Radiotherapy

When performing radiation therapy or radiotherapy, tumours are treated with ionising radiation. During this treatment energy, calculated by a physicist, targets and destroys the tumour or possible secondary tumours (metastases). Because of the rapid development of imaging and computer efficiency, radiation therapy can now be administered in an accurately targeted way. This allows us to treat the tumour area with higher doses of radiation while the surrounding tissue is protected. In this way, larger tumours can be destroyed whilst reducing side effects. 

Nowadays, it is also possible to further optimise the dose distribution with "intensity modulated radiotherapy" or IMRT which enables us to irradiate around healthy organs and to expose the tumour region to even more radiation. For this kind of radiation therapy precise accuracy is of great importance. The patient’s position is meticulously adjusted and permanently controlled, to ensure that even respiratory movements can be compensated for. This form of treatment is called “image guided radiotherapy" or IGRT. Mediclinic City Hospital’s CCC is the first in Dubai to offer all these technologies. 

The equipment used at the CCC is entirely orientated towards the well-being of the patients. The Centre uses the most modern radiotherapy equipment from leading manufacturers, as well as the most up-to-date forms of planning and therapy, such as virtual simulations and intensity-modulated radiotherapy.

Insurance information

Radiation therapy is an outpatient treatment. After the initial consultation with the radiation oncologist, an individual treatment plan is drawn up including dosimetry, treatment schedule and weekly assessments for each case, based on the total radiation dose which is delivered in fractions over a specific number of days. Good clinical practice dictates that courses of radiotherapy treatment should not be interrupted. There is evidence that treatment interruptions increase the risk of local recurrence. Any interruptions or prolongation of radiotherapy treatment may adversely affect patient outcome.

To minimise unscheduled interruptions, timely delivery of radiotherapy treatment needs to be maintained, therefore it is necessary that the whole course of the patient’s treatment is approved, and the intended prescription delivered, prior to the start of the treatment. This will assure the best outcome for the patients. As a result, the insurance team at Mediclinic City Hospital will request approval for the entire radiotherapy treatment before the treatment begins.

Radiotherapy Modalities            

The CCC offers all types of treatment from percutaneous radiotherapy and palliative emergency radiotherapy to high-precision, low volume, hyper fractionation therapy with IMRT (intensity-modulated radiotherapy) and Volumetric Modulated Arc Therapy - VMAT. Particularly important is the positioning and reproducibility of daily radiation. The “on-board imaging” system, used in all patients, provides a tool which permits the routine use of IGRT (image-guided radiotherapy), leading to even more precise planning and daily administration.

• Brachytherapy - treating cancer from the inside

Brachytherapy has proven to be a successful treatment for cancers of the cervix, endometrium, prostate and other types of cancers. Brachytherapy treats cancer by placing radioactive sources directly into or next to the area requiring treatment. This enables clinicians to deliver a high dose with minimal impact on surrounding healthy tissues.

Brachytherapy primarily uses two different techniques:

• Low Dose Rate (LDR) uses a lower strength radioactive source and is associated with longer treatment times (for the one time treatment).
• High Dose Rate (HDR) uses a higher strength radioactive source contained within an afterloader device. The afterloader delivers the source for a brief period of time to catheters, needles or other appliances placed in the tumour site. HDR is much shorter procedure (minutes vs. days) than LDR but it does require multiple treatments. Increasingly more common, HDR techniques have replaced LDR techniques for most body sites.

With any radiotherapy technique, the goal is the same: to conform the dose to the size and shape of the target while limiting side effects by sparing the surrounding healthy anatomy. In brachytherapy, radiation falls off very rapidly from the target area, easily accomplishing this objective.

• SRS (Stereotactic Radiotherapy Surgery), SBRT (Stereotactic Body Radiotherapy) and SABR (Stereotactic Ablative Body Radiotherapy)

Stereotactic radiosurgery (SRS) is a non-surgical radiation therapy used to treat functional abnormalities and small tumours of the brain. It can deliver precisely-targeted radiation in fewer high-dose treatments than traditional therapy, which can help preserve healthy tissue.

