gauze or towels, water
bags, and even three-dimensional printed materials. These materials
can be variable in tissue equivalence; measurements may be
appropriate to assure treatment intentions are met.
FIG. 8.13 A 90-degree orthogonal hinge angle.
Bolus thickness equivalent to maximum dose depth for the

treatment energy eliminates the beam’s skin-sparing effect, bringing
maximum dose deposition to the patient’s surface. Bolus may be
applied with this goal over entire treatment areas or simply over scars,
superficial nodes, or other areas of concern.
Bolus may be used to compensate for surface contour variations or
to eliminate cavity air gaps. For example, surgical procedures leaving
anatomic defects, such as sinus or eye removal, produce significant
irregularities. Filling the cavity with bolus material such as Vaseline
gauze or a water-filled balloon significantly improves dose
distribution in the target volume. This application is useful only in
situations where skin-sparing loss is acceptable or desired. When skin
sparing is to be maintained, individualized compensators should be
evaluated.
Compensators
MV treatment unit design produces a beam delivering a relatively
even dose across the perpendicular plane. Patients, however, rarely
provide a flat surface perpendicular with the incident treatment beam.
As just discussed, dose distribution skewing caused by irregular
surfaces can be addressed with bolus material, yet it eliminates skin
sparing. Compensators (beam modifier changing radiation output
across the beam profile) are positioned in the treatment machine head;
skin sparing is retained. As with bolus, materials vary; copper, brass,
lead, or Lucite may be used.
Tissue deficits are generally most significant over one dimension
(width or length), and a standardized two-dimensional compensator
addresses this treatment situation. With modern treatment techniques,
two-dimensional compensators are infrequently encountered.
Complex contours may necessitate custom three-dimensional
compensators.
Wedges
Combining multiple treatment fields may produce inhomogeneous
dose distributions over the target volume. Dose distribution for a
single treatment field meeting a flat surface is relatively parallel to the
surface. When a second beam is positioned directly opposite this
beam, the dose distribution combines relatively consistently across the
exposed volume. However, as the hinge angle (angle between two
intersecting treatment beams’ central rays) (Fig. 8.13) decreases, the
dose delivered to overlapping areas varies significantly; high- and
low-dose regions appear in the desired target volume.
Although physical wedges appear like two-dimensional
compensators, their application differs significantly. Wedges are
designed to change the isodose angle relative to the beam axis at a
specified depth within the patient. Wedges reduce the dose overlap
between fields with hinge angles less than 180 degrees. The thick
wedge end, the heel, attenuates the greatest radiation, thus drawing
isodose lines closer to the surface. Attenuation decreases along the
wedge to the thin end, or toe, where the dose delivered to the patient
will be greater than the dose at the opposite side. When wedges are
used, heels are typically positioned together, reducing high-dose
regions inside the hinge angle.
External wedges must be lifted and slid into position. The
manufacturer usually provides wedges that are customized for
specific treatment units. Standard wedge sizes are 15, 30, 45, and 60
degrees. Field sizes are limited with standard compensators and
wedges. Care must be taken to ensure that treatment fields do not
extend beyond the beam modification device’s heel or sides (flash or
extension beyond the toe is acceptable).
Internal wedge units allow wedge angle optimization. The machine
positions a physical 60-degree “universal” wedge in the beam path for
a specified number of MU. The beam is interrupted, the wedge
removed, and the remaining MU are delivered; the wedged-to-
unwedged beam ratio results in a custom wedge angle.
Nonphysical wedges slope dose distribution using jaw motion. Jaws
are positioned together at one field edge. As the moving jaw sweeps
away, the wedge toe forms as more dose is delivered to the field edge.
This lessens the dose across the field when the last exposure is made
and the wedge is in full position.
The photon beam interaction with attenuating materials produces

scatter electrons contaminating the photon beam and producing
increased skin dose for patients. Air attenuates low-energy electrons
absorbed in about 15 cm; therefore, all beam-shaping and
modification devices for photon beams must be secured at least 20 cm
from the patient surface.
Assess and Accept Treatment
Parameters
Before leaving the room, perform a final treatment setup review,
verifying patient positioning, beam direction, and beam modifier
placement. If arc therapy is being applied or if subsequent treatment
fields will be positioned from outside the treatment room, ensure free
clearance for gantry motion throughout the treatment rotation. Check
that the patient, accessory medical equipment, treatment table, and all
stretchers, chairs, and stools are all free from the gantry path. Once
satisfied that set parameters meet those prescribed by the treatment
plan, notify the patient that you are exiting the treatment room to
administer the radiation. Communicate the approximate time that the
beam will be on, and reassure the patient that he or she is always
being monitored. Exit confirming the patient is the only person in the
treatment room.
Patient Monitoring Systems

To protect radiation therapists from radiation exposure, the patient
must be left alone in the treatment vault during radiation delivery. In
some situations (orthovoltage or other low-energy treatments),
treatment may be monitored directly through leaded glass windows.
This is impractical with MV units, however, and indirect monitoring
systems are used. To maintain patient safety and treatment accuracy,
audio and visual contact must be maintained at all times. At least two
cameras maintain visual contact with the patient. Generally, at least
one long-view camera visualizes the whole patient, allowing
observation for general distress or movement, whereas another
provides a closer view of the treatment area for subtle patient
movement observation. Visual monitors must be positioned so that
the patient and gantry motion is always visible; a changing gantry
angle must not obstruct patient monitoring at any time.
Two-way audio communication between the treatment room and
console remains continuously audible in the console area. A switch
allows communication into the treatment room. A stop at the console
area before the first treatment allows monitoring system
demonstration to new patients, reassuring them they are heard and
seen during treatment delivery and that their privacy is protected.
Console
Radiation delivery is controlled at the treatment console area located
outside the treatment room. Console configuration varies widely and
may include multiple computer-controlled screens operating the
treatment unit and ancillary systems.
The console provides information regarding treatment unit status
and operation. Beam modifier use may require placement
confirmation to release safety interlocks. Interlocks prevent beam
initiation and include alerts prompting treatment setup and safety
procedure completion. Interlocks include closing doors, beam
modifier placement (wedges, compensators, electron cones), and
machine operation requirements (water, vacuum, etc.). Disagreement
with interlock requirements triggers a fault indicator on the console.
Fault-light panels provide diagnostic information regarding proper
functioning and equipment problem sources.
Although equipment maintenance is ultimately the radiation
physicist’s responsibility, monitoring equipment function and
reporting problems to the physics or engineering department is a
critical radiation therapist responsibility. Any equipment
malfunctions or setup errors affecting treatment delivery must be
reported to the radiation oncologist and corrective actions
documented in writing. Malfunctions or errors resulting in
misadministration must be reported following Nuclear Regulatory
Commission or state reporting requirements. Reportable events and
misadministration definitions may change over time, so reportable
event determination is made by the radiation safety officer.
Equipment malfunctions causing serious injury or death are reported
through the US Food and Drug Administration’s Medical Device
Reporting Act.
Treatment Delivery
Beam On and Beam Off
Set the parameters for treatment delivery, or confirm settings
downloaded from the V&R system, including the calculated primary
and backup monitor unit (or timer) settings.
Initiate the treatment beam. Red “radiation on” lights in and
outside the treatment room indicate radiation activity in the treatment
room. Monitor the patient and console meterset (e.g., MU, time)
administered.
At beam on, ion chambers within the beam measure radiation
output. The relative dose delivered is displayed in MU on the linear
accelerator console. Primary, secondary, and backup systems function
to interrupt the treatment beam after the prescribed dose has been
delivered. Backup systems may be manually or automatically set
depending on treatment unit sophistication and function as safety
interlocks, terminating the beam if the primary counter malfunctions.
The accelerator is designed to deliver the dose at specified rates;
decreases in that rate may indicate malfunctions. Backup systems
include secondary ion chambers calibrated a percentage lower than
the primary ion chamber and timers that interrupt the beam after a set
period.
After radiation delivery to the first treatment port, assess patient
and treatment unit position for each subsequent field. Set new field
size, table, gantry, collimator angles, and position-changing treatment
accessories. With computer-controlled field shaping through MLCs
and beam modification through dynamic wedges, V&R systems
provide parameters for sequential treatment field setup, and multiple
treatment fields may be delivered from the console without treatment
room reentry. Motion may be initiated using functions at the
accelerator console or on the pendant in the treatment room. Such
auto-setup procedures, reducing treatment time and incorrect
treatment parameters, must be accompanied by diligence observing
patient movement and proximity to moving equipment.
Treatment Interruptions
Machine conditions might cause a machine to turn off before a beam
is completely delivered. Patient movement, improper machine
motion, or treatment beam failure to stop may also require the
radiation therapist to interrupt the treatment beam. Options for beam
interruption by the radiation therapist include pressing a beam-off
button, turning the operation key to the “off” position, or opening the
treatment unit door. If these actions fail to stop the beam, an
emergency off switch must be available, completely turning off the
treatment unit. An emergency off switch is a final choice, as a machine
warm-up period before reuse is generally necessary.
Depending on the interruption circumstances, the beam may be
resumed or treatment terminated. The treating radiation therapist
determines the actions following beam interruption. Whenever
possible, treatment will be resumed and completed; however, when
equipment operation or beam quality are in question, the physician
must be involved in the assessment.
When treatment termination is necessary, accurately record the
partial treatment. Subsequent treatments may require revision to
achieve the intended treatment plan. Validate and write down
machine settings, including MU, at interruption. Check electronic and
physical backup counters, recording readouts in a manual system.
Compare machine readouts with those sent to the V&R system.
Record and report any discrepancy for investigation.
Field arrangement decisions depend on tumor location and nearby
critical structures. At simulation, the radiation therapist works with
the radiation oncologist and dosimetrist to plan field arrangements
within treatment machine capabilities to include target volumes,
minimize traversing normal tissues, and avoid critical structures.
Multiple Fields
Most treatment plans require radiation delivery through multiple
portals to achieve optimal dose homogeneity through the target
volumes. As fields overlap, an increased dose is deposited relative to
tissues receiving radiation from only one portal. Accuracy in multiple
field irradiation is greatly enhanced with isocentric treatment
techniques. With the treatment unit isocenter precisely positioned in
the target volumes, the machine may be moved to direct radiation
beams at the target from many directions without repositioning the
patient, thus preserving accuracy.
The most basic multiple-field technique is the parallel opposed
portal (POP). The hinge angle for POP fields equals 180 degrees. POP
fields may enter the patient from any two directions relative to the
patient and are often identified by those directions, for example, right-
and-left lateral (laterals), anteroposterior and posteroanterior, and
anterior oblique and posterior oblique (obliques). Parallel opposed
fields are not used frequently and usually require few treatment
accessories beyond beam shaping. Opposing fields for superficial
volumes on curved surfaces, such as the breast or ribs, which flash off
the patient’s surface, are referred to as tangential fields or tangents. The
hinge angle between tangential fields may vary slightly from 180
degrees, accommodating beams divergence so the deep field edge is
coincident rather than the beam axes (Fig. 8.14).
FIG. 8.14 (A) Parallel opposed. (B) Tangentials.
The wedge pair technique changes the volume receiving radiation

by decreasing the hinge angle between two treatment fields. The
relative dose in the area formed between the narrowing hinge angle
increases as the angle between the field pairs decreases. Overlapping
isodose lines are parallel to the treatment surface, not parallel to one
another, and combining them produces high dose deposition in the
shallow target portion relative to dose deposited more deeply. By
reducing the radiation delivered to the shallow region, wedges
distribute the dose more homogeneously throughout the target (Fig.
8.15). Three-field techniques often require wedges to achieve the same
dose homogeneity goal, as the dose increases on the side where the
third field enters.
Adding fields increases dose where beams intersect while
decreasing dose to surrounding tissues. Deep-seated tumors rely on
increasing beams to reduce normal tissue dose while increasing dose
where beams overlap. The four-field technique, sometimes referred to
as a four-field box, was commonly used in pelvis or abdomen
treatment. These fields are arranged 90 degrees from one another and
generally require no more than beam shaping for optimal dose
distribution.
Conformal therapy applies three-dimensional tumor volume
localization to treatment field definition. Adding couch rotations may
position the beam in directions that acquisition devices cannot be
positioned. With CT simulation, treatment planning systems can
define beam directions that cannot be viewed with two-dimensional
imaging. Fields are defined through a derived BEV and shaped to
include the target with minimal normal tissue margins. Six or more
fields, often in arrangements noncoplanar with the gantry rotation,
may be used to increase the dose to the target while producing sharp
dose falloff to surrounding tissue. Immobilization devices are
carefully designed, and treatment is delivered in the same manner as
in other multiple-field techniques. With high-energy beams, dose
distributions are comparable with arc therapy.
Arc therapy demonstrates the ultimate multiple-field technique,
and arcs may be defined in co-planar and noncoplanar arrangements.
In standard arc therapy, radiation is delivered through a static field as
the gantry moves through its rotation arc. In doing this, arc therapy
effectively delivers radiation through a continuous, overlapping
treatment portal sequence. Conformal arcs add a jaw and MLC
movement conforming exposure to the outermost target width as it
changes through the rotation (Fig. 8.16).
FIG. 8.15 (A) No wedge, dose gradient across overlapping beams.
(B) Wedge pair, homogeneity across overlapping region reduced.
FIG. 8.16 Conformal arc, beam aperture conforms to changing target
dimensions.
Adjacent Fields
Photon beam divergence and electron dose distribution bulging at
depth poses challenges for adjacent treatment field alignment. Over
and under dose areas are concerning. Methods include abutting fields
at the skin surface or at some depth with or without coplanar
treatment beam edge alignment. Abutting field edges produce “hot”
matches where beams overlap immediately below the surface. The
overlap area must be carefully evaluated for total dose tolerance.
When a low-dose area is acceptable at or near the surface, adjacent
fields may be separated by a calculated gap. Positioning the field edge
correctly, planes coplanar to one another may be accomplished
through using blocks or independent jaws eliminating divergence
(Fig. 8.17A) or using gantry, collimator, and table rotations to align
treatment field edges (Fig. 8.17B,C). Although abutting geometrically
matched fields theoretically provides a match without inhomogeneity,
setup variation must be a recognized risk. Abutting or gapped,
feathering (junction migration through the treatment course) may be
used to blur dose inhomogeneities at a junction.
Intensity-Modulated Radiation Therapy

Conventional and conformal treatment plans distribute a relatively
uniform dose across each field. Normal tissue is protected by
controlling field direction and shape, areas in which treatment fields
overlap, and receive an increased radiation dose relative to areas that
receive radiation from only one field. Intensity-modulated radiation
therapy (IMRT) alters this model, delivering nonuniform, modulated
exposure across the BEV. As radiation intensity varies across the
exposed field, critical structures in its path are given less dose. Target
areas receiving a low dose from one direction are compensated by
larger doses delivered through another gantry angle not intersecting
the protected structure. By overlapping multiple intensity-modulated
fields, high radiation doses are delivered to targets that are irregularly
shaped or close to critical structures. These nonuniform exposures
create even dose distribution to target volumes with steep dose
gradients to adjacent normal tissue. IMRT treatment planning requires
“inverse” planning algorithms where the clinical objectives are
specified first, and the planning system works in reverse to determine
optimal beam parameters.
Beam modulation may be accomplished using three-dimensional
compensators with material thickness increasing over protected
structures in each beam path. MLC motion, however, revolutionized
radiation treatment delivery. In addition to field shaping, MLCs
moving through beam delivery modulate radiation intensity across
the BEV. Planning and QA is accomplished in-house; treatment
delivery is efficient without the need to change physical compensators
between each treatment field.
MLC-modulated beams apply to one of two modes of delivery. Step
and shoot, or segmental MLC, positions MLC leaves and then initiates
beam. The therapist initiates the treatment field once; the MLC
controller manages beamlet off/on and leaf motion sequence. Once the
first beamlet (an IMRT field subdivision) is complete, the beam turns
off, leaves move to the next position, beam turns on/off, and so forth,
proceeding through each beamlet until treatment is delivered. Sliding
window, or dynamic MLC, moves leaves throughout a single beam
on/off sequence. Modulated arc therapy delivers IMRT through
rotational arcs, with moving MLCs and variable dose rate, further
conforming dose delivery.
FIG. 8.17 Geometric field matching. (A) Half-beam block. (B)
Collimator rotation. (C) Couch rotation.
Highly physics intensive, IMRT requires specially equipped

accelerators, inverse treatment planning, sophisticated dose
measurement, QA tools, and V&R systems to manage large and
complex treatment plans. At treatment delivery, immobilization and
IGRT setup verification is emphasized, as volumes with highly
defined treatment margins are particularly sensitive to positioning
and isocenter alignment.
Stereotactic Radiation Therapy

Stereotactic techniques treat small targets with many intersecting
beams creating concentrated dose areas with very sharp dose falloff.
By distributing the dose delivered to normal tissue over greater areas,
the high dose area is increasingly focused on the target. Linear
accelerator–based stereotactic radiosurgery (SRS) or stereotactic
radiation therapy (SRT) reduce penumbra with cones sharpening dose
gradients and multiple noncoplanar arcs directed at the tumor. The
Gamma Knife uses fixed cobalt-60 sources to produce similar dose
distributions. CyberKnife’s robotics direct a highly focused beam
through complex patterns not constrained by mounted systems.
SRS delivers a single large treatment fraction without overdosing
nearby normal tissue. SRT adds the fractionation radiobiological
benefits to the treatment. Stereotactic body radiation therapy
combines conformal or modulated radiation therapy elements with
stereotactic coordinate techniques and motion management for areas
outside the cranium, including spine, lung, and liver.10 Treatment is
hypofractionated with a single or few high-dose treatment sessions.
Targets are precisely defined while motion is minimized and
monitored. Setup verification procedures are applied at each
treatment session, seeking submillimeter accuracy. Sophisticated
immobilization and localization include integrated external fiducial
and immobilization devices, such as head or body frames, identifying
the isocenter and treatment field localization.
Total-Body Irradiation
Total-body irradiation (TBI) positions patients at an extended distance
to produce a sufficiently large field size. On treatment units not
specifically designed for this purpose, this usually means lying on the
floor or standing or sitting against a treatment room wall with the
gantry rotated 90 degrees. To achieve dose homogeneity, patients
must be treated with POP fields, requiring repositioning halfway
through the treatment. Several dedicated TBI treatment machines
have been developed in centers with a high demand for this
treatment. These machines simplify treatment by using fixed,
extended distance, or double-headed treatment units to deliver
radiation through both anterior and posterior surfaces with the
patient in a comfortable, constant position.
Adaptive Radiation Therapy
Adaptive radiation therapy (ART) accommodates anatomic changes
occurring over a treatment course. Tumors and normal structures
change shape and size from one day to the next and as tumors
respond to treatment. Structure movement in or out of beam paths
disrupts intended dose distribution. Repositioning via IGRT
accommodates for some interfraction variation; ART adapts dose
distribution with changing beam apertures and modulation. Strategies
include on- and offline plan adaptation. Offline adaptation may entail
resimulation and planning after several completed treatment sessions
or establishing a treatment plan “library” across a predictable organ
position range, such as bladder filling. Plan selection from the library
is informed at each session using pretreatment imaging. Online ART
takes place during the treatment session, requiring advanced imaging
and fast planning tools. A treatment planning system modifies a
reference plan using contours generated from pretreatment imaging.
System integration is prized, saving time and reducing opportunities
for error. As plan conformality increases, normal tissue dose
decreases, and tumor dose escalation may be supported.
FIG. 8.18 Electron cones.
Courtesy Elekta.
Electron Beam
Superficial treatment volumes may be addressed using electron
beams. Electrons provide rapid dose buildup and a uniform dose
region, followed by rapid dose falloff. Setup procedures are less
reliant on the isocenter, with distance, collimation, and SSD having
greater significance to dose distribution. Optimal gantry rotation
brings the beam cross plane parallel with the treatment surface. The
orientation may be referred to as en-face, meaning directly facing.
Special considerations for electron beam treatments include beam
collimation, shielding, and bolus requirements.
Electron Collimation and Beam Shaping

