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INFORMATION

The Ruber International Hospital Radiotherapy Oncology Service has been one of the first private centres in Spain, and as a result, it has countless years of experience and the highest cutting-edge technology. All in all, plus a quality and very human care provides the excellence in treatments performance.

Dr. Aurora Rodríguez, chief of service, leads and coordinates a medical team of great professionals whose mission is study, determine and set up the best treatment, customized for each patient. And, along with the use of the most advanced technology without neglecting the friendly and customized attention. This structure is due to the addition of an efficient and effective system. It is the result of the best way of working within the cancer treatment area, from the radiotherapy oncology perspective. In this regard, the patient’s attention times have been improved, the duration of treatments and the specialization of their different professionals, the adaptation in service requirements and the multidisciplinary work, well interconnected of all the specialists involved in the disease approach.

WHAT DO WE TREAT?

Head tumors

Head and neck tumors

There is a group of malign tumors named head and neck cancer which origin is in oral and nasal cavity, nasopharynx, oropharynx, hypopharynx, larynx, paranasal sinuses and salivary glands.
They are, approximately the 5% of cancers in men and the 2% in women. On the whole, they are the most frequent fifth neoplasm in world population, in Europe the most common is the larynx (40 % of total) followed by oropharynx, oral cavity and nasopharynx.

In these cases, the radiotherapy has a significant role in some indications:
– As tratamiento alternativo a la cirugía with equivalent results in:
Early stages and localized tumors: With results of disease control similar to the ones of surgery, but with a less impact in functionality.
Locally advanced stages: to preserve the organ. Normally it is related to a radiosensitizer chemotherapy. It is achieved cure the tumor in a significant number of patients preserving such important functions as swallowing and speech.
– As complementing treatment to surgery, postoperative radiotherapy: In locally advanced tumors by neighbouring structures affectations and/or by infiltration of regional lymphatic glands, diminishing the local relapse and improving the tumor control
In nasopharynx tumors (cavum): For its localization, it is impossible to perform the surgical resection and, consequently, the radiotherapy is the election treatment both exclusively in precocious stages as the advanced related to chemotherapy.

Planning:
It is necessary to prepare an immobilization mask adapted to the patient’s head after choosing the most favourable position for the treatment for the external radiotherapy planning (EBT). With it, after, a CT is done to plan the radiotherapy. At times, it is important to arrange a Resonancia Magnética and/or PET-TC as a support, since the fusion of all allows a better visualizing of the tumor and critical organs (healthy organs placed near the tumor where radiation dosage can be limited).Treatment:
In precocious tumors, early stages or localized: Radiotherapy can be the only treatment since it offers similar results to surgery.
Locally advanced tumors: Postoperative surgery and radiotherapy (with or without radiosensitizer QT) can be performed to these patients, or radiosensitizer radiotherapy with chemotherapy (if possible) radically in order to protect the organ. In such case, these tumors, by its irregular volumes, are often concave around the risked organs (spinal cord and parotid glans), gaining from the treatment planning with Intensity-modulated radiation therapy (IMRT), and image guided radiotherapy (IGRT). High accuracy and quickness Dynamic Arc therapy, are available for this purpose atAcelerador Lineal Varian 2300 iX, this is perfect for the treatment achievement.

Side effects:
Acutes: Mucositis (mucus irradiated area damage) and epithelitis (skin irritation in the radiation field).
Belated (months or years after): Xerostomia (dry mouth), decay and fibrosis.

Thyroid tumors

Amongst the malign thyroid tumors there are different types, depending on the cell where they are created. Those well differentiated, more common and with better evolution, they are papillar and follicular type, whose appearance is more usual in young women. The standard treatment is the surgical resection with or without radioactive iodine, sometimes complemented with external radiotherapy. Another type is the medullar carcinoma, from the neuroendocrine tumors and much less frequent than the previous ones. It is treated with surgery and, sometimes, postoperative radiotherapy. The group is completed with the anaplastic thyroid carcinoma, rare and with a more aggressive evolution, which treatment is the surgical removal (if possible) and chemotherapy with or without radiotherapy.

Schedule
Radiotherapy schedule takes place inTC, applied to the patient in the same position as he is going to be treated. The acquisition is done in supine (flat on one’s back), normally after the previous making of an adapted mask to the patient’s head and a system to immobilize shoulders and the upper thorax (the area to be treated includes the lower neck and upper thorax), to guarantee the exact position during the daily treatment. Radiotherapy is done in acelerador, with a 3D technique or often, IMRT.

Treatment
Well differentiated tumors, papillary and folliculary type are treated with surgical resection with or without radioactive iodine (I-131). I-131 is a radioactive isotope used due to its similitude to be compacted in the thyroid tissue. This kind of treatment is called metabolic radiation, because the isotope is taken as a liquid and moves along the organism to concentrate in tyroid cells and release high dosages of radiation to them producing its selective elimination. Necessarily the patient must remain some days in a special room, isolated, since he will be issuing radiation that could affect to the people around him. Doctors who control the treatment are the specialist in nuclear medicine and endocrines. Patients are discharged when they already have rid all the radioactive iodine. For some patients, it is indicated the external radiotherapy enhancing the treatment. The specialists team, whom joins also radioterapic oncologist, analyses each case and decides who can be benefited from the above-mentioned medical care.
In medullar tumors, the initial treatment is usually surgery, performing thyroidectomy and neck nodes dissection. Frequently postsurgical radiotherapy is indicated. The decision of the completing treatment is taken by the specialists, according to the tumor extension and the nodes impact. It is also indicated radiotherapy to reduce symptoms in patients with widespread disease.
The surgical removal if possible adding postoperative radiotherapy in anaplastic tumor cases. However, the tumor spread does not let the scission and the treatment is done with chemotherapy and radiotherapy in most patients.

 

Brain tumors

Primary brain tumors are developed in the brain tissue cells. In brain can also grow tumors which cells precede from located neoplasms in other organism areas (metastasis). Metastatics are much more usuals than primaries. Between 20% and 40% of cancer patients are capable to develop brain metastasis. In all cases radiotherapy is a main part of the treatment.
Schedule
Firstly, it is necessary to make a head fitted mask for casting the patient held to an attach device affixed to the table, both of TC de planificación, as for the acelerador lineal where radiation therapy is completed. It is carried out once the most favourable position for the patient’s treatment has been chosen, commonly in supine (flat on one’s back) with the neck correctly upheld. With it, TC is done to later plan the radiotherapy. The radiotherapic oncology specialist decides if Resonancia Magnética should be given, since, often its images mixture with the ones of CT for scheduling, allow a better visualization of the tumor and critical organs diagnose (healthy organs placed nearby the tumor, where the radiation dosage must be delimited.
If the chosen treatment is radiosurgery, the casting mask is more rigid and always turns to resonancia magnética to achieve a better tumor and annex tissue definition for a more accurate scheduling.

Treatment
In low-grade brain tumors (low-grade astrocytoma and oligodendroglioma) and the initial treatment is always surgical whenever the size, and the location of the tumor let it. If the removal is complete no postsurgical treatment will be necessary. If the scission is uncompleted, it will be complemented with postoperative radiotherapy, mainly in cases of patients with symptoms provoked by the tumor itself.
In non operable tumors the radiotherapy is usually the chosen treatment.
In recurring tumors, a new surgical resection is tried and, radiotherapy is administered in postoperative. Chemotherapy is also administered in some cases.
In high degree tumors (anaplastic astrocytoma and multiforme gliobastoma) the initial treatment, if possible, is surgery related to radiotherapy and, in many cases, postoperative chemotherapy. If surgical resection is impossible, concurrent radiotherapy is achieved with chemotherapy and subsequent chemotherapy.
For ependymoma treatment, first the tumor resection is attempted and, for mostly part of patients, after postsurgical radiation therapy is administered, localized and wide (including brain and spinal cord) depending on its spread.
In the medulloblastoma, the treatment is surgical resection and after the craniospinal irradiation (including brain and spinal cord), related or not to later chemotherapy.
The meningiomas treatment is devised depending on its size, characteristics and symptoms. In small and asymptomatic tumors, both options are possible, surgery or radiotherapy; this last one is preferred in cases where its growth, due to its location, or surgical resection could provoke neurologic aftermaths. Larger tumors (>3 cm) and/or causing symptoms, could be treated with surgery or radiotherapy. Patients with tumor resection are administered postoperative radiotherapy if the resection is incomplete or a malignant meningioma is treated.
In the brain metastasis treatment radiotherapy plays a crucial role. The treatment with holocraneal radiotherapy (all the brain) is for patients with growing tumors outside the brain and/or with multiple injuries. Radiosurgery related or not with holocraneal radiotherapy in those patients with few lesions, in general less than three, and if the primary tumor is controlled or considered to be controlled.
External radiotherapy Is done in acelerador lineal. Radiosurgery can be performed in acelerador lineal, Cyberknife o gammaknife, being the specialists team who choose the more convenient system in each case.

Side effects
Acute effects: Alopecia (hair fall), partial or complete. It will be permanent or transitory turning on the dosage. Brain edema (can cause headache, sickness, vomiting or sickness) and it is prevented or treated with corticoids.
Belated effects: Depending on some patient’s brain area treated with radiation certain degree of the upper functions deterioration can be noticed (ie.. Memory loss, concentration drop…)

 

Breast cancer

Breast cancer is the malign tumor made up in the breast gland tissue. It is the most common in occidental women and in Spain around 22.000 new cases per year are diagnosed.
Radiotherapy has a key role in comprehensive treatment of this disease for the following cases:
Early stages, as a fundamental part of the conservative treatment.
Locally advanced stages where it is administered once mastectomy is performed (breast removal).
Widespread disease, as a palliative treatment.
Schedule
It is necessary to do an immobilization and placement system for planning the external radiotherapy (EBT), by choosing the most suitable function of each patient’s anatomy letting reproduce the same posture each day of treatment. It is commonly done in supine (flat on one’s back) and, at times in prone position (lying upside down). With the chosen position, a CT is done which with later on, the radiotherapy will be planned. Finally in the thorax skin some marks will be drawn to fix the coordinates to allow the treatment be administered, in each session, as planned.

Treatment
Precocious stages: Generally, a conservative treatment is applied. The surgeon performs a lumpectomy (tumor removal) with axillary nodes resection and, later the radiotherapy is used to treat the remaining breast tissue including or not, depending on each case, axillary nodes and supra infraclavicular.
For indicated cases to complete the treatment with larger radiation dosages (boost), external radiotherapy (EBT) is administered in all the remaining breast in daily sessions during 4-5 weeks. This can be done with external radiation therapy, during 5-8 days more, including boost in the initial treatment, or with brachytherapy.
The external radiotherapy is done in a acelerador lineal, while braquiterapia is a minor surgery procedure – with appropriate anaesthesia where the oncologic radiotherapist, by a minor surgery, with the corresponding anaesthesia, – placing few needles of plastic pipes in the area where was the tumor, to introduce them in a radioactive source releasing the planned radiation dosage. Choosing one or another boost system is evaluated individually, selecting the most suitable for each patient.
-locally advanced stages with mastectomy: In these cases, external radiotherapy is indicated for patients with nodes affected by tumor, tumors bigger than 5 cms or if the resection margin from the tumor is scarce. The treatment is performed in acelerador lineal.
Both for precocious stages and advanced, if they are treated with chemotherapy, commonly radiotherapy is administered after it.
-Widespread disease. It is quite frequent to administer palliative radiotherapy in different moments of the disease. It is used for treating particular localizations of bone metastasis (vertebrals, pelvis, humerus or femur) and brain metastasis. It is carried out in a linear accelerator. In some cases of brain metastasis, radiosurgery or hypo-fractionated stereotactic radiotherapy can be used.

Side effects:
Acutes: Epithelitis (skin irritation in the radiation field)
Belated (months or years after): Fibrosis (consistency increase of breast)

 

Digestive tumors

It is a heterogeneous group of tumors as the digestive apparatus reaches all the entire digestive tube (esophagus, stomach, intestine, colon – rectum and anus) and, along with pancreas and liver.
Radiotherapy has a relevant role related or not to surgery and/or chemotherapy for the mostly part of localizations.