When SRS is used to treat body tumours, it’s called stereotactic body radiotherapy (SBRT).

SRS: Stereotactic radiosurgery (SRS) is a non-invasive treatment that uses radiation beams to accurately target brain tumours with a single high dose of radiation. SRS is not a surgical procedure and does not require an incision or anaesthesia. The radiation is administered by two to three RapidArc radiation beams. This allows radio-surgeons to target the tumour without affecting delicate structures nearby. SRS is performed as an outpatient session.

Stereotactic radiosurgery is effective for treating tumours in small areas in the head and neck that cannot be reached by surgery.

Indication for SRS treatment

Brain/neurological conditions, including:

• Artero-venous malformations, meningiomas,
acoustic neuromas,
pituitary tumours
• Brain metastases, malignant gliomas, functional conditions


SBRT: Stereotactic body radiation therapy (SBRT), also known as stereotactic ablative radiotherapy, administers very high doses of radiation using several beams of various intensities aimed at different angles to precisely target the tumour.

Stereotactic body radiation treatments are usually given as a single dose or up to five doses once a day, although this can vary depending on the type and location of the tumour and the patient’s physical condition. This procedure is chosen for patients with small, well-defined tumours who cannot tolerate surgery. For some patients, SBRT may be able to replace surgery as a primary cancer treatment.

Indications for SBRT treatment

Extracranial conditions
and other malignant and benign tumours (lung, liver, spine etc.

Treatment Pathway

Individual Treatment 

Behind every disease there is a person with his or her own personal and individual medical history. It is precisely for this reason that we provide individualised treatment for our patients. The following is a summary of the procedure: Initial Consultation Once the attending doctor has registered the patient for radiotherapy, they will receive an appointment for an initial consultation (either by mail or telephone). After registering at the reception, the patient and will be personally met by the attending in the waiting area. It is advisable to bring a family member, partner or friend to the initial consultation, where possible.

Assessing the Present Situation

In order to provide the correct treatment, the radio-oncologist must first assess the current situation. For this purpose, additional examinations may also be required before commencing the radiotherapy treatment. It is important to know whether the patient suffers from other illnesses which may influence the radiotherapy. The examining doctor will discuss all the details with the patient and explain any additional procedures that might be necessary. The examining doctor should also be informed of any medication currently being taken by the patient, as well as any other treatment the patient is undergoing.

Determining the Treatment Course

During the initial consultation, the doctor will explain the planned course of treatment and answer any questions. The patient will once again be asked questions about their illness and will be examined by the doctor, if necessary. This part of the process is essential, because a description or referral letter issued by the patient’s doctor to the radiotherapy department can never replace a personal discussion and examination. It is also possible that the disease may have changed fundamentally since the last examination was performed.

Side Effects

The doctor will also discuss the possible side effects of the therapy. He will try to explain the entire treatment process. He will also give the patient information on any further examinations, check-ups or treatments after the radiotherapy.

Possible Side Effects

All types of therapy have their side effects, and this to radiotherapy. However, as a result ofmore precise radiation techniques and better supportive measures, these have been significantly reduced in recent years.

Skin Reactions

A skin reaction may occur depending on the type of radiotherapy (location, volume, single dose and total dose). With radiotherapy targeting a tumour in the mouth or throat region, or with breast cancer treatment, the skin is relatively severely affected. After two to three weeks of treatment, patients may experience a skin reaction similar to sunburn. Patients experiencing such symptoms should contact the nursing staff who will coordinate further treatment with the doctor. Household remedies should not be used without prior consultation with the doctor. Many common skincare lotions and creams contain traces of heavy metals. The use of such creams causes the radiation to be scattered into the surface of the skin andleadsto even higher skin exposure.