Electron mass and charge give rise to increased interactions in air than
occur with photon beams. Electron beam scattering causes lateral dose
bowing at depth. Tertiary collimation, extensions close to the
treatment surface, sharpens dose gradient at the beam edges.
Collimation systems for electron therapy include static field size cones
attached to the gantry accessory tray or trimmer bars adjustable to
varying field sizes. Trimmer bars attached to the collimator provide
greater flexibility in field size, but increased distance from the patient
increases penumbra and lateral dose scattering. Cones or trimmer bars
are usually secured on the treatment unit before the patient is
positioned, as the patient will be positioned close to collimation (Fig.
8.18).
FIG. 8.19 Electron cutouts.
Courtesy Varian Medical Systems.
Electron field shaping may be positioned on the patient or within

the electron cone. Attenuated much more efficiently than photon
beams, surface field shaping require lead equivalent thicknesses
measured in millimeters (general rule: half energy in lead
millimeters). Surface shaping may be cut and formed to the patient
except where the weight is uncomfortable. Electron interaction with
surface-positioned metals produce low-energy scatter radiation,
increasing dose and reactions to surfaces. Covering with a low Z-
number material, such as aluminum, tin, or paraffin wax, absorbs
these low-energy photons. Alternatively, field-defining apertures, or
“cutouts,” fit directly inside the electron cone end (Fig. 8.19). Planning
field-shaping cutouts may be accomplished through a simulation or
manual procedure where the required field shape is drawn on a
template positioned on the patient’s surface. The template is then used
to form a mold and Cerrobend cutout.
Electron Therapy Shielding: Underlying
Structures
Thin structures, such as the nares, auricle, eyelids, and lips, are often
treated with electron therapy. Use additional shielding to protect
underlying normal tissue such as medial nasal membranes, skin
behind the ear, optic lens, lacrimal ducts and glands, and gingiva from
unnecessary radiation exposure. Because of the proximity of the beam
collimation and the constraints of superficial beam alignment, these
shields will typically be positioned before the treatment field is
positioned.
Electron Therapy and Bolus

Bolus materials in electron therapy are the same as those used with
photons; however, applications differ. Three applications for bolus
exist in electron therapy. First, electron beam dose distribution is
exquisitely sensitive to irregular surfaces and air cavities, and so
cavity filling is often necessary. Bolus over an even contour will
generally be positioned following beam alignment, whereas bolus to
fill a cavity or irregular surface may require placement in advance.
Second, as with photons, bolus may be used to eliminate skin sparing.
In contrast with photons, bolus only applies for low-energy electron
beams, as skin sparring decreases with increasing electron energy.
Third, overall treatment depth can be customized by combining
electron energy choice and bolus to decrease penetration.
Summary
• The radiation therapist is an active participant in the treatment
planning and delivery processes with a primary responsibility
to care quality. To meet treatment goals, whether palliative or
curative, the radiation therapist remains vigilant in accurate
treatment reproduction and delivery as prescribed by the
physician.
• As the expert in treatment delivery, the radiation therapist is
highly skilled in MV treatment units’ operation and
accessories used to customize each patient’s treatment.
Through treatment delivery and documentation, treatment
unit function monitoring, and inclusion on the departmental
QA committee, radiation therapists actively engage in
continuous patient care improvement.
• Patient safety and care are the radiation therapist’s
responsibility. As the treatment team member interacting with
the patient most frequently, the radiation therapist routinely
assesses patient mobility, pain, and social or other factors
affecting well-being. Physical and emotional reactions to
radiation treatment are addressed within the scope of practice
guidelines. Patients are directed to the physician or other
professionals as needs are discerned.
• Treatment room maintenance is critical to safe and efficient
patient care and treatment delivery. The radiation therapist
ensures access and proper treatment accessory handling, both
standard and customized for an individual patient.
• Before each patient’s arrival, the radiation therapist team
carefully reviews the treatment record to determine current
treatment status and the imminent session’s prescribed plan.
An action plan is prepared for, including positioning, beam-
shaping and beam-modification devices collection and
placement, and team agreement on verification procedures
and treatment field delivery sequence.
• Responses to treatment interruptions are understood and
appropriately applied with resumption protocols ranging
from immediate to delayed to deferring completion from the
session.
• Technical advances in diagnostic imaging, treatment planning
computers, and MV treatment units have created great
flexibility in treatment plans. Tumor volumes are identified
and localized with greater confidence, and treatment beams
are focused more narrowly. Normal tissue is increasingly
spared from radiation exposure and damage. Reduction in
setup error through improvements in positioning,
immobilization, and localization landmarks, then performing
precise pretreatment setup verification, is attained through
radiation therapist diligence, knowledge, and commitment to
their patients.
Review Questions
1. The patient arrives in the radiation oncology department
and is only able to stand and walk several steps at a time.
What is the most appropriate transportation and transfer
method?
a. Walk with assistance.
b. Wheelchair.
c. Stretcher without slide board.
d. Stretcher with slide board.
2. Recommended setup landmarks include:
I. Tattoos.
II. Palpable bony points.
III. Semipermanent ink marks.
a. I and II.
b. I and III.
c. II and III.
d. I, II, and III.
3. Which is added daily to the treatment record?
I. Treatment number.
II. Cumulative dose.
III. Elapsed days.
a. I and II.
b. I and III.
c. II and III.
d. I, II, and III.
4. The period over which radiation is delivered is:
a. Fractionation.
b. Exposure time.
c. Protraction.
d. Treatment plan.
5. Treatment beam shape and projection is verified through:
a. BEV evaluation.
b. Stereoscopic imaging.
c. CBCT.
d. Portal imaging.
6. Wedge systems include all the following except:
a. Global.
b. Universal.
c. Standard tray mounted.
d. Virtual.
7. Multileaf collimators may be used to:
I. Shape a beam.
II. Reduce dose to normal tissue.
III. Vary dose delivered across the beam.
a. I and II.
b. I and III.
c. II and III.
d. I, II, and III.
8. The feathering technique may be used to:
a. Eliminate overlap.
b. Increase dose to a gapped region.
c. Decrease dose to a gapped region.
d. Decrease dose between abutted fields.
9. The angle between two treatment beams’ central axes is
the:
a. Central angle.
b. Gantry angle.
c. Wedge angle.
d. Hinge angle.
10. Which is not a bolus use with electron treatments?
a. Eliminate high-energy electron skin sparing.
b. Eliminate low-energy electron skin sparing.
c. Decrease dose penetration depth.
d. Compensate for tissue deficits.
Questions to Ponder
1. Differentiate between an immobilization device and a
positioning aid.
2. Analyze information to be included in the radiation
therapy treatment chart.
3. Describe the treatment setup process.
4. Discuss factors contributing to decisions regarding portal
imaging frequency.
5. Discuss the radiation therapist’s role in continual patient
care quality improvement.
6. Practice converting closed- to open-ended questions.
References
1. Evans S.B, Fraass B.A, Berner P, et al. Standardizing
dose prescriptions: an ASTRO white paper. Pract
Radiat Oncol. 2016;6(6):e369–e381.
2. Mayo C.S, Moran J.M, Bosch W, et al. American
association of physicists in medicine task Group 263:
standardizing nomenclatures in radiation
oncology. Int J Radiat Oncol Biol
Phys. 2018;100(4):1057–1066.
3. American College of Surgeons. Standards for Oncology
Registry Entry. Effective January 1, 2018.
4. American Society of Radiologic Technologists. The
Practice Standards for Medical Imaging and Radiation
Therapy: Radiation Therapy Practice Standards. Effective
June 23, 2019. Available at
https://www.asrt.org/docs/default-source/practice-
standards/ps_radiationtherapy.pdf?
sfvrsn=18e076d0_22. Accessed September 25, 2019.
5. RO-ILS, ASTRO, AAPM. Radiation Oncology Incident
Learning System RO-ILS Year in Review 2015.
Available at
https://www.astro.org/uploadedFiles/_MAIN_SITE/Patient_Car
ILS/2015YIR.pdf. Accessed September 25, 2019.
6. The Joint Commission website.
www.jointcommission.org. Accessed January 2019.
7. David J.E, Castle S.K.B, Mossi K.M. Localization
tattoos: an alternative method using flourescent
inks. Radiat Ther. 2006;15:11–15.
8. Landig S.J, Kirby A.M, Lee S.F, et al. A randomized
control trial evaluating fluorescent ink vs dark ink
tattoos for breast radiotherapy. Br J
Radiol. 2016;89(1068):20160288.
9. Tadiparthi S, Shokrollahi K, Juma A, Croall J. Using
marker pens on patients: a potential source of cross
infections with MRSA. Ann R Coll Surg
Engl. 2007;89(7):661–664.
10. Timmerman R.D. (PI): RTOG 0618, A phase II trial of
stereotactic body radiation therapy (SBRT) in the
treatment of patients with operable stage I/II, non-
small cell lung cancer. Therapy Oncology
Group. 2012 Available
at. https://clinicaltrials.gov/ct2/show/NCT00591838 Accessed
September 25, 2019.
31
Digestive System Tumors
Leila Bussman-Yeakel
Colorectal Cancer,
Epidemiology and Etiology,
Anatomy and Lymphatics,
Clinical Presentation,
Detection and Diagnosis,
Pathology and Staging,
Routes of Spread,
Radiation Therapy,
Chemotherapy,
Field Design and Critical Structures,
Intraoperative Radiation Therapy,
Side effects,
Role of the Radiation Therapist,
Case I,
Preoperative Radiation for Rectal Cancer,
Anal Cancer,
Pathology, Staging, and Routes of Spread,
Case III,
Anal Cancer,
Esophageal Cancer,
Prognostic Indicators,
Routes of Spread,
Radiation Therapy,
Chemotherapy,
Side Effects,
Role of the Radiation Therapist,
Case IV,
Midesophagus,
Case V,
Lower Third of Esophagus,
Pancreatic Cancer,
Routes of Spread,
Radiation Therapy,
Chemotherapy,
Side Effects,
Case VI,
Case VII,
Pancreatic Cancer,
Summary,
Colorectal Cancer,
Anal Cancer,
Esophageal Cancer,
Pancreatic Cancer,
OBJECTIVES
• Identify, list, and discuss epidemiologic and etiologic factors that
may be responsible for induction of tumors in the colon, rectum,
anus, esophagus, and pancreas.
• Describe the symptoms produced by malignant tumors that arise
in the colon, rectum, anus, esophagus, and pancreas.
• Discuss the methods of detection and diagnosis for tumors in the
colon, rectum, anus, esophagus, and pancreas.
• List the varying histologic types of tumors that occur in the colon,
rectum, anus, esophagus, and pancreas.
• Describe the diagnostic procedures used in the workup and
staging of these sites.
• Describe in detail the most common routes of tumor spread for
these digestive system sites.
• Describe and diagram the lymphatic routes of spread for tumors of
the colon, rectum, anus, esophagus, and pancreas.
• Differentiate between histologic grading and staging.
• Describe in detail the anatomy and physiology of the colon,
rectum, anus, esophagus, and pancreas.
• Identify and discuss the rationale for treatment with regard to
treatment choice, histologic type, and stage of the disease.
• Describe the differing types of radiation treatment techniques that
can be used for tumors of the rectum, anus, esophagus, and
pancreas.
• Identify the appropriate tumor lethal dose or prescribed dose for
each site.
• Discuss the expected radiation reactions for the area based on
time-dose-fractionation schemes.
• Discuss tolerance levels of the vital structures and organs at risk.
• Describe the instructions that should be given to a patient with
regard to skin care, expected reactions, and dietary advice.
• Discuss the rationale for use of multimodality treatments for each
diagnosis.
• Describe the various treatment planning techniques.
• Discuss survival statistics and prognosis for various stages of
each cancer listed: rectum, anus, esophagus, and pancreas.
KEY TERMS
Abdominoperineal resection
Achalasia
Anterior resection
Barrett esophagus
Carcinoembryonic antigen
Chemoradiation
Chronic ulcerative colitis
Endocavitary radiation therapy
Endoscopic retrograde cholangiopancreatography
Endoscopic ultrasound scan
Familial adenomatous polyposis
Gardner syndrome
Hematochezia
Hereditary nonpolyposis colorectal syndrome
Intensity-modulated radiation therapy
Intraoperative radiation therapy
Leukopenia
Low anterior resection
Neoadjuvant
Odynophagia
Peritoneal seeding
Tenesmus
Three-point setup
Thrombocytopenia
Tylosis
Volume-modulated arc therapy
This chapter discusses the three major malignant diseases of the
gastrointestinal (GI) system that are managed with radiation therapy
(i.e., cancers of the rectum, esophagus, and pancreas). Colorectal
cancer is the most common GI malignancy; it is the second leading
cause of death from cancer among men and women combined, but it
is associated with the best prognosis of all GI malignancies.1 Cancers
of the esophagus and pancreas are usually diagnosed at an advanced
stage and do not have many long-term survivors.
Colorectal Cancer
Epidemiology and Etiology
The incidence rate of colorectal cancer has been steadily declining
since 1980 in men and women older than 50 years. However, the
incidence rate is rising in those younger than 50 years. Colon cancer
diagnosed in those younger than 50 years increased from 6% in 1990
to 11% in 2013, with most cases occurring in people in their 40s.2
About 101,420 cases of colon cancer and 44,180 cases of rectal cancer
are projected to occur each year.1 The disease affects men more
commonly than women. Cancer of the colon is ranked third in
incidence when men and women are compared separately. The risk of
development of cancer of the large bowel increases with age, with
more than 90% of cases occurring in people older than 55 years of
age.1,2 Colorectal cancer is the second leading cause of cancer death in
the United States; it accounts for approximately 50,000 deaths
annually. Death rates from colorectal cancer have been declining as a
result of early detection and better treatment.1,2
The cause of colorectal cancer has largely been attributed to a diet
high in animal fat and low in fiber. The excess fat in a person’s diet
may act as a promoter of the development of colon cancer. A diet high
in processed and red meats and low in fruit and vegetables has been
associated with an increased risk of colorectal cancer. The intake of
fiber in diets may act as an inhibitor, diluting fecal contents and
increasing fecal bulk, resulting in quicker elimination, and therefore
minimizing the exposure of the bowel epithelial lining to the
carcinogens. Other risk factors for the development of colorectal
cancer include obesity, smoking, type 2 diabetes, excessive alcohol
consumption (more than two drinks/day in men or one drink/day in
women), and minimal physical activity. There has been a steady
increase in the obesity rates among adults age 20 to 74. Men who are
obese have a 50% higher increased risk of developing colon cancer
compared with those who are of normal weight. Women who are
obese have a 20% increased risk of developing colon cancer.1,2
Recent studies have shown that the risk of colorectal cancer may be
decreased with the regular use of nonsteroidal antiinflammatory
drugs and postmenopausal hormone therapy. However, the use of
these drugs as a preventive measure is not recommended.1,2
Other principal factors in the development of colon cancer include
chronic ulcerative colitis, carcinomas that arise in preexisting
adenomatous polyps, and the hereditary cancer syndromes. These
syndromes are familial adenomatous polyposis (FAP) and hereditary
nonpolyposis colorectal syndrome (HNPCC), or Lynch syndrome.1–5
Individuals also at an increased risk for the development of colorectal
cancer are those with a first-degree relative with colorectal cancer or
adenomatous polyps before age 60 years. An increased risk also exists
if two or more first-degree relatives at any age had colorectal cancer or
adenomatous polyps in the absence of a hereditary syndrome.1–5
Chronic ulcerative colitis usually occurs in the rectum and sigmoid
area of the bowel but may spread to the rest of the colon. This
condition is characterized by extensive inflammation of the bowel
wall and ulceration. A patient experiences attacks of bloody mucoid
diarrhea up to 20 times a day. These attacks persist for days or weeks
and then subside, only to recur. The risk of development of colon
cancer depends on the extent of bowel involvement, age of onset, and
severity and duration of the active disease. The earlier the age at onset
and the longer the duration of the active disease, the higher the risk of
cancer. Studies have shown the risk to be 3% at 15 years’ duration,
with an increase to 5% at 20 years.4,5 Only 1% of patients with a
diagnosis of colorectal cancer have a history of chronic ulcerative
colitis.
Adenomatous polyps are growths that arise from the mucosal
lining and protrude into the lumen of the bowel. They are classified as
tubular or villous, based on their growth pattern and microscopic
characteristics. Polyps are considered a precursor to the development
of a malignancy. The larger the polyp, the greater the risk of
malignant transformation. Villous adenomas are 8 to 10 times more
likely than tubular adenomas to be malignant.6
FIG. 31.1 Anatomy of the large bowel.
From Thibodeau GA, Patton KT. The Human Body in Health and
Disease. 7th ed. St. Louis, MO: Mosby; 2018.
Virtually all patients with the hereditary condition FAP, if left

untreated, have colon cancer develop.4 FAP is characterized by the
studding of the entire large bowel wall by thousands of polyps.
Persons affected with this disease do not have polyps at birth.
Progression to extensive involvement of the colon usually occurs by
late adolescence. The cause of FAP is associated with a mutation on
the adenomatous polyposis coli gene on chromosome 5.7,8 FAP is
treated with the complete removal of the colon and rectum. Gardner
syndrome is another inherited disorder similar to FAP. Patients with
Gardner syndrome have adenomatous polyposis of the large bowel
and other abnormal growths, such as upper GI polyps, periampullary
tumors, lipomas, and fibromas.4,5
The frequent occurrence of colorectal cancer in families without
polyposis has been termed Lynch syndrome, formerly known as
HNPCC.1,4,5 This is the most common form of hereditary colorectal
cancer syndrome.1 The cause of Lynch syndrome (HNPCC) has been
attributed to mutations in repair genes located on chromosome 2, 3, or
7. Lynch syndrome has classically been defined as colorectal cancer
that develops in three or more family members, with at least two first-
degree relatives and involving people in at least two generations with
one family member with a diagnosis before the age of 50 years.2,7,8
Patients with this family history of colon cancer usually have right-
sided colon cancers develop at a much younger age than in the
general population. These patients are also at an increased risk for the
development of a second cancer of the colon and adenocarcinomas of
the breast, ovary, endometrium, and pancreas. Individuals with this
family history should undergo physical examinations regularly and
consider genetic testing.
Anatomy and Lymphatics