Planning
radioterapia externa (RTE) planning is carried out in TC done after place the patient in a positioning and casting system, chosing the most suitable depending on the treated area. The one that allows reproducing comfortably and firmly is choosing, the same position each day of the treatment. The esophagus cancer, gastric and esophageal-gastric join, the CT is done in supine (flat on one’s back), using IV contrast and/or oral in some cases.
It is used information provided by some or several of the following tests for localizing: panendoscopy, echoendoscopy, esophageal-gastroduodenal with barium radiological study (EGD) y PET-TC. The radiotherapy oncologist is who, after analysing each case, decides the necessary ones.
In rectum cancer, the common position for irradiating and, therefore, the operational in TC for planning, is prone (lying upside down) using the immobilization system of some type of device for excluding the intestine loops in radiation area. It is also possible to perform the CT planning supine (flat on one’s back) with a specific locking system The radiotherapy oncology specialist will be who determines the more suitable position according to the patient’s characteristics. Often, MR images (resonancia magnética) are used achieving a better definition of tumor spread.
In anal cancer , the position for the TC planning and treatment differs from each case, or supine (flat on one’s back) or prone. Both options, with the corresponding casting system letting the chosen position reproduction for each day of treatment.
For pancreas cancer, the radiotherapy position and the corresponding TC for planning is supine. It usually used intravenous and oral contrast and, often, images fusion are used of resonancia magnética (RM) and PET-TC for helping with the irradiation areas delimitation.
Once the planning CT acquisition is already completed, some marks are drawn in the treatment skin area. Thorax, for esophagus tumors cases; upper abdomen, stomach, pancreatic and liver cancer; and low abdomen, rectum tumors or anal region tumors, which will help to localize the coordinates to allow the radiotherapy administration in each session, as planned.

Treatment
In esophagus cancer, the options are: Exclusive surgery, in early stages of tumor (unusual); the remaining, a multimodal treatment (radiotherapy and chemotherapy combination and depending on each case, an esophagectomy—removal of part or all the esophagus.) Also, the radiotherapy is indicated as palliative treatment.
The treatment is administered in lineal accelerator with a 3D technique or with Intensity-modulated radiation therapy (IMRT), in some cases it is used for CT cone-beam, previously controlled for Imaging Guided Radiotherapy (IGRT).
For some patients, it is suitable a brachytherapy – external radiotherapy combination. For brachytherapy, a digestive endoscopy specialist physician performs a esophagoscopy to visualize the tumor and allowing that the radiotherapist puts, in this tumor area, a catheter where a radioactive source is inserted the necessary while releasing the correct radiation dosage. Esta técnica de braquiterapia endoluminal permite administrar dosis elevadas en la zona del tumor y mínimas en los tejidos sanos adyacentes.
In stomach cancer, small and localized, the initial treatment often is surgery, related or not to postoperative chemotherapy or radio-chemotherapy. Its indication is decided by the medical team according to the tumor spreading. In local tumors more advanced, the option is usually preoperative chemotherapy or radio-chemotherapy or, in some cases, postoperative.
The treatment is administered in acelerador Lineal with a 3D technique or with Intensity-modulated radiation therapy (IMRT).
In early rectum cancer it is decided, mainly by surgery. If in the tumor study, it is confirmed that it is limited to the inner wall and with nodes affectation it is reinforces as the unique treatment. However, it is not infrequent to discover that the tumor is bigger, in that situation, the indicated postoperative treatment will be radiotherapy and chemotherapy. In patients with locally advanced tumors from the initial diagnosis, the treatment is multimodal. Commonly, it is started with radiotherapy and chemotherapy, simultaneously administered and in a preoperative way, so that, after few weeks after finishing it, the surgery is performed (removal of the remaining tumor or in the area where it was). In postoperative, chemotherapy administration is usual. If the patient has been operated without receiving previous treatment, radiotherapy and chemotherapy can be applied.
Radiotherapy is administered in acelerador lineal with 3D technique, and it also has a key role in patients with a few tumor metastases, when diagnosed in liver and lung, if surgical removal is feasible. A multidisciplinary treatment can be often proposed in these cases which start chemotherapy or radiotherapy with chemotherapy on the rectum tumor and, then, surgery with rectum tumor removal and liver and/or lung metastasis.
For patients with unresectable rectum tumors, radiotherapy in acelerador lineal with 3D technique aids to improve symptoms as pain or bleeding.
In these cases, is normally combined with chemotherapy.
To patients with pulmonary or hepatic metastasis surgical irremovable, stereotactic body radiotherapy can be applied (SBRT) with Cyberknife (treatment that allows to administer a high dosage, particularly in tumor, respecting as much as possible the healthy tissue. It has the benefit of no need of limiting casting of breath movement due to its capacity to fit the bundle of radiation incessantly to the tumor movement inside the lung or liver.)
In anal cancer, radiotherapy has a key role, as for early tumors as for locally advanced ones, since related to chemotherapy is the chosen treatment. Surgery involving abdominoperineal amputation and permanent colostomy (excision of all the area from the anus, closing its skin and colostomy bag, in abdomen area, for faeces), is for patients in whom control of tumor with radio chemotherapy is not reached.
Radiotherapy is administered in lineal accelerator normally with modulated intensity (IMRT).
When indicated, in some cases, it would be done a treatment withbraquiterapia.In pancreas cancer, if possible, a surgical excision and postoperative treatment with chemotherapy or radio chemotherapy are applied. If resection were not possible, and it is considered that the tumor might turn resectable after the preoperative treatment, a chemotherapy related to radiotherapy is used in some cases for try to remove it later. In unresectable tumors, the treatment is focused in chemotherapy and radiotherapy administration.
Radiotherapy is administered in lineal accelerator with 3D technique or IMRT.
For some patients stereotactic body radiotherapy (SBRT) is indicated with Cyberknife (treatment that allows a very high dosage administration, only to the tumor, with the maximum respecting to the healthy tissue around. In pancreas tumors cases we talk about organs as the small intestine, liver, stomach and kidneys.

Side effects
Acutes: Sickness/vomits and pyrosis (burning sensation rising up to mouth) in localized treatments in the upper abdomen area (esophagus, stomach and pancreas). Diarrhea, vaginal irritation and urinary symptomatology by bladder and urethra irradiation.
Chronics: Intestine rhythm disturbances with more frequency of diarrhea disorders with constipation periods fundamentally in tumors of rectum and anus.

 

Urologic tumors

Bladder cancer is the most usual urinary apparatus malign neoplasm while, urethra and ureter cancer are slightly commons. Its occurrence is bigger in men over 60 years.
Radiotherapy has a key role in treatment of the two first, bladder and urethra as for exclusive therapy for protecting the organ as postoperative and palliative. On the contrary, in ureter tumors it is only used as palliative treatment.

Planning
For external radiotherapy planning (RTE) it is necessary to do a positioning system and a correct cast to be able to reproduce the same position each day of treatment. Normally it is done in supine (flat on one’s back). With the chosen position, a CT is done which with later on, the radiotherapy will be planned. Usually it is performed with a kind of bladder preparation (by inserting a small volume of contrast or with the bladder completely empty.) Specialists in radiotherapy oncology rate the most appropriate for each patient. Finally in the skin some marks will be drawn to fix the coordinates to allow the treatment be administered, in each daily session, as planned.
In these cases, radiotherapy is performed in accelerator, with a 3D technique of Modulated intensity (IMRT.)

Treatment
Bladder cancer: These tumors can be papillary-superficials or infiltratives. The first are very frequent but for them radiotherapy is not indicated.
In infiltrative tumors, the usual treatment is bladder scission (cystectomy), normally entire. In most advanced stages chemotherapy pre or postoperative is administered and in cases where a partial cystectomy is possible, the treatment will be completed with postoperative radiotherapy.
On the other hand, for patients who want to preserve the bladder or those who cannot be operated, the election is often radiotherapy combined with chemotherapy. Of course, radiotherapy will be carry out after the scission of major part of tumor as possible through the transurethtral resection (TUR) made by the urologist.
Besides, radiotherapy has an important role in palliative treatment of advanced tumors aiming to relieve the bleeding (hematuria), that often these tumors produce.
Urethra cancer: The treatment often is surgical, but more or less wider scissions could be required depending on the urethra duct section where the tumor is located. A treatment with radiotherapy or chemotherapy can be applied to some patients with the aim of preserving the organ. In wide tumor cases it is necessary postoperative radiotherapy and/or chemotherapy.Ureter cancer: In these types of tumors radiotherapy is not indicated since, for ureter anatomical location, organs with low tolerance to irradiation will be affected. So, surgery is a standard treatment, combined in some cases with pre or postoperative chemotherapy.

Side effects
Acutes: Symptoms of bladder irritation, burning to urinate and urgent need to do it. Tend to have diarrhoea due to intestine irritation.
Chronics: Very often urine need in cases of spread tumors, since the fibrosis that substitutes the tumor leaves a low capacity bladder.

 

Male genital apparatus tumors

Prostate cancer is the second more common in men and it is developed more frequently in individuals older than 50 years. It is a type of tumor where the radiotherapy has a very excellent role in multiple indications, so much as radical treatment, completely alternative to the surgery, as postoperative.
Likewise, the tumors testiculares although there are no very frequent, usually affect young males, of course, they are provided with the highest healing rate among all the types of cancer. They are classified as seminoma and non seminomatous tumors. In the first one, radiotherapy sometimes is administered after surgery, and in seconds the indication is lower and exclusively palliative.

Planning
Prostate cancer: For the planning of the external radiotherapy (RTE) it is necessary to realize a suitable system of position and immobilization that allows to reproduce the same position every day of the treatment. Normally it is done in supine (flat on one’s back). With the chosen position, a CT is done which with later on, the radiotherapy will be planned. Generally it is carried out with full bladder and clear rectum or placing a device inside so that the size is equal during the whole treatment. Finally in the lower part of abdomen, some marks will be drawn in the skin to fix the coordinates to allow the treatment be administered, in each session, as planned.
Prostate is properly visualized in MR and this, can be fused with the CT for the planning. Inside the prostate can be placed as well few radio-opaque seeds, in the days before the CT planning, to ease its location during radiotherapy and guarantee that the treatment is properly administered. The seeds are placed by puncturing the prostate from outside, across the perineum skin (region between the anus and the penis root), under anaesthesia or by transeptal via under ultrasound control. The oncology radiotherapist will set, for each patient if some of these procedures should be used and which one is the suitable.
During irradiation, it is important to reproduce the same conditions of rectum and bladder used for the TC planning. The treatment is carried out in a lineal accelerator, with 3D or intensity-modulated radiation therapy (IMRT), being appropriate a daily control with imaging guided radiotherapy (IGRT).
If the option is brachitherapy, alone or combined with external radiotherapy, it turns to the interstitial implantation (place a radioactive brachytherapy area to be treated, in this case, prostate). To achieve this, under anaesthesia in OT few needles are placed from the perineum skin to prostate, controlling the correct location by transrectal ultrasound.
Testicular tumors: The external radiotherapy (RTE) is planned on CT images, performed to the patient in the position in which every day will receive treatment. To support and reproduce every day the chosen position, supine in this case (flat on one’s back) with the arms extended along the body, it is necessary to set up a positioning system and appropriate immobilization. Muscles are often slightly separated, and a protection is set on the scrotum. By finishing the CT acquisition in the lower part of abdomen, some marks will be drawn in the skin to fix the coordinates to allow the treatment be administered as planned.
The treatment is performed in the lineal accelerator, with a 3D planning.

Treatment
Prostate cancer: Prostate tumors are divided in groups of low, intermediate and high risk. The grouping is made depending on the tumor parameters: Gleason grade, PSA and cancer staging (size and tumor spread) and, the treatment is delayed according to those groups of risk.
In low risk tumors, the options are: Surgery with prostate scission (radical prostatectomy), brachytherapy or external radiotherapy.
In intermediate risk, a prostatectomy can be indicated or an exclusive external radiotherapy or combined with brachytherapy. Obviously in most cases, related to short term hormone treatment, previous and concomitant with irradiation. Both options have often similar results, so its election will depend on the final decision taken by doctor and patient.
It is necessary a major follow up, many clinical studies support the efficacy and safety of SBRT or extracranial stereotatic radiotherapy in the preferred groups of patients with prostate cancer. Cyberknife enables this kind of treatment in few sessions, reducing the whole treatment duration.
In the high risk group, the prostatectomy has a much lower significant indication than radiotherapy. This could be exclusively external or combined with brachytherapy. In most patients, it is related to the long term hormonal treatment, prior concomitant and after irradiation.
In any of these cases, if a prostatectomy has been performed, the postoperative external radiotherapy appliance is indicated in the area where the tumor was. Besides, in many cases, it is necessary for patients who, after surgery, the PSA analysis starts with a high and progressive rise without finding the tumor in any body region. This situation is known as biochemical relapse.
Eventually, in other cases the radiotherapy is used with a palliative aim on diverse areas of bone metastasis. In these cases, radiotherapy is administered also in lineal accelerator, but the treatments are less complex, as in its planning as in dosages/number of sessions.
Once more, the radiotherapy oncologist will set individually the most suitable treatment.
Testicular tumors: Initially, the treatment for testicular tumors is surgical, scission of the testicle holding the tumor(orchiectomy). The subsequent treatment will rely on if it is a seminoma or germinal tumor non seminomatous. The next seminoma handling will depend on the disease spread; it could be intensive surveillance, radiotherapy administered on the pelvis nodes and the paraaortic region (both inside the abdomen), or chemotherapy. When each case is studied, the medical team proposes the most appropriate treatment to the patient. In non seminomatous tumors, according to the disease extension they can be controlled, or operated to resect the retroperitoneal nodes (inside the abdomen) and/or chemotherapy. Radiotherapy only is used as a palliative treatment.

