Post Graduate in Rediotheraphy & Oncology

Post- Graduate in Rediotheraphy & Oncology

Radiotherapy is a highly specialized and technical discipline in clinical medicine dedicated, as
one of the major arms, in management and treatment of Cancer. With a view to update, by inclusion of
newer topics, and to provide a uniform syllabus and course contents in universities and teaching medical
institutions, it is proposed to frame the syllabus and course outline based on the recent developments in
clinical medicine, radiobiology and medical physics.

Objectives:
At the end of the training, the candidate should have attained sufficient and in depth knowledge of
-Basic and radiologic physics of ionizing radiation;
- Etiology, pathology and epidemiology and cancer statistics in malignant diseases;
-Radiology and laboratory methods in radiotherapy;
-Investigations and practice of clinical oncology with special reference to radiotherapy and
chemotherapy;
-Multi-disciplinary approach in the treatment of cancer with surgery, radiotherapy and
chemotherapy;
-Prevention, early detection, management, and rehabilitation of cancer patients and
their emotional problems.

Medical Physics related to Radiotherapy
1. Atomic and Nuclear Structure
A. Atomic structure
1) Energy levels, binding energy
2. Transitions, characteristic radiations
B. Nuclear structure
1. Mass, atomic and neutron numbers
2. Nuclear binding energy
3. Fission, fusion
4. Nuclear reactors
2. Radioactive Decay
A. Modes of decay
1. N/P ratio, even-odd relationship
2. Beta decay
3. Positron decay and electron capture
4. Alpha decay
5. Isomeric transitions, gamma emission, internal conversion
B. Mathematics of Radioactive Decay
1. Units half life, graphing
2. Transient and secular equilibrium
3. Radionuclide generators
C. Natural Radioactivity
1. Naturally occurring isotopes
2. Decay series
D. Artificial Radioactivity
1. Production by neutron bombardment
2. Fission products
3. Production by charged particle bombardment
3. Production of X-rays
A. X-.ray tubes
1. Requirements for X-ray production
2. Historical development
3. Focal: spot size
4, Reflection and transmission targets
5. X-ray production efficiency
B. X-ray circuits
1. Primary circuits
2. Secondary circuit
3. Filament circuit
.4. Modes of rectification
4. High Energy Treatment Machines
A. Cobalt units
B. Van de graaff generators
C. Linear accelerators
D. Betatrons
E. Resonance transformers
f. Cyclotrons for neutron therapy
5. Interactions of x- and Gamma-rays
A. Attenuation of a beam of x- or gamma-rays
1 .Attenuation and absorption coefficients
2. Attentuation in the body
B. Modes of interaction
1 .photoelectric absorption
2. Compton scattering
3- Pair production
4. Photo-disintegration
6- Interactions of particulate Radiations
A. Types of interactions
1. Elastic, inelastic
2. Excitation, ionization
B. Properties of particulate radiations
1. Specific ionization
2. LET
C. Interactions of heavy charged particles and pions
1. Bragg's peak
2. Applications in radiation therapy
D. Interactions of electrons
1 .Interactions with electrons
2. Interactions with nuclei
3. Applications to radiation therapy
E. Neutron interactions
1. Slow neutron interactions
2. Fast neutron interactions
3. Applications to radiation therapy
F. Radioactive sources used in diagnosis and therapy-Production and properties
7. Measurement of Radiation Exposure
A. photon and energy flux density and fluence
B. The roentgen
C. Electronic equilibrium
D. Ionization chambers
1. Free-air chambers
2. Thimble chambers
3. Condenser chambers
4. Electrometers
5. Extrapolation chambers
E. Exposure calibration of an x. or gamma-ray beam
1. Selection of calibration variables
2. Selection of chamber
3. positioning of chamber
4. Corrections to readings
F. Quality assurance checks on radiation therapy units