Cancer of the large bowel is usually divided into cancer of the colon or
rectum because the symptoms, diagnosis, and treatment are different
based on the anatomic area involved. A major factor that determines
the treatment and prognosis is whether a lesion occurs in a segment of
bowel that is located retroperitoneally or intraperitoneally. This is
discussed further in the section on the anatomy and lymphatic
drainage of these areas.
The colon is divided into eight regions: the cecum, ascending colon,
descending colon, splenic flexure, hepatic flexure, transverse colon,
sigmoid, and rectum. Located intraperitoneally, the cecum, transverse
colon, and sigmoid have a complete mesentery and serosa and are
freely mobile (Fig. 31.1). Lesions that occur in these regions can
usually be surgically removed with an adequate margin unless the
tumor is adherent or invades adjacent structures. Treatment failure or
recurrence is most likely attributed to peritoneal seeding.
Located retroperitoneally, the ascending and descending colon and
the hepatic and splenic flexures are considered immobile. They lack a
true mesentery and a serosal covering on the posterior and lateral
aspect. Because of the retroperitoneal location and lack of a mesentery
for these regions, early spread outside the bowel wall and invasion of
the adjacent soft tissues, kidney, and pancreas are common.
The rectum is continuous with the sigmoid and begins at the level
of the third sacral vertebra. Like the sigmoid, the upper rectum is
covered by the peritoneum, but only on its lateral and anterior
surfaces. The peritoneum is then reflected over the anterior wall of the
rectum onto the seminal vesicles and bladder in males or the vagina
and uterus in females, forming a cul-de-sac termed the rectovesical
pouch or rectouterine pouch, respectively. The lower half to two-thirds
of the rectum is located retroperitoneally. Three transverse folds
divide the rectum into areas known as the upper valve, middle valve,
and lower valve, or ampulla (Fig. 31.2). The middle valve is located 11
cm superior from the anal verge and represents the approximate
location of the peritoneal reflection.9 Because of the retroperitoneal
location, tumors of the rectum can invade adjacent structures of the
pelvis, such as the prostate, bladder, vagina, and sacrum. Treatment
options depend on the location of the lesion.
FIG. 31.2 A coronal section through the rectum.
From Patton KT. Anatomy and Physiology. 10th ed. St. Louis, MO:
Elsevier; 2019.
FIG. 31.3 A cross section of the bowel wall.
From Thibodeau GA, Patton KT: The human body in health & disease,
ed 7, St. Louis, 2018, Mosby, Copyright Elsevier (2018).
A cross section through a segment of large bowel reveals four main

layers: the mucosa, submucosa, muscularis propria, and serosa (Fig.
31.3).10,11 These layers are used in the staging system to define the
amount of involvement through the bowel wall. The mucosa, or
innermost layer, forms the lumen of the bowel and consists of two
supporting layers: the lamina propria and the muscularis mucosa. The
next layer, the submucosa, is rich in blood vessels and lymphatics. The
muscularis propria contains two muscle layers, one circular and one
longitudinal, which are responsible for peristalsis. Beneath the
muscularis layer is a lining of fat termed the subserosal layer. The
outermost layer is the serosa. Not all segments of the colon have a
serosal layer. This layer is provided by the visceral peritoneum.
The lymphatic drainage of the colon follows the mesenteric vessels.
The right colon follows the superior mesenteric vessels and includes
the ileocolic and right colic nodes (see Fig. 31.1). The left colon follows
the inferior mesenteric vessels and includes the regional nodes termed
the midcolic, inferior mesenteric, and left colic. The sigmoid region
drains into the inferior mesenteric system but also includes the nodes
along the superior rectal, sigmoidal, and sigmoidal mesenteric
vessels.10 Lymphatic drainage of the upper rectum follows the
superior rectal vessels into the inferior mesenteric system. Middle and
lower rectum lymphatic drainage is along the middle rectal vessels,
with the principal nodal group that comprises the internal iliac
nodes.12,13 Other nodal groups at risk for involvement with rectal
cancer are the perirectal, lateral sacral, and presacral nodes.10,14 Low
rectal lesions that extend into the anal canal can drain to the inguinal
nodes (Fig. 31.4).
With any of these regions, other nodal groups may be involved or at
risk for involvement if the tumor has invaded an adjacent structure.
For example, if a rectal cancer has invaded the vagina or prostate, the
external iliac nodes may be involved with disease.
FIG. 31.4 Lymphatic drainage of the rectum: 1 and 2, Nodes at the
origin of the inferior mesenteric artery and origin of the sigmoid vessels;
3, nodes of the sacral promontory; 4, sacral nodes; 5 and 6, internal
iliac nodes, hypogastric; 7, external iliac nodes that may be involved in
low rectal lesions; 8, nodes located at the rectal wall; 9, ischiorectal
nodes; and 10, inguinal nodes.
From del Regato JA, Spjut HJ, Cox JD. Ackerman and del Regato’s
Cancer: Diagnosis, Treatment, and Prognosis. 6th ed. St Louis, MO:
Mosby; 1985.
Patients with rectal cancer usually have rectal bleeding, which may be
bright red blood in the toilet or may be mixed in or on the stool.1,2
This bleeding is termed hematochezia. Other symptoms include a
change in bowel habits, diarrhea versus constipation, or a change in
the stool caliber.1,9,14 Pencil-thin stools, constipation, or diarrhea may
be indicative of a tumor that fills the rectal valve area and causes an
obstructive-type process. Dark or black-colored stools may also be a
symptom of cancer in the colon. This symptom results from a
chemical reaction of hemoglobin and the intestinal enzymes and
bacteria that gives stool a dark color. Tenesmus (spasms of the rectum
accompanied by a desire to empty the bowel) may be a patient’s
report with locally advanced rectal cancer. Pain in the buttock or
perineal area may occur from tumor extension posteriorly.4,9
Presenting symptoms of patients with lesions in the left colon are
similar to those of rectal cancer. Blood in the stool, a change in stool
caliber, obstructive symptoms, and abdominal pain are the most
common reports.2,4,5 In contrast, patients with right-sided colon
lesions usually have abdominal pain, which is often accompanied by
an abdominal mass. Nausea and vomiting are other possible
symptoms. Occult blood in the stool and microcytic anemia are two
other symptoms of colon cancer.4,5

In general, cancer in the large bowel is diagnosed via findings of
physical examination and radiographic and endoscopic studies.
Together, these findings provide crucial information in the detection
and extent of the disease process. In 2019, the American Cancer
Society (ACS) changed the screening guidelines for the early detection
of colorectal cancer, lowering the age recommendations from 50 to 45
years of age for a person at average risk.1,15 Screening tests include a
fecal occult blood test or fecal immunochemical test annually, fecal
immunochemical test-DNA exam every 3 years, flexible
sigmoidoscopy, double-contrast barium enema, or computed
tomographic colonography (CTC) every 5 years. A colonoscopy
should follow any positive test results. A colonoscopy, the preferred
screening test, examines the entire colon and can visualize polyps and
allow them to be removed for examination. Colonoscopy is done
every 10 years.1,2,7,15 Another technique for evaluation of the colon,
CTC, uses a CT scanner and three-dimensional (3D) software to
examine the inside the large intestine without insertion of the lengthy
scope through the rectum. The examination requires less bowel
preparation than a conventional colonoscopy and results in a
radiation dose that is equivalent to a barium enema. The procedure
can be used for patients who refuse colonoscopy or who are unable to
complete a regular colonoscopy procedure because of a combination
of technical factors. The fecal immunochemical test-DNA or
Cologuard is a new type of stool test that detects mutations in the
DNA of cells found in the stool that have been shed by a colorectal
cancer or large adenoma. This test also detects blood in the stool.2,15
Individuals at high risk, those with a family history of FAP or
Lynch syndrome, should undergo colonoscopies before age 45 years
and should determine a plan for screening with their healthcare
providers.2,4 These persons also benefit from counseling to consider
genetic testing.
The initial procedure for any patient with a malignancy is a
thorough history and physical examination. For all patients with
colorectal cancer, a digital rectal examination should be performed,
and attention should be given to the approximate size of the lesion,
the mobility, the location from the anal verge, and the rectal wall
involved.14 Enlarged perirectal nodes may also be detected during the
digital examination.
A proctosigmoidoscopy is performed as a complementary
procedure and allows a more accurate depiction of the size and
location of the lesion. This procedure also determines whether the
mass is exophytic or ulcerative. A tissue diagnosis is obtained from a
biopsy during the endoscopic procedure. A pelvic examination should
be performed for colon or rectal cancer to rule out any other pelvic
masses. An anterior extrarectal mass (a lesion in the cul-de-sac) may
be indicative of peritoneal seeding. In women, an anterior rectal mass
may invade the vaginal wall and put the external iliac nodes at risk for
involvement. The left supraclavicular and inguinal lymph nodes
should also be palpated, especially in patients with low rectal lesions
nearing the dentate line.12,13 Supraclavicular lymph node involvement
indicates extensive incurable disease and generally occurs as a result
of spread from metastatically involved paraaortic nodes via the
thoracic duct. The physical examination should also assess potential
sites of distant spread. Palpation of the abdomen should be performed
to check for masses in the abdomen, liver, and ascites.
Endoscopic procedures, colonoscopies, and proctosigmoidoscopies
can assess the size, location of lesion, and circumferential extent and
provide the distance of the lesion from the anal verge. They are also
used for obtaining biopsies of lesions or removing polyps for
histologic confirmation of malignancy.
After a diagnosis is established, a patient undergoes a staging
workup for determination of the extent or amount of spread of the
disease. A chest radiograph is usually obtained for detection of
metastasis to the lungs. CT scan or magnetic resonance imaging (MRI)
of the pelvis is done for evaluation of whether the tumor has extended
into other pelvic organs or structures and for determination of pelvic
lymph node involvement. An abdominal CT scan may also be
obtained for detection of metastasis to the liver or other abdominal
structures.14
Positron emission tomography (PET) has been used as part of the
staging workup for location of areas of uptake in the primary tumor,
lymph nodes, or distant metastasis. PET scans have shown uptake in
lymph nodes that was not seen on initial CT scan. A combined PET-
CT scan examination provides better anatomic correlation of areas of
involvement than PET alone. PET-CT scan is becoming a commonly
used examination for cancer staging and radiation treatment
planning.16
Laboratory studies used in the diagnosis and workup of colon
cancer include a complete blood count (CBC) and blood chemistry
profile. Elevated liver function test results indicate the need for
imaging of the liver with CT scan or with sonography. The tumor
specimen may also be evaluated for changes in the KRAS gene in the
cancer cells. If this mutation is found, the patient does not benefit
from treatment with monoclonal antibodies such as cetuximab or
panitumumab. Carcinoembryonic antigen (CEA) is a type of protein
molecule that may be associated with certain malignant tumors, such
as colon and ovarian cancer. It is sometimes used as a tumor marker
for colon cancers. If the protein marker levels are above normal before
treatment, they are expected to fall to normal levels after treatment.
Levels of more than 20 ng/mL before therapy may be associated with
widespread metastatic disease. A rising CEA level usually indicates a
recurrence of the cancer. For this reason, the protein molecule serves
as indicator for disease. The higher the level, the more disease may be
present.
Pathology and Staging

Adenocarcinoma is the most common malignancy of the large bowel;
it accounts for 90% to 95% of all tumors.4,17 Other histologic types
include mucinous adenocarcinoma, signet-ring cell carcinoma, and
squamous cell carcinoma.12,13
The American Joint Committee on Cancer (AJCC) tumor, node,
metastasis (TNM) system may be used clinically (before surgery) or
after surgery. The TNM system is the more commonly used system.
(For more information on staging colorectal cancer, see:
https://www.cancer.org/cancer/colon-rectal-cancer/detection-
diagnosis-staging/staged.html.)
The TNM system has incorporated changes from previous staging
systems into the current system. The revisions in the staging systems
reflect the two most important prognostic indicators of survival: the
number of nodes positive for tumor and the depth of penetration
through the bowel wall.4,5,10,12
The staging system devised by Dukes in the 1930s was the first
useful system.10 Tumors were classified according to the level of
invasion into the bowel wall and the absence or presence of nodes
positive for tumor. The tumors were given a letter designation from A
to C. Dukes’s A designation indicates a lesion that has not penetrated
through the bowel wall. The B designation indicates a lesion that has
penetrated the bowel wall with nodes negative for tumor, and the C
designation indicates a lesion with nodes positive for tumor. The
TNM system is the more commonly used system.
More than 95% of colon and rectal cancers are adenocarcinomas.
These are cancers of the cells that line the inside of the colon and
rectum. There are some other, rarer types of tumors of the colon and
rectum.2,7
Routes of Spread
As implied in the staging system, malignancies of the large bowel
usually spread via direct extension, lymphatics, and hematogenous
spread. Direct extension of the tumor is typically in a radial fashion,
with penetration into the bowel wall rather than longitudinally.5
Lymphatic spread occurs if the tumor has invaded the submucosal
layer of the bowel. The initial lymphatic and venous channels of the
bowel wall are found in the submucosal layer. Lymphatic spread is
orderly. The initial nodes involved for rectal cancer are the perirectal
nodes. Approximately 50% of patients have nodes positive for tumor
at the time of diagnosis.5
Blood-borne spread to the liver is the most common type of distant
metastasis. The mechanism of spread involves the venous drainage of
the GI system (the portal circulation). The second most common site
of distant spread is the lung. This spread results from tumor embolus
into the inferior vena cava (IVC).5
Lesions may also spread within the peritoneal cavity. The growth of
a tumor through the bowel wall onto the peritoneal surface of the
colon can result in tumor cells shedding into the abdominal cavity.
These shed cells then take up residence on another surface (i.e.,
peritoneal lining, cul-de-sac) and begin to grow. This process is called
peritoneal seeding. The implantation of tumor cells onto a surface at
the time of surgery is another mechanism of spread.
Surgery is considered the treatment of choice. The tumor, an adequate
margin, and the draining lymphatics are removed. The type of
procedure depends on the location of the tumor. For colon tumors, the
removal of a large segment of bowel, the adjacent lymph nodes, and
the immediate vascular supply is common with procedures such as a
right hemicolectomy or left hemicolectomy. Some colon surgeries are
done laparoscopically instead of with the traditional open procedure.
Patients who undergo laparoscopic colectomy recover from the
procedure sooner and have a shorter hospital stay than patients who
undergo an open procedure. For rectal cancer, the two most common
procedures are the low anterior resection (LAR) and the
abdominoperineal resection (APR). The use of a laparoscopic surgical
procedure for rectal cancer is more difficult to perform.
The LAR involves the removal of the tumor plus a margin (an en
bloc excision) and the immediately adjacent lymph nodes. The bowel
is then reanastomosed. Therefore a colostomy is not necessary. This
procedure is used in the treatment of colon cancers and select rectal
cancers.
An APR is used in patients with rectal cancer in the lower third
(distal 5 cm) of the rectum. An anterior incision is made into the
abdominal wall to construct a colostomy. Then, a perineal incision is
made to resect the rectum, anus, and draining lymphatics, with the
entire en bloc specimen pulled out through the perineal opening. The
final phase of the procedure involves the reconstruction or
reperitonealization of the pelvic floor through the use of an absorbable
mesh, omentum, or peritoneum. This is extremely important for the
patient who needs postoperative radiation therapy.
Reperitonealization allows the small bowel to be displaced superiorly,
reducing the amount of small bowel in the treatment field and
minimizing the treatment toxicity from radiation therapy.9
Radiation Therapy
Radiation therapy is most commonly used as an adjuvant treatment
for rectal cancer. This treatment is done either before or after surgery
and in conjunction with chemotherapy.
Postoperative adjuvant radiation therapy with concurrent
chemotherapy is advocated based on the high local failure rate of
surgery alone in patients with rectal cancer who have nodes positive
for tumor or tumor extension beyond the wall. Postoperative radiation
therapy and chemotherapy consistently have been shown to improve
local control and survival rates in patients with rectal cancer. A major
advantage of postoperative adjuvant treatment is that the physician
has pathologic confirmation of the extent of the tumor spread through
the wall to nodes or distant sites. This information is critical in
determining whether adjuvant treatment is necessary.12
Preoperative radiation therapy is another commonly used technique
for patients who have large rectal cancers that have invaded through
the muscle layer (T3) or who have imaging studies (MRI) that show
enlarged lymph nodes that indicate N1 or N2 disease. The goal of this
treatment is sphincter preservation. Radiation therapy combined with
chemotherapy is done before surgery to shrink the tumor so that a
LAR can be done, rather than an APR, to spare the patient a
colostomy. The potential advantages of preoperative radiation
therapy are downstaging of the primary tumor, which decreases the
chance of tumor spillage or seeding at the time of surgery; increased
radiosensitivity because of well-oxygenated cells in the nonoperative
pelvis; increase in local control of the disease; and less acute side
effects.12,18–20 A disadvantage to preoperative radiation therapy is the
lack of pathologic tumor (T) staging that results in the irradiation of a
patient with a T1or T2 tumor. Preoperative or neoadjuvant
chemoradiation is the most common treatment used today for locally
advanced rectal cancer.18,19,21,22
Radiation alone has also been used in patients who have conditions
that are medically inoperable or who have locally advanced rectal
cancer that is deemed unresectable.12,13 In this setting, radiation
provides palliation and is rarely curative. Radiation combined with
chemotherapy (5-fluorouracil [5-FU]) has proved more effective than
radiation alone in relieving symptoms, decreasing tumor progression,
and increasing overall survival.
Chemotherapy
The addition of adjuvant chemotherapy combined with radiation
therapy in the preoperative or postoperative setting in high-risk rectal
and colon cancer cases (T3 or N1, N2) has shown an increase in overall
survival rates (Fig. 31.5).12,18,19,23 Many studies have shown decreased
disease recurrence and improved survival rates with a combination of
5-FU and pelvic radiation therapy. The National Comprehensive
Cancer Network (NCCN) has established treatment guidelines for
patients with colon and rectal cancer. The current recommendations
for T3 rectal cancer are for continuous venous infusion 5-FU or oral
capecitabine during radiation therapy in the preoperative or
neoadjuvant setting.18,19 In the neoadjuvant setting, the
chemoradiation is followed by curative resection and then additional
5-FU with or without leucovorin, FOLFOX (5-FU, leucovorin,
oxaliplatin) regimen, or capecitabine with or without oxaliplatin. In
the postoperative setting, 5-FU with or without leucovorin or
FOLFOX is done first followed by radiation therapy with continuous
5-FU. Once the radiation therapy is completed, additional
chemotherapy with 5-FU with or without leucovorin or FOLFOX is
done. In the case of recurrent or metastatic rectal cancer, the same
drugs can be used or a regimen called FOLFIRI may be used. FOLFIRI
consists of 5-FU, leucovorin, and irinotecan.5,14 Two monoclonal
antibodies, bevacizumab and cetuximab, are being studied in the use
of advanced or metastatic colon or rectal cancer. Bevacizumab
(Avastin, Genentech, San Francisco, CA) is a drug that blocks the
growth of new blood vessels to the tumor and hinders the supply of
oxygen and nutrients necessary for continued growth of the tumor.
This drug is used in combination with FOLFOX or FOLFIRI.
Cetuximab (Erbitux, Bristol-Myers Squibb, NY) blocks the effects of
hormone-like factors that promote cancer cell growth and thus cause
cell death. Cetuximab may be used alone or in combination with other
chemotherapy drugs in patients who do not respond to the
chemotherapy agent irinotecan.7,14
FIG. 31.5 Improved survival rates with postoperative radiation and
chemotherapy versus radiation alone.
Modified from Krook JE, Moertel CG, Gunderson LL, et al. Effective
surgical adjuvant therapy for high-risk rectal carcinoma. N Engl J Med.
1991;324:709–715.
Field Design and Critical Structures