Side effects
Acutes: In radiotherapy treatment for prostate tumors, some bladder irritation symptoms can rise (urine needs every short time, urgent need to urinate and burning at the beginning or finish of urinating.) Rectum irritation symptoms (increase of a number of bowel movements and /or loose stools and irritation around the anus.) Normally, they are minor and improve rapidly after the end of radiotherapy. In the seminoma irradiation, some sicknesses may be produced since there are wide abdominals areas, including a loop of the intestine. Radiotherapy oncologists often indicate the treatment to patients with antiemetics, controlling those annoyances.
Belaters: They occur months or years after the treatment is finished. After the prostate cancer treatment rectitis and cystitis (rectum wall or bladder disorder) can be produced. The number of cases is very short.

 

Haematological tumors

Leukaemia, lymphoma –Hodgkin and not Hodgkin- and multiple myeloma

They are a heterogeneous group of diseases affecting blood, medulla and lymphatic nodes. The most usual are chronic lymphatic leukaemia (LLC) and all the lymphomas group (including Hodgkin and the B and T cells). Even if the great part of hematologic tumors are treated with chemotherapy, radiotherapy has a significant role in many cases.

Planning
Radiotherapy planning is performed in a CT with the right position, previously chosen depending on the area to be covered, used to place the patient during the treatment. Therefore, for every day of irradiation, a positioning system and immobilization are looked up for reproducing it. The used system will differ in each case, as they can be located in several areas (neck, thorax, abdomen or pelvis).
PET-TAC will be used or RM MR (magnetic resonance) to help with the planning in those cases where the radiotherapy oncologist consider necessary to achieve a better definition and a better definition of the areas to irradiate.
The treatment is performed in acelerador, with a 3D technique or IMRT.

Treatment
Whithin the group of tumors named non-Hodgkin lymphomas (LNH) are included several types, which are treated differently. Most of them are combated with chemotherapy, in many cases, combined with radiotherapy.
The different treatment options in case of follicular lymphoma of low degree localized (stages I and II) are: exclusively radiotherapy, immunotherapy with/without chemotherapy or immunotherapy/chemotherapy and radiotherapy.
In large follicular lymphomas (stages III and IV), the watching or treatment will be the options depending on the affected areas, the disease development and symptoms existence or not. In these patients, radiotherapy is used if necessary to relieve some symptoms, in likely areas to be irradiated.
The identified mantle cell lymphomas can be treated with chemotherapy alone, combined with radiotherapy or only radiotherapy as a unique treatment.
In Burkitt lymphoma the chemotherapy is the chosen treatment and, sometimes it is necessary a medullar transplant in patients who do not achieve the complete disease remission. In some cases, the disease does not disappear completely after chemotherapy, and could be necessary palliative radiotherapy.
The diffused lymphomas of big B cells are treated with chemotherapy and, in bulky diseases radiotherapy is used to reinforce the response to chemotherapy. It also can be used as an exclusive treatment in refractory patients or unsuitable for chemotherapy. Another indication is the medullar pre or post-transplant.
In skin lymphomas, depending on the type and extension, radiotherapy can be used as the only treatment or combined with chemotherapy.
The T cells lymphomas often are treated with chemotherapy followed by radiotherapy.
The treatment of NK lymphoma/T cells nasal or extra nasal, often is with chemotherapy and radiotherapy although, in some precocious cases, is used only radiotherapy.
The gastric MALT lymphoma is related with the Helicobacter pylori, it is treated with antibiotics to eliminate the germ. If it is not related to early stage H. pylori infection, is often treated with radiotherapy or with chemo/immunotherapy. In non-gastric, precocious stage, can be treated with surgical resection or radiotherapy. If it is advanced, it is possible to opt for watching or treatment according to the affected areas, the disease development and the existence or not of symptoms. The treatment could be with chemotherapy with/without immunotherapy and radiotherapy if it is necessary to relieve the symptoms.
The Hodgkin lymphoma is divided into various subtypes as the disease expansion and size and the type of prevailing cell. In the most cases, the treatment combines chemotherapy with posterior radiotherapy. The irradiation is administered on the areas of bigger initial disease development or the remaining of it after chemotherapy. In a determined number of patients, diagnosed in early stage of the lymphocyte-predominant radiotherapy can be proposed as the only treatment.
Inside the myeloma we include the solitary bone plasmocytoma or extra-bone and the multiple myeloma. The first one is a malign tumor of detected plasmatic cells or in any bone (much more frequent) or in soft tissues of the body. In the multiple myelomas, the disease is spread affecting various levels. The bones and extra-bones solitary plasmocytomes are treated only with radiotherapy and/or surgical removal if possible. In patients with multiple myelomas the treatment proposed is depending on the affectation and the symptoms showed; it can be from watching in asymptomatic patients, and with few disease affectations to chemotherapy followed or not by medullar transplant.

 

Tumores Musculoesqueléticos

Los sarcomas óseos y de partes blandas comprenden todos aquellos que se originan en huesos, músculos, articulaciones u otros tejidos blandos.

Los sarcomas óseos incluyen varios tipos: osteosarcoma, condrosarcoma, sarcoma de Ewing, etc. Cada uno de ellos requiere de un tratamiento multimodal diferente, donde la radioterapia representa un papel importante según el momento del proceso.

Por otro lado, los sarcomas de partes blandas son tumores originados en los tejidos blandos del cuerpo (músculos, grasa, vasos sanguíneos, ligamentos, etc.). Por su gran variedad y localización, existen numerosos tipos: liposarcoma, leiomiosarcoma, rabdomiosarcoma, sarcoma sinovial, fibrohistiocitoma maligno, sarcoma alveolar, sarcoma fibromixoide, entre otros. Son frecuentes en extremidades, retroperitoneo, tronco, abdomen y cabeza y cuello. y La radioterapia forma parte fundamental del tratamiento en la mayoría de ellos.

Planificación

Para la planificación de la radioterapia externa (RTE) es necesario realizar un sistema de posicionamiento e inmovilización adecuado para poder reproducir la misma postura cada día del tratamiento. Con la posición seleccionada, se realiza una TC en la que, posteriormente, se planificará la radioterapia. Finalmente, se efectúan unos tatuajes en la piel de la región a tratar, que servirán para localizar las coordenadas que permiten que el tratamiento se administre, en cada sesión diaria, según lo planificado.

La planificación de la braquiterapia, en aquellos pacientes en que se utiliza como sobreimpresión (administrar una dosis adicional), se realiza también con un sistema de planificación 3D.

Tratamiento

Los sarcomas óseos requieren de tratamientos diferentes según el tipo. En el caso del sarcoma de Ewing, la radioterapia tiene un papel muy relevante como parte del tratamiento radical, junto a la quimioterapia o asociada a la cirugía, tanto pre como postoperatoria. En el resto de tumores, se emplea como tratamiento, fundamentalmente, postoperatorio. Asimismo, la radioterapia está indicada en tumores irresecables (los que no se pueden extirpar quirúrgicamente) y como tratamiento paliativo. En todos los casos, se administra en aceleradores lineales que permiten técnicas de radioterapia 3D y radioterapia de intensidad modulada (IMRT).

En los sarcomas de partes blandas el tratamiento habitual es la cirugía junto a radioterapia pre, post o intraoperatoria y con frecuencia una combinación de las mismas. Al igual que en los sarcomas óseos, la radioterapia externa (RTE) se administra en aceleradores lineales que permiten técnicas de radioterapia 3D y radioterapia de intensidad modulada (IMRT).

Con frecuencia, en los sarcomas de partes blandas está indicada una sobreimpresión (administrar una dosis adicional) en la zona del lecho tumoral. Ésta puede realizarse mediante radioterapia externa, localizando la zona mediante la visualización en el TC de planificación, o mediante braquiterapia. En el mismo acto quirúrgico de extirpación del tumor, puede realizarse el implante de los tubos plásticos o agujas metálicas donde entran las fuentes radiactivas necesarias para la braquiterapia. Esto tiene múltiples ventajas para el paciente ya que, en la misma cirugía, se extirpa el tumor y se posicionan los catéteres en el lecho tumoral, permitiendo que una dosis alta de radiación llegue solo a dicha zona, preservando los tejidos sanos cercanos. Esto es posible gracias a un equipo multidisciplinar en el que participan los cirujanos y oncólogos radioterápicos.

Efectos Secundarios

Agudos: Epitelitis (irritación de la piel).

Crónicos: Fibrosis.

Lung and thymus cancer

The lung cancer is the most usual tumor and, in some cases, often affects smokers or people who recently gave it up. Tumors developed inside the thymus remains (lymphatic system organ of upper chest, under the breastbone, greater in childhood than in adult age of which it only remains a small part) are known as thymoma.
In these cases, the radiotherapy has a significant role in:
Precocious disease: in inoperable patients (due to diseases preventing surgery or in those who reject it).
Locally advanced disease: Main part of the treatment, generally multimodal (relating various treatments: Radiotherapy, chemotherapy and/or surgery).
Widespread disease: With local palliative treatment or metastasis.

Planning
For the planning of the external radiotherapy (RTE) it is necessary to realize a suitable system of position and immobilization reproducing the same position every day of the treatment. It is normally carried out in supine (flat on one’s back) with arms separated from the body and over the head, subjects or stabilized in the immobilization system. With the chosen position, a CT is done which with later on, the radiotherapy will be planned. Finally in the thorax skin some marks will be drawn to fix the coordinates to allow the treatment be administered, in each session, as planned.
In most cases PET-TCwill be used for planning, since in this pathology, especially useful for tumoral volume correct definition.
For the cases which a stereotactic body radiotherapy (SBRT) is going to be applied, fiducial marks (small marks settle inside or next to the tumor to allow the treatment) placement will be valued. If needed, the placement of them is made by a puncture from outside, guided by CT.

Treatment
Precocious disease, in inoperable patients or patients with surgery rejection: The chosen treatment for detected lung cancer is surgery. Nevertheless, in inoperable patients or who push this alternative back, the radiotherapy is, also, a good treatment option. In this case, the procedure to be used will depend on the size, location and tumor extension.
In small tumors, the suitable procedure is the stereotactic body radiotherapy(SBRT) with Cyberknife <http://www.neuroruber.com/especialidades/oncologia_radioterapica/index.php> (treatment that allows to administer a very high dosage, exclusively to the tumor, with maximum regard of the healthy tissue, with the additional benefit of not being necessary immobilization of the respiratory movement for its capacity to fit the radiation bundle continuously to the tumor movement inside the lung). The treatment is performed with linear gas pedals <http://www.neuroruber.com/especialidades/oncologia_radioterapica/index.php> that allow radiotherapy 3D technique and modulated radiotherapy intensity (IMRT) in the other precocious tumors, without having criteria to be able to realize SBRT.
As postoperative treatment: Radiotherapy benefits the outlook decreasing of tumor recurrence in the area, both for operated patients whose tumor has a spread in mediastinum nodes (area between both lungs) greater than the shown in the preoperative study as in patients whose resection margin is scarce.
Locally advanced disease: Radiotherapy is a decisive part of the treatment in such cases, normally combined with chemotherapy. The treatment can be concurrently achieved (radiotherapy and chemotherapy simultaneously) or sequentially (radiotherapy after chemotherapy). aceleradores lineales are used for this, allowing 3D radiotherapy techniques and intensity-modulated radiation therapy (IMRT). If the tumor has an endobronchial compound, the combination of external radiotherapy with brachiterapia <http://www.neuroruber.com/especialidades/oncologia_radioterapica/index.php> can be a good option.
Postoperative radiotherapy in unsuitable patients for an initial surgery is also indicated for locally advanced tumors, treated with chemotherapy and reducing the tumor size before the surgical resection. Radiation therapy helps to reinforce the treatment of the tumor that was affecting the mediastinum nodes or the pulmonary tumor area, when it is near the resection margin.
-Widespread disease: With local palliative treatment or metastasis.
In some cases of cerebral metastasis or of other extracranial metastases, if the tumor burden is low (oligometastasis), radiosurgery or hypo-fractionated stereotactic radiotherapy in specific units for these treatments, as they are gammaknife and cyberknife.