8. Radiation Quality
A. Measures of quality
1. HVL and effective energy
B Factors influencing quality
1. Variations in quality across a beam
2. Filtration and acceleration potential
9. Measurement of Absorbed Dose
A. Units of radiation dose, dose equivalent, RBE.-dose
B. Calculation of dose from exposure
C. Measurement of absorbed dose with an ionization chamber
1 Bragg-Gray cavity theory
D: Direct measurement of absorbed dose
1. Film
2. TLD
3. Calorimetry
4. Chemical dosimetry
10. Calibration of High Energy photon and Electron Beams
A. Photons
1. Stopping power ratios and energy absorption coefficients
2. Acq
3. C
B. Electrons
1. CE
11. Dose Distribution, External Beam Therapy
A. Dosimetric variables
1. Backscatter factor
2. Percent depth dose
3. Tissue-air ratio
4. Scatter-air ratio
5. Tissue-maximum and tissue-phantom ratios
6. Isodose distributions
7. Treatment time calculations
8. Fixed SSD and isocentric treatment techniques
B. Single and multiple field dose distributions
1. Corrections for wedges
2. Design of compensating filters
3. Corrections for surface obliquities
4. Corrections for heterogeneities
5. Dose perturbations at interfaces
6. Adjoining fields
7. Integral dose
C. Dose distribution for rotational therapy
D. Calculation of dose in large. irregular fields
12. Dose Distribution, Sealed Source Therapy
A. Handling of sealed radioactive sources
B. Dose distributions for sealed implant sources
C. Design of sealed source implants
D. Radium and its substitutes
E. Special techniques for 192Ir and 125Ir
F. Other sealed sources in therapy ...
13. Computerized Treatment Planning
A. External x. and gamma-.ray beams
1. Rectangular fields
2. Irregular fields
B. Electron beams
C. Implanted sources
1. Intracavitary implants
2. Interstitial implants
3. Surface mould
14. Radiation Protection from External Sources
A. Concepts and units
. 1. Quality factors
2. Dose equivalent
3. Protection regulations
B. Treatment room design
1. Primary radiation
2. Scatter
3. Leakage
4. Special problems with high energy photon and electron beam.
Special problems with neutron, proton and meson
C. Sealed source storage
D. Protection surveys
E. Personnel monitoring
15. Radiation Protection from Internal Sources
A. Body burdens and critical organs
1. Effective half lives for uptake and elimination
B. Internal dose computations
1. Locally absorbed radiation
2. Penetrating radiation
C. Handling radionuclide therapy patients
D. Licensing procedure for using radionuclides
16. Planning of a Radiotherapy Department
A. Building designs
B. Choice of various equipments and sources
C. Acceptance and Calibration Tests
D. Various maintenance steps and procedures
Appendix B
RADIOBIOLOGY
Radiobiology and Laboratory Radiotherapy
1 .Mammalian Cell Radiosensitivity
A. Interphase and reproductive death
B. Cell survival curves in vitro
C. Characterization of cell survival curves
D. Critical sites and target theory
1. DNA
2. Membranes
E. Dose response curves in vivo
1. Skin clone
2. Surviving crypts
3. Bone marrow colonies growing in spleen. monolayer culture
F. Quantitative normal tissue reaction based on systems
1. Pig skin
2. Rodent skin
3. Lung
4. Esophagus
5. Kidney
6. CNS and spinal cord
2. Factors that Modify Radiation Response
A. The Oxygen effect
1. Effect of oxygen concentration
2. Time of action of oxygen
3. Mechanism of the oxygen effect
4. Implications for radiotherapy
5. Methods to overcome problems of hypoxic cells
B. The age response function
1. The cell cycle
2. Age response for cells cultured in vitro
3. Age response for tissues in vivo
4. Age response for neutrons
5. The oxygen eftect through the cell cycle
6. Implications for radiotherapy
C. Potentially lethal damage
1. Repair in vitro
2. Repair in vivo
3. Pill and high LET radiations
4. Implications in radiotherapy
D- Sublethal damage.