Patients who undergo preoperative or postoperative adjuvant
radiation therapy for rectal cancer are at a high risk for local
recurrence. These patients include those with extension beyond the
bowel wall, tumor adherence (T3, T4), or lymph nodes positive for
tumor (N1, N2). The treatment fields are typically designed to
encompass the primary tumor volume and pelvic lymph nodes, which
shrinks the field to treat the primary target volume to a higher dose.
Anatomic boundaries of the portals depend on whether the patient
underwent an anterior resection or anteroposterior (AP) resection
directly related to the areas at risk for recurrence. For patients with
rectal cancer, most recurrences occur in the posterior aspect of the
pelvis, including metastasis to the internal iliac and presacral lymph
nodes.12,13 These two nodal groups are not included in a standard
surgical resection for rectal cancer and need to be encompassed in
radiation portals.12,13 For irradiation of the pelvis, the dose-limiting
structure or organ at risk (OAR) is the small bowel. The small bowel
dose should be less than 45 Gy. Radiation treatment techniques and
the field design must take into consideration the amount of small
bowel in the field to minimize treatment-related toxicities. The
reduction of the small bowel dose is achieved through patient
positioning and positioning devices, bladder distention, multiple-
shaped fields, and dosimetric weighting.4,5,12 The dose to the small
bowel is more easily reduced during preoperative radiation therapy
than during postoperative radiation because with postoperative
radiation, the rectum and peritoneum have been removed, which
allows the small bowel to be displaced more inferiorly in the pelvis
and results in more small bowel within the radiation field. The dose
delivered to the large volume (tumor plus regional nodes) is 4500 cGy,
with the coned-down volume (primary tumor bed) receiving 5000 to
5500 cGy in 6 to 6.5 weeks. Doses in excess of 5000 cGy are not
advisable unless the small bowel can be excluded from the field.4,5,12,24
In the neoadjuvant treatment setting, a newer short-course radiation
therapy regimen has been used. The NCCN states that 2500 cGy in 5
fractions may be given as an alternative for T3 N0 patients followed
by surgery within 1 week. This approach is more commonly
performed in Europe but is in use in the United States. Short-course
radiation therapy may be an option for patients who live farther from
a cancer center, whose health is declining or are unable to receive
chemotherapy.21–24
Traditionally, a three-field technique in which the patient is
positioned prone (posteroanterior [PA] and opposed laterals wedged)
is used, which allows a homogenous dose to the tumor bed with
sparing of anterior structures, such as the small bowel. A four-field
PA/AP and opposed laterals technique may be used when the anterior
structures such as the prostate or vagina are at risk for involvement or
are involved. For patients who have undergone an anterior resection,
the superior extent of the field is placed 1.5 cm superior to the sacral
promontory, which correlates to L5 to S1 innerspace.4,9 Depending on
the superior extent of the lesion and clinical indications, the field may
need to be placed at the L4 to L5 interspace or extend superiorly to
include the paraaortic lymph node chain. The more superiorly the
field extends, the more precautions are necessary to avoid small bowel
injury and complications. The width of the PA/AP field is designed to
provide adequate coverage of the iliac lymph nodes. This border is
placed 2 cm lateral to the pelvic brim and inlet. The inferior border
generally includes the entire obturator foramina, although this may
vary depending on the location of the lesion. The recommended
inferior margin is 3 to 5 cm beyond the gross tumor before surgery or
below the most distal extent of dissection after surgery (Fig. 31.6). A
rectal tube is inserted at the time of simulation. Contrast (30 to 40 cm2)
is injected into the rectum to facilitate the localization of critical
structures and design of treatment fields. A radiopaque marker or BB
is placed on the anal verge to reference the perineal surface on
digitally reconstructed simulation radiographs (DRRs).
Lateral treatment portals and prone positioning with full bladder
distention allow the small bowel to be excluded from the treatment
volume. This position also assists in the localization of critical
posterior structures. Anatomically, the rectum and perirectal tissues
are extremely close to the sacrum and coccyx. In locally advanced
disease, the tumor may spread along the sacral nerve roots and result
in tumor recurrence in the sacrum. Therefore the posterior field edge
is placed 1.5 to 2.0 cm behind the anterior bony sacral margin. In
advanced situations, the entire sacral canal plus a 1.5-cm margin is
recommended.4,12 This margin allows day-to-day variances in the
patient setup caused by movement. Anteriorly, the field border is
placed at the anterior edge of the femoral heads to ensure coverage of
the internal iliac nodes. The lower third of the rectum lies immediately
posterior to the vaginal wall and prostate, which places these organs
and their draining lymphatics at risk for involvement. If the rectal
lesion has invaded anterior structures (prostate or vagina), the
anterior border is placed on pubic symphysis for inclusion of the
external iliac nodes (Fig. 31.6B).4,5,12
The use of a CT simulator allows the physician to more accurately
localize and outline the pertinent anatomic structures described
previously. The CT simulator software enables physicians to digitize
in different colors the target volume and critical healthy structures,
such as the rectum, bladder, and lymph nodes on each CT slice. The
intimate relationships of target versus healthy tissues are available at
the time of simulation and with the patient in treatment position. This
assists the physician and the dosimetrist in the accurate placement of
the isocenter and in the design of the fields. A DRR is produced to
show the radiation field outline, the treatment isocenter, and the
pertinent anatomic structures (Fig. 31.7). The CT images can be sent
electronically directly to dosimetry for treatment planning.
The CT simulation procedure requires the radiation therapist to
position patients prone on a positioning device, such as a belly board,
with the elbows “in” so that they do not hit the sides of the CT gantry
during the scan. Patients may also be positioned supine if treated
using volume-modulated arc therapy (VMAT) or intensity-modulated
radiation therapy (IMRT). The supine position is a more stable and
comfortable for the patient than prone. A vacuum bag immobilization
device under the legs provides a reproducible setup. It is extremely
important that patients be as straight as possible before the scan
because they cannot be repositioned once the scan is complete.
Patients may be given oral contrast to drink 45 minutes before the CT
simulation to allow the small bowel to be localized on the CT scans.
Additional contrast is typically placed in the rectum at the time of
simulation, and the tube is removed before scanning. IV contrast may
also be used at the time of simulation. The contrast allows blood
vessels to be highlighted and assists in the outlining of lymph node
groups at risk.
Initially, patients should be straightened with the external laser
system and any useful topographic anatomy. With the lasers,
temporary reference marks can be drawn on the patient and marked
with small radiopaque BBs. These marks may be used later in the
simulation process as a reference to check patient positioning or to
help place fiducial marks after topograms are acquired (if fiducial
marks are necessary with the virtual simulation software). The
reference isocenter is used to ensure that the patient did not move
during the scan. The reference isocenter is also used as the zero
coordinates from which the treatment isocenter is marked. A typical
topogram may extend from the level of the second lumbar vertebrae
to below the lesser trochanters. After the CT scan, the physician
determines the treatment isocenter while the patient is still on the CT
couch; images are reviewed by the physician, and the treatment
isocenter is determined based on the areas contoured on the CT
images. The isocenter coordinates are then programmed into the
movable lasers in the scanner room, and the patient is marked
accordingly. The patient then goes home with marks that will actually
be used for treatment delivery.
IMRT and VMAT are more recent techniques that are used in the
treatment of rectal cancer. VMAT combines IMRT with arc therapy.
The multileaf collimator leaves move while the treatment unit rotates
360 degrees around the patient to provide a highly conformal dose.
IMRT and VMAT use inverse forward planning to place dose limits
on OARs such as the small bowel, colon, bladder, and femoral heads.
VMAT allows more dose conformity to the planning target volume
and spares the small bowel more than conventional methods. IMRT
and VMAT are more costly than 3D conformal methods, and although
more tissues are exposed to low doses of irradiation with VMAT, the
benefit of sparing more healthy tissues is considered a greater
advantage. Treatment of rectal cancer with VMAT consisting of two
full arcs is becoming a more commonly used approach than 3D
conformal prone treatment fields.
Dose-limiting structures for treatment of ascending or descending
colon cancer include the kidney and the small bowel. Contrast studies
for assessment of renal function and kidney localization should be
performed before treatment or at the time of simulation to ensure the
adequate sparing of at least one kidney. For example, with treatment
of a right-sided colon lesion, 50% or more of the right kidney may be
in the field; therefore the left kidney must be spared.12,13 Three-
dimensional conformal radiation therapy techniques and IMRT may
be used. IMRT allows more sparing of the kidneys, liver, and small
bowel and is more commonly used.
FIG. 31.6 Radiation treatment fields. In all figures, the dotted line
indicates the field extension to be used after an abdominal-perineal
resection. (A) A standard lateral field. (B) A lateral field to include
external iliacs in patients who have involvement of structures with
external iliac lymph node drainage. (C) A standard
anteroposterior/posteroanterior field.
In patients with locally advanced colorectal cancer or recurrent

disease, local control is difficult to achieve because of limited surgical
options that result from fixation of the tumor to pelvic organs
(prostate, uterus) or unresectable structures, such as the presacrum or
pelvic sidewall. If microscopic residual disease exists, an external
beam dose of 6000 cGy or greater is necessary to provide a reasonable
chance for control. This dose is even higher (>7000 cGy) if gross
residual disease exists. These doses exceed the healthy tissue tolerance
dose of abdominal or pelvic structures and cannot be safely delivered
with conventional external beam.
The radiation therapist is also responsible for ensuring the accurate
delivery of the radiation treatments. Today, image-guided radiation
therapy (IGRT) is used to ensure radiation fields are correctly aligned
before initiation of treatment. Many different types of image guidance
technologies exist. One type is the linear accelerator equipped with a
kV imager along with electronic portal imaging device (EPID). The kV
imager produces an image of greater contrast and detail than the
equivalent EPID image taken with 6-MV photons. Radiation therapists
have the responsibility of taking the pretreatment port of the
treatment field or orthogonal pair and then matching the bony
anatomy on the kV image with the DRR from simulation and
applying any shifts (i.e., anterior, posterior, superior) in treatment
position before turning on the beam. Another IGRT system is cone-
beam CT (CBCT). The resultant scan is used to compare cone-beam
scan with the simulation CT scan. The simulation CT scan is registered
to allow the CBCT to be compared with it. Bony anatomy, soft tissues,
or fiducial marks, are matched to determine whether any shifts in
isocenter are necessary.
FIG. 31.7 (A) Computed tomography scan shows tumor (yellow
arrows) invading rectum. (B) Beam’s-eye lateral view. (D) Isodose
distribution of primary fields.
From Czito BG, Hsu D, Palta M, et al. Colon cancer. In: Gunderson L,
Tepper JE, eds. Clinical Oncology. 4th ed. Philadelphia, PA: Elsevier;
2016.
Recall the dose limits of radiation for the kidneys, liver, and small
bowel. What is the healthy tissue tolerance for each of these OARs?
Which of the three organs is most sensitive to radiation damage?
IMRT may help reduce the dose to OARs.
Intraoperative Radiation Therapy

Intraoperative radiation therapy (IORT) is a mechanism for
supplementing the external beam dose to assist in obtaining local
control of the tumor while sparing dose-limiting healthy structures.14
IORT is a specialized boost technique similar to brachytherapy. IORT
is also used when cancer recurs in the pelvis. As the name implies,
IORT involves an operative procedure that requires general
anesthesia. The radiation oncologist and surgeon must work closely
with one another to determine whether IORT is appropriate and
which diagnostic tests are helpful in planning the IORT and external
beam radiation treatments. A contraindication for IORT is the
presence of distant metastasis. The surgeon and radiation oncologist
also determine the optimal sequence of surgery and external radiation
by discussing the benefits and side effects of each.9,14
Patients who undergo an IORT procedure may receive a dose of
1000 to 2000 cGy of electrons in a single fraction directly to the tumor
bed. Critical dose-limiting structures (i.e., kidney, bowel) are shielded
or surgically displaced out of the radiation portal so that these healthy
tissues receive little or no radiation. This dose, delivered in a single
fraction, is two to three times the dose if delivered at conventional
fractionation of 180 to 200 cGy/fraction. For example, an IORT single
dose of 1500 cGy equals 3000 to 4500 cGy fractionated external
radiation. With the effective IORT dose added to the 4500 to 5000 cGy,
delivered with conventional external beam radiation, the total
effective dose equals 7500 to 9500 cGy. A dose this high cannot be
safely given with standard external irradiation.17,25
FIG. 31.8 Use of a belly board in the treatment of colorectal cancer.

(A) The patient lies prone on a belly board, allowing the small bowel to
be displaced anteriorly. (B) Computed tomography scan confirms
displacement of the small bowel.
A, From Rich T, Ajani JA, Morrison WH, et al. Chemoradiation therapy
for anal cancer. Radiation plus continuous infusion of 5-fluorouracil with
or without cisplatin. Radiother Oncol. 1993;27:209-215.) B, From
Janjan NA, Delclos ME, Crane CH. Colon and rectum. In: Cox JD, Ang
KK eds. Radiation Oncology: Rationale, Techniques, Results. 9th ed.
St. Louis, MO: Mosby; 2010.
The IORT dose is calculated at the 90% isodose line, with the energy
and dose delivered depending on the depth or amount of residual
disease. Electron energies of 9 to 12 MeV are used after a gross total
resection, or minimal residual and high energies of 15 to 18 MeV are
used for patients who have recurrent disease with gross residual or
unresectable disease. Some newer portable equipment is now
available for use in the operating room.
The precise role of IORT in the treatment of large bowel cancer is
still being studied. IORT continues to be used in locally advanced and
recurrent colorectal cancer. This treatment in addition to combined
modality therapy is associated with better local control and survival
rates.25 Moreover, toxicity can be significant. Further study is needed
before IORT becomes a widely accepted tool in the treatment of
colorectal cancer.
Side Effects
The acute and chronic side effects of irradiation to the pelvis or
abdomen are directly related to the dose, volume, and type of tissue
irradiated. The larger the area treated, the greater are the associated
toxicities. The toxicities of treatment increase with escalating doses
and depend on the healthy tissue tolerances of the structures in the
irradiated volume. For patients with colorectal cancer, the main dose-
limiting structure for acute and chronic side effects is the small bowel.
Acute toxicities of treatment include diarrhea, abdominal cramps and
bloating, proctitis, bloody or mucus discharge, and dysuria. Patients
may also experience leukopenia (an abnormal decrease in the white
blood cell count) and thrombocytopenia (an abnormal decrease in the
platelet count). GI and hematologic toxicities are increased when
chemotherapy is used with radiation therapy.12,13 In patients who
have their perineum treated, a brisk skin reaction (moist
desquamation) may result, which sometimes necessitates a treatment
break.
Chronic effects occur less often than acute side effects but are more
serious. Persistent diarrhea, increased bowel frequency, proctitis,
fistula, urinary incontinence, and bladder atrophy have occurred in
patients after radiation therapy. The most common long-term
complication is damage to the small bowel that results in enteritis,
adhesions, and obstruction.9,14 The incidence of small bowel
obstruction that necessitates surgery may be decreased by radiation
oncologists and surgeons working together to determine methods for
minimizing the amount of small bowel in the radiation field.
As mentioned previously, treatment techniques and fields are
designed to limit the dose to the small bowel. These include surgical
and radiation therapy interventions. For example, the surgeon can
reconstruct the pelvis to minimize the amount of small bowel in the
pelvis after an AP resection. The surgeon can help limit the volume of
tissue irradiated by placing clips to demarcate the tumor bed, which
allows the radiation oncologist to more precisely outline the area at
risk instead of requiring a more generous treatment volume.9,14
Radiation therapy techniques for limiting the small bowel dose are
numerous and involve the efforts of the radiation oncologist, radiation
therapists, and dosimetrists. Before CT simulation, the patient drinks
oral contrast to highlight the small bowel on the CT simulation scan.
Because the patient is scanned in treatment position, the physician can
use this information along with previous imaging studies, such as CT
scan and barium studies, to determine the tumor-small bowel
relationship and design the radiation field. Treatment with the patient
in a prone position with a full bladder causes the small bowel to shift
superiorly out of the treatment field and further reduces the dose to
the small bowel (Fig. 31.8). VMAT or IMRT reduces the dose to the
small bowel and allows the patient to be treated in a supine position.
The patient must be in a stable and reproducible position with use of
IMRT or VMAT.
The radiation oncologist and dosimetrist work together to further
reduce the small bowel dose by carefully planning the initial and
boost-field volumes with the use of 3D conformal treatment planning
with multileaf collimation (MLC). High-energy beams (≥6 MV) are
preferable with 3D conformal treatment planning because of the
depth-dose characteristics that deliver a homogeneous dose to the
target volume while allowing the more anterior healthy structures to
be spared. A multiple-field approach (three or four fields) coupled
with weighting of the fields to the posterior in patients with rectal
cancer further reduces the dose to the anteriorly located small bowel
(Fig. 31.9). The use of IMRT and VMAT is another method of reducing
dose to small bowel and other healthy tissues.

The radiation therapist plays a major role in the education of patients
and their families. Communication is the key factor in making a
patient’s experience with a cancer diagnosis and treatment less
traumatic and anxiety ridden. The therapist’s first major role with the
patient is in simulation. The therapist should inform the patient that
the simulation is not a treatment but a planning session to locate and
outline the area that needs treatment. The therapist should describe
the procedure to the patient, indicating the length of time it will take
and pointing out that the treatments do not require the same amount
of time. The patient’s position during the treatment should also be
discussed. The therapist should inform the patient about the contrast
materials that are used during the procedure, the skin marks to be
used to align the patient, and the importance of maintaining those
marks. If tattoos are used to indicate treatment isocenter or
positioning marks, the patient should be told about the process of a
needle stick and the permanency of these marks before the simulation
to obtain consent. If the patient is treated in the prone position, the
therapist should explain the procedure before the patient is
positioned. After the simulation begins, the therapist should
continually update the patient on what is happening throughout the
procedure. Keeping patients informed reduces the anxiety that they
may experience. Instrumental music played during the simulation or
treatment can calm and further reduce a patient’s anxieties and fears.
FIG. 31.9 Isodose distribution of a three-field plan for the treatment of
rectal cancer.
From Minsky BD, Rödel CM, Valentini V. Rectal cancer. In: Gunderson
L, Tepper JE, eds. Clinical Oncology. 4th ed. Philadelphia, PA:
Elsevier; 2016.
At the time of the first treatment, therapists should familiarize

patients with the treatment room and the location of the camera and
audio equipment and explain what patients should do if they need
something (e.g., raising their right hand). A common fear of patients is
being alone in the room. Therapists should discuss the actual length of
time that the machine is on per treatment. Therapists should also
inform the patients about the types of noises that are heard as the
machine is programmed and treatment is initiated. If the patient’s
family members are also present, the therapist may offer to show
them the treatment room and control area so that they may see the
video camera; however, the family should not be in the control area
during the initiation of treatment so that the therapist’s performance is
not hindered.
The therapist should assess the information given to the patient
regarding treatment instructions (e.g., full bladder) and potential side
effects. Written materials regarding bladder distention, a low-residue
diet, and available support services should be distributed during the
first week of treatment.
As treatments progress, the therapist is responsible for inquiring
about how the patient is feeling, monitoring any treatment-related
side effects, and checking on the patient’s emotional well-being. If the
patient reports abdominal cramping and diarrhea, the therapist
should determine whether the patient is following a low-residue diet
or has a prescription for an antidiarrheal agent, such as diphenoxylate
(Lomotil, Pfizer, NY) or loperamide (Imodium, Janssen
Pharmaceuticals, Beerse, Belgium). The therapist should ask the
patient about the physician’s instructions regarding the prescription.
In some instances, the patient may not be taking the medication
correctly. Dietary suggestions regarding which foods to avoid or
recommendations for a low-residue diet are the therapist’s
responsibility. If the patient is experiencing diarrhea, instructions to
avoid whole-grain breads or cereals, fresh fruits, raw vegetables, fried
or fatty foods, milk, and milk products may be helpful. Recommended
foods include white bread; meats that are baked, broiled, or roasted
until tender; peeled apples; bananas; macaroni and noodles; and
cooked vegetables (Table 31.1).7 If the patient still reports diarrhea
after diet and medications have been discussed, the patient may need
to be referred back to the physician or dietitian for further evaluation.
Skin reactions on the perineum or in the region of the gluteal cleft
may occur with the three-field technique. Skin reactions range from
brisk erythema (treated with topical steroid creams) to moist
desquamation (requiring sitz baths, Domeboro solution). Therapists
play an important role in monitoring the perineal area, which the
patient cannot easily see. The therapist meets with the patient daily
and can assess whether the reaction has intensified. The therapist can
question patients to determine the way in which they are caring for
their skin. If the patient has a moist desquamation, recommendations
include taking sitz baths in tepid water, wearing loose undergarments
or none at all, and allowing the area to be exposed to air and kept dry
after the bath. These suggestions keep the area clean, dry, and less
irritated.
TABLE 31.1
Dietary Guidelines for Patients Receiving Pelvic Irradiation

