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Braquiterapia historia
1. The History of RO: Brachytherapy
• Jesse N. Aronowitz, M.D.
• Martin Colman, M.D.
• Gustavo S. Montana, M.D.
• Roger Robison, M.D.
• Herman D. Suit, M.D., D. Phil.
• J. Frank Wilson, MD
2. Objectives
• Learn about the need for and the development of
the first oncology societies, which were based on
gamma ray therapy.
• Understand how low-dose-rate brachytherapy
developed as the gold standard.
• Explain the continuing development of radioactive
seed implantation and of after-loading
intracavity/interstitial brachytherapy.
3. ASTRO 2007
History of Radiation Oncology
Origins of Brachytherapy
J. Frank Wilson, M.D.
4. Natural Artificial
Radioactivity Radioactivity
1898 1935
The Curie Era
5. Röntgen observed the
fluorescence of platino -
cyanide salts exposed to
x-rays.
Wilhelm Conrad Röntgen
1845-1923
6. In 1896, Becquerel reported the
“phosphorescence” of uranium
capable of fogging photographic
plates through a thickness of
aluminum.
Antoine Henri Becquerel
1852-1908
Radiogram of a medal
10. “ It seemed to me that the first
thing to do was to measure the
phenomenon with precision.”
“Instead of the usual electroscope,
I used a more perfect apparatus.”
Marie Curie, 1923
Electrometer built by P. Curie
11. Pierre Curie
c. 1899
Shown working
with the quartz
piezo-electroscope
he invented, by
which rays of
radium could be
measured.
13. “ One of our joys was to go into our workroom at
night; we perceived on all sides the feebly
luminous silhouettes of the bottles or capsules
containing our products. It was really a lovely
sight and one always new to us. The glowing
tubes looked like faint, fairy lights.”
Marie Curie, 1923
14. “ In this miserable old shed we passed the best
and happiest years of our life…”
Marie Curie, 1923
15. • Nobel’s will was contested.
• First prize awarded in 1901.
• Roentgen was the first Nobel
Laureate in Physics.
• Becquerel and the Curies were
Alfred Nobel
Nobel Laureates in 1903.
1833 - 1896
16. “In criminal hands radium might prove very
dangerous, and the question therefore arises
whether it be to the advantage of humanity to
know the secrets of nature, whether we be
sufficiently mature to profit by them, or whether
that knowledge may not prove harmful.”
Pierre Curie
Nobel Acceptance Speech, 1903
17. Pierre Curie’s self-inflicted severe skin
reaction to radium.
1903
As early as 1905 both Pierre and Marie were
showing negative health effects from their work.
18. Radium applicators for surface and intracavitary applications,
used by Danlos and later by Wickham.
19.
20. “…there is no reason why a tiny fragment of
radium sealed up in a glass tube should not be
inserted into the very heart of the cancer; thus
acting directly upon the diseased material.”
A.G. Bell
Letter to Science, 1903
21. Pasteur Pavilion, Claudius Regaud,
Radium Institute 1870 - 1940
c. 1913
22. Marie Curie, WW I (c. 1917)
First radiographer and inventor of mobile radiology.
41. RADIATION THERAPY HISTORY
Important Dates
1901 Henri Becquerel and Pierre Curie described the biological
biological effects of radium on the skin. Becquerel carried
carried a radium tube in his waistcoat pocket and Pierre
Curie intentionally exposed his arm.
1903 Alexander Graham Bell proposes the use of interstitial
therapy
1903 Margaret A. Cleaves describes the treatment of a
gynecological patient with intracavitary radium in New
York.
1903 H. Streble describes afterloading interstitial technique.
42. RADIATION THERAPY HISTORY
Important Dates
1904 W. Pusey and E. Caldwell treat uterine cancer with a
radium capsule inserted in the uterus.
1905 L. Wickman and P. Degrais designed applicator for
intracavitary therapy for treatment of carcinoma of the
cervix.
1910 L. Wickman and P. Degrais published brachytherapy
textbook and described gynecological applicators.
1912 Dr. Koning uses large quantity of radium externally, for
for treatment of pelvic cancers. “The Radium Canon”
43. RADIATION THERAPY HISTORY
Important Dates
1934 Irene and Frederic Joliot-Curie discover
artificial radioactivity.
1937 First clinical use of the Van de Graaf accelerator.
1948 First clinical use of the Betatron.
1951 First patient treated with a kilocurie cobalt unit.
1956 First Linear Accelerator installed in the U.S.
44. RADIATION THERAPY HISTORY
Important Dates
1963 Afterloading Intracavitary
1974 High Dose Rate Brachytherapy
1977 Afterloading Transperineal
1977 3D Treatment Planning
1996 (IMRT) Intensity Modulated
Radiation Therapy
45. BRACHYTHERAPY
Requirements
• Accessible Tumors
• Radiosensitive Tumors
• Tolerance of Normal Tissues
• Orderly Pattern of Spread
46. BRACHYTHERAPY
ADVANTAGES
• Inverse Square Law
• High Dose to Limited Volume
• Differential Effect of High Dose Rate
on Tumor & Normal Tissues
48. CARCINOMA of the CERVIX
Intracavitary Systems
* Paris
* Stockholm
* Manchester
* MD Anderson
* Mallinckrodt Institute of
Radiology
* CT/MR 3D System
49. The Paris System
Curie Institute, Paris, France.
Claudius Regaud 1910-1920
• Tandem: Rubber.
• Colpostats: Cork, coated with paraffin.
• Uterine dilatation for 24 hours prior to procedure.
• Five consecutive days application (120 hours).
• Applicator removed every day for douching.
• Loading:
Tandem: 6.66 – 13.33 – 13.33 = 33.32 mgs Rd
Colpostats: 13.33 – (6.66) – 13.33 = 26.66 to 33.32
mgs Rd
• Dose: 7200 mgm/hrs.
51. The Stockholm System
Radiumhemment Institute
Stockholm, Sweden
Dominici & Forsell 1913 - 1914
• Tandem: metal tube
• Colpostats: metal box wrapped in lead?
• Three applications of 20 to 30 hours,
over a period of 3 weeks
Loading:
• Tandem 33.7 to 40.1 mgs Rd
• Vaginal plaque: 70 mgs Rd
• Dose: 6844 to 7266 mgm/hrs
53. The Manchester System
Holt Radium Institute
Manchester, England
M. Tod & Meredith 1938
• Tandem: Rubber
• Ovoids: Rubber (large, medium and small)
• Loading: Units of radium (1 unit = 5 mgs Rd)
Tandem: long = 2-2-1; medium = 2-1; short = 2
Ovoids: large 5; medium 4; small 3
• Dose: 7200 r prescribed to Point A. Calculation of
of dose to Points A & B based on Sievert’s formula.
formula.
55. MD ANDERSON SYSTEM
MD Anderson Hospital
Houston, Tx, USA
G. Fletcher 1952
• Dimensions: Similar to those of the Manchester
System
• Loading: Similar to the Manchester System
1.2 to 1 ratio uterine to vaginal cavity activity
• Prescription: According to stage of disease
“Milligram/hours + EBRT” dose to the whole pelvis
pelvis
• Vaginal Mucosa Dose Tolerance
• Bladder and Rectal Dose Tolerance
56. Mallinkcrodt Institute of
Radiology System (MIR)
St. Louis MO, USA
W. Powers & C. Perez 1979
• Closely related to the MD Anderson System
• Loading of the uterine tandem and the ovoids somewhat
different than MDA System. Higher ovoid loading
• Intracavitary performed during EBRT, if possible
• EBRT to parametria between intracavitary insertions
• Dose Prescription: Mgr/hours + EBRT & Dose to
Manchester Points
• Vaginal Mucosa Dose Tolerance
• Bladder and Rectal Dose Tolerance
57. MANCHESTER SYSTEM
“CAVEATS”
• Variable Definition and Measurement
• No Constant Applicator/Anatomical Relationship
• Different Isodose Dose Contour ⇒
Same Dose to Point A
• Described as Tolerance Dose
• Difference in Biological Effects of Brachytherapy
Brachytherapy and EBRT not taken into account
58. MGHRS SYSTEM
“CAVEATS”
• Different loadings can result in different
different isodose = mghrs dose
• No Constant Applicator/Anatomical
Relationship
• Difference in Biological Effects of
Brachytherapy and EBRT not taken into
into account
63. Radium Institute
Paris, France
C. L. Regaud (1925)
Treatment Symptom-Free
Survival
Year (1-6 years)
1919 9.1%
1920 19.3%
1921 29.5%
1922 34.4%
1923 43.9%
64. Radiumhemmet
Stockholm, Sweden
Heyman (1924)
5-year
Year # of Symptom-Free
of Rx Patients Survival
1914 26 26.9%
1915 40 32.5%
1916 47 8.5%
1917 63 14.3%
1918 41 26.8%
65. Radiumhemmet
Stockholm, Sweden
Heyman (1934)
5 - Year Results (1914 - 1925)
Total number of patients treated 1455
Symptom-free after 5 years 327
Relative Cure Rate 22.5%
66. Holt Radium Institute
Manchester, England
W. J. Meredith (1948)
Year 5-year
# Patients
of Rx Survival
1934 - 1935 332 26%
1936 - 1937 298 28%
1938 - 1939 307 32%
1940 - 1940 612 35%
1942 - 1943 577 38%
67. M.D. Anderson
Katz (2004)
5 - Year DFS
Early Stage 78%
Advanced Stage 61%
69. Afterloading Brachytherapy
Review of the Early Development
Herman Suit
Massachusetts General Hospital
Harvard Medical School
Collaboration with T Mauceri, Peter Biggs, G Chen, A Russell and K Doppke
70. Start of Radiation Therapy
• Immediately After Röntgen’s
• Discovery: Nearly Worldwide
• Rush into Radiology
72. Radiation Biology 1896
• T Grover Lyons Papers in Lancet
• Feb 1 Proposed Effect on Bacteria
• Feb 17 No effect on TB and Diphtheria
73. Start of Radiation Therapy
• EBRT Success Against Skin SCC
• Lupus Vulgaris and Misc Lesions
74. Radiation Injury In Man 1896
• E Grubb January 27, 1896 to Hospital
• For “painful, swollen and inflamed hands”
• Dr J Gilman ¿Therapeutic Effect on
Diseased Tissues?
75. Early Radiation Martyrs
• 1904 Clarence Dally Asst to T Edison
• 1916 Walter Dodd MGH Radiologist
• Numerous Others
76. Alexander Graham Bell
• 1903:
• Insert 226Ra [Glass Tube] into Tumor.
• 1st Radium User : Margaret Cleaves
80. Early Clinical Use of AL
• Many Publications 1956-70
• Long After Strobel of 1903
• and the Many Martyrs
81. Early Clinical Use of AL
• Mowatt 1956
• Fishman 1956
• Henschke 1960
• Wolever 1960
• Morphis 1960
• Suit 1961
82. Rationale for After Loading
• Zero Dose to OR Staff
• Radiation Oncologists
• Physicists
• Nurses Anesthesiologists
83. Rationale for After Loading
• Transportation Personnel
• Nurse and Staff on the Ward
• Medical Staff for Patient Exam
84. Rationale for After Loading
• 2. No Time Pressure for the Implant
• 3. No risk in Imaging of the Implant
• 4. Decision to Re-position Un- Affected
by Risk of Radiation
126. Objectives
• Learn about the need for and the development of the first oncology
societies, which were based on gamma ray therapy.
• Understand how low-dose-rate brachytherapy developed as the gold
standard.
• Explain the continuing development of radioactive seed implantation and
of after-loading intracavity/interstitial brachytherapy
129. ...the rays emitted by radium
have been found to have a
marked curative effect upon
external cancers...
...there is no reason why a
tiny fragment of
radium...should not be
inserted into the very heart of
the cancer... Alexander Graham Bell
American Medicine
p. 261, August 15, 1903
130. “I then determined to
plunge it directly in the
tumor…. I ventured… to
pierce the tumor by a fine
knife… the radium tube
was pushed into the knife
channel. The tube was…
all buried in the tumor. I
left the radium in situ three
hours. The treatment was
repeated three times
weekly for 15 times.”
Robert Abbe The Subtle Power of Radium
1851-1928
131. Obstacles to
Interstitial
Radiumtherapy
• Cost ($120,000/gram) •
Bulk
135. “Radium treatment has caused with
surprising regularity the reduction or
disappearance of carcinomatous
nodules of the prostate.
Striking results have been obtained
...”
Benjamin Barringer
JAMA, 68:1227-30, 1917
136. Technique
Low activity, heavily screened needles
• 2 mg/3 cm or 3mg/4.8 cm
• 0.6mm platinum filtration
• Typically 100mg (35 needles)
• in situ 7 days (1200 -1800 mghr)
138. ‘… it is easy to concentrate attention too
much upon the main mass of growth, and to
forget that secondary dissemination occurs
within the mammary gland. Properly, the
whole breast… should be treated.’ 1932
‘… residual nodules were removed…
In 50% there was evidence of active cancer.