1. Split-dose experiments with cells in vitro
2- Sublethal damage repair in normal tissues
3. Sublethal damage repair in tumours
4. Sublethal damage and hypoxia
5. Sublethal damage and high LET radiations
6. Dq as a measure of repair
E. Dose-rate ;
1. Dose-rate effects in cells invitro
2. Dose-rate effect in normal tissues
3. Dose-rate effect tumours
4. Interstitial therapy
5. Beam therapy at low dose rate
F. Radiosensitizers
1- The halogenated pyrimidines
2- Hypoxic cell radiosensitizers
a. Structure and mode of action
b. Enhancement ratio
c. Metronidazole/misonidazole
d. Pharmokinetics in the human
e. Clinical limitations
3. Antibiotics
G. Radioprotectors ;
1. Free radical scavenger
3. Linear Energy Transfer
A. Definition
B. Track and energy average
C. LET for different types of radiation
D. OER as a function of LET
4. Relative Biological Effectiveness
A. Definition
B. RBE for different cells and tissues
C. RBE as a function of dose
D. RBE and fractionation
E- RBE as a function of LET
F. Q factor
5. Cell and Tissue Kinetics
A. The cell cycle.
B. Autoradiography
C. Constituent parts of the cell cycle
D. Percent labelled mitoses technique
E. Growth fraction
F. Cell loss factor
G. Growth kinetics of human tumours
6. Tissue Radiosensitivity
A. Classification based on radiation pathology
B. Types of cell populations
1. Self renewal
2. Conditional renewal
3. Stem cell
4. Differentiated
7- Time-Dose and Fractionations
A. The 4 R's of radiobiology
B. The basis of fractionation
C. The Strandquist's plot
D. Nominal standard dose
E Linear Quadrate equation
8- New Radiation Modalities
A. Protons
1- Production
2. Processes of absorption
3. Depth dose patterns
4. Advantage compared with x-rays
5. Facilities available
B. Neutrons
1. Production
2. Processes of absorption
3. Depth dose patterns
4. Advantages compared with x-rays
5. Facilities available
C. Pions
1. Production
2. Processes of absorption
3. Depth dose patterns
4. Advantages compared with x-rays
5. Facilities available
D. High energy heavy ions
1. Production
2. Processes of absorption
3. Depth Dose Patterns
4. Advantages compared with x-rays
5. Facilities available
9. Hyperthermia
A. Methods of heating
1. RF microwaves ,
2. Ultrasound
3. Water baths
B. Systematic hyperthermia
C. Localized heating
D. Cellular response to heat
E. Repair of thermal damage
F Thermotolerance
G. Hyperthermia combined with ionising radiations
H. Time sequence of heat and irradiation
I. Hypoxic cells and heat
J. Effect of pH on the response to hyperthermia
K. Response of transplanted tumours to heat
L. Response of spontaneous tumours to heat
M. Response of normal tissues to heat
N. Heat and the therapeutic gain factor
O. Hyperthermia and chemotherapy
10. Total Body Irradiation-Acute Effects
A. Prodromal radiation syndrome
B. Central nervous system/cerebrovascular syndrome
C. Gastrointestinal syndrome
D. Hematopoietic syndrome
E. Mean lethal dose: (LD50)
F: Treatment of radiation accidents
11 .Late Effects
A. Non-specific life shortening
1. Definition
2. In animals
3. In man
B. Carcinogenesis
1. The latent period
2. Dose response curve in animals
3. Leukemia
4. Breast cancer
5. Thyriod cancer
6. Bone cancer
7. Skin cancer
8. Lung cancer
9. Other tumours
10. Malignancies in prenatally exposed children
12. Mechanisms of Radiation Carcinogenesis
C. Genetics of irradiation
1. Point mutations.
2. Relationship to dose
3. Chromosome aberrations
4. Relationship to dose
5. Doubling dose
6. Genetically siginificant dose (GSD)
7. Genetic .effect in humans
8. Background radiation in relation to the GSD
13. Radiation Effects in the developing Embryo and Fetus
A. Intrauterine death
B. Congenital abnormalities including neonatal death
C. Growth retardation
D. Dependence of the above effects on dose, dose-rate and stage in gestation
E. Carcinogenesis following in utero exposure
F: Human experience of pregnant women exposed to therapeutic doses
G. Occupational exposure of potentially pregnant women
H. Elective booking or "10 day rule"
I. The "practical threshold" for therapeutic abortion
14. Radiophysiology of Human Tissues
A. Effects of irradiation of the skin
1. Clinical manifestations
2. Histological substratum of effects
3. Repair
4. Degree of sequelae
5. Injurious effects
B. Effects of irradiation of bone and cartilage
1. Effects on growing bones and cartilage
2. Effects on adult bones and cartilage
3. Clinical manifestations
4. Histological substratum of effects
5. Functional consequences and sequelae
C. Effects of irradiation of the kidney
1. Clinical manifestations
2. Histological substratum of effects
3. Acute and chronic functional repercussions
4. Permanent Sequelae
D. Effects of irradiation of the lung
1. Acute clinical effects
2. Ultimate effects
3. Histologic substratum of effects
4. Measures to reduce final effects
5. Sequelae
E. Effects of irradiation of nervous tissues
1. Effects on the brain
2. Effects on spinal cord
3. Effects on peripheral nerves
4. Clinical manifestations
5. Histological substratum
6. Sequelae
F. Effects of irradiation of the ovary
1. Clinical manifestations
2. Histological substratum
3. Reversibility of effects
4. Therapeutic implications
G. Effects of irradiation of the testis
1. Clinical consequences
2. Histological substratum
3. Reversibility
4. Protective measures
H. Effects of irradiation of the eye ,
1. Clinical consequences
2. Histological substratum
3. Protective measures
4. Time-dose connotations
5. Sequelae-therapy
I. Effects of irradiation of lymphoid tissues
1. Clinical manifestations
2. Histological manifestations
3. Reversibility
J. Effects of irradiation of the bone marrow
1. Clinical and laboratory manifestations
2. Chronology of effects
3- Histologic substratum
4. Recovery
5. Therapeutic applications
K. Effects of irradiation of the oral. pharyngolaryngeal and esophageal mucous membrane
1. Clinical manifestations
2. Histological manifestations
3. Repair
4. Sequelae
L. Effects of irradiation of the salivary glands
1. Acute manifestations
2. Histological substratum
3. Dental consequences
4. Prophylaxis
M. Radiation effects observable in clinical radiotherapy
1. Technological protection
2. Role of total dose
3. Role of fractionation
4. Measures of Prevention
5. Therapeutic measures
N. Effects of irradiation of human embryo
1. Role of age
2. Role of dose
3. Teratogenic effects
4. Measures of prevention
Appendix C
BASIC SCIENCES
1 . Pathology of Benign and Malignant Diseases
A. Principles and methods of definite diagnosis
Surgical biopsy.