Recommended Foods Foods to Avoid
White bread Whole-grain breads or cereals
Meat baked, broiled, or roasted until tender Fried or fatty foods
Macaroni Milk and milk products
Cooked vegetables Raw vegetables
Peeled apples and bananas Fresh fruit
The physical side effects of treatment are often the most visible and
easiest to address; however, the therapist must be alert to the
emotional needs of the patient and family. The psychosocial aspect of
a cancer diagnosis and treatment can be just as painful as the
treatment or cancer itself. Therapists are not expected to diagnose but
should listen to what the patient is saying and be available to offer
suggestions and support. Sometimes, all the patient needs is for
someone to listen and know someone cares. The therapist should
provide the patient with information about community or hospital
services, such as the ACS, the hospital oncology social worker or
chaplain, and other support groups in the area. Patients with a
colostomy may be having difficulty adjusting to their appliance, so the
therapist can refer them to an endostomal therapist, (a healthcare
professional trained to care for individuals with stomas) for
assistance. The therapist should listen to patients and determine the
way their diagnosis and treatment has affected their self-image and
self-esteem. The ACS’s written materials about specific types of cancer
or other publications for patients with cancer should be handed out or
made available to the patient. These documents can be used by
patients as references and shared with families and friends because
patients may have trouble remembering much of this information
when given verbally by the physician.
Many patients today access much of the information about their
cancer and its treatment on the internet (for instance, much useful
information is posted on the ACS website, www.cancer.org).
Case I
Preoperative Radiation for Rectal Cancer
A 70-year-old woman presented to her primary care physician with a
reported change in bowel habits, blood in the stool, and weight loss. A
colonoscopy was obtained that revealed a rectal mass starting at 5 cm
from the anal verge. Biopsies were positive for invasive
adenocarcinoma. As part of the patient’s staging workup, a CT of the
chest, abdomen, and pelvis was obtained. An MRI of the pelvis was
also completed. The CT of the pelvis confirmed the presence of a large
rectal mass with involvement of the internal sphincter. The MRI of the
pelvis showed a low rectal mass with extension into the mesorectal
space and enlargement of multiple pelvic lymph nodes. The rest of the
imaging studies were negative for any distant metastasis.
Based on the imaging studies, the patient was staged as T3d, N2a,
and M0 or Stage III B. Because the tumor had spread beyond the
bowel wall into the mesorectal space, surgery to obtain negative
margins would be difficult. Therefore a course of
neoadjuvant chemoradiation was recommended. An APR was
planned after the completion of chemoradiation.
The patient received oral capecitabine chemotherapy and 5040cGy
in 28 fractions to the primary tumor. The radiation treatment
technique used was VMAT with four full 360-degree arcs to the pelvis
with IMRT planning minimizing the dose to OARs: small bowel,
colon, bladder, and femoral heads. Therapists would perform daily
onboard imaging and match to bony anatomy (pelvic bones).
Case II
A 51-year-old man presented to his primary care physician with a 1-
year history of intermittent hematochezia and mucus. He recently had
development of rectal discomfort. Physical examination results
revealed a mass that was freely mobile and exophytic on the left rectal
wall beginning about 4 to 5 cm above the anal verge. A colonoscopy
was done and showed a 2-cm to 3-cm polypoid mass in the lower
rectum. The mass was biopsied and found to be a moderately
differentiated adenocarcinoma. A CT scan of the chest, abdomen, and
pelvis was performed, and results were negative for metastatic
disease. An MRI of the pelvis was also completed. This showed a 3.8-
cm-long mass in the rectum that did not involve the sphincter but was
close to the mid- and caudal left levator ani muscle. The muscularis
propria was involved without any extension to the perirectal fat. One
6-mm perirectal lymph node and two sacral lymph nodes were
suspicious for cancer. Endoscopic ultrasound scan (EUS) could have
been performed but was not believed necessary as it would not have
changed the management of the case. The patient was given a stage of
IIIA T2 N1 M0 based on imaging studies.
Because the tumor was located close to the sphincter, the patient
was recommended to undergo neoadjuvant chemoradiation to shrink
the tumor to facilitate a better surgery with negative margins. The
patient’s chemotherapy consisted of infusion 5-FU and capecitabine.
A radiation dose of 5040 cGy to the pelvis was prescribed and
delivered with a three-field approach, with posterior and right and
left lateral IMRT fields. The patient was treated prone with full
bladder distension to minimize the amount of small bowel in the
treatment field. Daily IGRT, with an OBI kV imager, was useful in
matching the boney landmarks in the and sacrum.
Anal Cancer
Cancers of the anus occur more often in women than in men and
constitute approximately 1% to 2% of all large bowel malignancies.3
The ACS predicts that about 8300 new cases of anal cancer will occur
each year: 5530 in women and 2770 in men.1 The median age at the
time of diagnosis is 60 years.1 A general age distribution of 30 to 90
years is reported. The human papilloma virus infection (HPV) is
considered the causative factor in 90% of anal cancers.3,26 Other
etiologic factors for the development of anal cancer are associated
with genital warts, genital infections, anal intercourse, intercourse
before age 30 years, human immunodeficiency virus infection, and
immunosuppression.26–29 HPV-16 is the type of virus found in
squamous cell cancers of the anus. It is also found in some genital and
anal warts. HPV has been found to make two proteins, E6 and E7,
which are able to shut down two tumor suppressor proteins, p53 and
Rb, in healthy cells. When these tumor suppressors are rendered
inactive, cells can become cancerous.27,30 Cigarette smoking has also
been associated with the development of anal cancer.27

The anal canal is 3 to 4 cm long and extends from the anal verge to the
anorectal ring at the junction of the anus and rectum. The anal canal is
lined with a hairless, stratified squamous epithelium up to the dentate
or pectinate line. At this line, the mucosa becomes cuboidal in
transition to the columnar epithelium found in the rectum (Fig.
31.2).11,14
Lymphatic spread occurs initially to the perirectal and anorectal
lymph nodes. If the tumor extends above the dentate line, the nodal
groups at risk are the internal iliac and lateral sacral nodes; this is
similar to rectal cancer. With involvement below the dentate line,
inguinal lymph nodes may be involved. Inguinal lymph node
involvement is found in approximately 10% to 30% of patients.14,30
The most common presenting symptom is rectal bleeding (bright red).
Other symptoms are pain, change in bowel habits, and the sensation
of a mass. Pruritus or itching has been reported less often and is
associated with a perianal lesion.26,27,30

A thorough physical examination should be performed that includes a
digital anorectal examination (with notation of anal sphincter tone
and direct extension to other organs) and palpation of the inguinal
lymph nodes. Anoscopy or proctoscopic examination and biopsy
should be obtained. A further workup includes a CT scan of the
abdomen and pelvis to evaluate the liver and perirectal, inguinal,
pelvic, and paraaortic nodes. A PET scan for further assessment of
spread of tumor to lymph nodes or liver or an MRI has been
advocated. Transrectal sonography may also be done to determine
depth of invasion into the bowel wall.27,30 A chest radiograph, a CBC,
and liver function tests also are performed.
Pathology, Staging, and Routes of Spread

Squamous cell carcinoma is the most common histology of anal
cancer; it comprises approximately 80% of cases.26,30 The next most
frequent type is basaloid, or cloacogenic, cancer. These tumors occur
in the region of the dentate line where the epithelium is in transition.
Also found in this region are adenocarcinoma (arising from the anal
glands), mucoepidermoid tumors, and melanoma. Cancers that occur
in the perianal region are typically squamous or basal cell carcinomas
consistent with skin cancers.
The most commonly used staging system is the AJCC system. In
this clinical system, tumors are staged according to their size and
extent. (For more information about staging anal cancer, see
https://www.cancer.org/cancer/anal-cancer/detection-diagnosis-
staging/staging.html)
Tumors of the anal canal spread most frequently via direct
extension into the adjacent soft tissues. Lymphatic spread occurs
relatively early to pelvic nodes but more commonly to inguinal lymph
nodes, whereas hematogenous spread to the liver or lungs is less
common. The incidence rate of inguinal node involvement may be as
high as 20% for tumors more than 4 cm in diameter and as high as
60% with direct invasion of adjacent pelvis structures.30
Combination radiation therapy and chemotherapy (5-FU and
mitomycin C [MMC]) is advocated as the preferred method of
treatment and is considered the standard of care for most patients.
Cisplatin in combination with 5-FU has also been used. Cisplatin is
associated with fewer side effects and is more easily tolerated by the
patient.7,26,27,30 Radiation alone may be advocated for patients who
cannot tolerate chemoradiation. Studies have shown that the
multimodality (radiation and chemotherapy) approach provides good
local control and colostomy-free survival. Most series report survival
rates from 65% to 80% at 5 years, with a local control rate of 60% to
89%.7,27,30 An AP resection with a wide perineal dissection is the most
common surgical procedure for anal cancer. This procedure is no
longer done as the initial treatment, but it is done in the case of local
recurrence after conventional chemoradiation.7,27,30
A variety of radiation techniques exist for the treatment of anal
cancer. Current radiation treatment techniques today includes VMAT
fields. Traditionally, a four-field or AP/PA pelvic field with electron
fields to the inguinal nodes, including a boost to the tumor bed with a
perineal electron field or another multifield technique, has been used.
The pelvic field extends from the lumbosacral-sacroiliac region to 3
cm distal to the lowest extent of the tumor (noted by a radiopaque
marker at the time of simulation). The inferior border typically flashes
the perineum, which results in brisk erythema and moist
desquamation of the perineal tissues. The lateral border may extend to
include treatment of the inguinal lymph nodes on the AP field only,
placing that field edge at the midlateral aspect of the femoral heads.
The PA field is kept narrower because the anteriorly located inguinal
nodes do not receive much contribution from the posterior field. This
also avoids an excessive dose to the femoral heads and yet
encompasses the tumor bed and deep pelvic nodes. Anterior electron
fields centered over each inguinal region and abutting the PA lateral
border are used to further supplement the dose to the inguinal lymph
nodes. These fields require careful matching to avoid overlap into the
pelvic fields from the inguinal electron fields.
Many structures are identified as OARs in treatment of anal cancer,
such as the femoral head and necks, genitalia/perineum, small bowel,
and bladder. For this reason, VMAT is the standard treatment of anal
cancer. The inverse planning of IMRT allows doses to be conformed to
the primary tumor and has shown improved dosimetric coverage of
inguinal lymph nodes. The use of VMAT greatly reduces the doses to
healthy tissues (OARs) compared with the conventional 3D conformal
AP/PA technique and reduces the side effects patients
experience.21,23,26,30–32
A variety of radiation dose schemes have been used. The NCCN
recommendations for T2 to T4 anal cancer is a dose of 4500 cGy to the
pelvis and inguinal nodes followed by a shrinking field boost to
reduce small bowel toxicity with an additional 900 to 1400 cGy
delivered to the primary tumor.33A higher total dose is advocated for
T3 or T4 disease.19,34Total radiation doses range from 5400 to 5900
cGy.29,32,35
Chemoradiation, although a very effective treatment, is associated
with much acute toxicity. Almost all patients treated with AP/PA
fields experience a perineal skin reaction, with about half of the
patients encountering moist desquamation. IMRT has reduced the
type and severity of skin reactions patients experience. Nausea,
vomiting, and mild to moderate diarrhea are also reported. The most
severe and life-threatening complication is bone marrow suppression
from the irradiation to the pelvis and the 5-FU and mitomycin
regimen.7,26,29,30 Radiation therapists are responsible for monitoring a
patient’s blood counts and reporting any low counts, including the
absolute neutrophil count, to the radiation oncologist. The radiation
therapist sees the patient daily and should keep a watchful eye on the
perineal skin and advise patient on proper skin care. The radiation
therapist should also refer patients to the oncology nurse or radiation
oncologist for further advisement on skin care in case a break in
treatment is warranted.
In conclusion, radiation therapy in combination with chemotherapy
is considered the standard of care for the treatment of anal cancer and
provides sphincter preservation and satisfactory cure rates.
Case III
Anal Cancer
A 53-year-old woman presented with noticeable bleeding in her stool
and anal pain. A physical examination was performed, and a mass
was palpated. The patient then underwent a sigmoidoscopy, which
showed a 6-mm mass extending into the anal canal. The lesion was an
ulcerating fissure with raised edges located on the right lateral aspect
of the canal. A biopsy obtained demonstrated a well-differentiated
squamous cell carcinoma. Staging workup procedure included a PET-
CT of the pelvis that confirmed the mass in the anal canal and showed
no evidence of disease in inguinal lymph nodes or distant spread. The
patient was stage II T2 N0 M0.
To maintain continuity of the GI tract, chemoradiation was the
recommended course of treatment. Chemotherapy consisting of 5-FU
and MMC was given during the first and fifth weeks of radiation
treatment. The patient was prescribed 5040 cGy in 28 treatments to the
anal mass plus margin, and 4200 cGy was delivered to the elective
nodal regions, including the inguinal and pelvic nodes. The treatment
technique used VMAT with four full 360-degree arcs.
Esophageal Cancer
Cancer of the esophagus accounts for 1% of all cancers in the United
States, with approximately 17,650 cases reported each year.1 Men are
three to four times more commonly affected than are women (13,750
vs. 3,900, respectively).1,5 Most cancers of the esophagus are
diagnosed in patients between 55 and 85 years of age.36 Esophageal
cancer is usually diagnosed at an advanced stage and is nearly a
uniformly fatal disease. Each year, the ACS estimates about 16,080
esophageal cancer–related deaths will occur in the United States.1
Survival rates have been improving, with a current 21% overall
survival rate at 5 years compared with only 9% 5-year survival in
1989.1 Cancer of the esophagus occurs with the greatest frequency in
northern China, northern Iran, and South Africa.36–38 This has been
attributed to environmental and nutritional factors.
Many risk factors or etiologic factors contribute to the development
of esophageal cancer. Certain risk factors increase one’s chance of
development of a squamous cell carcinoma or adenocarcinoma of the
esophagus. For example, the most common and important etiologic
factors in the development of squamous cell cancer of the esophagus
in western countries are excessive alcohol and tobacco use. The
combination of these two factors has a synergistic effect on the
mucosal surfaces, which increases the risk of esophageal cancer and
other aerodigestive malignancies.34,39,40 Excessive alcohol use has
been an implicated risk factor for the development of squamous cell
carcinomas. The use of tobacco products has been shown to cause
squamous cell carcinomas. Tobacco use has also been shown to
increase an individual’s chance of development of adenocarcinoma of
the esophagus.36–38 The risk of development of esophageal cancer
increases with the number of packs of cigarettes smoked per day and
the amount of alcohol consumed.
Barrett esophagus is a condition in which the distal esophagus is
lined with a columnar epithelium rather than a stratified squamous
epithelium. This mucosal change usually occurs with
gastroesophageal (GE) reflux. One theory to explain this phenomenon
is that chronic chemical trauma that results from reflux causes the
mucosa to undergo metaplasia, leading to various degrees of
dysplasia that are precancerous.36–38 Adenocarcinoma of the
esophagus occurs in patients with a history of Barrett esophagus.
Longstanding GE reflux disease (GERD) is associated with the
development of adenocarcinomas of the distal esophagus.
Approximately 30% of esophageal cancers are associated with
GERD.36,41 Patients with GERD may or may not have development of
Barrett esophagus.
Dietary factors have also been implicated in the development of
cancer of the esophagus. Diets low in fresh fruits and vegetables and
high in nitrates (i.e., cured meats and fish, pickled vegetables) have
been cited as risk factors for persons from Iran, China, and South
Africa. A diet high in fruits and vegetables is considered a preventive
measure against the development of esophageal and other cancers.
Overweight and obesity have been linked to the development of
adenocarcinomas.36,40,41
Other conditions predispose individuals to the development of
esophageal cancer. They include achalasia, Plummer-Vinson
syndrome, caustic injury, and tylosis.
Achalasia is a disorder in which the lower two-thirds of the
esophagus loses its normal peristaltic activity. The esophagus
becomes dilated (termed megaesophagus), and the esophagogastric
junction sphincter also fails to relax, which prohibits the passage of
food into the stomach. Clinical symptoms include progressive
dysphagia and regurgitation of ingested food. Patients with achalasia
have a 5% to 20% risk of development of squamous cell cancer of the
esophagus.36
Tylosis is a rare inherited disorder that causes excessive skin
growth on the palms of the hands and soles of the feet. Individuals
with this condition are at significant risk of about 40% of development
of a squamous cell carcinoma. A mutation on chromosome 17 is
thought to cause tylosis and the associated squamous cell carcinoma.36
Many believe that some risk factors, such as use of tobacco or
alcohol abuse, cause esophageal cancer by damaging the DNA of cells
that line the inside of the esophagus. The DNA of esophageal cancer
cells microscopically often shows many abnormalities; however, no
special changes have been described that are typical of this cancer.
Long-term irritation of the lining of the esophagus, as with GERD,
Barrett esophagus, achalasia, esophageal webs, or scarring from
swallowing lye, can promote the formation of cancers.36
Prognostic Indicators
Tumor size is an important prognostic tool. According to a series by
Hussey and colleagues,39 patients with tumors less than 5 cm in
length had a better 2-year survival rate (19.2%) than did patients with
lesions larger than 9 cm (1.9%). Tumors 5 cm or less in length were
more often localized (40% to 60%), whereas tumors larger than 5 cm
had distant metastasis 75% of the time.39 Other factors that indicate a
poor prognosis are weight loss of 10%, a poor performance status, and
age greater than 65 years.

The esophagus is a thin-walled 25-cm-long tube lined with stratified
squamous epithelium. The esophagus begins at the level of C6 and
traverses through the thoracic cage to terminate in the abdomen at the
esophageal gastric junction (T10 to T11).
For accurate classification, staging, and recording of tumors in the
esophagus, the AJCC has divided the esophagus into three regions:
upper thoracic, middle thoracic, and lower thoracic or GE junction.
The staging system is also subdivided based on pathology: squamous
cell carcinoma or adenocarcinoma. Because lesions are localized with
an endoscopy, reference is made to the distance of the lesion from the
upper incisors (front teeth). This distance is also used in defining each
region (Fig. 31.10).10
The cervical esophagus extends from the cricoid cartilage to the
thoracic inlet (suprasternal notch [SSN]), corresponding to vertebral
levels C6 to T2 to T3 and measuring about 18 cm from the upper
incisors. The thoracic inlet (SSN) to the level of the tracheal bifurcation
(carina)—24 cm from the incisors—defines the upper thoracic portion.
The middle thoracic esophagus begins at the carina and extends
proximally to the esophageal gastric junction, or 32 cm from the
incisors. The lower thoracic portion includes the abdominal
esophagus and is approximately 8 cm long at a level of 40 cm from the
incisors.10
The esophagus lies directly posterior to the trachea and is anterior
to the vertebral column. Located laterally and to the left of the
esophagus is the aortic arch. The descending aorta is situated lateral
and posterior to the esophagus (see Fig. 31.10). During an endoscopy,
an indentation is visible where the aorta and left mainstem bronchus
are in contact with the esophagus. Because of the esophagus’s intimate
relationship with these structures, tumors are often locally advanced,
fistulas may occur, and surgery is often not feasible.34,39,40
FIG. 31.10 The relationship of the esophagus with surrounding
anatomic structures, including divisions of the esophagus and their
location from the upper central incisors.
From Cox JD, Ang KK, eds. Radiation Oncology: Rationale,
Techniques, Results. 9th ed. St. Louis, MO: Mosby; 2010.
Histologically, the esophagus consists of the usual layers of the

bowel common to the GI tract (i.e., the mucosa, submucosa, and
muscular layers). However, the esophagus lacks a serosal layer. The
outermost layer, the adventitia, consists of a thin, loose connective
tissue. This is another factor that contributes to the early spread of
these tumors to adjacent structures.39
The esophagus has numerous small lymphatic vessels in the
mucosa and submucosal layers. These vessels drain outward into
larger vessels located in the muscular layers (Fig. 31.11). Lymph fluid
can travel the entire length of the esophagus and drain into any
adjacent draining nodal bed, which places the entire esophagus at risk
for skip metastasis and nodal involvement.
Although the entire length of the esophagus is at risk for lymphatic
metastasis, each region still has primary or regional nodes that
specifically drain the area. For example, the upper third (cervical area)
of the esophagus drains into the internal jugular, cervical,
paraesophageal, and supraclavicular lymph nodes. The upper and
middle thoracic portion has drainage to the paratracheal, hilar,
subcarinal, paraesophageal, and paracardial lymph nodes. Finally, the
principal draining lymphatics for the distal or lower third of the
esophagus include the celiac axis, left gastric nodes, and nodes of the
lesser curvature of the stomach (Fig. 31.12). Lymphatic spread is
unpredictable and may occur at a significant distance from the tumor.
Nodes positive for tumor outside a defined region represent distant
metastasis rather than regional spread. For example, supraclavicular
nodal involvement in a primary tumor located in the cervical
esophagus is considered regional lymph node involvement, but this is
a distant metastasis for tumors that arise in the thoracic esophagus.10
FIG. 31.11 Lymphatic vessels located in the wall of the esophagus.
From Cox JD, Ang KK, eds. Radiation Oncology: Rationale,
Techniques, Results. 9th ed. St. Louis, MO: Mosby; 2010.
The most common presenting symptoms are dysphagia and weight
loss, which occur in 90% of patients. Patients report food sticking in
their throat or chest and may point to the location of this sensation.
Initially, patients have difficulty with bulky foods, then with soft
foods, and finally even with liquids. Patients may recall having this
difficulty in swallowing for 3 to 6 months before the diagnosis.
Regurgitation of undigested food and aspiration pneumonia may also
occur. Odynophagia (painful swallowing) is reported in
approximately 50% of patients. Patients may report pressure or a
burning sensation similar to heartburn. Weight loss, as a result of the
difficulty in swallowing food, is a common finding. Symptoms of a
locally advanced tumor include the following: hematemesis (vomiting
blood), coughing (caused by a tracheoesophageal fistula), hemoptysis,
Horner syndrome, and hoarseness, as a result of nerve
involvement.34,39
FIG. 31.12 Lymphatic drainage of the esophagus. The arrows
represent potential spread to cervical, mediastinal, and
subdiaphragmatic lymph nodes, based on the location of the
esophageal lesion. Subdiaphragmatic involvement is unusual in the
upper-third tumors.
Cancer: Diagnosis, Treatment, and Prognosis. 6th ed. St Louis, MO:
Mosby; 1985.