Reactions of the Mucous Membranes

With radiotherapy of the throat and thorax areas (e.g. for lung or oesophageal cancer), parts of the mucous membranes of the mouth, throat and oesophagus are often treated simultaneously. These membranes develop an inflammation which may beginto manifest itself in the second or third week of radiotherapy. Any inflammation causes redness, swelling and particularly pain, which mainly affect the patient while eating. In case such symptoms occur, the patient should notify the nursing staff. The nursing staff will coordinate further treatment and care, for example the prescription of a painkiller, with the doctor.

Diarrheoa and "Radiation Hangover"

With radiotherapy in the stomach and abdomen areas, side effects often include diarrhoea. Treatment of the rectum often causes increased urge to defecate (however, without the actual defecation). Such symptoms are also caused by inflammation in the treated intestinal area as a result of the radiotherapy. Occasionally, patients who receive radiation targeting the intestinal area may feel slightly nauseous an hour or two after treatment. This frequently occurs at the start of a radiotherapy course during the first sessions and is also known as “radiation hangover”. Such symptoms mostly disappear after one to two weeks of treatment and can be easily treated with medication. Such symptoms should also be discussed with the specialisednursing staff.

Individual Reactions are Difficult to Predict

In general, the severity of the side effects varies from individual to individual and dependson the volume and type of radiotherapy. Each person reactsslightly differently to the treatments and unfortunately it is impossible to predict which side effects mightactually occur.

Technology

Radiotherapy Advantages

Since the late 1970s, radiotherapy has advanced mainly as a result of developments in computer technology. While the basic technology of the linear accelerator has remained the same, the planning options for treatment and the precision of irradiation have become more accurate. Thanks to the use of computer tomography, it is now possible to depict tumours within the body. The regions requiring radiotherapy can be marked on the CT layers, and the tumour can be recorded as a three-dimensional area. 

Gentle Radiotherapy 

The planning computer depicts thetumour as a three-dimensional volume, which then serves as the basis for the radiation plan created by the medical physicist. Mostly, the tumour volume will be “attacked” from various directions within defined safety margins, ensuring that the risk organs are omitted from the field arrangements, if possible. These fields are no longer rectangular, but are instead adapted using shielding in accordance with the defined radiation volume.The aim of any radio-oncological treatment is to subject the tumour region to the highest possible radiation dose while simultaneously protecting the risk organs to the greatest possible extent. The probability of being able to sterilise a tumour depends on its size and histology, as well as particularly on the radiation dose applied. However, the likelihood of suffering side effects depends on the exposure of normal, healthy tissue to radiation. In recent years it has become possible to control and modulate the intensity of the flow of photons within the field (intensity modulated radiotherapy, IMRT). As a result, the high-dose area can be better adapted to the defined tumour field and risk organs can be protected. 

The more precise the treatment is, the less side effects are caused All these new technologies require the radiotherapy treatment to be carried out under exactly the same conditions. The geometry of the linear accelerator is fixed and the dose calculation is based on the assumption that the conditions are always exactly the same as those depicted in the planning computer tomography. If this deviates from the actual situation, the tumour region may be targeted with an insufficient dose, or a risk organ may be exposed to too much irradiation. If the position of the patient deviates by just one to two centimetres from the position originally planned, the radiation will also be “off-target” by this distance. This inaccuracy must be considered and included in the treatment concept. During planning, a safety margin around the tumour volume is calculated in order to ensure the most extensive radiation possible during all fractions. The disadvantage of this approach is a significant increase of the radiation volume, along with the corresponding side effects. The more precisely a radiation therapy can be performed, the smaller this required safety margin is and the smaller the treatment volume becomes. 

On-board Imaging 

In addition to the positioning aids described, it is now possible to check the accuracy of the patient’s position and particularly improve it with the help of a positioning control system. Two short radioscopies can be performed in different directions before the radiotherapy begins. These images show the current position of the patient and are then compared with a digital reconstruction of the planning CT. The images of the current radioscopy and the planning CT images are merged, so any deviations between the current radiation position and the originally planned position can directly be determined.