Side effects
Acutes: Esophagitis (inflammation of the oesophagus).
Subacutes or chronics: Pneumonitis (lung inflammation) , can come out after 3-6 moths from radiotherapy, although, generally they are minor and temporary.

 

Skin cancer

It is the cancer which is developed in skin tissues. There are several types: which is formed in the melanocytes, known as melanoma, in the inner part of the epidermis, called carcinoma of basal cells or basement squamous cells origin, called squamous cells carcinoma and the neuroendocrine skin carcinoma, formed in the neuroendocrine cells.
-Skin cancer (not melanoma): Radiotherapy has an important role as an exclusive treatment, surgery alternative, as postsurgical in some cases.
-Melanoma: In this case, radiotherapy is indicated in various situations: As initial tumor treatment, after surgery; in postoperative irradiation of lymph node chains affected by the tumor; alternatively, with palliative aim in brain metastases, bone metastases, etc.

Planning
Skin tumors (not melanoma) often appear in the sun-exposed skin areas. If external radiotherapy is used, to plan it, the first thing is choosing the position and the more suitable immobilization system, according to the location.
If the cutaneous tumor and not the node is only necessary to treat, the Radiotherapy Oncologist takes the decision to value if it is indispensable to realize a TC <http://www.neuroruber.com/especialidades/oncologia_radioterapica/index.php> to plan the radiotherapy, or it is possible to carry out the setting up without it, since the tumor can directly be visualized. When the nodes must be treated it turns always to a TC.
If a palliative irradiation is needed, due to the metastasis, depending on the area to be treated, the suitable position and immobilization are chosen and a TC is performed in which the radiotherapy is planned. The treatment is performed in acelerador lineal. In some patients with brain metástasis cerebral, according to the number, size and location of them, the medical team can consider the radiosurgery as the most suitable treatment, which would be accomplished assessing every case individually with Cyberknife <http://www.neuroruber.com/especialidades/oncologia_radioterapica/index.php>

Treatment
Not melanoma tumors:
– Basal cell carcinoma or basal cells. Surgical tumor resection can be performed or radiotherapy. After valuing each patient one or another is settled on, bearing in mind, besides healing, the aesthetic results. If the surgery is the option and the tumor reaches the resection margin of the resected area, postsurgical radiotherapy can be indicated or a larger surgery.
-Squamous cells carcinoma. As in previous tumors, a surgical tumor scission can be done or radiotherapy. However, the feasibility of nodes affectation is much bigger. For this reason, the medical team in indicated cases carries out a study to estimate if there is node infiltration, and if it is necessary to apply any kind of treatment to them. Normally, the choice is the resection of the corresponding lymph nodes and the latter area irradiation. Surgery is not possible for some patients and exclusive radiotherapy is applied.
-Melanoma: The initial treatment of melanoma is the surgical resection. If the margin of resected skin around the tumor is scarce, a bigger resection can be accomplished. However, radiotherapy is indicated to some patients. It is also normal to resect the lymph node chains affected by the tumor. Often a postoperative radiotherapy can be performed in these lymph nodes areas, depending upon the indication or not of irradiation, of the node number infiltrated by the tumor.

Side effects
Acutes: Skin area irritation, shown as reddish of different intensity, even with a small skin ulceration in some cases. It is restored in a few weeks after the treatment conclusion.
Chronics: Many patients do not show disorders at long term. In some ones, the thinner skin in the treated area can be seen. It depends on the necessary dose administered and the irradiated area.

 

Benign pathology

Although radiotherapy is mainly used for malignant tumors healing, it is also indicated for treating some benign diseases.
• The benign pathology to be treated with radiation can be divided in: benign tumors: Pituitary adenoma, benign neurinoma, classic meningioma, desmoid tumors…
• Processes on the borderline between hyperproliferation cases and neoplasias: Histiocytosis of Langerhns cells, Kimura disease…
• Vascular system disorders: Arteriovenous abnormalities, hemangiomas…
• Inflammatory disorders or soft tissues proliferative: Dupuytren disease, keloids, Graves’ ophthalmology, orbital pseudotumors…
• Osteoarticulars disorders: Tendinopathies and bursitis, calcaneal spur, prophylaxis of hip heterotopic ossification, periarthritis…

Planning
The planning is carried out in aTC, performed in the most suitable regarded position. The position and immobilization system choice depends upon the area to be treated, whenever the optimum selection allows reproducing the desired position for irradiation, all the days of therapy.
Radiotherapy Is accomplished in acelerador lineal. Specific pathologies, as arterio-venous abnormalities or brain neurinomas also can be healed with Gammaknife.

Treatment
Radiotherapy has proven to be an effective treatment for certain benign illnesses, like the previously reported ones, when they cause a serious disturbance of the patients’ quality of life. The medical team is who, after analyzing each case, decides the precise moment to propose irradiation. Sometimes it is indicated after the failure of other therapies. Other times, it is considered the first therapeutical option, if the potential risk of another treatment is bigger than the irradiation.

 

Head tumors

There is a group of malign tumors named head and neck cancer which origin is in oral and nasal cavity, nasopharynx, oropharynx, hypopharynx, larynx, paranasal sinuses and salivary glands.
They are, approximately the 5% of cancers in men and the 2% in women. On the whole, they are the most frequent fifth neoplasm in world population, in Europe the most common is the larynx (40 % of total) followed by oropharynx, oral cavity and nasopharynx.

In these cases, the radiotherapy has a significant role in some indications:
– As tratamiento alternativo a la cirugía with equivalent results in:
Early stages and localized tumors: With results of disease control similar to the ones of surgery, but with a less impact in functionality.
Locally advanced stages: to preserve the organ. Normally it is related to a radiosensitizer chemotherapy. It is achieved cure the tumor in a significant number of patients preserving such important functions as swallowing and speech.
– As complementing treatment to surgery, postoperative radiotherapy: In locally advanced tumors by neighbouring structures affectations and/or by infiltration of regional lymphatic glands, diminishing the local relapse and improving the tumor control
In nasopharynx tumors (cavum): For its localization, it is impossible to perform the surgical resection and, consequently, the radiotherapy is the election treatment both exclusively in precocious stages as the advanced related to chemotherapy.

Planning:
It is necessary to prepare an immobilization mask adapted to the patient’s head after choosing the most favourable position for the treatment for the external radiotherapy planning (EBT). With it, after, a CT is done to plan the radiotherapy. At times, it is important to arrange a Resonancia Magnética and/or PET-TC as a support, since the fusion of all allows a better visualizing of the tumor and critical organs (healthy organs placed near the tumor where radiation dosage can be limited).

Treatment:
In precocious tumors, early stages or localized: Radiotherapy can be the only treatment since it offers similar results to surgery.
Locally advanced tumors: Postoperative surgery and radiotherapy (with or without radiosensitizer QT) can be performed to these patients, or radiosensitizer radiotherapy with chemotherapy (if possible) radically in order to protect the organ. In such case, these tumors, by its irregular volumes, are often concave around the risked organs (spinal cord and parotid glans), gaining from the treatment planning with Intensity-modulated radiation therapy (IMRT), and image guided radiotherapy (IGRT). High accuracy and quickness Dynamic Arc therapy, are available for this purpose atAcelerador Lineal Varian 2300 iX, this is perfect for the treatment achievement.

Side effects:
Acutes: Mucositis (mucus irradiated area damage) and epithelitis (skin irritation in the radiation field).
Belated (months or years after): Xerostomia (dry mouth), decay and fibrosis.

Thyroid tumors

Amongst the malign thyroid tumors there are different types, depending on the cell where they are created. Those well differentiated, more common and with better evolution, they are papillar and follicular type, whose appearance is more usual in young women. The standard treatment is the surgical resection with or without radioactive iodine, sometimes complemented with external radiotherapy. Another type is the medullar carcinoma, from the neuroendocrine tumors and much less frequent than the previous ones. It is treated with surgery and, sometimes, postoperative radiotherapy. The group is completed with the anaplastic thyroid carcinoma, rare and with a more aggressive evolution, which treatment is the surgical removal (if possible) and chemotherapy with or without radiotherapy.

Schedule
Radiotherapy schedule takes place inTC, applied to the patient in the same position as he is going to be treated. The acquisition is done in supine (flat on one’s back), normally after the previous making of an adapted mask to the patient’s head and a system to immobilize shoulders and the upper thorax (the area to be treated includes the lower neck and upper thorax), to guarantee the exact position during the daily treatment. Radiotherapy is done in acelerador, with a 3D technique or often, IMRT.

Treatment
Well differentiated tumors, papillary and folliculary type are treated with surgical resection with or without radioactive iodine (I-131). I-131 is a radioactive isotope used due to its similitude to be compacted in the thyroid tissue. This kind of treatment is called metabolic radiation, because the isotope is taken as a liquid and moves along the organism to concentrate in tyroid cells and release high dosages of radiation to them producing its selective elimination. Necessarily the patient must remain some days in a special room, isolated, since he will be issuing radiation that could affect to the people around him. Doctors who control the treatment are the specialist in nuclear medicine and endocrines. Patients are discharged when they already have rid all the radioactive iodine. For some patients, it is indicated the external radiotherapy enhancing the treatment. The specialists team, whom joins also radioterapic oncologist, analyses each case and decides who can be benefited from the above-mentioned medical care.
In medullar tumors, the initial treatment is usually surgery, performing thyroidectomy and neck nodes dissection. Frequently postsurgical radiotherapy is indicated. The decision of the completing treatment is taken by the specialists, according to the tumor extension and the nodes impact. It is also indicated radiotherapy to reduce symptoms in patients with widespread disease.
The surgical removal if possible adding postoperative radiotherapy in anaplastic tumor cases. However, the tumor spread does not let the scission and the treatment is done with chemotherapy and radiotherapy in most patients.

 

Brain tumors

Primary brain tumors are developed in the brain tissue cells. In brain can also grow tumors which cells precede from located neoplasms in other organism areas (metastasis). Metastatics are much more usuals than primaries. Between 20% and 40% of cancer patients are capable to develop brain metastasis. In all cases radiotherapy is a main part of the treatment.

Schedule
Firstly, it is necessary to make a head fitted mask for casting the patient held to an attach device affixed to the table, both of TC de planificación, as for the acelerador lineal where radiation therapy is completed. It is carried out once the most favourable position for the patient’s treatment has been chosen, commonly in supine (flat on one’s back) with the neck correctly upheld. With it, TC is done to later plan the radiotherapy. The radiotherapic oncology specialist decides if Resonancia Magnética should be given, since, often its images mixture with the ones of CT for scheduling, allow a better visualization of the tumor and critical organs diagnose (healthy organs placed nearby the tumor, where the radiation dosage must be delimited.
If the chosen treatment is radiosurgery, the casting mask is more rigid and always turns to resonancia magnética to achieve a better tumor and annex tissue definition for a more accurate scheduling.

Treatment
In low-grade brain tumors (low-grade astrocytoma and oligodendroglioma) and the initial treatment is always surgical whenever the size, and the location of the tumor let it. If the removal is complete no postsurgical treatment will be necessary. If the scission is uncompleted, it will be complemented with postoperative radiotherapy, mainly in cases of patients with symptoms provoked by the tumor itself.
In non-operable tumors the radiotherapy is usually the chosen treatment.
In recurring tumors, a new surgical resection is tried and, radiotherapy is administered in postoperative. Chemotherapy is also administered in some cases.
In high degree tumors (anaplastic astrocytoma and multiforme gliobastoma) the initial treatment, if possible, is surgery related to radiotherapy and, in many cases, postoperative chemotherapy. If surgical resection is impossible, concurrent radiotherapy is achieved with chemotherapy and subsequent chemotherapy.
For ependymoma treatment, first the tumor resection is attempted and, for mostly part of patients, after postsurgical radiation therapy is administered, localized and wide (including brain and spinal cord) depending on its spread.
In the medulloblastoma, the treatment is surgical resection and after the craniospinal irradiation (including brain and spinal cord), related or not to later chemotherapy.
The meningiomas treatment is devised depending on its size, characteristics and symptoms. In small and asymptomatic tumors, both options are possible, surgery or radiotherapy; this last one is preferred in cases where its growth, due to its location, or surgical resection could provoke neurologic aftermaths. Larger tumors (>3 cm) and/or causing symptoms, could be treated with surgery or radiotherapy. Patients with tumor resection are administered postoperative radiotherapy if the resection is incomplete or a malignant meningioma is treated.
In the brain metastasis treatment radiotherapy plays a crucial role. The treatment with holocraneal radiotherapy (all the brain) is for patients with growing tumors outside the brain and/or with multiple injuries. Radiosurgery related or not with holocraneal radiotherapy in those patients with few lesions, in general less than three, and if the primary tumor is controlled or considered to be controlled.
External radiotherapy Is done in acelerador lineal. Radiosurgery can be performed in acelerador lineal, Cyberknife o gammaknife, being the specialists team who choose the more convenient system in each case.

Side effects
Acute effects: Alopecia (hair fall), partial or complete. It will be permanent or transitory turning on the dosage. Brain edema (can cause headache, sickness, vomiting or sickness) and it is prevented or treated with corticoids.
Belated effects: Depending on some patient’s brain area treated with radiation certain degree of the upper functions deterioration can be noticed (ie.. Memory loss, concentration drop…)

 

Breast cancer

Breast cancer is the malign tumor made up in the breast gland tissue. It is the most common in occidental women and in Spain around 22.000 new cases per year are diagnosed.
Radiotherapy has a key role in comprehensive treatment of this disease for the following cases:
Early stages, as a fundamental part of the conservative treatment.
Locally advanced stages where it is administered once mastectomy is performed (breast removal).
Widespread disease, as a palliative treatment.

Schedule
It is necessary to do an immobilization and placement system for planning the external radiotherapy (EBT), by choosing the most suitable function of each patient’s anatomy letting reproduce the same posture each day of treatment. It is commonly done in supine (flat on one’s back) and, at times in prone position (lying upside down). With the chosen position, a CT is done which with later on, the radiotherapy will be planned. Finally in the thorax skin some marks will be drawn to fix the coordinates to allow the treatment be administered, in each session, as planned.

Treatment
Precocious stages: Generally, a conservative treatment is applied. The surgeon performs a lumpectomy (tumor removal) with axillary nodes resection and, later the radiotherapy is used to treat the remaining breast tissue including or not, depending on each case, axillary nodes and supra infraclavicular.
For indicated cases to complete the treatment with larger radiation dosages (boost), external radiotherapy (EBT) is administered in all the remaining breast in daily sessions during 4-5 weeks. This can be done with external radiation therapy, during 5-8 days more, including boost in the initial treatment, or with braquitherapy.
The external radiotherapy is done in a acelerador lineal, while braquiterapia is a minor surgery procedure – with appropriate anaesthesia where the oncologic radiotherapist, by a minor surgery, with the corresponding anaesthesia, – placing few needles of plastic pipes in the area where was the tumor, to introduce them in a radioactive source releasing the planned radiation dosage. Choosing one or another boost system is evaluated individually, selecting the most suitable for each patient.
-locally advanced stages with mastectomy: In these cases, external radiotherapy is indicated for patients with nodes affected by tumor, tumors bigger than 5 cms or if the resection margin from the tumor is scarce. The treatment is performed in acelerador lineal.
Both for precocious stages and advanced, if they are treated with chemotherapy, commonly radiotherapy is administered after it.
-Widespread disease. It is quite frequent to administer palliative radiotherapy in different moments of the disease. It is used for treating particular localizations of bone metastasis (vertebrals, pelvis, humerus or femur) and brain metastasis. It is carried out in a linear accelerator. In some cases of brain metastasis, radiosurgery or hypo-fractionated stereotactic radiotherapy can be used.

Side effects:
Acutes: Epithelitis (skin irritation in the radiation field)
Belated (months or years after): Fibrosis (consistency increase of breast)

 

Digestive tumors

It is a heterogeneous group of tumors as the digestive apparatus reaches all the entire digestive tube (esophagus, stomach, intestine, colon – rectum and annus) and, along with pancreas and liver.
Radiotherapy has a relevant role related or not to surgery and/or chemotherapy for the mostly part of localizations.

Schedule
radioterapia externa (RTE) planning is carried out in TC done after place the patient in a positioning and immobilizing system, chosing the most suitable depending on the treated area. The one that allows reproducing comfortably and firmly is choosing, the same position each day of the treatment. The esophagus cancer, gastric and esophageal-gastric join, the CT is done in supine (flat on one’s back), using IV contrast and/or oral in some cases.
It is used information provided by some or several of the following tests for localizing: panendoscopy, echoendoscopy, esophageal-gastroduodenal with barium radiological study (EGD) y PET-TC. The radiotherapy oncologist is who, after analysing each case, decides the necessary ones.
In rectum cancer, the common position for irradiating and, therefore, the operational in TC for planning, is prone (lying upside down) using the immobilization system of some type of device for excluding the intestine loops in radiation area. It is also possible to perform the CT planning supine (flat on one’s back) with a specific locking system The radiotherapy oncology specialist will be who determines the more suitable position according to the patient’s characteristics. Often, MR images (resonancia magnética) are used achieving a better definition of tumor spread.
In anal cancer, the position for the TC planning and treatment differs from each case, or supine (flat on one’s back) or prone. Both options, with the corresponding casting system letting the chosen position reproduction for each day of treatment.
For pancreas cancer, the radiotherapy position and the corresponding TC for planning is supine. It usually used intravenous and oral contrast and, often, images fusion are used of resonancia magnética (RM) and PET-TC for helping with the irradiation areas delimitation.
Once the planning CT acquisition is already completed, some marks are drawn in the treatment skin area. Thorax, for esophagus tumors cases; upper abdomen, stomach, pancreatic and liver cancer; and low abdomen, rectum tumors or anal region tumors, which will help to localize the coordinates to allow the radiotherapy administration in each session, as planned.

Treatment
In esophagus cancer, the options are: Exclusive surgery, in early stages of tumor (unusual); the remaining, a multimodal treatment (radiotherapy and chemotherapy combination and depending on each case, an esophagectomy—removal of part or all the esophagus.) Also, the radiotherapy is indicated as palliative treatment.
The treatment is administered in lineal accelerator with a 3D technique or with Modulated Intensity radiotherapy (IMRT), in some cases it is used for CT cone-beam, previously controlled for Imaging Guided Radiotherapy (IGRT).
For some patients, it is suitable a brachytherapy – external radiotherapy combination. For brachytherapy, a digestive endoscopy specialist physician performs a esophagoscopy to visualize the tumor and allowing that the radiotherapist puts, in this tumor area, a catheter where a radioactive source is inserted the necessary while releasing the correct radiation dosage. This endoluminal brachytherapy allows the high dosages administration in the tumor area and minimum for the surrounding healthy tissues.
In small and localized gastric cancer, the initial treatment is often surgery, combined or not to chemotherapy or postoperative chemoradiation, which indication is decided by the medical team according to the tumor spread. In locally advanced tumors, the option is usually chemotherapy or preoperative chemoradiation or, in some cases, postoperative.
The treatment is administered in acelerador Lineal with 3D technique or with intensity-modulated radiation therapy (IMRT).
In precocious rectum cancer surgery is the main option. If in the study of the tumor, it is confirmed that it is settled to the inner wall without lymph nodes affectation, then it is reinforced as unique treatment. However, it is not infrequent to discover that the tumor is bigger, then the indicated postoperative treatment would be radiotherapy and chemotherapy. In patients with locally advanced tumors from the moment of initial diagnosis the treatment is multimodal. Generally, it begins with radiotherapy and chemotherapy, simultaneously administered as a preoperative and, after some weeks it can be finally operated (remaining tumor scission or in the area where it was found). In postoperative, it is frequent the chemotherapy administration. If the patient has been operated without a previous treatment, subsequent radiotherapy and chemotherapy can be applied.
Radiotherapy is administered in acelerador lineal with a 3D technique, and it also has a role in patients with a small amount of tumor metastasis in liver or lung, in the diagnosis moment, if it is feasible to resect them surgically. In these cases, a multidisciplinary treatment is often proposed what implies beginning with chemotherapy and chemoradiation on the rectum tumor and, then a surgery resecting the rectum tumor and the liver and/or lung metastasis.
For the patients with non resectable rectum tumors, the radiotherapy in acelerador lineal with 3D techniques helps to improve symptoms as the pain and bleeding. In such cases, chemotherapy is often combined.
In some patients with hepatic or pulmonary metastasis, not surgically resectable, a stereotactic body radiotherapy (SBRT) with Cyberknife <http://www.neuroruber.com/especialidades/oncologia_radioterapica/index.php> can be applied (treatment that allows to administer a very high dosage, exclusively to the tumor, with maximum regard of the healthy tissue, with the additional benefit of not being necessary immobilization of the respiratory movement for its capacity to fit the radiation bundle continuously to the tumor movement inside the lung or liver).
In anal cancer, the radiotherapy has a key role, both for precocious tumors as locally advanced, since combined with chemotherapy is the chosen procedure. Surgery, which is an abdominoperineal amputation and permanent colostomy (excision in all the area from the anus with skin closure and colostomy bag, in abdomen area, for feces discharge), if the entire control of the tumor with chemoradiation is not reached for these patients, the bag is left.
Radiotherapy is administered in the lineal accelerator usually with modulated-intensity (IMRT).
In some cases, if indicated, the treatment could be applied with braquiterapia.
In pancreas cancer, if possible, surgical scission and postoperative treatment with chemotherapy or chemoradiation can be applied. If the scission could not be done and it is considered that the tumor could be resectable after preoparative treatment, combined chemotherapy with radiotherapy is applied in some cases, later trying the excision. In unresectable tumors the treatment is focused in the chemotherapy and radiotherapy administration.
Radiotherapy is administered in the lineal accelerator with a 3D or IMRT technique.
In some patients stereiotactic body radiotherapy (SBRT) is indicated with Cyberknife (treatement that allows to administer a very high dosage, exclusively to the tumor, with the maxiumum regard of the surrounding healthy tisssue. In case of pancreas tumors we mean organs as small bowel, liver, stomach and kidneys.)

Side effects
Acutes: Nausea/vomiting and heartburn (burning sensation rising up to the mouth) in the treatments concentrated in the upper area of the abdomen (oesophagus, stomach and pancreas). Diarrhoea, vaginal irritation, anal irritation and urinary symptomatology due to bladder and urethra irradiation.
Chronics: Intestine rhythm disorder with more frequency in diarrhea cases alternating with constipation periods, mostly in rectum and anal tumors.

 

Urological tumors

The bladder cancer is the most frequent malignant neoplasia of the urinal tract while the urethra cancer and ureter cancer are slightly commons. Its rate is bigger in men over 60.
Radiotherapy plays a key role in the two first treatment: bladder and urethra, as exclusive therapy for the organ preservation as postoperative and palliative. On the contrary, in ureter tumors it is only applied as palliative treatment.

Schedule
For the planning of the external radiotherapy (RTE) it is necessary to realize a suitable system of position and immobilization reproducing the same position every day of the treatment. Normally it is done in supine (flat on one’s back). With the chosen position, a CT is done which with later on, the radiotherapy will be planned. Regularly, it is performed with some type of bladder preparation (inserting a small volume of contrast or with the empty bladder). Radiotherapy oncologists specialists evaluate the most convenient option for each patient. Finally in the skin some marks will be drawn to fix the coordinates to allow the treatment be administered, in each session, as planned.
Radiotherapy in these cases is done in the accelerator, with 3D technique or modulated-intensity radiotherapy (IMRT).

Treatment
Bladder cancer: These tumors can be papillars- superficials or injecting. The first are very common but radiotherapy is not indicated for them.
En los tumores infiltrantes, el tratamiento suele ser la extirpación de la vejiga (cistectomía), generalmente completa. En los estadios más avanzados se administra quimioterapia pre o postoperatoria y en los casos donde es posible una cistectomía parcial el tratamiento se completa con radioterapia postoperatoria.
Furthermore, for patients who want to preserve their bladder or who cannot be operated, the choice often is radiotherapy combined with chemotherapy. Obviously the radiotherapy will be carried out after the urologist resects the maximum tumor as possible through the transurethal resection (TUR).
In addition, the radiotherapy has also an important role in the palliative treatment of advanced tumors with the aim of relieving bleeding (hematuria), that often produces these tumors.
Urethral cancer: The treatment is often surgical, involving more or less wide resections according to the urethra stretch in which the tumor is located. A radiotherapy or chemotherapy treatment can be preferred to some patients to preserve the organ. In wide tumors cases it is necessary postoperative radiotherapy and/or chemotherapy.
Ureter cancer: In these types of tumors radiotherapy is not indicated since, for ureter anatomical location, organs with low tolerance to irradiation will be affected. So, surgery is a standard treatment, combined in some cases with pre or postoperative chemotherapy.

Side effects
Acutes: Symptoms of bladder irritation, burning to urinate and urgent need to do it. Tend to have diarrhoea due to intestine irritation.
Chronics: Very often urine need in cases of spread tumors, since the fibrosis that substitutes the tumor leaves a low capacity bladder.

 

Female genital apparatus tumors

(Endometrium, cervix, vagina and vulva)
Female genital apparatus tumors encloses those formed in endometrium, cervix, vagina and vulva. In their treatment, la radioterapia externa (RTE) and the braquiterapia are very important, as exclusive treatment or postsurgical. As the location and extension of the tumor, radiotherapy is used in the initial handling with healing purpose or in palliative treatment for those patients with very advanced tumors in which radical treatment is impossible.

Schedule
For the planning of the external radiotherapy (RTE) it is necessary to realize a suitable system of position and immobilization reproducing the same position every day of the treatment. With the chosen position, a CT is done which with later on, the radiotherapy will be planned. In combined treatments with brachytherapy, an applicator can be used inserting it into the vagina for a more precise evaluation of the dosage to be administered with the both types of irradiation. Finally in the skin of the pelvis, some marks will be drawn to fix the coordinates to allow the treatment be administered, in each daily session, as planned.
In some patients, individually, the radiotherapy oncologist will set the need to perform a PET/CT planning and a pelvic MR for merging with the CT planning.

Treatment
Endometrium cancer: Generally in most cases, the initial treatment is surgery being complemented with radioterapia externa (RTE),braquiterapia or the combination of both. The election of one or another will depend on the characteristics and length of the tumor. Although there are also situations that do not require surgery and the radiotherapy becomes the first option of treatment combined or not with chemotherapy.
Cervix cancer: The radical radiotherapy is the choice for a considerable number of patients. It is combined the radioterapia externa and the braquiterapia for this. Nevertheless, those operated patients can require or not postoperative radiotherapy (it will be decided on the tumor extension study in the resected area.)
Vagina tumors: In terms of size and tumor location a surgical resection can be done and postoperative radiotherapy or a combination of external radiotherapy and brachytherapy as an exclusive treatment.
Vulvar tumors: The initial treatment is, commonly, the surgical scission complemented with postoperative radiotherapy. Even though there are also situations where radiotherapy becomes the first option of treatment with external irradiation combined or not with brachytherapy.
In addition, in all the gynaecologic tumors, the radiation therapy is used as a palliative treatment in manifold situations.

Side effects
Acutes: Diarrhoea and vagina mucous irritation.
Chronics: Diarrhoea and vaginal wall adherence. Less frequents: Rectum bleeding and fistulas.

 

Haematological tumors

Leukaemia, lymphoma –Hodgkin and not Hodgkin- and multiple myeloma

They are a heterogeneous group of diseases affecting blood, medulla and lymphatic nodes. The most usual are chronic lymphatic leukaemia (LLC) and all lymphomas group (including Hodgkin and the B and T cells). Even if the great part of hematologic tumors are treated with chemotherapy, radiotherapy has a significant role in many cases.

Schedule
Radiotherapy planning is performed in a CT with the right position, previously chosen depending on the area to be covered, used to place the patient during the treatment. Therefore, for every day of irradiation, a positioning system and immobilization are looked up for reproducing it. The used system will differ in each case, as they can be located in several areas (neck, thorax, abdomen or pelvis).
PET-TAC will be used or RM MR (magnetic resonance) to help with the planning in those cases where the radiotherapy oncologist consider necessary to achieve a better definition and a better definition of the areas to irradiate.
The treatment is performed in acelerador, with a 3D technique or IMRT.

Treatment
Whithin the group of tumors named non-Hodgkin lymphomas (LNH) are included several types, which are treated differently. Most of them are combated with chemotherapy, in many cases, combined with radiotherapy.
The different treatment options in case of follicular lymphoma of low degree localized (stages I and II) are: exclusively radiotherapy, immunotherapy with/without chemotherapy or immunotherapy/chemotherapy and radiotherapy.
In large follicular lymphomas (stages III and IV), the watching or treatment will be the options depending on the affected areas, the disease development and symptoms existence or not. In these patients, radiotherapy is used if necessary to relieve some symptoms, in likely areas to be irradiated.

The identified mantle cell lymphomas can be treated with chemotherapy alone, combined with radiotherapy or only radiotherapy as a unique treatment.
In Burkitt lymphoma the chemotherapy is the chosen treatment and, sometimes it is necessary a medullar transplant in patients who do not achieve the complete disease remission. In some cases, the disease does not disappear completely after chemotherapy, and could be necessary palliative radiotherapy.

The diffused lymphomas of big B cells are treated with chemotherapy and, in bulky diseases radiotherapy is used to reinforce the response to chemotherapy. It also can be used as an exclusive treatment in refractory patients or unsuitable for chemotherapy. Another indication is the medullar pre or post-transplant.
In skin lymphomas, depending on the type and extension, radiotherapy can be used as the only treatment or combined with chemotherapy.
The T cells lymphomas often are treated with chemotherapy followed by radiotherapy.
The treatment of NK lymphoma/T cells nasal or extra nasal, often is with chemotherapy and radiotherapy although, in some precocious cases, is used only radiotherapy.

The gastric MALT lymphoma is related with the Helicobacter pylori, it is treated with antibiotics to eliminate the germ. If it is not related to early stage H. pylori infection, is often treated with radiotherapy or with chemo/immunotherapy. In non-gastric, precocious stage, can be treated with surgical resection or radiotherapy. If it is advanced, it is possible to opt for watching or treatment according to the affected areas, the disease development and the existence or not of symptoms. The treatment could be with chemotherapy with/without immunotherapy and radiotherapy if it is necessary to relieve the symptoms.

The Hodgkin lymphoma is divided into various subtypes as the disease expansion and size and the type of prevailing cell. In the most cases, the treatment combines chemotherapy with posterior radiotherapy. The irradiation is administered on the areas of bigger initial disease development or the remaining of it after chemotherapy. In a determined number of patients, diagnosed in early stage of the lymphocyte-predominant radiotherapy can be proposed as the only treatment.
Inside the myeloma we include the solitary bone plasmocytoma or extra-bone and the multiple myeloma. The first one is a malign tumor of detected plasmatic cells or in any bone (much more frequent) or in soft tissues of the body. In the multiple myelomas, the disease is spread affecting various levels. The bones and extra-bones solitary plasmocytomes are treated only with radiotherapy and/or surgical removal if possible. The bones and extra-bones solitary plasmocytomes are treated only with radiotherapy and/or surgical removal if possible.

Side effects
The side effects will depend on the irradiation area due to the lymphoma possible locations. The radiotherapy dosage is, in general, lower than for other tumors; therefore, the probability of suffering side effects is also minor.

Musculoskeletal tumors

Bone sarcomas and soft tissues comprise all these formed in bones, muscles, joints and other soft tissues.
Bone sarcomas include varios types: Osteosarcoma, chondrosarcoma, Ewing sarcoma, etc. Each one requires a different multimodal treatment; radiotherapy represents an important role in terms of the process.
Furthermore, the soft tissue sarcomas are tumors formed in the soft tissues of the body (muscles, fat, blood vessels, ligaments, etc.). There are several types classified in great variety and locaiton: Liposarcoma, leiomyosarcoma, rhabdomyosarcoma, synovial sarcoma, malignant fibriohistiocytoma, alveolar sarcoma, fibromyxoids sarcoma, among others. They are frequent in limbs, retroperitoneum, trunk, abdomen and head and neck, the radiotherapy is a crucial part of the treatment for most of them.

Planning
For the planning of the external radiotherapy (RTE) it is necessary to realize a suitable system of position and immobilization reproducing the same position every day of the treatment. With the chosen position, a CT is done which with later on, the radiotherapy will be planned. Finally in the skin of the region to treat, some marks will be drawn to fix the coordinates to allow the treatment be administered, in each daily session, as planned.
The planning of the braquiterapia in patients which usage is as boost (an additional dosage administration) is also applied with a 3D planning system.

Treatment
Bone sarcomas require different treatments according to their type. It is the situation of Ewing sarcoma, radiotherapy has a very significant role as a part of the radical treatment, together with chemotherapy combined with surgery, as pre as postoperative. In the other tumors, it is used as treatment, mainly postoperative. Moreover, radiotherapy is indicated in unresectable tumors (which cannot be surgically removed) and as a palliative treatment. In all these cases It is administered in lineal accelerators, allowing 3D radiotherapy techniques and intensity-modulated radiation therapy (IMRT).

In the soft parts sarcomas the normal treatment is surgery combined with radiotherapy pre, post or intraoperative and frequently a mix of them. As bone sarcomas, external radiotherapy (RTE) is administered in aceleradores linealestechniques of 3D radiotherapy and intensity-modulated radiation therapy (IMRT).
Habitually, in soft tissues sarcomas it is indicated the boost (an additional dosage administration) in the cancer site. This can be performed by external radiotherapy, determining the area by the visualization in the TC planning, or by braquiterapia. In the same surgery of tumor scission, it can be done the plastic tubes implant or metal needles with the necessary radioactive sources for brachytherapy. This has many advantages for the patient, since in the same surgery, the tumor is removed and the catheters in the cancer site are placed letting the high radiation dosage to reach the area, preserving the healthy tissues around it. It is possible, thanks to a multidisciplinary team of engaged surgeons and radiotherapy oncologists.

Side effects
Acutes: Epitheliitis (skin irritation).
Chronics: Fibrosis.

 

Lung and thymus cancer

The lung cancer is the most usual tumor and, in some cases, often affects smokers or people who recently gave it up. The lung cancer is the most usual tumor and, in some cases, often affects smokers or people who recently gave it up.
In these cases, the radiotherapy has a significant role in:
Precocious disease: in inoperable patients (due to diseases preventing surgery or in those who reject it).
Locally advanced disease: Main part of the treatment, generally multimodal (relating various treatments: Radiotherapy, chemotherapy and/or surgery).
Widespread disease: With local palliative treatment or metastasis.

Planning
For the planning of the external radiotherapy (RTE) it is necessary to realize a suitable system of position and immobilization reproducing the same position every day of the treatment. It is normally carried out in supine (flat on one’s back) with arms separated from the body and over the head, subjects or stabilized in the immobilization system. With the chosen position, a CT is done which with later on, the radiotherapy will be planned. Finally in the thorax skin some marks will be drawn to fix the coordinates to allow the treatment be administered, in each session, as planned.
In most cases PET-TCwill be used for planning, since in this pathology, especially useful for tumoral volume correct definition.
For the cases which a stereotactic body radiotherapy (SBRT) is going to be applied, fiducial marks (small marks settle inside or next to the tumor to allow the treatment) placement will be valued. If needed, the placement of them is made by a puncture from outside, guided by CT.

Treatment
Precocious disease, in inoperable patients or patients with surgery rejection: The chosen treatment for detected lung cancer is surgery. Nevertheless, in inoperable patients or who push this alternative back, the radiotherapy is, also, a good treatment option. In this case, the procedure to be used will depend on the size, location and tumor extension.
In small tumors, the suitable procedure is the stereotactic body radiotherapy(SBRT) with Cyberknife <http://www.neuroruber.com/especialidades/oncologia_radioterapica/index.php> (treatment that allows to administer a very high dosage, exclusively to the tumor, with maximum regard of the healthy tissue, with the additional benefit of not being necessary immobilization of the respiratory movement for its capacity to fit the radiation bundle continuously to the tumor movement inside the lung). The treatment is performed with linear gas pedals <http://www.neuroruber.com/especialidades/oncologia_radioterapica/index.php> that allow radiotherapy 3D technique and modulated radiotherapy intensity (IMRT) in the other precocious tumors, without having criteria to be able to realize SBRT.
As postoperative treatment: Radiotherapy benefits the outlook decreasing of tumor recurrence in the area, both for operated patients whose tumor has a spread in mediastinum nodes (area between both lungs) greater than the shown in the preoperative study as in patients whose resection margin is scarce.
Locally advanced disease: Radiotherapy is a decisive part of the treatment in such cases, normally combined with chemotherapy. The treatment can be concurrently achieved (radiotherapy and chemotherapy simultaneously) or sequentially (radiotherapy after chemotherapy). aceleradores lineales are used for this, allowing 3D radiotherapy techniques and intensity-modulated radiation therapy (IMRT). If the tumor has an endobronchial compound, the combination of external radiotherapy with brachiterapia <http://www.neuroruber.com/especialidades/oncologia_radioterapica/index.php> can be a good option.
Postoperative radiotherapy in unsuitable patients for an initial surgery is also indicated for locally advanced tumors, treated with chemotherapy and reducing the tumor size before the surgical resection. Radiation therapy helps to reinforce the treatment of the tumor that was affecting the mediastinum nodes or the pulmonary tumor area, when it is near the resection margin.
-Widespread disease: With local palliative treatment or metastasis.
In some cases of cerebral metastasis or of other extracranial metastases, if the tumor burden is low (oligometastasis), radiosurgery or hypo-fractionated stereotactic radiotherapy in specific units for these treatments, as they are gammaknife and cyberknife.

Side effects
Acutes: Esophagitis (inflammation of the oesophagus).
Subacutes or chronics: Pneumonitis (lung inflammation) , can come out after 3-6 moths from radiotherapy, although, generally they are minor and temporary.

 

Skin cancer

It is the cancer which is developed in skin tissues. There are several types: which is formed in the melanocytes, known as melanoma, in the inner part of the epidermis, called carcinoma of basal cells or basement squamous cells origin, called squamous cells carcinoma and the neuroendocrine skin carcinoma, formed in the neuroendocrine cells.
-Skin cancer (not melanoma): Radiotherapy has an important role as an exclusive treatment, surgery alternative, as postsurgical in some cases.
-Melanoma: In this case, radiotherapy is indicated in various situations: As initial tumor treatment, after surgery; in postoperative irradiation of lymph node chains affected by the tumor; alternatively, with palliative aim in brain metastases, bone metastases, etc.

Planning
Skin tumors (not melanoma) often appear in the sun-exposed skin areas. If external radiotherapy is used, to plan it, the first thing is choosing the position and the more suitable immobilization system, according to the location.
If the cutaneous tumor and not the node is only necessary to treat, the Radiotherapy Oncologist takes the decision to value if it is indispensable to realize a TC <http://www.neuroruber.com/especialidades/oncologia_radioterapica/index.php> to plan the radiotherapy, or it is possible to carry out the setting up without it, since the tumor can directly be visualized. When the nodes must be treated it turns always to a TC.
If a palliative irradiation is needed, due to the metastasis, depending on the area to be treated, the suitable position and immobilization are chosen and a TC is performed in which the radiotherapy is planned. The treatment is performed in acelerador lineal. In some patients with brain metástasis cerebral, according to the number, size and location of them, the medical team can consider the radiosurgery as the most suitable treatment, which would be accomplished assessing every case individually with Cyberknife <http://www.neuroruber.com/especialidades/oncologia_radioterapica/index.php>

Treatment
Not melanoma tumors:
– Basal cell carcinoma or basal cells. Surgical tumor resection can be performed or radiotherapy. After valuing each patient one or another is settled on, bearing in mind, besides healing, the aesthetic results. If the surgery is the option and the tumor reaches the resection margin of the resected area, postsurgical radiotherapy can be indicated or a larger surgery.
-Squamous cells carcinoma. As in previous tumors, a surgical tumor scission can be done or radiotherapy. However, the feasibility of nodes affectation is much bigger. For this reason, the medical team in indicated cases carries out a study to estimate if there is node infiltration, and if it is necessary to apply any kind of treatment to them. Normally, the choice is the resection of the corresponding lymph nodes and the latter area irradiation. Surgery is not possible for some patients and exclusive radiotherapy is applied.
-Melanoma: The initial treatment of melanoma is the surgical resection. If the margin of resected skin around the tumor is scarce, a bigger resection can be accomplished. However, radiotherapy is indicated to some patients. It is also normal to resect the lymph node chains affected by the tumor. Often a postoperative radiotherapy can be performed in these lymph nodes areas, depending upon the indication or not of irradiation, of the node number infiltrated by the tumor.

Side effects
Acutes: Skin area irritation, shown as reddish of different intensity, even with a small skin ulceration in some cases. It is restored in a few weeks after the treatment conclusion.
Chronics: Many patients do not show disorders at long term. In some ones, the thinner skin in the treated area can be seen. It depends on the necessary dose administered and the irradiated area.

 

Benign pathology

Although radiotherapy is mainly used for malignant tumors healing, it is also indicated for treating some benign diseases.
• The benign pathology to be treated with radiation can be divided in: benign tumors: Pituitary adenoma, benign neurinoma, classic meningioma, desmoid tumors…
• Processes on the borderline between hyperproliferation cases and neoplasias: Histiocytosis of Langerhns cells, Kimura disease…
• Vascular system disorders: Arteriovenous abnormalities, hemangiomas…
• Inflammatory disorders or soft tissues proliferative: Dupuytren disease, keloids, Graves’ ophthalmology, orbital pseudotumors…
• Osteoarticulars disorders: Tendinopathies and bursitis, calcaneal spur, prophylaxis of hip heterotopic ossification, periarthritis…

Planning
The planning is carried out in aTC, performed in the most suitable regarded position. The position and immobilization system choice depends upon the area to be treated, whenever the optimum selection allows reproducing the desired position for irradiation, all the days of therapy.
Radiotherapy Is accomplished in acelerador lineal. Specific pathologies, as arterio-venous abnormalities or brain neurinomas also can be healed with Gammaknife.

Treatment
Radiotherapy has proven to be an effective treatment for certain benign illnesses, like the previously reported ones, when they cause a serious disturbance of the patients’ quality of life. The medical team is who, after analyzing each case, decides the precise moment to propose irradiation. Sometimes it is indicated after the failure of other therapies. Other times, it is considered the first therapeutical option, if the potential risk of another treatment is bigger than the irradiation.

 

MEDICAL TEAM

Dra. Rodríguez Pérez, Aurora Team leader
Más información

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  • Licenciada en Medicina y Cirugía por la Universidad Autónoma de Madrid y doctora sobresaliente Cum Laude por la Universidad Complutense.
  • Especialista en Oncología Radioterápica, se formó en el Hospital Central de la Defensa Gómez Ulla y completó su formación en el Institut Curie de Paris. Es Jefa de Servicio en el Hospital Rúber Internacional y anteriormente Jefa en funciones en el Hospital Universitario de Fuenlabrada.
  • Comandante médico en excedencia, ha participado en varias misiones internacionales como Médico Militar. Máster en Gestión de Calidad Total por la Escuela de Organización Industrial ha trabajado en el Departamento de Formación y Calidad de IBM España.
  • Profesora colaboradora en el Máster Universitario en Tecnologías de la Información y Comunicaciones en Ingeniería Biomédica y colaboradora honoraria en la asignatura de Oncología de la Facultad de Medicina de la Universidad Rey Juan Carlos.
  • Profesora en el curso de Técnico Superior de Radioterapia en la Universidad San Pablo CEU.
  • Coordinadora del Grupo de Infraestructuras de la Sociedad Española de Oncología Radioterápica (SEOR) y Vocal de la Junta Directiva de GICOR (Grupo de Investigación Clínica en Oncología Radioterápica).
  • Miembro de los Grupos de Mama (GEORM), Cáncer de Pulmón (GOECP) y Braquiterapia (GEB) de la Sociedad Española de Oncología Radioterápica (SEOR).
  • Idiomas: español (nativo), francés bilingüe e inglés
  • Autora de treinta y ocho publicaciones en libros y revistas especializadas y más de cien comunicaciones y ponencias en Congresos y Jornadas nacionales e internacionales. Participación en varios ensayos clínicos.
  • Distinguida con varias menciones y condecoraciones militares.

Dra. Belinchón Olmeda, Belén
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Licenciada en Medicina y Cirugía por la Universidad de Alcalá, realizó su periodo de formación como Médico Especialista en Oncología Radioterápica en el Hospital Universitario Puerta de Hierro. Actualmente, compatibiliza su trabajo el Hospital Ruber Internacional con el de Médico Adjunto en el Servicio de Oncología Radioterápica del Hospital Universitario La Paz, centrando su actividad en cáncer de mama, tumores ginecológicos, sarcomas y tumores digestivos, así como en braquiterapia.

Miembro de los Grupos de Sarcomas y Tumores de partes blandas, Mama (GEORM), Braquiterapia y Tumores Digestivos (SEOR-GI) de la Sociedad Española de Oncología Radioterápica (SEOR)

Idiomas: español (nativo) e inglés.

Dra. Caballero Guerra, María Pastora
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Licenciada en Medicina y Cirugía por la Universidad de Valladolid, realizó su periodo de formación como Médico Especialista en Oncología Radioterápica en el Hospital Universitario Doce de Octubre, y posteriormente ha trabajado, además de en dicho hospital, en el Hospital Universitario Ramón y Cajal y en otros centros privados. Actualmente compatibiliza su trabajo en el Hospital Ruber Internacional con el de Médico Adjunto en el Servicio de Oncología Radioterápica del Hospital Universitario de Fuenlabrada, centrando su actividad en el cáncer de mama, tumores del SNC, neoplasias hematológicas y SBRT con Cyberknife.

Dra. Lozano Martín, Eva María
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Licenciada en Medicina y Cirugía por la Universidad Complutense de Madrid. Especialista vía MIR en Oncología Radioterápica en el Hospital Universitario Doce de Octubre. Ha trabajado como médico adjunto del Servicio de Oncología Radioterápica del Centro Oncológico de Galicia y, posteriormente, como Coordinador Médico de Unidad de Ciudad Real en grupo Instituto Madrileño de Oncología. Actualmente, compatibiliza su trabajo en el Hospital Ruber Internacional con el de Jefa del Servicio de Oncología Radioterápica del Hospital General Universitario de Ciudad Real, centrando su actividad en tumores digestivos, tumores de mama, neoplasias hematológicas y braquiterapia de mama y tumores ginecológicos. Profesor asociado en la Facultad de Medicina de Ciudad Real en las asignaturas de Radiología y Terapéutica Física y Oncohematología.

Miembro del Grupo de Linfomas de la Sociedad Española de Oncología Radioterápica (SEOR).

Idiomas: español (nativo) e inglés.

Dra. Sotoca Ruiz, Amalia
Más información

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  • Licenciada en Medicina y Cirugía por la Universidad Complutense de Madrid, realizó su periodo de formación como Médico Especialista en Oncología Radioterápica en el Hospital Universitario Doce de Octubre. Ha trabajado, además de en dicho hospital, en el Hospital Central de la Defensa,  en el Hospital Universitario de la Paz, y en el Hospital Universitario de Fuenlabrada, centrando su actividad en el cáncer de mama, de pulmón, de próstata y SBRT.
  • Miembro de los Grupos de Mama (GEORM), Tumores Digestivos (SEOR-GI) y Cáncer de Pulmón (GOECP) de la Sociedad Española de Oncología Radioterápica (SEOR).
  • Idiomas: español (nativo), francés bilingüe e inglés.

Dra. Vallejo Ocaña, Mª Carmen
Más información

Dra Vallejo
  • Licenciada en Medicina y Cirugía por la Universidad Autónoma de Madrid.
  • Doctora Sobresaliente Cum Laude por la misma Universidad.
  • Especialista en Oncología Radioterápica vía MIR en el Hospital Universitario 12 de Octubre Madrid.
  • Médico Adjunto en el Hospital Militar del Aire Madrid, Hospital Central de la Defensa-Gómez Ulla Madrid.
  • Actualmente compatibiliza su trabajo en el Hospital Ruber Internacional con el de Médico Adjunto en el Servicio de Oncología Radioterápica de Hospital Universitario Ramón y Cajal de Madrid, centrando su actividad en tumores de pulmón, tumores de cabeza y cuello, tumores de próstata y vejiga y en tratamiento con técnica de Radioterapia Estereotáxica Hipofraccionada (SBRT), tanto en tumores primarios como en enfermedad oligometastásica.
  • Acreditación como Profesor Contratado Doctor Universidad Pública y Profesor Doctor de Universidad Privada, por la Agencia de Calidad, Acreditación y Prospectiva de las Universidades de Madrid (ACAP).
  • Profesora Asociado  de Facultad de Medicina Universidad Complutense Madrid durante 14 Cursos Académicos, en 3º y 6º de la Licenciatura.
  • Profesora en Programas de Doctorado de Universidad Complutense Madrid, durante 19 Cursos Académicos.
  • Profesora Programa de Técnico Superior de Radioterapia en la Universidad San Pablo CEU, durante 4 cursos académicos.
  • Profesora en más de 25 cursos de formación continuada y más de 30 Comunicaciones a congresos.
  • Publicaciones: 37 revistas y 11 capítulos en libros.
  • Proyectos de investigación: Participación en 2 Becas del Fondo de Investigación  Sanitaria FIS 2011 y FIS 2013, y en 18 ensayos clínicos.
  • Tutora de Residentes del Servicio de Oncología Radioterápica del Hospital  Ramón y Cajal durante 5 años.
  • Miembro de la Comisión Clínica de Tumores del Hospital Central de la Defensa y del Hospital Ramón y Cajal.
  • Miembro de los Grupos de Cabeza y Cuello (GEORCC), Cáncer de Pulmón (GOECP), Tumores Urológicos (URONCOR) y de SBRT, de la Sociedad Española de Oncología Radioterápica (SEOR).

Dr. Vázquez Masedo, Gonzalo
Más información

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Licenciado en Medicina y Cirugía por la Universidad Complutense de Madrid y doctor sobresaliente Cum Laude por la Universidad Complutense. Realizó su periodo de formación como Médico Especialista en Oncología Radioterápica en el Hospital Universitario Doce de Octubre y, posteriormente, ha trabajado en el Hospital Universitario Puerta del Mar de Cádiz, el Hospital Infanta Cristina de Badajoz, el Hospital Ramón y Cajal, la Clínica RADON (CROASA) de Algeciras, la clínica M.D. Anderson Internacional de Madrid, el Instituto Oncológico de Castilla La Mancha y el Complejo Hospitalario Universitario de Albacete. Actualmente, compatibiliza su trabajo el Hospital Ruber Internacional con el de Médico Adjunto en el Servicio de Oncología Radioterápica del Hospital Clínico San Carlos de Madrid. Profesor Asociado de Ciencias de la Salud en el Departamento de Radiología y Medicina Física de la Facultad de Medicina de la Universidad Complutense de Madrid

SERVICES PORTFOLIO

Computed tomography

Technique using x-ray to obtain multiple images not only cross-sectional but in different axes inside the body. It is an examination aiming internal organs details, easing the diagnoses of some diseases, as many types of cancers. Moreover, It is frequently used to stage –see the spread- and assess the response from the tumor to the treatments.
The Radiotherapy Oncology Service has a CT for planning the treatments. It is a key element for, together with the appropriate immobilizing positions and systems for each type of tumor, be able to find the areas to irradiate and the surrounding organs to be protected.
Magnetic resonance imaging
It is the diagnosis examination where a magnetic field is used and radio waves to obtaining detailed images of the inner body organs and structures, enabling to doctors determine certain diseases presence. It is the most sensible to visualize the brain.

PET-CT

Tecnology that combines an imaging technique of nuclear medicine, the PET (positron emission tomography) with CT. With the PET/CT the abnormal metabolism of a radioactive marker is measured and injected in the patient’s blood for specific tumors. The simultaneously obtained CT images provide anatomical details. The combined examinations –PET/CT— provide images identifying the anatomical placement of the abnormal metabolic activity within the body, they offer more precise diagnosis than both examinations separately. This enables to evaluate the occurrence and location of certain tumors, its spread and if there is a metastasis.

The radiotherapy oncology technologists typically combine images of MRI and/or PET-TC, with the CT planning to localize even more precisely the tumor extension when it is necessary for the treatment preparation.
In addition, it has the more innovative and modern systems of TREATMENT granting us a better accuracy, speed, security and comfortability, letting the medical team to reach the best efficacy and efficiency.

Cyberknife

The first and unique system of robotic radiosurgery intended for treating invasive or not invasively the small tumors, detected in some parts from the body as lung, livers, vertebrae surrounding the spinal cord or prostate.
It is a lineal accelerator, very light and compact, mounted on a robotic arm controlled by software that incorporates images capturing systems and the organs and tumor movement. It is skilled to move along the patient’s body in practically any direction and adjusting its movements with the ones of the tumor and the internal organs, as breathing, keeping the maximum accurateness, less than a millimetre over the irradiation area.
This means that the medical team can administer a greatly high dosage to the tumor, even to the moving lesions, without being necessary to provide big security margins, what enables that the surrounding healthy tissue receives extremely low dosages, minimizing the side effects and letting the patients to breathe normally and during the treatment.
The CiberKnife System is capable of treating a wide range of tumors in the whole body, including prostate, lung, brain, spine, liver, pancreas and kidney. Likewise, it offers a non-surgical option for patients with inoperable tumors or who are looking for a substitute for surgery. It enables treatment with quite favourable cost-benefit rate, in one hand the treatment time reduction –allowing to administer high dosages it is performed in a less of days–, on the other hand, there are fewer side effects.
In Spain, the Ruber International Radiotherapy Oncology was the early pioneer in implementing this innovative technology and, currently, it is one of the few in having it.

VARIAN 600 and 2300 iX Linear accelerators

They allow performing treatments of 3D external radiotherapy; it uses three-dimensional anatomic images, taken in the planning CT, to define more precisely the areas to irradiate and to calculate the 3D dosage. Moreover IMRT (intensity-modulated radiation therapy), technique that enables the radiation intensity different in several areas, previously defined by the physician to maximize the dosage in the tumor and to minimize it in the normal tissues. The accelerator model 2300 iX with an imaging acquisition system equivalent to CT, just before to irradiate the patient. Those images are overlapped with CT planning, comparing them and performing the precise corrections. This is known as image-guided radiation therapy (IGRT). It also provides dynamic archotherapy of high accuracy.

All this, helps to administer the treatment highly fast and safe to the patient.

Brachytherapy

The oncology radiation therapy service is promoting distinct brachytherapy techniques consisting in placing, through different devices the sources of radiation, nearby or even inside the tumor or in the area to irradiate. The aim is administering an elevated radiation dosage in the tumor preserving, really safely and efficiently the surrounding healthy organs. Brachytherapy treatments may be performed for diverse tumors, as exclusive treatment or combined with external radiotherapy.

In terms of placing technique of the radioactive source can be:
– Endocavitary, placing the device for the radioactive source in body natural cavities for treating the tumors of such areas (intra-vaginal and intra-uterine in gynaecologic tumors).
-Endoluminal placing it into the tube (bronchial tube or esophagus of theses locations) or interstitial, placing it directly inside the tumor to be treated or the area of cancer site to irradiate (breast, prostate, soft tissues sarcomas…).
In terms of the particular procedure, it can be performed with or without anaesthesia and outpatients or hospitalized. The treatment is completed in few days.

Radiotherapy oncology

Radiotherapy oncology is a branch of clinical medicine that uses the ionizing radiation, alone or combined with other therapeutic types for treating cancer and some diseases non neoplastic.
It is considered as one of the two therapeutic tools, which is more effective against cancer, together with surgery. Throughout history, it has given good results as a primary way of treatment in many malignant tumor in precocious stages.
Radiotherapy is the treatment with ionizing radiations used in oncological radiotherapy. It has been replacing mutilating surgery or causing functional losses in long term control of many tumors as breast, head and neck, prostate, to name some of them, as anal duct tumors, sarcomas, etc. Its contribution to the local control of the disease, when it is used with radical or healing aim, allows significantly enlarging as the free range of disease as the global survival in many types of cancer. Used with palliative purpose its effect on the symptoms controlling places it among the more useless choices for many patients. Together with other oncologic therapies as are: Surgery, chemotherapy, hormonotherapy, immunotherapy and new molecular targets, the radiotherapy is a main part of the therapeutic arsenal for the fight against the neoplasic disease. Between a 60 and 75% of diagnosed patients of cancer will need a treatment with radiotherapy, with a radical or palliative purpose, exclusively or combined with other therapies, in some moment of their disease.

Frequent Questions

Head and neck tumors

In larynx cancer, the healing possibility is equal if I’m operated, or if I have exclusive radiotherapy?
Yes, they are similars.

If I chose to be treated with radiotherapy and the tumor is not cured, can I be operated later?
Yes, typically a surgical treatment can be carried out in case of not effectively controlling the tumor with ratiotherapy or chemoradiation.

What can I do to improve the mucositis?
It is necessary to follow the indications of the team which is treating you, both the physician and nurse. It is beneficial to do a good oral hygiene, washing it after meals with an extra-soft toothbrush and doing frequent rinses with camomile water. It is also helpful drinking enough water, eating bland food and smooth consistency or grind food, avoiding spices, vinegar and other irritants at a moderate temperature.

Brain tumors

In all the brain metastasis cases, a treatment with radiosurgery can be applied?
No. It is only indicated in determined brain metastasis, depending on its number, size and location.
If radiosurgery is for treating brain metastasis, must it be done, in addition to the radiotherapy of the rest of the brain?
Not always, although yes for many patients. The doctor specialist in radiotherapy oncology is who analyses each case, individually and he proposes the best treatment.

Is the surgery better with Gammaknife or with Cyberknife?
The treatment can be applied with both techniques. The Ruber International Hospital offers both. They are medical teams who work in each one, who study the cases and decide the most suitable for each patient.

Breast cancer

The boost of the area where the tumor was, after the breast radiotherapy, is it better with external radiotherapy or with brachytherapy?
The election of one or another treatment technique, depends on every patient and it is studied, individually, by the medical team. The most suitable is proposed to each patient.

What can I do to take care of the skin of the breast during the radiotherapy?
It is necessary to follow the indications of the team, both the physician and nurse. It is convenient to wash it softly, with water and neutral soap; dry it without rubbing; use emollient cream, without perfume (names will be indicated); not to scratch; and use a cotton bra without hoop).

Is it important to follow up the reviews after completing the treatment?
Reviews are important to control eventual metastasis or second tumors. They are also useful to help to the resolution or mitigation of the side effects if it was the case.

Digestive tumors

Whenever there is a hepatic metastasis, can be carried out the body stereotactic radiotherapy (SBRT)?
No. It is a treatment only indicated in certain cases, in terms of the number of metastasis as the size and location of them.

How the feeding can be figured out in esophagus tumors, when it is impossible to swallow?
There are several ways. If possible, a prosthesis is placed within the esophagus area, in the tumor, through a central light, allowing to swallow again and, therefore, feed on normally, by mouth. In some patients, a small probe can be settled from the nose into the stomach, to bring in food, liquid or semi liquid, by a special syringe. When none of the above are feasible, a probe is placed to connect a small hole in the top wall of the abdomen, from the stomach; by it, the food is inserted with a special syringe.

During radiotherapy, what can I do to feel better?
Always follow indications and support treatments recommended by your physicians. That will help you to have a better therapy tolerance. You also must take care of feeding: do meals of a small amount (at least five times a day), bland diet and if you have diarrhoea take astringents, and drink enough liquids (1.5 l./day minimum) of non-gaseous nor alcoholic drinks.

Digestive tumors

Which are the tumor of bladder symptoms?
The most common is blood in urine (hematuria). Other symptoms are: Continuous need of urinating, pain on doing it and burning sensation without having cystitis (infection).

If the conservative bladder treatment is chosen, if the tumor is not healed, it is possible to operate later?
Usually yes, although the surgery may come to be more complicated.

Genital apparatus tumors

Female
What can I do to have a diagnosis of cervix cancer in due time?
It is important to perform the gynaecologic check-ups following your age corresponding schedule.

Which are the warning symptoms in female genital apparatus tumors?
You must ask the doctor when there are abnormal vaginal bleedings, it could be after menopause, after intercourse or between menstruations. You can also search his advice if you notice a lump or ulceration in vulva or in the vagina.

Male
If I am diagnosed with a low-risk prostate cancer, can a choose between a surgical treatment, external radiotherapy or brachytherapy with the confidence that the healing possibilities are equal?
Yes, they are treatments with similar possibility of disease control.

Being submitted to PSA analysis to discard a prostate cancer is it always indicated?
As other tumors with screening studies performed (providing a precocious diagnosis when the tumor symptoms still has not appeared) it has its indiciations, as for target people and the suitable moment to do it, that must be settled by the doctor.

Haematological tumors

The solitary plasmacytoma in bone, can be cured only with radiotherapy?
Correct, and in a significant number of patients it happens. However, an evolutionary follow-up is needed in case that, later a multiple myeloma can be diagnosed and requires a correct treatment.

If I am submitted to a medullae transplant, can I have a normal life?
In order to be able to perform a bone cells infusion, your own medullae must remain without any kind of cells; this is known as conditioning process for transplant. This treatment to destroy all the bone marrow cells is often performed with high dosages of chemotherapy, but it also can be achieved by a special technique of radiotherapy, called total body irradiation (TBI). This last one consists in administering a radiation dosage to all the bones (in which is the bone marrow).

Bone sarcomas and soft tissues

What is better? Preoperative or postoperative radiotherapy?
The correct and suitable moment to apply radiotherapy is not always the same, and the medical team will determine the most appropriate for each case.
Is it good to combine treatment of external radiotherapy and brachytherapy in all sarcomas?
No, it is not indicated in all cases, nor feasible. The multidisciplinary unit (surgeons, traumatologists and radiotherapy oncologists) study each case to propose the best treatment for each patient.

Lung and thymus cancer

Why perform beam cranial prophylactic in carcinoma undifferentiated from small cell?
Because the tumor that frequently produces metastasis in brain, and the chemotherapy used for the treatment does not reach it, due to not crossing the layer that is covering it, to protect it.

Does pneumonitis have any treatment?
Yes. The medical team must indicate and monitor the treatment.