A thorough history and physical examination should be performed.
Information should be obtained regarding weight loss and the use of
alcohol and tobacco. The physical examination should include
palpation of the cervical and supraclavicular lymph nodes and
abdomen for assessment of potential spread to the nodes or liver. A
chest radiograph and barium swallow are necessary for localizing the
lesions causing the dysphagia. A barium swallow depicts
characteristic features of esophageal cancers. The reported incidence
of tumors located in each third of the esophagus varies in the
literature. Lesions in the upper third of the esophagus occur with the
least frequency. The most common site of occurrence in the United
States is in the lower one-third of the esophagus and the GE junction.
A CT scan of the chest and upper abdomen should be obtained. This
scan may show extramucosal spread and invasion of adjacent
structures such as the trachea or aorta. Spread to lymph nodes in the
thorax and abdomen can be also assessed. Blood-borne metastases to
the liver and adrenals may be imaged via CT scan, although small
lesions may not be detectable.34,36
A histologic confirmation is obtained during an esophagoscopy. A
rigid or flexible endoscope can be used to examine the entire
esophagus, with brushings and biopsies of all suspicious lesions
obtained. EUS is also helpful for visualizing the tumor, its depth of
invasion, and lymph node status.40 A bronchoscopy should also be
performed for all upper-third or middle-third lesions to detect any
possible communication or fistula of the tumor with the
tracheobronchial tree.10,34,39
The PET scan has become a standard test for the staging workup of
patients with esophageal cancer. Fluorodeoxyglucose (FDG), a sugar,
is taken up by cancer cells because of their high mitotic activity.
Recent studies have shown the effectiveness of PET in the staging of
esophageal cancer. A PET scan demonstrates involvement of lymph
nodes and liver, as well as the primary tumor. Metastatic disease was
detected in 15% to 20% of patients with PET after the original workup
with endoscopy and CT scan.41

The most common pathologic types of esophageal cancer are
squamous cell carcinoma and adenocarcinoma. Squamous cell
carcinomas are found most frequently in the upper and middle
thoracic esophagus.34 Adenocarcinoma typically occurs in the distal
esophagus and GE junction; however, it can occur in other regions of
the esophagus. In the United States, the most common pathologic type
and site that occurs is adenocarcinomas of the distal esophagus and
GE junction.37,41,42 A variety of other epithelial tumors arise in the
esophagus but are rare. These include adenoid cystic carcinoma,
mucoepidermoid carcinoma, adenosquamous carcinoma, and
undifferentiated carcinoma.39,40
Nonepithelial tumors also arise in the esophagus, although these
are rare. Leiomyosarcoma (a tumor of the smooth muscle) is the most
common nonepithelial tumor. Leiomyosarcomas yield a more
favorable prognosis than do squamous cell carcinomas. Malignant
melanoma, lymphoma, and rhabdomyosarcoma are other
nonepithelial tumors that can occur in the esophagus.39
The tumor specimen may be examined for a specific gene or protein
called HER2. Some patients with cancer of the esophagus have an
excess of this protein on the surface of the cancer cells. This protein
allows the cancer cells to grow. In addition, if the HER2/neu oncogene
is overexpressed in adenocarcinoma of the esophagus, the disease
may carry a poorer prognosis. Patients whose cancer is found to have
excess HER2 may benefit from targeted therapy with a monoclonal
antibody called trastuzumab.34
The AJCC staging system for esophageal cancer is available more
information about staging esophageal cancer. See:
https://www.cancer.org/cancer/esophagus-cancer/detection-diagnosis-
staging/staging.html
Squamous cell carcinoma and adenocarcinoma of the esophagus
have separate staging systems. The staging for squamous cell
carcinoma includes tumor location relative to the pulmonary vein and
histologic grade. The staging for adenocarcinoma of the esophagus
includes tumor grade but does not include location.10
Routes of Spread
Because the esophagus is distensible, lesions are large before they
cause obstructive symptoms. Spread is usually longitudinal.
Occasionally, skip lesions may be present at a significant distance
from the primary lesion. This is principally the result of submucosal
spread of the tumor through interconnecting lymph channels. Locally
advanced disease, invasion into adjacent structures, and early spread
to draining lymphatics are common in esophageal cancer. Because the
esophagus lacks a serosa layer, tracheoesophageal fistulas or
bronchoesophageal fistulas may easily occur.34 Distant metastasis can
occur in many different organs, with the liver and lung being the most
common.
The treatment of esophageal cancer is highly complex and technically
difficult. Most patients have locally advanced or metastatic disease at
the time of diagnosis and need multimodality treatment. Treatment is
usually categorized as curative or palliative and may be given with
surgery or radiation for the locoregional problem and chemotherapy
for distant spread of disease. Patients who receive either modality
(surgery or radiation) alone have a significant risk of local recurrence
and distant metastasis. The primary goal of either treatment is to
provide relief of the dysphagia and a chance for cure. Many different
combined modality treatment regimens are being studied to
determine whether one approach provides a better local control and
survival outcome than others. The two most commonly used
combined modality techniques are definitive chemoradiation therapy
and neoadjuvant chemoradiotherapy followed by surgery.26,43,44
Definitive chemoradiation therapy has been the current nonsurgical
standard for the treatment of esophageal cancer. Current studies are
evaluating preoperative chemoradiotherapy with different
chemotherapeutic agents and definitive chemoradiotherapy for
locoregional cancers of the esophagus. Current studies are being done
to review biomarkers on DNA repair protein that might predict a
patient’s response to chemotherapy or radiation.39
A variety of surgical techniques exist for the resection of esophageal
cancer. In many centers, surgical resection is limited to the middle and
lower thirds of the esophagus. The cervical esophagus is not
considered a surgically accessible site in many institutions and is often
managed with radiation therapy and chemotherapy. Curative surgery
usually involves a subtotal or total esophagectomy. The type of
procedure chosen depends on the location of the lesion and extent of
involvement. Typically, the entire esophagus is removed. The
continuity of the GI system is maintained by placing either the
stomach or left colon in the thoracic cavity. Complications from
surgery include anastomotic leaks (which can be life-threatening),
respiratory failure, pulmonary embolus, and myocardial infarctions.
Strictures, difficulty in gastric emptying, and GE reflux are mechanical
side effects that result from surgery. Even after a curative resection,
most patients have distant failure with blood-borne spread to the
lungs, liver, or bone.
Radiation Therapy
Neoadjuvant chemoradiation followed by curative surgery remains
the treatment standard.45–47 Radiation therapy with chemotherapy is
considered the current nonsurgical treatment of choice for esophageal
cancer. Studies have showed a clear advantage for radiation therapy
and chemotherapy compared with radiation therapy alone.34,39,40
Radiation therapy alone might be used in patients who are medically
unable to undergo combined modality treatment.
Chemotherapy
The poor survival rates of esophageal cancer are associated with the
high percentage of patients with local failure and with distant
metastases after curative treatment. The addition of combination
chemotherapy has resulted in a decrease in local and distant failures
and an increase in the overall survival rate compared with radiation
alone (Figs. 31.13 and 31.14).34,39,40,48
FIG. 31.13 A comparison of radiation alone with combined radiation

and chemotherapy regarding the time to a local recurrence in patients
with esophageal cancer.
From Herskovic A, Martz K, al-Sarraf M, et al. Combined chemotherapy
and radiotherapy compared with radiotherapy alone in patients with
cancer of the esophagus. N Engl J Med. 1992;326:1596.
FIG. 31.14 A comparison of radiation alone with combined radiation

and chemotherapy regarding the time to a distant metastasis in
patients with esophageal cancer.
Modified from Herskovic A, Martz K, al-Sarraf M, et al. Combined
chemotherapy and radiotherapy compared with radiotherapy alone in
patients with cancer of the esophagus. N Engl J Med. 1992;326:1595.
Carboplatin and paclitaxel have replaced continuous-infusion 5-FU

and cisplatin as the standard drugs used in the treatment of
esophageal cancer. These two drugs have less toxicity and are better
tolerated by the patient than 5-FU and cisplatin. Combined-modality
therapy has definite local control and survival benefits. Many drug
combinations are being studied and are in use.47
Esophageal cancer spreads longitudinally, with skip lesions up to 5
cm from the primary lesion. Regional spread to draining lymphatics is
a common early presentation and must be taken into consideration in
the design of the radiation field. The cervical, supraclavicular,
mediastinal, paraesophageal, and subdiaphragmatic (celiac axis)
lymph node regions are at risk. The degree to which these nodal
groups are at risk depends on the location of the primary tumor.
Supraclavicular nodes are involved more often with a proximal lesion
than a distal lesion. However, neck or abdominal nodal disease
involvement can occur with any esophageal primary site.34,39,40
FIG. 31.15 Proton beam treatment for gastroesophageal junction

tumor. Note sparing of heart and lungs.
From Chuong, MD, Hallemeier, CL, Jabbour, SK, et al. Improving
outcomes for esophageal cancer using proton beam therapy. Int J
Radiation Oncol Bio Phys. 2016;95[1]:488–497.
The clinical treatment volume includes the regional lymphatics and

encompasses the primary tumor with a 3-cm to 4-cm margin above
and below the gross tumor volume and a 1-cm radial margin.34 The
margin on the lymph nodes should be expanded 0.5 to 1.5 cm from
the gross tumor volume. The planning target volume is also expanded
an additional 0.5 to 1 cm for radial or lateral margins.34,47 Lesions of
the upper third of the esophagus are treated with a field that begins at
the level of the thyroid cartilage and ends at the level of the carina to
include supraclavicular, low anterior cervical, and mediastinal lymph
nodes.34 In patients with tumors of the distal third of the esophagus,
the inferior margin must include the celiac axis lymph nodes, which
are located at the T12 to L1 vertebral level. The superior extent of the
treatment field should include the paraesophageal nodes and
mediastinal nodes and may not include the supraclavicular nodes
because they are at a low risk of being involved.34,39,40 For tumors of
the midthoracic esophagus, the anatomic borders included in the
treatment field include the periesophageal lymph nodes and
mediastinal nodes but may not include the supraclavicular fossa or
the esophagogastric junction.34,48
A variety of radiation techniques are used in the treatment of
esophageal cancer. This includes 3D conformal fields (AP/PA, laterals,
or obliques), IMRT fields, and VMAT. The technique chosen is
dependent on the location of the esophageal cancer, proximal versus
distal, and which technique minimizes the dose to OARs. Many
critical structures need to be considered, such as the lung, heart, spinal
cord, kidneys, and liver. Many studies have been done to determine
which technique provides adequate coverage of the target volume
with minimal dose to healthy tissues. IMRT and VMAT result in
radiation dose distributions that are highly conformal to the target
volume and have shown better sparing of healthy tissues, such as
lung, heart, and spinal cord than 3D conformal fields.39,49–55
The use of proton beam therapy for the treatment of esophageal
cancer is also being evaluated. The characteristic properties of a
proton beam result in no exit dose, thus sparing the anatomic
structures beyond the target. The use of intensity-modulated proton
therapy (IMPT) or pencil beam scanning paints the dose to the target
level resulting in a highly conformal dose distribution. Preliminary
studies show that proton therapy significantly reduces the dose to the
lung, heart, liver, and spinal cord more than traditional IMRT with
photons or 3D conformal techniques.15,45,51,52 Treatment field
arrangements that have been used include two posterior oblique fields
or AP and two posterior oblique fields, which allows sparing of
anterior structures such as the heart and lungs14,21 (see Fig. 31.15).
For treatment of the esophagus with radiation alone, the prescribed
dose is 60 to 65 Gy. With preoperative combined radiation and
chemotherapy, the total dose is 41.4 to 50.4 Gy to minimize healthy
tissue toxicity. The dose for definitive chemoradiation is 50 to 50.4
cGy.50 Both of these doses exceed the radiation tolerance dose of the
spinal cord, which is 45 to 50 Gy. Careful dosimetry planning for
VMAT or static IMRT is necessary to ensure the dose constraints for
lung, heart, spinal cord, kidney, and liver doses are met.
Patients are typically placed in the standard supine position for
simulation. Because lateral treatment field arrangements or rotational
arcs may be used, the patient’s arms are often positioned above the
head, with the patient clasping the elbows or wrists. This position can
be difficult for the patient to hold and maintain, which can cause
reproducibility problems later during treatment. Custom-made
immobilization devices such as body casts, foaming cradles, and
vacuum bag devices greatly assist the daily reproducibility of the
setup. Care should be taken when making the immobilization device
to ensure it fits within the bore of the CT scanner. With or without a
custom-made device, measurements of the elbow-to-elbow separation
and a photograph of the patient arm position assist in the consistency
of the daily setup.
For the simulation of patients with their arms along their sides for
cancers of the upper esophagus, the elbows should be bent slightly
out from the body so that a set of marks can be placed on the thoracic
cage for a three-point setup. The arms are mobile and are not reliable
for positioning and maintaining the established isocenter daily. A
thermoplastic mask that fits over the shoulders may be used to
maintain shoulder and head position. Marks may be placed on
midline at the inferior field edge of patient in addition to the isocenter
mark for alignment and straightening purposes. A set of three
reference points are placed lower on the thoracic cage and are used to
establish the isocenter. The AP source-skin distance, or setup distance,
is double-checked and maintained, especially with oblique treatment
fields.
A liquid or pudding-type contrast may be given at the time of the
CT simulation to visualize the esophagus. Patients with severe
dysphagia may not tolerate this, especially in the supine position. Oral
contrast may not be used at all for simulation or treatment to maintain
consistency in daily treatment setup. The patient is instructed not to
eat 2 to 3 hours before the simulation or for treatment. Intravenous
contrast may be used to assist in definition of target volume for
treatment. The simulation may also include a four-dimensional (4D)
CT scan to assess the amount of respiratory motion that occurs and
how this affects internal target volumes. Margins for clinical treatment
volumes may need to be adjusted based on the 4D CT data.
Respiratory gating may be beneficial for the treatment of some
patients.45,42,49,47
The radiation therapist ensures that the patient is straight and
places reference marks on the thoracic cage and radiopaque markers
on these marks for visualization on the scan. The coordinates of these
reference marks, pilot, or scout length may be recorded. A scan from
above the mandible to the iliac crest to include the entire esophagus
and stomach may be obtained. After the scan, the physician digitizes
in different colors the target volume and critical anatomy as listed
previously. The treatment isocenter also is identified. After the CT
scan, the physician determines the treatment isocenter while the
patient is still on the CT couch. Images are reviewed by the physician,
and the treatment isocenter is determined based on the areas
contoured on the CT images. The isocenter coordinates are then
programmed into the movable lasers in the scanner room, and the
patient is marked accordingly. The patient then goes home with
marks that will actually be used for treatment delivery. Patient setup
information, such as positioning and immobilization devices, is
recorded at the time of simulation. Field size parameters and gantry
or couch angles are recorded once treatment planning is complete.
Axial (transverse) and sagittal treatment planning images are seen in
Fig. 31.16, which represent the dose distribution for a patient with a
distal esophageal tumor.
Side Effects
After 2 weeks of radiation treatment, patients begin to experience
esophagitis. They report substernal pain during swallowing and the
sensation of food sticking in their esophagus. Patients may be unable
to eat solid foods and may need a diet of bland, soft, or pureed foods.
In addition, patients should eat small, frequent meals that are high in
calories and protein (Table 31.2). High-calorie liquid supplements
such as Carnation Instant Breakfast and Ensure are good alternatives
for a high-calorie snack during the day or at bedtime.
To ease the pain of swallowing, the physician may suggest that the
patient take liquid analgesics or viscous lidocaine before meals. These
drugs provide local and systemic pain relief. Esophagitis can become
severe by the end of the treatment and may even necessitate the
placement of a nasogastric tube.
Concomitant chemotherapy increases the sensitivity of the
esophageal mucosa to radiation. Therefore more severe esophagitis
and possibly ulceration may occur. The radiation tolerance of the
esophagus is 65 Gy delivered with 1.8-Gy to 2.0-Gy fractions. When
concurrent chemotherapy is administered, the total radiation dose
safely delivered is 50 Gy, based on the increased treatment-related
toxicities associated with combined-modality treatment. Decreased
blood counts, nausea, and vomiting also occur with chemotherapy. A
break in a patient’s treatment may be necessary if the leukocyte or
platelet count becomes too low.
FIG. 31.16 Three-dimensional treatment planning for a patient with
distal gastroesophageal junction cancer. Axial and sagittal
representations illustrate the dose distribution.
From Blackstock AW, Russo S. Cancer of the esophagus. In:
Gunderson L, Tepper JE, eds. Clinical Oncology. 4th ed. Philadelphia,
PA: Elsevier; 2016.
TABLE 31.2
Dietary Guidelines for Patients Receiving Thoracic Irradiation

Recommended Foods Foods to Avoid
Cottage cheese, yogurt, and milkshakes Hot and spicy foods
Puddings Dry to coarse foods
Smoothies Crackers, nuts, and potato chips
Casseroles Raw vegetables, citrus fruits, and juices
Skinless poultry Alcoholic beverages
Scrambled eggs Tobacco
Meats and vegetables in sauces or gravies Acidic foods
Low-fat tofu
Radiation pneumonitis or pericarditis may occur if a large volume

of lung or heart is in the radiation field. Proper field shaping and
careful treatment planning greatly reduce the likelihood of severe
complications. Perforation and fistula formation can result from rapid
shrinkage of a tumor that was adherent to the esophageal-tracheal
wall.
Long-term side effects from irradiation of the esophagus include
stenosis or stricture as a result of scar formation. Dilations of the
esophagus can be performed to relieve the obstructive symptoms and
restore the patient’s ability to swallow. Transverse myelitis is a late
complication that should not occur if the radiation treatments are
delivered and planned precisely and accurately.
Recall the dose limits of radiation for the lung, heart, and spinal
cord. What is the healthy tissue toxicity for each of these OARs?
Which of the three organs is most sensitive to radiation damage?
Careful planning with IMRT or VMAT may help reduce the dose to
OARs.

