External beam radiotherapy

External beam radiotherapy (EBRT) is the most common form of radiotherapy (radiation therapy). The patient sits or lies on a couch and an external source of ionizing radiation is pointed at a particular part of the body. In contrast to brachytherapy (sealed source radiotherapy) and unsealed source radiotherapy, in which the radiation source is inside the body, external beam radiotherapy directs the radiation at the tumour from outside the body. Orthovoltage ('superficial') X-rays are used for treating skin cancer and superficial structures. Megavoltage X-rays are used to treat deep-seated tumours (e.g. bladder, bowel, prostate, lung, or brain), whereas megavoltage electron beams are typically used to treat superficial lesions extending to a depth of approximately 5 cm (increasing beam energy corresponds to greater penetration). X-rays and electron beams are by far the most widely used sources for external beam radiotherapy. A small number of centers operate experimental and pilot programs employing beams of heavier particles, particularly protons, owing to the rapid dropoff in absorbed dose beneath the depth of the target. Conventionally, the energy of diagnostic and therapeutic gamma- and X-rays is expressed in kilovolts or megavolts (kV or MV), whilst the energy of therapeutic electrons is expressed in terms of megaelectronvolts (MeV). In the first case, this voltage is the maximum electric potential used by a linear accelerator to produce the photon beam. The beam is made up of a spectrum of energies: the maximum energy is approximately equal to the beam's maximum electric potential times the electron charge. Thus a 1 MV beam will produce photons of no more than about 1 MeV. The mean X-ray energy is only about 1/3 of the maximum energy. Beam quality and hardness may be improved by X-ray filters, which improve the homogeneity of the X-ray spectrum. Medically useful X-rays are produced when electrons are accelerated to energies at which either the photoelectric effect predominates (for diagnostic use, since the photoelectric effect offers comparatively excellent contrast with effective atomic number Z) or Compton scatter and pair production predominate (at energies above approximately 200 keV for the former and 1 MeV for the latter), for therapeutic X-ray beams. Some examples of X-ray energies used in medicine are: Megavoltage X-rays are by far most common in radiotherapy for treatment of a wide range of cancers. Superficial and orthovoltage X-rays have application for the treatment of cancers at or close to the skin surface. Typically, higher energy megavoltage X-rays are chosen when it is desirable to maximise 'skin-sparing' (since the relative dose to the skin is lower for such high-energy beams). Medically useful photon beams can also be derived from a radioactive source such as iridium-192, caesium-137 or radium-226 (which is no longer used clinically), or cobalt-60. Such photon beams, derived from radioactive decay, are more or less monochromatic and are properly termed gamma rays. The usual energy range is between 300 keV to 1.5 MeV, and is specific to the isotope. Notably, photon beams deriving from radioisotopes are approximately monoenergetic, as contrasted with the continuous bremsstrahlung spectrum from a linac. Therapeutic radiation is mainly generated in the radiotherapy department using the following equipment: