Hacettepe University Faculty of Medicine
Department of Radition Oncology
Radiotherapy Subdivision which was established in 1967 within the scope of Department of Radiology then became Radiation Oncology Subdivision in 1991. Radiation Oncology Subdivision has offered service since 1993, within the scope of Hacettepe University Oncology Hospital. Radiation Oncology Subdivision offers service to patients diagnosed with cancer at Hacettepe Oncology Hospital. Radiotherapy services of our division are performed by academic staff and instructors, radiotherapy physics specialists, residents, technicians and nurses. Radiation Oncology is located on floors -1 and -2 of Hacettepe Oncology Hospital, covering a total area of 2500 square meters.
It has external and brachytherapy (intra-tumor or relevant organ) treatment options. 5 devices in total are used for external treatments. Four of them are latest technology Linear Accelerators, and they can produce 6 MV and 18 MV X-rays, and 6 different levels of electron beams. Thus, deep and superficial tumors can be treated. Two of these devices, Cyberknife® and Novalis®, can carry out focal irradiation that is named stereotactic radiotherapy or radiosurgery.
In brachytherapy we have a high dose speed device that enables outpatient treatment. With this device, high treatment dose can be applied safely through close-range radiation for gynecologic tumors and lung tumors being in the first place, and many other types of tumors.
Furthermore, there are 2 simulators (Conventional simulator and CT simulator) and one C-armed X-ray device in the division which is used for determining treatment regions.
There are 3 computerized treatment planning devices that have the function of performing sophisticated, three dimensional planning and IMRT (Intensity Modulated Radiation Therapy) and enable us to plan the treatments in a healthy and detailed manner. On the other hand, Accuray Cyberknife® and Novalis® devices have their own peculiar planning systems, and they are sufficiently equipped to perform any kind of modern planning, including respiration and tumor monitoring. The comprehensive technical substructure and a network system which is necessary for high-quality treatment goes through with the equipment of our division.
Pre-treatment preparation is consisted of two sections. Pre-simulation preparation and simulation. During pre-simulation preparation customized thermo-plastic head-neck masks that enable the patient to stand still when needed and beds that can take the shape of the patient’s body are prepared. In necessary situations, tomography cross-sections are taken with computed tomography device for the aim of planning treatment. Since auxiliary elements like masks or therapy beds are used by the patient for radiotherapy during this procedure, the test should be performed at the computed tomography of our hospital under the supervision of physicians or technicians. The most appropriate planning is made by using the computed tomography data of patient, which are transferred to the treatment planning computer of our division.
The appointment for simulation of patient is booked for the same day or a few days further, since these procedures will take some time.
Simulation is the determination of areas where radiation would be applied by fulfilling the conditions of the treatment devices. The patient that comes for simulation is met by technicians, and the simulation is applied after the necessary information is provided. It is necessary for the patient not to move during simulation. At the beginning, the parents can be enabled to accompany their children, by taking special precautions (putting on a lead vest). After the patient is laid down to bed, the treatment areas are determined with appropriate techniques. After the procedure, the treated areas of the body are marked with special marks, by using special markers or marking bands. Following this procedure, it is necessary to keep these marks until and during the treatment. The patient may comfortably take a bath, but these areas should be washed with warm water and should not be rubbed with washcloth or bath-glove for the marks not to be erased and the treated areas of skin not to get irritated.
5 devices in total are used for external treatments. Four of them are Linear Accelerators, and they can produce 6 and 18 MV X-rays, and 6 different levels of electron beams. These devices are on floors -1 and -2. Other two devices used for external purposes are Novalis® and Cyberknife®, and they are located on floor -2 at their specially constructed sites.
External treatment devices are kept in specially constructed rooms with thick walls in order to prevent radiation emission to environment and managed from a control room where a technician is placed. During the treatment, there exist a closed circuit camera system by which the patient is monitored and a diaphone system that enables mutual conversation.
After the patient is taken to the therapy room, he is prepared in dressing cabins leaving the treatment areas in open as deemed appropriate by the physicians and technicians. Patient is laid down to the treatment table. After the patient is placed on the treatment table as in the simulator, other conditions like mask or treatment bed are provided, if available. The physician, radiotherapy specialist, and technicians perform the necessary procedures according to the treatment areas specified previously and the treatment is started after the team leaves the room, where the device is located.
Patient feels nothing during the treatment. He may hear a low, mild, continuous noise when the radiation is given. Treatment takes approximately 10-20 minutes. The duration may be longer if there is more than one area. The device spins around the patient. It is significant for the patient not to move during the treatment. After the treatment is completed, the patient is taken out of the room by the technician, and appointment is scheduled for the patient for following treatments.
While the treatments differ according to the treatment protocol to be applied for patient, they vary between 1 and 7 weeks, generally being applied on 5 days in a week (Monday - Friday). In particular situations, the treatment may be applied 2-3 times in a day.
Brachytherapy means close treating. It is applied by placing radioactive sources directly into organ and body cavities and tissues. We have a high dose speed device in the division for the brachytherapy method which has different application methods.
After the patient comes to his brachytherapy appointment for treatment, he is informed by the brachytherapy nurse. A mild sedative injection is made according to the procedure to be applied. Certain applicators that do not involve radioactive sources are placed to the area where treatment will be applied. In certain patients general anesthesia is used to perform the procedure, and it is generally executed in the operating rooms of Hacettepe Adult Hospital. After the application, the patient is taken to the CT simulator. The patient whose CT scan is obtained is taken to the brachytherapy section to wait while the treatment planning is made.
After the computed treatment planning which is made by radiotherapy physicists and physicians, the patient is taken to the treatment room. The treatment team leaves and the treatment is started after the connections between the applicators on patient and the treatment device are established. During brachytherapy, the treatment is performed in rooms with thick walls, in order to prevent radiation emission to environment and it is managed from an outer control room where nurses are placed. During the treatment, there exist a closed circuit camera system by which the patient is monitored and a diaphone system that enables mutual conversation. The radioactive source exits from its protective cover and goes into the applicators that are previously applied to the patient and the radiation process starts. During the treatment patient feels nothing, however a mild vibration may be perceived. Generally the treatment takes 1-20 minutes; it is significant for the patients not to move during this period. After the treatment is completed, the patient is taken out of the room and appointment is scheduled for the patient for the following treatment.
Cyberknife (Space Scalpel: Robotic Armed /Robotic Tabled Linear Accelerator)
Stereotactic radiotherapy or radiosurgery based on the ray beams that focus on the same center from several different angles in order to apply maximum dose over the tumor to be treated and minimum dose over the surrounding healthy tissues by using of the data obtained through imaging techniques (computed tomography, magnetic resonance, positron emission tomography, angiography). If the treatment is performed on more than one fractions, it is called “Stereotactic radiotherapy” and it is called “Stereotactic radiosurgery” when performed on a single fraction. One of the most important developments on recent years in this field is to begin applying stereotactic radiosurgery with Cyberknife® for cranial and extra-cranial lesions.
Determining optimal target and homogenous and more conformal treatments within 1 mm clinical correctness deviation are possible by the help of image fusion with Cyberknife (CT, MRI, PET/CT, 3D angiography fusion). Its significant differences with other treatment devices are that it does not require a framework that is screwed on head in the treatment of intracranial lesions, it can compensate the patient’s movements and organ movements during treatment by using dynamic ray, and it offers a safe treatment with control radiograms per 20-30 seconds. It uses the utmost radiotherapy technology as Image Guided Radiation Therapy (IGRT). It is the only device which called 4-dimensional radiotherapy and that can simultaneously treat and actively monitor the respiration movements in cases that involve organ tumors moving with respiration (early phase lung cancers and metastases of Lungs being in the first place). The linear accelerator of robotic arm offers a wide range of use in radiosurgery and radiotherapy:
Brain:
• Benign brain tumors
• Arteriovenous malformations
• Functional tumors
• Malignant brain tumors (combined with adulthood and childhood conventional external treatment)
• Metastases (1-3)
Whole body:
• Lung cancers
• Prostate cancer
• Head-neck cancers
• Vertebra tumors
• Certain gastrointestinal tumors (particularly pancreas)
• Metastases (1-3 liver and lung metastases)
Intensity-modulated radiotherapy (IMRT)
It is extremely difficult to apply maximum dose only to tumors or tissues highly possible to contain tumors by protecting normal tissues with conventional radiotherapy, especially in irregular areas. The maximum dose over the tissue has been applied by changing the radiation beam intensity and meanwhile protect the normal tissues sensitive to radiation with the help of three dimensional planning systems and linear accelerators with dynamic multi-leaf collimator systems developed in recent years. Intensity-modulated radiotherapy (IMRT) is a method that can appropriately perform complex treatment planning which result in calibrated flow of photon ray profiles and radiation of irregular structures by applying dynamic radiation. In this method the radiation density is changed along the beam and inverse treatment planning algorithms are benefited for this purpose. In inverse treatment planning procedure, target and critical organs and desired dose distribution are defined into the treatment planning computer and desired optimal dose distribution is tried to be get with various beam combinations. In recent years IMRT has increasingly been used in the treatment of particularly brain tumors, head–neck tumors, breast cancers, prostate cancers. In practices, while a more homogenous dose distribution at the target mass obtained by IMRT when compared to conventional chemotherapy, lesser toxicity in normal tissues due to the decrease in the radiation dose is reported.
Whole body irradiation
Whole body irradiation is a treatment method which is generally applied before bone marrow transplantation and for some other diseases. The Linear Accelerator on floor -1 is used for the treatment of the patient.
Before the treatment a serum and necessary medication are given to the patient to diminish side effects. During the treatment, which is teamwork, the patient is laid down on a stretcher. After the special measures are taken, the patient is treated from both side areas. Patient feels nothing during the treatment. Generally the treatment may take 20-40 minutes; it is significant for the patient not to move during this period. After the treatment, the patient is taken out from the device room. It is normally applied for 3 days by 6 sessions.
Cyberknife® Robotic Armed/Robotic Tabled Linear Accelerator
Cyberknife® is a radiosurgery system which has a robotic armed linear accelerator and a robotic table. The robotic system carries a 6 MV linear accelerator on it. Unlike other linear accelerators, its collimator system is conus shaped. Treatment table is robotic and it can be moved from the control room. It is the latest member of CyRISTM Multiplan planning system product range and has the latest features of dose optimization technology. This planning system can use forward or reverse planning algorithm which is single concentric or not. Synchrony™ system enables Cyberknife® to move with the inhaling and exhaling patient to prevent the problem of missing the target tumor position which changes due to respiration. Being found in certain centers around the world, Cyberknife® is unique with its distinctive technology.
Novalis Linear Accelerator
This device, which has was designed for brain tumors, has enabled treatment of other tumors possible with its table and linear accelerator features. Novalis® has micro-MLC system. By this means, the miniscule tumors can be treated. 3-dimensional planning could be made with reverse planning algorhythm in this system which can make both stereotactic radiosurgery and IMRT planning.
Two Varian Clinac DHX High Performance + 80 MLC Linear Accelerators
The device, which has two like-for-like Varian brand linear accelerators , has 6 MV and 18 MV X-ray energies. By being able to perform arc therapy, conformal therapy, and IMRT therapy, the device has 80 multi-leaf collimators (MLC). These devices also have IMRT QA software. In addition to having dynamic wedge feature, it also has 15º, 30º, 45º, 60º fixed wedges. Protective blocks are not needed by means of MLC system. The Clinac, which can also perform electron therapy, has 6 different energy levels. Portal imaging can be executed in electronic environment and dose values can be checked by means of the EPID system and amorphous silicon detectors. The system, which is accordant with the DICOM™ protocol, is connected to all devices through Aria™ Network system.
Elekta Synergy Linear Accelerator
It is a linear accelerator with 80 multi-leaf collimators. By means of its MLCs it can open areas with the desired geometry without the need for protective blocks. Port control is carried out in electronic environment with EPID (electronic portal imaging system). Its low energy X-ray is 6 MV and high energy X-ray is 18 MV. It also has 6 different electron energies. The device which is planned for conformal radiotherapy also has the IMRT option. 3-D conformal planning is performed with Precise™ treatment planning system. Owing to its carbon-fiber table the treatment becomes available from all angles.
GammamedPlus iX HDR Brachytherapy System
Gammamed, which uses Ir-192 radioactive source, is a high dose rate brachytherapy system. In brachytherapy, the radioactive sources are inserted inside the target region or its immediate surroundings. Along with this system, it has Varian BrachVision™ treatment planning system which is its own TPS system. This system enables patient treatment through 24 channels.
GE™ Hi-speed NX/I BT Simulator
In contradistinction to conventional simulator device, from this device which can make simulation over BT, 8 cross-sections at every rotation with cross-section ranges between 1 mm and 10 mm can be obtained. It can make spiral scanning. The number of projections performed by the system is 1388 per second. The detection distance of the device is 160 cm. The system has quad moving laser system Advantage Workstation and CT SIM™ software, to perform simulation with CT images. The system has 46 solid phase detectors placed in two lines.
Varian Acuity Conventional Digital Simulator Device
The planning coming from treatment planning system are simulated in 3-dimensional patterns with Acuity device. The system that is connected with treatment planning devices via DICOM, is one of the latest versions of conventional digital simulators. It has the CT simulator option through software update. The simulation procedure takes very short by means of the user interface and user-friendliness. The device, having the digital projection feature, does not need MLC fibers that MLC projection drop on patient, in gantry in MLC simulations. The simulation problem arising from the table is eliminated by means of the carbon-fiber table.
Electron and Photon Dosimetry Systems #1 and #2
Our division, which has a wide range of dosimetry pack, it has 2 0.015 cc pinpoint ion rooms, 1 Diamond detector, 2 Roos ion rooms, 2 729 2-D array ion rooms, 1 DAVID in vivo detector systems within its inventory, in addition to the latest technology systems such as 2 water phantoms and systems, solid phantom, Marcus and Advanced Marcus ion rooms, 0.6 cc ion rooms, 0.125 cc ion rooms, TLD and in vivo diode, etc.. The quality control measurements and calibration procedures of linear accelerators are made with these systems.
First Examination and Control Appointments
Outpatient clinic examination and control appointments are scheduled by the secretariat of outpatient clinic of Radiation Oncology Subdivision which is located on floor -1 of Hacettepe Oncology Hospital and by secretariats of Cyberknife unit which is on the floor -2. Furthermore you can book appointments by calling “Call Center” via the phone number 444 4 444. For receiving appointment please bring the routing note of Hacettepe University Hospitals, original of your identity card and your referral document, if any. Please also bring all reports concerning your disease (operation, epicrisis, the information on your previous radiotherapy, if any, etc.), radiologic tests and pathology preparations.
Simulation and treatment appointments
These appointments are scheduled for patients while their examination results are evaluated.
The division is located on floors -1 and -2 (under the ground floor) of Hacettepe University Oncology Hospital. The offices of faculty members and instructors, radiation physicists and research assistants of treating sections and Radiation Oncology Subdivision of Hacettepe University Faculty of Medicine, are located on floors -1 and -2.
Telephone:
+90 (312) 305 28 76 (Outpatient Clinic)
+90 (312) 305 29 00 - 01 (Chieftaincy of Subdivision)
+90 (312) 305 28 73 - 74 (Cyberknife Robotic Radiosurgery / Radiotherapy Unit)