… led to a reconsideration of the procedure.
I therefore decided to remove… the tumour…
before irradiation.’ 1937
139. ‘The rapid improvement of x-
ray technique… suggests
that x-rays may be used as
an alternative.’ 1937
143. DENVER RADIUM CAPITAL
• Ore sent from Paradox Valley by mule,
• then truck, then narrow gauge D&RG/W.
• Then standard gauge to Denver.
• Refineries in downtown Denver (N.R.I.).
• Or shipped by RR to PA (Standard).
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194. ASTRO Annual Conference
Los Angeles, CA
October 27 to November 1, 2007
Educational Session
History of Radiation Oncology II:
Brachytherapy
Founding of the American Radium Society
Martin Colman, MD
Department of Radiation Oncology
University of Texas Medical Branch,
Galveston
196. The Four Doctors, by John Singer Sargent
Photograph by Aaron Levine
Courtesy of The Alan Mason Chesney Archives, The Johns Hopkins Medical Institutions
197. Howard Kelly 1858-1943
Radium Pioneer
One of original four faculty
at Johns Hopkins,
“The Four Doctors”
198. American Radium Society
(ARS)
• Founded in 1916
• Oldest Multidisciplinary Oncology Society
• Surgical Oncologists & Radiation Therapists
• Radiation Oncology as a Medical Specialty
• Foundation of Brachytherapy
• Main Organization for Radiation Oncology
• For 40 years before ASTR/ASTRO
203. William Duane 1872-1935
Adapted Marie Curie’s radon
production system and glass
seeds in Boston in 1913
Facilitated similar systems at
Memorial-NY and Baltimore
206. The Radium Research Laboratory
Standard Chemical Company of
Pittsburgh and The Radium
Chemical Company
• 1913 – 1st radium
production in the USA
• 71 grams through 1921
• >50% of world supply
• “sponsor” of ARS
207. Employees of SCC of
Pittsburgh
< William H. Cameron, MD (1879-1944)
Clinic Director
Radium Therapy Pioneer
Charles H. Viol, PhD 1886-1928 >
Director of Research
209. Henry K. Pancoast 1875-1939
Founder Member of ARS
President of ARS, 1920
First Professor of Radiology
University of Pennsylvania
210. Henry B. Aikins 1859-1924
First President of ARS
1916 & 1917
211. Henry Schmitz 1871-1939
Founder Member of ARS
President of ARS, 1921
6th Janeway Lecturer, 1938
Prepared statutes for first meeting
that were adopted unanimously
Established the name, ARS
212. Principal Founders of ARS
< William H. Cameron, MD (1879-1944)
Founder Member of ARS
Radium Therapy Pioneer
President of ARS, 1935
Charles H. Viol, PhD 1886-1928 >
Founder (Assoc) Member of ARS
213. Marie Curie 1867-1934
Discoverer of Radium
Nobel Laureate, 1903 & 1907
1921 Elected Honorary
Member of ARS
215. James Ewing 1866-1943
1st Janeway Lecturer, 1933
AJR 31:153-163, 1934
• Time Cover
• Cancer Man Ewing
• January 12, 1931
• Included article
written at time of
retirement from
Cornell
225. James T. Case, 1882 – 1960
Founding Member of ARS
President of ARS, 1924
24th Janeway Lecturer, 1959
ARS Historian #1
AJR 70:487-490, 1953
AJR 82:574-585, 1959
227. Edith H. Quimby 1891-1982
8th Janeway Lecturer, 1940
ARS President, 1954
ARS Historian
AJR 75:443-456, 1956
228. Juan del Regato
ARS President, 1969
38th Janeway Lecturer, 1973
Historian Par Excellence
ARS Historian #4
AJR 108:429-430, 1969
AJCO 14(2):93-100, 1991
229. E.R.N Grigg
• Radiologist, Chicago
• Radiology Historian
• Author -
“The Trail of Invisible Light”
From X-Strahlen to Radio(bio)logy
• Chas Thomas, 1965
230. Other Significant Texts
• Claudia Clarke – Radium Girls, 1997
• Ruth and Edward Brecher – The Rays: A
History of Radiology in the USA, 1969
• Juan del Regato – Radiological
Oncologists: The Unfolding of a Medical
Specialty, 1993.
• Raymond Gagliardi and Frank Wilson – A
History of the Radiological Sciences –
Radiation Oncology, 1996