Patients who undergo radiation therapy for esophageal cancer need a
lot of supportive care. They usually experience substantial weight loss
as a result of the tumor’s obstructive process and are nutritionally
compromised. Esophagitis, as a result of the treatment, can cause
more weight loss and further debilitate the health of the patient. The
therapist should question patients about the way they are feeling,
their appetite, and their food intake. Dietary suggestions regarding
recommended foods or those to avoid should be made available to the
patient. Some radiation therapy centers have printed sheets for the
therapist or nurse to give to the patient. Many centers also have a
dietitian to whom the patient may be referred for meal planning and
dietary supplements.
Esophagitis can be emotionally and physically draining for these
patients. The therapist should try to monitor the patient’s emotional
well-being as much as the physical aspects. The therapist should
inform the patient about local cancer support groups that assist in
coping with side effects of radiation treatments and disease.
Case IV: Midesophagus
A 64-year-old man presented to his local physician with a 1-month
history of dysphagia and painful swallowing. This was especially
noticeable when eating hot foods and foods with a scratchy texture
such as chips or crackers. The patient had an upper GI barium
swallow study that revealed a midesophageal lesion that was several
centimeters in length and extended 30 to 34 cm from the incisors. The
lesion did not appear to be completely circumferential. Biopsies of the
lesion were taken and found to be poorly differentiated high grade
invasive squamous cell carcinoma.
A PET-CT scan was done to assist in the staging workup. The PET
scan showed increased FDG uptake in the known area of the lesion
and in a right azygous lymph node. No other sites of distant
metastasis were noted. An EUS of the esophagus was discussed but
not ordered because the outcome would not change the plan for
treatment. The patient was at stage IIB T2 N1 M0 of the middle third
of the esophagus. The thoracic surgery team saw the patient and
believed he was not a surgical candidate based on the patient’s poor
performance on recent pulmonary function tests and his history of
chronic obstructive pulmonary disease and cardiac issues. The patient
was then seen for definitive chemoradiation therapy. The patient was
to receive carboplatin and paclitaxel administered on a weekly basis
as a radiation sensitizer. Radiation consisted of a total dose of 5040
cGy delivered in 28 fractions. The initial larger treatment fields were
treated to 4500 cGy in 25 fractions with a four-field technique
(anterior, posterior, right, and left laterals) with IMRT static fields. A
shrinking field boost for an additional three treatments with the same
beam arrangement and IMRT technique brought the total dose to 5040
cGy.
Case V: Lower Third of Esophagus

A healthy 75 year old man presented with an increase in reflux
symptoms with central chest burning and bitterness in his mouth
which he had experienced over the last year. Over the last 2 months,
he began to have a sensation of solid food sticking at the level of the
lower aspect of the sternum. He did not take any regular medications
for this. At times, this would lead to spontaneous regurgitation. His
weight has fallen approximately 6 pounds. He was seen by a local
endoscopist who proceeded with an esophagogastroduodenoscopy
(EGD) revealing a medium-size hiatal hernia and a nodular mass at
the level of the GE junctions. Biopsies of the area revealed
adenocarcinoma. The patient denies any chest of other abdominal
symptoms. He denies any pain. The patient is a nonsmoker and
drinks alcoholic beverages very minimally.
The patient underwent a staging workup that included CT of the
chest, abdomen, and pelvis to check for metastatic spread. Pending
the results of the CT scan, the patient will have a PET scan to further
check for spread of the disease regionally and distantly. If no
metastatic spread is noted, an EGD, an endoscopic ultrasound, will be
completed to locally stage the tumor.
The CT of the chest, abdomen, and pelvis showed a moderate
esophageal hiatal hernia with irregular mural thickening at the GE
junction at the region of the known biopsy-proven cancer. The scan
also showed a mildly enlarged distal right paraesophageal lymph
node, suspicious for metastasis. In addition, there were opacities in
the right lung that may be infectious or inflammatory in nature. There
is evidence of diffuse, mild cylindrical bronchiectasis in the lower
lungs, which may be secondary to recurrent microaspiration. There
was no evidence of hepatic metastasis or abdominal or pelvic
lymphadenopathy. A PET scan was then obtained. The PET
demonstrated uptake at the site of the GE cancer and in the right
paraesophageal metastatic lymph node.
Next, the patient underwent an EGD and EUS. The malignancy was
found 41 cm from the incisors. The endoscope was able to get past the
stenosis, and on EUS, the mass was found spanning from 39 to 41 cm
from the incisors. Suspicious subcarinal nodes were identified in the
mediastinum. A fine-needle aspiration (FNA) was done and came
back positive for malignancy. The patient was staged as a T3 N1 M 0
stage III.
Based on the findings, the patient was referred to radiation
oncology and medical oncology to discuss treatment options. The
treatment recommendation is for trimodality therapy consisting of
neoadjuvant (preoperative) chemoradiation followed by surgery. An
Ivor Lewis esophagectomy was planned following completion of the
chemoradiation therapy.
The patient was unable to receive the usual chemotherapy regimen
of carboplatin and paclitaxel because of an elevated bilirubin. Instead
he was prescribed FOLFOX (5-FU, oxaliplatin, leucovorin) every 2
weeks for 3 cycles. The side effects from this course of chemotherapy
was discussed with the patient. This includes fatigue, cytopenia,
diarrhea, nausea, vomiting, mouth sores, rash joint pain, and hair
thinning. Radiation would be delivered concurrently with the
chemotherapy.
Treatment with proton therapy was recommended with a dose of
5000 cGy prescribed to the gross disease plus margin and 4500 cGy to
elective nodes and esophageal margin. The treatment field
arrangement consists of two posterior oblique fields delivered with
IMPT. The patient was instructed to eat nothing through the mouth
(NPO) 2 hours before treatment to ensure an empty stomach. A light
snack such as toast or crackers may be consumed, but no heavy or
large meals. Liquid intake should be limited to less than 3 oz of
noncarbonated beverage. Side effects, including fatigue, nausea,
esophagitis, and radiation dermatitis, were discussed with the patient.
Pancreatic Cancer
Cancers of the pancreas account for approximately 2% of all cancers
diagnosed annually in the United States. Each year, the ACS estimates
that about 56,770 new cases of pancreatic cancer will occur. The
incidence rate of pancreatic cancer has been increasing for the past 10
years.5,43 Pancreatic cancer is the fourth leading cause of cancer-
related deaths in the United States, with an estimated 45,750 deaths
expected to occur each year.1,5,43,53 Pancreatic cancer has a high
mortality rate and is considered one of the deadliest malignancies. It
occurs more commonly in men than in women, with incidence and
mortality rates greater in black persons than in white persons. The
disease rarely occurs in persons younger than 45 years, with most
patients in the 50- to 80-year age group.
FIG. 31.17 Anatomy and lymphatic drainage of the pancreas. Note
the intimate relationship of the pancreas with the duodenum, stomach,
transverse colon, spleen, and common bile duct. The four main trunks
of lymphatic drainage: 1, Left side drains along the tail into splenic hilar
nodes; 2, superior pancreatic lymph nodes and the celiac axis; 3,
inferior pancreatic, mesenteric, and left paraaortic nodes; 4, right-side
drainage to anterior and posterior pancreaticoduodenal nodes and right
paraaortic nodes.
Cancer: Diagnosis, Treatment, and Prognosis. 6th ed. St. Louis, MO:
Mosby; 1985.
No known cause exists for the development of pancreatic cancer,

although smokers have a two times higher risk of development of
pancreatic cancer.1 Cigarette smoking is thought to cause about 20%
of pancreatic cancers.5,43,53 Lynch syndrome H, familial breast cancer
associated with the BRCA2 mutation, p16 gene mutations in familial
pancreatic cancer, and hereditary pancreatitis have been implicated as
risk factors for the development of pancreatic cancer.43,53 Exposure to
industrial chemicals such as benzidine and beta-naphthylamine over
an extended period is related to an increased incidence of pancreatic
cancer. Obesity, lack of physical activity, and diets high in fats, red
meat, and processed meat (bacon, sausage) are thought to increase
one’s risk of development of pancreatic cancer. Conversely, diets high
in vegetables and fruits lower one’s risk for pancreas cancer. More
studies are being conducted to determine whether a high-fat diet does
indeed cause pancreatic cancer. Pancreatic cancer is also more
common in people with type 2 (adult-onset) diabetes.1,53

The pancreas is located retroperitoneally at the T12 to L2 level and lies
transversely in the upper abdomen. The pancreas is divided into three
anatomic regions: the head, body, and tail. The head of the pancreas is
located in the C-loop of the duodenum. The body lies just posterior to
the stomach near the midline and is anterior to the IVC. Extending
laterally to the left, the tail terminates in the splenic hilum. The
pancreas is in direct contact with the duodenum, jejunum, stomach,
major vessels (IVC), spleen, and kidney. Tumors of the pancreas
commonly invade these structures and are therefore usually
unresectable at the time of diagnosis.
Numerous lymph node channels drain the pancreas and its
surrounding structures. The main lymph node groups include the
superior and inferior pancreaticoduodenal nodes, porta hepatis,
suprapancreatic nodes, and paraaortic nodes. Tumors that arise in the
tail of the pancreas drain to the splenic hilar nodes (Fig. 31.17). Most
patients have advanced local or metastatic disease at the time of
diagnosis.6
The four most common presenting symptoms of pancreatic cancer are
jaundice, abdominal pain, anorexia, and weight loss. Tumors that
arise in the head of the pancreas may obstruct the biliary system and
result in jaundice. An obstruction of the biliary system results in
excess bilirubin to be excreted in urine and less bilirubin to enter the
bowel, which results in dark urine and light-colored stools. Patients
who are jaundiced also report pruritus or itching.1 Tumors that occur
in the body or tail of the pancreas are not associated with obstruction
of the biliary system and commonly involve severe back pain and
weight loss. Pancreatic cancers occur most frequently in the head and
neck of the pancreas.53

A thorough history and physical examination are extremely
important. The abdomen should be assessed for palpable masses. The
tumor’s obstruction of the biliary system can result in an enlarged
pancreas, gallbladder, or liver. Palpable supraclavicular nodes or
rectal masses discovered during a digital rectal examination indicate
peritoneal spread. All of these signs suggest an advanced stage
disease. The presence or absence of jaundice is assessed by paying
particular attention to the sclera, skin, and oral cavity mucosa.53
The most valuable and important diagnostic test is a CT scan of the
abdomen. This scan provides a complete view of the abdominal
structures most likely involved with the tumor. This image localizes
the mass in the pancreas and depicts whether it is a head, body, or tail
primary. The scan also shows whether the tumor has invaded
surrounding structures, such as the duodenum, superior mesenteric
vessels, or celiac axis vessels. Spread to the regional lymph nodes,
peritoneal implants, and distant metastasis to the liver can also be
assessed.
The resectability of the tumor can be determined with the
information found on the CT scan. Liver metastasis and the
involvement of the superior mesenteric artery or other major vessels
are two contraindications to surgery. A CT-guided fine-needle biopsy
of the primary tumor or metastatic lesions may be performed to
establish the diagnosis.
MRI may also be used to evaluate local extension of the tumor into
adjacent structures. The MRI may provide better soft tissue
delineation than CT scan and can provide information related to
respectability of pancreatic tumor.53,54
A PET scan is an additional test that may be done. PET scans are
useful for showing spread of the cancer outside of the pancreas to
lymph nodes or liver or into adjacent tissues. This information is used
in conjunction with the CT scan findings.8,53–55
Endoscopic retrograde cholangiopancreatography (ERCP) is used
in evaluation of the obstruction and potential involvement of the
biliary system. A biopsy of the ampulla or duodenum may be
obtained at the time of the ERCP. This procedure is even more
beneficial for the diagnosis of a primary tumor of the biliary system.
Ultrasound scan has also been used to assess ductal obstruction, blood
vessel invasion, and liver metastasis.
With EUS, a transducer is passed down the esophagus to the
duodenum adjacent to the pancreas. This examination is more useful
than CT scan for visualization of small lesions in the head of the
pancreas and evaluation of the potential involvement of lymph nodes
and vasculature.8 EUS, along with FNA, is used as a tool to obtain
tissue for diagnosis with less chance of tumor seeding as compared
with a percutaneous approach.
A laparoscopy to obtain a biopsy is commonly performed before
any surgical intervention and may rule out small liver metastases (1 to
2 mm) that were undetectable on a CT scan.53 A laparoscopic
procedure does not require a big incision and is much easier on the
patient.53 According to a study done by Warshaw and colleagues,56
laparotomy results indicated that 40% of patients had small
metastases in the liver or on parietal peritoneal surfaces. These
patients were spared the morbidity of unnecessary abdominal
surgery. If the patient’s tumor appears to be resectable, based on the
diagnostic workup, exploratory surgery and a biopsy are performed
to determine the histology of the pancreatic mass.
Carbohydrate antigen-19 (CA-19) or serum carbohydrate antigen is
a tumor marker that is often elevated in pancreatic cancer. It is not
considered effective as a screening tool because it can be elevated in
other cancers, such as ovarian, GI, and hepatocellular carcinoma, and
inflammatory conditions of the pancreas or liver. A blood value is
obtained before and after surgery. If the CA-19 level remains elevated
after treatment, residual disease or metastasis is present.

Adenocarcinomas comprise 80% of pancreatic cancers. Other
histologic types include islet cell tumors, acinar cell carcinomas, and
cystadenocarcinomas.5,33
A formal TNM staging system for pancreatic cancer is available at
https://www.cancer.org/cancer/pancreatic-cancer/detection-diagnosis-
staging/staging.html.
Cases with disease confined to the pancreas, T1 to T3, are generally
considered resectable.43 More than 50% of patients who are diagnosed
with pancreatic cancer have distant metastasis at the time of
diagnosis.8,53,54
FIG. 31.18 Pancreaticoduodenectomy (Whipple procedure); resection
of the head of the pancreas, duodenum, distal stomach, gallbladder,
and common bile duct.
From Beazley RM, Cohn I Jr: Tumors of the pancreas, gallbladder, and
extrahepatic ducts. In Murphy G, Lawrence W, Lenhard R, ed:
American Cancer Society textbook of clinical oncology, Atlanta, 1995,
American Cancer Society.
Routes of Spread
Cancers of the pancreas are locally invasive. Lymph node
involvement or direct extension into the duodenum, common bile
duct, stomach, and colon is not uncommon at the time of diagnosis.
The tumor often encases or invades the superior mesenteric artery,
portal vein, and celiac axis artery, rendering the tumor unresectable.
Hematogenous spread to the liver via the portal vein is another
common pathway of spread.
Surgery is the treatment of choice. Most tumors, however, are
unresectable. Pancreas tumors are categorized into resectable,
borderline resectable, or locally advanced unresectable based on the
extent of disease and likelihood of resectability. Borderline resectable
means the cancer is localized but the tumor abuts major vessels in the
abdomen such as the superior mesenteric vein (SMV) or portal vein,
making it difficult to resect the tumor and have negative margins.
Locally advanced pancreatic cancer that is unresectable is when the
tumor mass encases the major abdominal vessels such as the SMV,
portal vein, or the superior mesenteric artery and surgery is not
recommended.48, 82 Contraindications for a curative surgical
procedure are liver metastasis, extrapancreatic serosal implantation,
and invasion or encasement of major vessels.55,57
The most common potentially curative surgical procedure is a
pancreaticoduodenectomy (Whipple procedure), which involves a
resection of the head of the pancreas, entire duodenum, distal
stomach, gallbladder, and common bile duct (Fig. 31.18).
Reconstruction is done to maintain the continuity of the biliary-GI
system. The remaining pancreas, bile ducts, and stomach are
anastomosed onto various sites of the jejunum (Fig. 31.19). The
operative mortality rate from this procedure has greatly improved in
recent years; it has been as high as 30%, but it is now less than 5%. The
surgeon should place clips to outline the extent of the tumor to assist
the radiation oncologist in planning adjuvant radiation therapy
fields.53
FIG. 31.19 Reconstruction of the biliary and gastrointestinal system.
The remaining pancreas, stomach, and bile ducts are anastomosed to
the jejunum.
From Beazley RM, Cohn I Jr: Tumors of the pancreas, gallbladder, and
extrahepatic ducts. In Murphy G, Lawrence W, Lenhard R, ed:
American Cancer Society textbook of clinical oncology, Atlanta, 1995,
American Cancer Society.
Because pancreatic cancers are often locally advanced at the time of

diagnosis, neoadjuvant chemotherapy with or without radiation is
considered standard of care. Induction chemotherapy plus
chemoradiation therapy has been effective in downstaging the tumor
and making resection possible in borderline resectable or locally
advanced-unresectable pancreatic cancer.54,57 Palliative biliary bypass
procedures are often performed for unresectable tumors to redirect
the flow of bile from obstructed ducts back into the GI system.
Typically, this is done by anastomosing the uninvolved bile ducts into
the jejunum. Resolving the obstruction provides patients with relief of
jaundice.
The two general types of surgery used to treat cancer of the
pancreas are as follows8:
• Potentially curative surgery is used when imaging tests

suggest that removal of all the cancer is possible.
• Palliative surgery may be done if imaging tests show that the
tumor is too widespread to be completely removed. This is
done to relieve symptoms or to prevent certain complications
such as blockage of the bile ducts or the intestine by the
cancer.
Pancreatic cancer surgery is one of the most difficult operations a

surgeon can do. It is also one of hardest for patients to undergo.
Multiple complications may occur, and several weeks may be
necessary for patients to recover.
Radiation Therapy
Because of the high rate of distant metastasis and locoregional failure
rate after surgery alone, combined-modality therapy versus
observation was investigated in a randomized trial of patients with
resected tumors. Adjuvant combined-modality treatment after
surgery resulted in a significant improvement in the overall survival
rate of 18 to 29 months compared with no further treatment.
Radiation therapy and chemotherapy are considered the preferred
treatments for borderline resectable, and locally advanced,
unresectable pancreatic cancers. Studies that compared radiation
alone with radiation and chemotherapy alone have shown that the
combined-modality treatment provides modestly improved survival
rates.5,58,59
Chemotherapy
As mentioned, chemotherapy is used with radiation therapy as an
adjuvant treatment in resected pancreatic tumors and as neoadjuvant
treatment with or without radiation for borderline resectable and
locally advanced unresectable disease.54,55,57 Gemcitabine is the most
common drug used in the treatment of pancreatic cancer and was
found to result in better survival rates than with 5-FU.60 Different
drug combinations and sequences are being investigated for
improving survival rates. Gemcitabine has been paired with various
drugs such as capecitabine, paclitaxel or oxaliplatin to see if these
combinations results in better survival.57 FOLFIRINOX, a four-drug
regimen consisting of leucovorin, 5-FU, irinotecan, and oxaliplatin, is
another drug combination being explored for borderline resectable or
locally advanced pancreatic cancer.54,57 More research is needed to
determine what drugs and in what combinations provide the best
outcome for patients with pancreatic cancer.54,55,57 Even with
combined-modality treatment, the overall survival rate of patients
with pancreatic cancer is extremely poor.
TABLE 31.3
Approximate Tissue Tolerance Dose for Specific Dose Limiting Structures

Related to the Treatment of Pancreatic Cancer
Kidneys 1500–1800 cGy
Liver 3000–3200 cGy
Small bowel 4500 cGy
Spinal cord 5000 cGy
Stomach 4500 cGy
QUANTEC, Quantitative Analysis of Normal Tissue Effects in the Clinic.
Modified from Marks LB, Yorke ED, Jackson A, et al. Use of normal
tissue complication probability models in the clinic. Int J Radiat Oncol
Biol Phys. 2010;76(3):S10–S19; and from Emami B, Lyman J, Brown A,
et al. Tolerance of normal tissue to therapeutic irradiation. Int J Radiat
Oncol Biol Phys. 1991;21:109–122.

The primary tumor bed and draining lymphatics, as defined by
surgical clips in the adjuvant setting or on CT scan in the neoadjuvant
setting, are the key target volumes. The typical treatment field
arrangement used is VMAT with two to three full 360-degree arcs.
IMRT static fields may also be used. A dose of 45 to 54 Gy is delivered
in 1.8Gy fractions with a reduction in the field volume after 45 Gy.33
The upper abdomen contains many dose-limiting structures that must
be considered for the designing and planning of radiation treatments.
These structures include the kidneys, liver, stomach, small bowel, and
spinal cord. Table 31.3 contains the tolerated dose (TD) 5/5 and tissue
tolerance data of these structures. Conformal 3D treatment planning
and IMRT or VMAT systems may allow higher doses of radiation to
be delivered while keeping the dose-limiting structures within
tolerance. Three-dimensional treatment planning permits the design
of coplanar and noncoplanar beams that use a couch rotation to enter
at unique angles to avoid critical structures and allow a higher dose to
be achieved. Intensity-modulated systems use unique beam
directions; however, they also vary the beam intensity and shape of
the field with the use of MLCs. Studies that compare IMRT with 3D
conformal have shown that IMRT and VMAT further reduce the dose
to the liver, kidneys, stomach, and small bowel than 3D
conformal.56,61,62 Ongoing research studies are being conducted to see
whether dose escalation is possible with IMRT techniques as a result
of the improved dose conformality to the tumor volume and sparing
of critical structures.63 Stereotactic body radiotherapy (SBRT) alone
and in combination with chemotherapy is one option of the NCCN
recommendations for locally advanced pancreatic cancer. Additional
studies are ongoing for the use of SBRT in locally advanced
unresectable pancreas cancers.62–66 Preliminary studies have shown
that treatment with SBRT has similar or better local control rate as
conventional external beam. In some studies, SBRT resulted in the
tumor shrinking enough that allowed resection of the tumor to be
done.66 Treatment-related GI toxicities, duodenal bleeding, and ulcers
have been a concern, especially in early studies when higher total
doses were delivered.65 Dose fraction schemes vary from 25 to 33 Gy
in three to five fractions to 45 Gy in three fractions.23,58,67 These lower
total doses were applied to reduce toxicity to OARs such as the
duodenum, small bowel, and stomach.62,65,68 The SBRT short
treatment time has been viewed as a benefit for the patient’s quality of
life when compared with 5 to 6 weeks of conventional radiotherapy.64
The short treatment course of SBRT may also be more cost-effective
when compared with the standard course of external beam
treatments.66 SBRT is a complex treatment that may include
respiratory gating, breath hold, and IGRT. IGRT is of extreme
importance in treatment of patients with SBRT. The therapist is
responsible for obtaining CBCT and kV images before treatment.64,65
Proton beam therapy may provide another future treatment option for
patients with locally advanced and unresectable pancreas cancer. The
characteristic finite depth in tissue that protons travel may provide an
advantage of sparing more healthy tissue. This is critically important
in treatment of the upper abdomen because of the kidneys, liver, small
bowel, and stomach being in such close proximity to the target
volume. Some studies have shown that proton beam therapy results in
less dose delivered to the kidneys, liver, and small intestine when
compared with IMRT or VMAT. For CT simulation, the patient is
placed in the supine position with the arms above the head for easier
placement of the lateral isocenter marks. A vacuum device or foaming
cradle immobilization device is made before the simulation. The
therapist should make sure the patient is straight on the table before
the immobilization device is made. This can be accomplished by using
the sagittal laser and lining up midline structures such as SSN,
xiphoid, and pubic bone. The device is measured to ensure that it fits
inside the scanner, and an image of patient setup is taken. With
simulation of a patient for SBRT, a full-body vacuum device for
immobilization is made that might include abdominal compression.62
The pancreas is an area associated with a large amount of movement.
The simulation should include a 4D CT scan to determine the amount
of respiratory-related motion.11 The CT simulation also requires that
contrast be administered. With this simulation, the patient is
instructed to drink contrast 30 minutes to 1 hour before the scan. If
oral contrast is used, the NCCN guidelines suggest giving the patient
the same amount of water before treatment each day to reproduce the
same amount of stomach distention. Conversely, no oral contrast may
be used, and the patient is instructed to be NPO before simulation and
treatment, ensuring an empty stomach to maintain similar internal
anatomy for each treatment.33 Some centers may inject IV contrast for
kidney localization or blood vessels to assist in determining nodal
volumes. Fiducial markers may be inserted into the pancreas before
CT simulation for patients treated with SBRT.62,66
The radiation therapist places reference marks on the patient’s
abdomen before scanning. A scan from above the diaphragm to below
the iliac crest is obtained. The physician can digitize in the location of
the target volume, lymph nodes, porta hepatis, and superior
mesenteric artery to ensure coverage of these structures in the
treatment field. The OARs, kidneys, liver, stomach, small bowel, and
spinal cord, may be outlined as well.
Once the treatment isocenter has been identified, the radiation
therapist makes the appropriate shifts from the reference isocenter
and marks the final three points to be used for treatment. The CT
images are then sent to the dosimetrist for 3D conformal planning or
IMRT or VMAT planning. IMRT or VMAT highly conformal dose
distributions and treatment planning dose constraints allows dose to
kidneys, liver, stomach and spinal cord to be minimized11,60,33 (Fig.
31.20).
Side Effects
The most common reports of patients receiving radiation for
pancreatic cancer are nausea and vomiting. Antiemetics may be given
to mitigate these adverse effects. Other potential acute side effects
include leukopenia, thrombocytopenia, diarrhea, and stomatitis.
Long-term side effects such as renal failure are rare and suggest the
possibility of the kidney receiving a higher dose of radiation.
FIG. 31.20 Dose distribution obtained with VMAT treatment for

pancreatic tumor. Note the kidneys and spinal cord are outlined in blue
and tan, respectively.
From Avanzo M, Chiovati P, Boz G. Image-guided volumetric arc
radiotherapy of pancreatic cancer with simultaneous integrated boost:
optimization strategies and dosimetric results. Physica Medica
32(1):169–175.
Case VI
Locally Advanced Pancreatic Cancer, Potentially

Resectable
A 64-year-woman presented to her physician with a 27-lb
unintentional weight loss over 3 months, lower abdominal bloating,
and pressure. CT scan of the abdomen/pelvis showed a 2.6 × 3.6-cm
pancreatic head mass with massive cystic enlargement of the
pancreatic duct through the pancreatic neck, body, and tail with
atrophy of the associated pancreatic parenchyma. The common bile
duct was also enlarged and measured up to 1.5 cm in caliber.
Intrahepatic biliary ductal dilation was observed. The area of ill-
defined abnormality in the pancreatic head bordered the SMV
abutting approximately 40% of the wall, which also appeared to abut
the superior mesenteric artery, although to a lesser extent. A CT scan
of the chest was done and was negative for metastasis. EUS was done
and showed a 3.7 × 3.5-cm mass in the pancreatic head, which was
biopsied. The pathology report came back as adenocarcinoma,
moderately differentiated. An ERCP was done to place a stent to
relieve obstruction of bile duct.
The patient was referred to radiation oncology for neoadjuvant
radiation therapy and chemotherapy for her borderline resectable
pancreatic cancer. She enrolled in a clinical trial that began with
neoadjuvant FOLFIRINOX for four cycles and then began
chemoradiation after a 2- to 6-week break. The chemoradiation with
Xeloda was followed by a break before surgery. More chemotherapy
with gemcitabine was given adjuvantly after surgery.
The patient had a 4D CT scan simulation to determine tumor
movement with breathing. Oral contrast was administered. A dose of
5040 cGy at 180 cGy per 28 fractions was delivered via VMAT with
two 360-degree arcs. Daily IGRT with kV imaging was performed
with the therapists matching the spine from T-10 to L-4.
Case VII
Pancreatic Cancer
A 69-year-old woman in her usual state of health began to notice dark
urine in June. She also noticed she was losing weight. In addition to
this, she later developed jaundice. She then went to see her primary
care provider in August for a routine medical exam. Blood tests were
ordered, and she was found to have elevated liver function tests. This
prompted an ultrasound of liver and pancreas to be ordered. This
showed narrowed bile ducts. Next, a CT scan of the abdomen and
pelvis was obtained. The CT showed narrowed bile ducts at the head
of the pancreas and soft tissue mass. Because of findings on the CT
scan, an ERCP was ordered. This demonstrated a stricture in the lower
third of the main bile duct. A biopsy and brushings of the common
bile duct were done that were suspicious for adenocarcinoma. A stent
was placed in the bile duct to alleviate the obstruction. Following her
stent placement, her symptoms of jaundice and dark urine resolved.
During his time, the patient continued to lose weight, nearly 10% of
her body weight.
A PET MRI scan was ordered that showed increased metabolic
activity in the pancreatic head and tail. A mass in the head of pancreas
was visualized measuring 2.4 × 2.8. × 3.2 cm. There was also a
suspicious lymph node. The head of pancreas mass had less than 180-
degree contact with the SMV. No evidence of distant metastasis was
seen. The patient was referred to the gastroenterology department. An
endoscopic ultrasound was ordered and performed that identified a
3.4-cm mass in the head of the pancreas with invasion into the SMV
and splenoportal confluence. A FNA biopsy of the pancreas head
showed adenocarcinoma. Because of the less than 180-degree of
invasion of the SMV, the tumor is considered a borderline resectable
pancreatic cancer. She was referred to medical and radiation oncology
for the consideration of neoadjuvant treatment.
The plan of treatment is 4 months of induction chemotherapy
followed by chemoradiation. The patient received FOLRINOX that
resulted in a decrease in the size of pancreas lesions and no distant
metastasis.
She began chemoradiation, receiving capecitabine as a
radiosensitizer. The radiation oncologist prescribed a course of 5000
cGy in 25 fractions to the GTV with a dose of 4500 cGy delivered to
elective lymph nodes. The patient was treated with VMAT with three
full 360-degree arcs and instructed to be NPO 3 hours before
treatment, the same as for simulation.
Summary
Colorectal Cancer
• The risk of development of cancer of the large bowel increases
with age, with more than 90% of cases in people over 50 years
of age. Cancer of the large bowel more commonly affects the
rectum or distal colon. Colorectal cancer is the second leading
cause of cancer death in the United States; it accounts for
approximately 51,000 deaths annually.
• The colon is divided into eight regions: cecum, ascending
colon, descending colon, splenic flexure, hepatic flexure,
transverse colon, sigmoid, and rectum.
• Patients with rectal cancer usually have rectal bleeding. Other
symptoms include a change in bowel habits, diarrhea versus
constipation, and a change in the stool caliber.
• Cancers in the large bowel are diagnosed via findings of the
physical examination and radiographic and endoscopic
studies.
• Adenocarcinoma is the most common malignancy of the large
bowel; it accounts for 90% to 95% of all tumors. Other
histologic types include mucinous adenocarcinoma, signet-
ring cell carcinoma, and squamous cell carcinoma.
• Surgery is considered the treatment of choice for rectal cancer.
Radiation therapy is most commonly used as an adjuvant
treatment for rectal cancer, either done before or after surgery
and in conjunction with chemotherapy.
Anal Cancer
• The etiologic factors for the development of anal cancer are
associated with human papillomaviruses, genital warts,
genital infections, anal intercourse in men or women before
age 30, and immunosuppression.
• The most common presenting symptom is rectal bleeding.
Other symptoms are pain, change in bowel habits, and the
sensation of a mass.
• Squamous cell carcinoma is the most common histology of
anal cancer; it comprises approximately 80% of cases.
• Combination radiation therapy and chemotherapy is
advocated as the preferred method of treatment and is
considered the standard of care for most patients. A variety of
radiation techniques exist for the treatment of anal cancer.
VMAT and IMRT techniques are more commonly done than a
four-field or AP/PA pelvic field with matching electron fields
to the inguinal nodes.
Esophageal Cancer
• Risk factors such as use of tobacco or alcohol abuse cause
esophageal cancer. Long-term irritation of the lining of the
esophagus, as with GERD, Barrett esophagus, achalasia,
esophageal webs, or scarring from swallowing lye, can cause
esophageal cancers.
• The esophagus is a 25-cm-long tube lined with stratified
squamous epithelium. The esophagus begins at the level of C6
and traverses through the thoracic cage to terminate in the
abdomen at the esophageal gastric junction (T10 to T11).
• The most common presenting symptoms are dysphagia and
weight loss, which occur in 90% of patients.
• The most common pathologic types of esophageal cancer are
squamous cell carcinoma and adenocarcinoma. Squamous cell
carcinomas are found most frequently in the upper and
middle thoracic esophagus. Adenocarcinoma typically occurs
in the distal esophagus and GE junction. Adenocarcinoma is
the most commonly occurring type in the United States.
• Because the esophagus is distensible, lesions are large before
causing obstructive symptoms. Spread is usually longitudinal.
Occasionally, skip lesions may be present at a significant
distance from the primary lesion.
• The treatment of esophageal cancer is highly complex and
technically difficult. Radiation therapy with concurrent
chemotherapy is considered the current nonsurgical treatment
of choice for esophageal cancer. Trimodality therapy may be
done for cancers in the lower one-third of the esophagus.
Chemoradiation is done first, followed by resection if feasible
and if no distant metastasis is present.
Pancreatic Cancer
• Cancers of the pancreas account for approximately 2% of all
cancers diagnosed annually in the United States and have a
high mortality rate. No known cause exists for the
development of pancreatic cancer, although smokers have a
two to three times higher risk of development of pancreatic
cancer.
• The pancreas is located retroperitoneally at the L1 to L2 level,
lies transversely in the upper abdomen, and is divided into
three anatomic regions: the head, body, and tail.
• The four most common presenting symptoms of pancreatic
cancer are jaundice, abdominal pain, anorexia, and weight
loss.
• The most valuable and important diagnostic test is a CT scan
of the abdomen, which provides a complete view of the
abdominal structures most likely involved with the pancreatic
tumor.
• Adenocarcinomas comprise 80% of pancreatic cancers.
• Surgery is the treatment of choice. Most tumors, however, are
unresectable.
• Radiation therapy and chemotherapy are considered the
preferred treatments for locally advanced, unresectable
pancreatic cancers.
Review Questions
1. Which of the following methods may reduce dose to the
small bowel during pelvic radiation therapy?
a. Supine position.
b. Prone position.
c. Treatment with a full bladder.
d. Both b and c.
2. The principal advantage of IMRT or VMAT over
conventional 3D conformal in the treatment of rectal, anal,
or pancreatic cancer is:
a. Fewer long-term radiation side effects.
b. Better dose conformity to target volumes.
c. More sparing of healthy structures (OARs).
d. All of the above.
3. The principal lymph node group involved in patients with
rectal cancer is the:
a. Common iliac nodes.
b. Hepatic nodes.
c. Paraaortic nodes.
d. Internal iliac nodes.
4. The principal etiologic factor(s) in the development of
adenocarcinomas of the esophagus in North America is
(are):
a. A diet high in fat and high in nitrate content.
b. A diet low in fat and high in vegetables and fruits.
c. GERD.
d. Barrett’s esophagus.
5. A common site of blood-borne metastasis from rectal,
pancreatic, or esophageal malignancies is the:
a. Brain.
b. Bone.
c. Adrenal gland.
d. Liver.
6. For radiation treatment to the thorax for esophageal
cancer, the dose-limiting structure of most concern is the:
a. Spinal cord.
b. Heart.
c. Esophagus.
d. Trachea.
7. The radiation-field design most commonly used to avoid
the critical structure in Question 6 is:
a. Lateral-opposed fields.
b. AP/PA fields.
c. Conformal 3D VMAT or IMRT.
d. Wedge pair.
8. Which of the following are common presenting symptoms
of pancreatic cancer?
I. Jaundice.
II. Nausea and vomiting.
III. 10% weight loss.
IV. Anorexia.
a. I and II.
b. II and III.
c. I, II, and IV.
d. I, III, and IV.
e. I, II, III, and IV.
9. Which of the following statements regarding pancreatic
cancer is not correct?
a. It is locally invasive into surrounding structures.
b. Hematogenous spread to the liver at the time of
diagnosis is common.
c. The 5-year survival rate is 50%.
d. Most tumors are unresectable.
10. For irradiation of the upper abdomen for pancreatic
cancer, the most radiosensitive dose-limiting structure is
the:
a. Kidney.
b. Liver.
c. Small bowel.
d. Spinal cord.
Questions to Ponder
1. Describe the rationale for the use of neoadjuvant
preoperative radiation therapy and adjuvant postoperative
radiation therapy for rectal cancer.
2. What is the rationale for a 4D CT scan and respiratory
gating when simulating patients with cancer of the
esophagus or pancreas?
3. What are the theoretic advantages and disadvantages of
proton therapy for the treatment of esophageal cancer?
4. What techniques are used to decrease or limit the radiation
dose to the small bowel? Why are these important?
5. In treatment of the thorax for esophageal cancer, the arms
and shoulders can create problems with the
reproducibility of the setup. What can be done to ensure
consistency in the daily setup of the treatment fields?
6. What is the main advantage of CT simulation and 3D
conformal irradiation techniques?
7. What is the purpose of chemoradiation?
8. Barrett’s esophagus and GERD are factors that are
associated with the development of what histologic type of
esophageal cancer?
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Washington and Leaver's

Principles and Practice of

Charles M. Washington, EdD, MBA,

Dennis Leaver, MS, RT(R)(T), FASRT

Megan Trad, PhD, MSRS, RT(T)

Detection and Diagnosis

The Radiation Oncology Team

2. The Ethics and Legal Considerations of Cancer Management

The Case for Ethics in Radiation Therapy

Ethical Aspects of Cancer Management

Patient Autonomy and Informed Consent

Dying Patients and Their Families

Medical-Legal Aspects of Cancer Management

Patient Assessment Defined

Interaction of Radiation and Matter

Cellular Response to Radiation

Cell Survival Curves

Systemic Response to Radiation

Total-Body Response to Radiation

Late Effects of Radiation

Present Status of Radiation Therapy

5. Detection and Diagnosis

Introduction to Detection and Diagnosis

Patient Interviews as a Diagnostic Tool

Medical Record and Medical History

Cancer Diagnosis (Biopsy)

Medical Imaging Technology Overview

X-Ray Interactions With (Body) Matter

Technical Factors and Image Characteristics

An Overview of Early Advances in Imaging Modalities

Imaging Modalities in Radiation Therapy

Nuclear Medicine Imaging

Intravenous Contrast Agents Used in Medical Imaging

7. Treatment Delivery Equipment

Characteristics of Kilovoltage X-Ray Equipment

Clinical Applications of Kilovoltage Equipment

Radiation Oncology Record

Treatment Session Preparation

The Treatment Room

Patient Position, Isocenter, and Field Placement

Verification Imaging (Isocenter)

Beam Position and Shape

Portal Verification Imaging

Assess and Accept Treatment Parameters

9. Infection Control in the Radiation Oncology Facilities

Infection Control in Radiation Oncology Facilities

Rights of the Healthcare Worker

Role of the Central Services Department

Sterilization and Disinfection Techniques

Sterility Quality Control Measures

10. Infection Control: Health and Safety

Health and Safety

Regulatory Agencies and Public Oversight

Infection Cycle and Disease Phases

Drug use and Drug-Resistant Microorganisms

Personnel and Student Health Services and Pertinent Infectious

Human Immunodeficiency Virus and Acquired Immunodeficiency

11. Pharmacology and Drug Administration

Drug Legislation and Standardization

Drug Nomenclature and Terminology

Variables that Affect Patient Response

Professional Drug Assessment and Management

Drug Categories Relevant to Radiation Therapy