Exfoliative cytology
Fine needles aspiration cytology and biopsy
B General histologic and cytologic features of malignancy
C Classification of benign and malignant tumours and their interpretation
D Methods of dissemination of cancer and its biolocgical behaviour
E. Degree of differentiation of cancer
F. Radiation pathology
2. Applied Anatomy and Physiology
A. Anatomy of oral cavity, larynx, pharynx, paranasal sinuses, CSF pathways salivary glands,
middle ear; external orbit, breast, broncho-pulmonary segments, mediastinum, oesophagus, liver;
spleen, small and large bowels. pelvic and genito-urinary organs (bladder; uterus, ovary testis
rectum, anal canal etc.)
B. Lympahtic system and drainage
C. Relationship of vital structures
D. General principles of physiology of respiratory cardio vascular, nervous and biliary systems
3. Various Investigative and Imaging Procedures in Diagnosis, Staging, Management and
Follow up of Cancer
Appendix D
CLINICAL ONCOLOGY
1. Clinical Practice of Radiotherapy and Oncology
A. Principles of Radiotherapy
1 .General -Radiosensitivity and Radiocureability
-Tumor lethal dose, Tissue Tolerance and Therapeutic Ratio (TR)
-Factors influencing TR
-Target Volume
-Choice of Time, dose fractionation and technique
2. Teletherapy
Radiation factors
Megavoltage therapy
Orthovoltage therapy
Electron therapy
Heavy particle therapy (Neutron, photon, pi-meson)
3. Brachytherapy
Radium and its substitutes
Practice of -surface, intracavitary and interstitial
Clinical application
Rules and techniques
a. Newer developments
b. after loading
c. Low and high dose rates
B. Techniques of Radiotherapy
Small field beam directed therapy
Extended and irregular field therapy
Single, double and multiple field therapy
Beam modification therapy (wedge filter/compensator etc.)
Rotation and Arc therapy
Techniques in Brach therapy
Intracavitary
Interstitial
Mould application
Modern development and afterloading devices
C. Clinical Practice
Radical (curative)
Palliative
Pre-operative
Post -operative
Supplementary
Combination (both Pre. & Post operative-Sandwitch techniques)
Nutritional care and local hygiene during and after therapy
D. Treatment Planning and Presentation
Mouldroom practices
Simulation
Computerised treatment planning system
Clinical dosimetry
Prescription and execution
2. Cancer Chemotherapy and Hormones
A. Chemotherapy
Principles and clinical practice
Classification of drugs
Clinical application of
a. Single drug therapy
b. Polychemotherapy and various combinations
c. Adjuvant therapy
d. Prophylactic therapy
B. Hormone Treatment in Cancer
General Principles
Role in cancers of the Breast, thyroid, prostate, kidney etc.
Complications and their management
3. Related Specialities
A. Principles and practice of general surgery, gynaecology and paediatric surgery as
related to cancer
Surgical treatment decisions
Surgical diagnosis and staging of cancer
B. Clinical staging and TNM system
Staging procedures
Methods of clinical staging and TNM classification
C. Terminal care of cancer patients-principles and practice of control of pain
D. Cancer registry and epidemiology
E. Prevention and early detection in cancer
F. Cancer education and oncology organization
G. Statistical methods.
4. Principles of Treatment and Management in tumors of
A. Skin
B. Head and Neck (including Orbit and Eye ball)
C. Nervous System
D. Thorax and Mediastinum
E. GIT
F. Genitourinary
G. Other Abdomen and Pelvic Structures
H. Breast
I. Blood and Reticulo-Endothelial System
J. Bone and other connective tissues
K. Endocrine Glands
L. Paediatric tumours
M. Metastatic tumours with occult primary
5. Special Topics
A. Oncological Emergencies
B. Causes of Treatment Failure and Retreatment
C. Radiation Treatment of Benign Diseases and tumor like conditions
D. TLI and TBI _ Role, Philosophy and Techniques
E. Supportive care in Radiation treatment and Oncology.
F. Infections, nutritional and other problems in cancer patients
G. Preventive Oncology.
H. Psychosocial aspects of cancer and Rehabilitation
I. Hospice Programme
J. Immunotherapy and Role of Monoclonal antibodies in diagnosis staging and
management of cancer.
K. Recent advances coming up in various fields as applicable to oncology.
L. Care and Nursing of patients on Radiotherapy and chemotherapy